Opinion

 

If I traveled back in time to meet with a 60-year-old Sigmund Freud, the first thing I would say to him is: “Stop smoking, and get out of Austria!”

That was my thought as I read “Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works” (Dog Ear Publishing, 2016), in which the author, psychiatrist Steven B. Sandler, MD, holds a series of imaginary meetings with Freud to discuss the evolution of psychoanalysis into Sandler’s preferred mode of short-term dynamic psychotherapy (STDP) and to present case material for Freud’s supervision.

The author’s main stated intention in writing the book is to “explain psychotherapy to the general reading public” and to do so in a style that holds the reader’s attention – hence, the fictional aspect. My annoyance with Sandler for not immediately warning Freud of his future perils is a good indication that the book’s fictional aspect works: The fantasied meetings feel alive, and the exchanges with Freud, authentic. Sandler also notes that the secondary intention of writing the book is to process some of his own feelings about his father.

The chapters in “Tea with Freud” alternate between the imagined meetings with Freud and Sandler’s clinical work, presented from what I assume are transcripts of videotaped sessions with some disguises and composites to protect patients’ privacy. These clinical vignettes bring the reader into the nitty-gritty of the treatment room, which may be highly instructive for a lay person – particularly one who has never been in therapy.

At the same time, the book has the potential to be quite misleading. This would not be the case if Sandler were simply trying to introduce the reader to STDP. Instead, he attempts to convince the reader, and apparently himself, that the therapy he practices is a modern rendition of psychoanalysis because it tries to access the patient’s unacceptable, unconscious feelings; encourages her to “remember with emotion” or “experience” her feelings; and leads to some sort of cathartic resolution and improvement in symptoms and outlook.

While, “Aha!” moments and cathartic abreaction were characteristic of very early analyses, modern psychoanalysis is about slow but permanent change in character structure. The unwritten message in the book is that Freud’s true heirs practice psychotherapy as Sandler does. He does not seem to consider the significance of the many psychoanalysts, myself included, practicing psychoanalysis today.

Sandler uses a (mercifully) attenuated Davanloo technique to provoke patients into dramatic enactments. He is highly directive, with statements like, “We don’t solve any particular problem if we jump around all over.” I wonder how he can possibly learn about his patients when he begins with a foregone conclusion about where they should be headed.

His treatments are very brief. During his first session with a patient named Carla, he deduces that she is suffering from unresolved anger related to childhood trauma and manifesting it in chronic anxiety with angry outbursts. He then proceeds to “cure” her in five sessions.

Sandler wonders why some of his patients relapse and decides it is because they have not explored their “positive memories” in treatment, as though memories were univalent.

And he talks way too much.

All of this is decidedly un-analytic, which, again, would not matter if he were only trying to demonstrate STDP in action. Nonanalytic psychotherapies are entitled to be nonanalytic. Sandler has Freud point out precisely these analytic errors, so he must be aware that he is making them. And, yet, he stubbornly maintains his position that his work is analytic. What a waste of time travel it would be to meet with Freud only to reinforce one’s own opinions.

“Tea with Freud” is a way for Sandler to promote STDP and his theories about “positive memories” using an established authority, Freud, to validate them. This makes the book disappointing, but fortunately, there is something more to it. I kept wondering why it was so important to the author to seek out Freud’s – that is, his father’s – approval for his work. The book never answers that question. But in his attempts to understand his motives, Sandler, who is very adept at describing his own thoughts and feelings, becomes a model for the awareness of internal states and the effects of unconscious processes. Perhaps this is the most important lesson in “Tea with Freud.”

 

Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York.

 

If I traveled back in time to meet with a 60-year-old Sigmund Freud, the first thing I would say to him is: “Stop smoking, and get out of Austria!”

That was my thought as I read “Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works” (Dog Ear Publishing, 2016), in which the author, psychiatrist Steven B. Sandler, MD, holds a series of imaginary meetings with Freud to discuss the evolution of psychoanalysis into Sandler’s preferred mode of short-term dynamic psychotherapy (STDP) and to present case material for Freud’s supervision.

The author’s main stated intention in writing the book is to “explain psychotherapy to the general reading public” and to do so in a style that holds the reader’s attention – hence, the fictional aspect. My annoyance with Sandler for not immediately warning Freud of his future perils is a good indication that the book’s fictional aspect works: The fantasied meetings feel alive, and the exchanges with Freud, authentic. Sandler also notes that the secondary intention of writing the book is to process some of his own feelings about his father.

The chapters in “Tea with Freud” alternate between the imagined meetings with Freud and Sandler’s clinical work, presented from what I assume are transcripts of videotaped sessions with some disguises and composites to protect patients’ privacy. These clinical vignettes bring the reader into the nitty-gritty of the treatment room, which may be highly instructive for a lay person – particularly one who has never been in therapy.

At the same time, the book has the potential to be quite misleading. This would not be the case if Sandler were simply trying to introduce the reader to STDP. Instead, he attempts to convince the reader, and apparently himself, that the therapy he practices is a modern rendition of psychoanalysis because it tries to access the patient’s unacceptable, unconscious feelings; encourages her to “remember with emotion” or “experience” her feelings; and leads to some sort of cathartic resolution and improvement in symptoms and outlook.

While, “Aha!” moments and cathartic abreaction were characteristic of very early analyses, modern psychoanalysis is about slow but permanent change in character structure. The unwritten message in the book is that Freud’s true heirs practice psychotherapy as Sandler does. He does not seem to consider the significance of the many psychoanalysts, myself included, practicing psychoanalysis today.

Sandler uses a (mercifully) attenuated Davanloo technique to provoke patients into dramatic enactments. He is highly directive, with statements like, “We don’t solve any particular problem if we jump around all over.” I wonder how he can possibly learn about his patients when he begins with a foregone conclusion about where they should be headed.

His treatments are very brief. During his first session with a patient named Carla, he deduces that she is suffering from unresolved anger related to childhood trauma and manifesting it in chronic anxiety with angry outbursts. He then proceeds to “cure” her in five sessions.

Sandler wonders why some of his patients relapse and decides it is because they have not explored their “positive memories” in treatment, as though memories were univalent.

And he talks way too much.

All of this is decidedly un-analytic, which, again, would not matter if he were only trying to demonstrate STDP in action. Nonanalytic psychotherapies are entitled to be nonanalytic. Sandler has Freud point out precisely these analytic errors, so he must be aware that he is making them. And, yet, he stubbornly maintains his position that his work is analytic. What a waste of time travel it would be to meet with Freud only to reinforce one’s own opinions.

“Tea with Freud” is a way for Sandler to promote STDP and his theories about “positive memories” using an established authority, Freud, to validate them. This makes the book disappointing, but fortunately, there is something more to it. I kept wondering why it was so important to the author to seek out Freud’s – that is, his father’s – approval for his work. The book never answers that question. But in his attempts to understand his motives, Sandler, who is very adept at describing his own thoughts and feelings, becomes a model for the awareness of internal states and the effects of unconscious processes. Perhaps this is the most important lesson in “Tea with Freud.”

 

Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York.

 

If I traveled back in time to meet with a 60-year-old Sigmund Freud, the first thing I would say to him is: “Stop smoking, and get out of Austria!”

That was my thought as I read “Tea with Freud: An Imaginary Conversation about How Psychotherapy Really Works” (Dog Ear Publishing, 2016), in which the author, psychiatrist Steven B. Sandler, MD, holds a series of imaginary meetings with Freud to discuss the evolution of psychoanalysis into Sandler’s preferred mode of short-term dynamic psychotherapy (STDP) and to present case material for Freud’s supervision.

The author’s main stated intention in writing the book is to “explain psychotherapy to the general reading public” and to do so in a style that holds the reader’s attention – hence, the fictional aspect. My annoyance with Sandler for not immediately warning Freud of his future perils is a good indication that the book’s fictional aspect works: The fantasied meetings feel alive, and the exchanges with Freud, authentic. Sandler also notes that the secondary intention of writing the book is to process some of his own feelings about his father.

The chapters in “Tea with Freud” alternate between the imagined meetings with Freud and Sandler’s clinical work, presented from what I assume are transcripts of videotaped sessions with some disguises and composites to protect patients’ privacy. These clinical vignettes bring the reader into the nitty-gritty of the treatment room, which may be highly instructive for a lay person – particularly one who has never been in therapy.

At the same time, the book has the potential to be quite misleading. This would not be the case if Sandler were simply trying to introduce the reader to STDP. Instead, he attempts to convince the reader, and apparently himself, that the therapy he practices is a modern rendition of psychoanalysis because it tries to access the patient’s unacceptable, unconscious feelings; encourages her to “remember with emotion” or “experience” her feelings; and leads to some sort of cathartic resolution and improvement in symptoms and outlook.

While, “Aha!” moments and cathartic abreaction were characteristic of very early analyses, modern psychoanalysis is about slow but permanent change in character structure. The unwritten message in the book is that Freud’s true heirs practice psychotherapy as Sandler does. He does not seem to consider the significance of the many psychoanalysts, myself included, practicing psychoanalysis today.

Sandler uses a (mercifully) attenuated Davanloo technique to provoke patients into dramatic enactments. He is highly directive, with statements like, “We don’t solve any particular problem if we jump around all over.” I wonder how he can possibly learn about his patients when he begins with a foregone conclusion about where they should be headed.

His treatments are very brief. During his first session with a patient named Carla, he deduces that she is suffering from unresolved anger related to childhood trauma and manifesting it in chronic anxiety with angry outbursts. He then proceeds to “cure” her in five sessions.

Sandler wonders why some of his patients relapse and decides it is because they have not explored their “positive memories” in treatment, as though memories were univalent.

And he talks way too much.

All of this is decidedly un-analytic, which, again, would not matter if he were only trying to demonstrate STDP in action. Nonanalytic psychotherapies are entitled to be nonanalytic. Sandler has Freud point out precisely these analytic errors, so he must be aware that he is making them. And, yet, he stubbornly maintains his position that his work is analytic. What a waste of time travel it would be to meet with Freud only to reinforce one’s own opinions.

“Tea with Freud” is a way for Sandler to promote STDP and his theories about “positive memories” using an established authority, Freud, to validate them. This makes the book disappointing, but fortunately, there is something more to it. I kept wondering why it was so important to the author to seek out Freud’s – that is, his father’s – approval for his work. The book never answers that question. But in his attempts to understand his motives, Sandler, who is very adept at describing his own thoughts and feelings, becomes a model for the awareness of internal states and the effects of unconscious processes. Perhaps this is the most important lesson in “Tea with Freud.”

 

Dr. Twersky-Kengmana is a psychiatrist and psychoanalyst in private practice in New York.

 

The interim final rule for the second year of Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) was released on November 2, 2017. This rule will apply to performance and reporting for calendar year 2018 and impact payment in 2020. Below, I have highlighted a few of the key components of the 1,653-page rule with special attention to the Merit-based Incentive Payment System (MIPS).

To briefly review, there are two pathways for participation in the QPP, namely MIPS and the Advanced Alternative Payment Models (A-APMs). For 2018, we still expect that the majority of surgeons eligible to participate in the QPP will do so via the MIPS pathway. That said, and for reasons discussed below, CMS estimates that approximately half of the 1.2 million MIPS-eligible clinicians will be required to submit MIPS data in 2018. In addition, CMS estimates that approximately 200,000 eligible clinicians will participate in the QPP in 2018 via the A-APMs.

Performance in MIPS will continue to be based on four components: Quality, Cost, Advancing Care Information (ACI), and the Improvement Activities (IA).

1) Quality – For 2018, CMS continues to require reporting on six measures, one of which must be an outcome measure or other high-priority measure. Should surgeons choose to report on more than six measures, CMS will use the six with the highest score for purposes of calculating their score for the Quality component. However, CMS did increase the percentage of patients on which reporting is required, aka the completeness threshold, in 2018 to 60%. Measures submitted that fall below the completeness threshold will receive one point. Small practices will receive three points for measures that fail to meet the completeness threshold. Multiple options remain available for submission of data, i.e., electronic health record (EHR), Medicare claims, a qualified registry or a qualified clinical data registry (QCDR). For 2018, the Quality component will make up 50% of the MIPS final score.

Cost

Those familiar with the 2017 version of MIPS will remember that the Cost component was weighted at zero for the first year of the program. CMS discussed, and indeed, initially proposed, to continue weighing cost at zero for 2018. However, because current law requires CMS to weigh cost at 30% beginning with the 2019 performance period, CMS finalized a 10% weight for cost in 2018 with the goal of making the impact of the transition in 2019 less dramatic. CMS will base its calculation of the cost component on the total per capita costs for all beneficiaries attributed to a provider and the Medicare Spending per Beneficiary measure for the entirety of the 2018 performance period. CMS intends to provide performance feedback on both measures by July 1, 2018. Surgeons are not required to submit data for purposes of cost component.
 

 

Advancing Care Information (ACI)

There are no major changes to the scoring policy for 2018 and all the applicable Base Score measures must still be reported in order to receive a score for the ACI component. The performance period requirement remains a minimum of 90 continuous days. For 2018, both 2014 Edition and 2015 Edition certified electronic health record technology (CEHRT) remain acceptable. However, those using only a 2015 Edition will be eligible for a 10% bonus. Regardless of edition used , bonus points are also available for reporting to a public health agency or clinical data registry and for the completion of an Improvement Activity (IA) using CEHRT. A significant hardship exemption remains available for those in small practices. As was the case in 2017, the ACI component represents 25% of the final score. However, as was also the case in 2017, one is not required to have an electronic health record to avoid a penalty in 2018.
 

Improvement Activities

The weight assigned to the IA component remains at 15%. CMS added 21 new IAs in the final rule, bringing the number of IA available from which to choose up to well over 110. CMS also made changes to 27 activities previously adopted. Reporting remains a simple attestation of participation in the activity for 90 continuous days. To receive full credit for the IA component, most surgeons will be required to attest to having participated in two, three, or four activities depending on whether the activities chosen are of medium value or high value. This is not a change. However, those in small or rural practices must only participate in one or two activities to receive full credit. It should be noted that for 2018, one will be able to avoid a penalty in 2020 solely by fulfillment of the requirements imposed by the Improvement Activities component.

As mentioned above, CMS estimates that only approximately 622,000 providers out of the 1.2 million eligible will be required to submit data under MIPS. Many providers are excluded from MIPS based on the low-volume threshold. For 2018, CMS set this threshold at less than or equal to $90,000 in Medicare Part B charges OR less than or equal to 200 Medicare Part B beneficiaries. The effect of this change, compared to the values set for 2017 low-volume threshold, is to exclude more providers from MIPS reporting.

Lastly, many will remember that for 2017, the performance threshold was set at three points, and thus, required only minimal reporting in either quality, ACI, or IA to avoid a penalty. It was expected that the threshold necessary to avoid a penalty for 2018 performance would be increased and indeed, CMS has set that value at 15. Those scoring above 15 will be eligible for a positive update in their Medicare payments in 2020, while those scoring below 15 will receive a penalty. Those who choose to not participate in 2018 will receive a 5% penalty in 2020. However, two points made above warrant reiteration:

a) By fully participating in the IA component, one can accrue the 15 points necessary to avoid a penalty.

b) An EHR is not required to avoid a penalty.

In the coming weeks, we will be updating the QPP website (www.facs.org/qpp) to reflect the changes in the program for 2018. New videos will be available as will be new electronic and print materials to assist Fellows to participate in the program.
 

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

 

The interim final rule for the second year of Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) was released on November 2, 2017. This rule will apply to performance and reporting for calendar year 2018 and impact payment in 2020. Below, I have highlighted a few of the key components of the 1,653-page rule with special attention to the Merit-based Incentive Payment System (MIPS).

To briefly review, there are two pathways for participation in the QPP, namely MIPS and the Advanced Alternative Payment Models (A-APMs). For 2018, we still expect that the majority of surgeons eligible to participate in the QPP will do so via the MIPS pathway. That said, and for reasons discussed below, CMS estimates that approximately half of the 1.2 million MIPS-eligible clinicians will be required to submit MIPS data in 2018. In addition, CMS estimates that approximately 200,000 eligible clinicians will participate in the QPP in 2018 via the A-APMs.

Performance in MIPS will continue to be based on four components: Quality, Cost, Advancing Care Information (ACI), and the Improvement Activities (IA).

1) Quality – For 2018, CMS continues to require reporting on six measures, one of which must be an outcome measure or other high-priority measure. Should surgeons choose to report on more than six measures, CMS will use the six with the highest score for purposes of calculating their score for the Quality component. However, CMS did increase the percentage of patients on which reporting is required, aka the completeness threshold, in 2018 to 60%. Measures submitted that fall below the completeness threshold will receive one point. Small practices will receive three points for measures that fail to meet the completeness threshold. Multiple options remain available for submission of data, i.e., electronic health record (EHR), Medicare claims, a qualified registry or a qualified clinical data registry (QCDR). For 2018, the Quality component will make up 50% of the MIPS final score.

Cost

Those familiar with the 2017 version of MIPS will remember that the Cost component was weighted at zero for the first year of the program. CMS discussed, and indeed, initially proposed, to continue weighing cost at zero for 2018. However, because current law requires CMS to weigh cost at 30% beginning with the 2019 performance period, CMS finalized a 10% weight for cost in 2018 with the goal of making the impact of the transition in 2019 less dramatic. CMS will base its calculation of the cost component on the total per capita costs for all beneficiaries attributed to a provider and the Medicare Spending per Beneficiary measure for the entirety of the 2018 performance period. CMS intends to provide performance feedback on both measures by July 1, 2018. Surgeons are not required to submit data for purposes of cost component.
 

 

Advancing Care Information (ACI)

There are no major changes to the scoring policy for 2018 and all the applicable Base Score measures must still be reported in order to receive a score for the ACI component. The performance period requirement remains a minimum of 90 continuous days. For 2018, both 2014 Edition and 2015 Edition certified electronic health record technology (CEHRT) remain acceptable. However, those using only a 2015 Edition will be eligible for a 10% bonus. Regardless of edition used , bonus points are also available for reporting to a public health agency or clinical data registry and for the completion of an Improvement Activity (IA) using CEHRT. A significant hardship exemption remains available for those in small practices. As was the case in 2017, the ACI component represents 25% of the final score. However, as was also the case in 2017, one is not required to have an electronic health record to avoid a penalty in 2018.
 

Improvement Activities

The weight assigned to the IA component remains at 15%. CMS added 21 new IAs in the final rule, bringing the number of IA available from which to choose up to well over 110. CMS also made changes to 27 activities previously adopted. Reporting remains a simple attestation of participation in the activity for 90 continuous days. To receive full credit for the IA component, most surgeons will be required to attest to having participated in two, three, or four activities depending on whether the activities chosen are of medium value or high value. This is not a change. However, those in small or rural practices must only participate in one or two activities to receive full credit. It should be noted that for 2018, one will be able to avoid a penalty in 2020 solely by fulfillment of the requirements imposed by the Improvement Activities component.

As mentioned above, CMS estimates that only approximately 622,000 providers out of the 1.2 million eligible will be required to submit data under MIPS. Many providers are excluded from MIPS based on the low-volume threshold. For 2018, CMS set this threshold at less than or equal to $90,000 in Medicare Part B charges OR less than or equal to 200 Medicare Part B beneficiaries. The effect of this change, compared to the values set for 2017 low-volume threshold, is to exclude more providers from MIPS reporting.

Lastly, many will remember that for 2017, the performance threshold was set at three points, and thus, required only minimal reporting in either quality, ACI, or IA to avoid a penalty. It was expected that the threshold necessary to avoid a penalty for 2018 performance would be increased and indeed, CMS has set that value at 15. Those scoring above 15 will be eligible for a positive update in their Medicare payments in 2020, while those scoring below 15 will receive a penalty. Those who choose to not participate in 2018 will receive a 5% penalty in 2020. However, two points made above warrant reiteration:

a) By fully participating in the IA component, one can accrue the 15 points necessary to avoid a penalty.

b) An EHR is not required to avoid a penalty.

In the coming weeks, we will be updating the QPP website (www.facs.org/qpp) to reflect the changes in the program for 2018. New videos will be available as will be new electronic and print materials to assist Fellows to participate in the program.
 

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

 

The interim final rule for the second year of Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) was released on November 2, 2017. This rule will apply to performance and reporting for calendar year 2018 and impact payment in 2020. Below, I have highlighted a few of the key components of the 1,653-page rule with special attention to the Merit-based Incentive Payment System (MIPS).

To briefly review, there are two pathways for participation in the QPP, namely MIPS and the Advanced Alternative Payment Models (A-APMs). For 2018, we still expect that the majority of surgeons eligible to participate in the QPP will do so via the MIPS pathway. That said, and for reasons discussed below, CMS estimates that approximately half of the 1.2 million MIPS-eligible clinicians will be required to submit MIPS data in 2018. In addition, CMS estimates that approximately 200,000 eligible clinicians will participate in the QPP in 2018 via the A-APMs.

Performance in MIPS will continue to be based on four components: Quality, Cost, Advancing Care Information (ACI), and the Improvement Activities (IA).

1) Quality – For 2018, CMS continues to require reporting on six measures, one of which must be an outcome measure or other high-priority measure. Should surgeons choose to report on more than six measures, CMS will use the six with the highest score for purposes of calculating their score for the Quality component. However, CMS did increase the percentage of patients on which reporting is required, aka the completeness threshold, in 2018 to 60%. Measures submitted that fall below the completeness threshold will receive one point. Small practices will receive three points for measures that fail to meet the completeness threshold. Multiple options remain available for submission of data, i.e., electronic health record (EHR), Medicare claims, a qualified registry or a qualified clinical data registry (QCDR). For 2018, the Quality component will make up 50% of the MIPS final score.

Cost

Those familiar with the 2017 version of MIPS will remember that the Cost component was weighted at zero for the first year of the program. CMS discussed, and indeed, initially proposed, to continue weighing cost at zero for 2018. However, because current law requires CMS to weigh cost at 30% beginning with the 2019 performance period, CMS finalized a 10% weight for cost in 2018 with the goal of making the impact of the transition in 2019 less dramatic. CMS will base its calculation of the cost component on the total per capita costs for all beneficiaries attributed to a provider and the Medicare Spending per Beneficiary measure for the entirety of the 2018 performance period. CMS intends to provide performance feedback on both measures by July 1, 2018. Surgeons are not required to submit data for purposes of cost component.
 

 

Advancing Care Information (ACI)

There are no major changes to the scoring policy for 2018 and all the applicable Base Score measures must still be reported in order to receive a score for the ACI component. The performance period requirement remains a minimum of 90 continuous days. For 2018, both 2014 Edition and 2015 Edition certified electronic health record technology (CEHRT) remain acceptable. However, those using only a 2015 Edition will be eligible for a 10% bonus. Regardless of edition used , bonus points are also available for reporting to a public health agency or clinical data registry and for the completion of an Improvement Activity (IA) using CEHRT. A significant hardship exemption remains available for those in small practices. As was the case in 2017, the ACI component represents 25% of the final score. However, as was also the case in 2017, one is not required to have an electronic health record to avoid a penalty in 2018.
 

Improvement Activities

The weight assigned to the IA component remains at 15%. CMS added 21 new IAs in the final rule, bringing the number of IA available from which to choose up to well over 110. CMS also made changes to 27 activities previously adopted. Reporting remains a simple attestation of participation in the activity for 90 continuous days. To receive full credit for the IA component, most surgeons will be required to attest to having participated in two, three, or four activities depending on whether the activities chosen are of medium value or high value. This is not a change. However, those in small or rural practices must only participate in one or two activities to receive full credit. It should be noted that for 2018, one will be able to avoid a penalty in 2020 solely by fulfillment of the requirements imposed by the Improvement Activities component.

As mentioned above, CMS estimates that only approximately 622,000 providers out of the 1.2 million eligible will be required to submit data under MIPS. Many providers are excluded from MIPS based on the low-volume threshold. For 2018, CMS set this threshold at less than or equal to $90,000 in Medicare Part B charges OR less than or equal to 200 Medicare Part B beneficiaries. The effect of this change, compared to the values set for 2017 low-volume threshold, is to exclude more providers from MIPS reporting.

Lastly, many will remember that for 2017, the performance threshold was set at three points, and thus, required only minimal reporting in either quality, ACI, or IA to avoid a penalty. It was expected that the threshold necessary to avoid a penalty for 2018 performance would be increased and indeed, CMS has set that value at 15. Those scoring above 15 will be eligible for a positive update in their Medicare payments in 2020, while those scoring below 15 will receive a penalty. Those who choose to not participate in 2018 will receive a 5% penalty in 2020. However, two points made above warrant reiteration:

a) By fully participating in the IA component, one can accrue the 15 points necessary to avoid a penalty.

b) An EHR is not required to avoid a penalty.

In the coming weeks, we will be updating the QPP website (www.facs.org/qpp) to reflect the changes in the program for 2018. New videos will be available as will be new electronic and print materials to assist Fellows to participate in the program.
 

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

 

About 2.5 million people received mental and/or substance use disorder treatment last year, according to the Substance Abuse and Mental Health Services Administration.¹ Of those, a small but significant percentage chose support from a luxury type facility. This article intends to provide clinicians with guidance in addressing medically supervised luxury detox and/or rehabilitation programs for drug and alcohol abuse.

We recommend that individuals entering substance abuse services pursue these treatments with “eyes wide open.” A vast amount of literature indicates a rise in programs designed to attract vulnerable clients seeking treatment.² They offer an array of luxury services such as equine, massage, and yoga therapy, as well as holistic approaches. These services are all packaged in a five-star hotel–like environment in a desirable area (by the sea, mountains, etc.).

The guidelines that we are presenting do not take into account the diversity of regulations across the country that allow programs to avoid maintaining the appropriate rate of minimal clinical environment that is ideal.

The question is whether a $50,000-per-month treatment center is better at keeping its clients in remission than a facility that charges a fraction of the price per month. We believe that success rates may be less a function of financial cost and more a function of evidenced-based treatment strategies that are specific to recovery.

We would like to advise individuals to look for the following elements when reviewing a potential treatment center:

• Accredited and/or licensed by the Commission on Accreditation of Rehabilitation Facilities (CARF) and/or The Joint Commission.

• Accepted by major insurance companies such as Blue Cross/Blue Shield and United Healthcare, to name a few.

• No cookie-cutter approaches: Programs allowing for inter-individual flexibility regarding length of stay (not specifically 21, 30, or 45 days), as well as flexibility of services.

• Group therapy should have no more than 15 clients. Some individuals may not be appropriate for group therapy or may have a strong aversion to this modality.

• Licensed and/or certified staff (not peer coaching and/or paraprofessionals alone).

• Minimum of 20 hours per week, per client, of clinically supervised evidence-based methods, techniques, and/or practices including individual counseling, group therapies, and family involvement.

• Staff-to-client ratio of no more than 10 clients per one staff member, especially if the length of stay exceeds 21 days.

• If the length of stay is longer, fewer staff members may be more appropriate.

• Availability of higher level of professional staff, psychologists, psychiatrists, and other physicians to address all comorbid concerns.

• Adequate aftercare treatment.

After reviewing social media that rate treatment facilities, one common thread we noticed was the total absence of aftercare services.³ Aftercare services were something that clients may not think of at the initial intake.

Lastly, another often overlooked but important component of treatment is family support and/or direct involvement. Provision for child care may be a concern and necessary for some. Given the distant and isolated locations, this support is many times denied to the prospective client. As in other areas of life, “caveat emptor” (let the buyer beware). One should also be aware that many online searches for substance abuse facilities lead consumers to click on website ads paid for by the facility. As reported in the New York Times,⁴ companies paying for the most ads are the ones most likely to be seen in online searches. Nevertheless, we are seeing efforts by Google to set limits to these practices.
 

References

1 Substance Abuse and Mental Health Services Administration (SAMHSA). “Behavioral Health Treatments and Services.”

2 The Verge, Sept. 6, 2017

3 Rehabs.com

4. The New York Times, Sept. 14, 2017

Dr. Lesser is executive director of RANE, Medical & Mental Health, in New York City. In his recent positions as medical director for New York City and State, he was instrumental in developing and implementing nationally recognized emergency and response programs. Dr. Brenner is chief of Behavioral Health Service Line for Catholic Health Services of Long Island, in New York. He is a clinical professor of psychiatry for the State University of New York, Brooklyn, and medical director and CEO of Neurobehavioral Research Inc. Dr. Ferber is a licensed psychologist in New York and California. He has been the director of Behavioral Health Central Intake at Catholic Health Services of Long Island for the last 2 years. Dr. Ferber specializes in addiction treatment. Ms. Howard is a psychologist in training with specialization in clinical psychology. She currently treats numerous dual-diagnosed patients with comorbidities on an acute psychiatric ward.

 

About 2.5 million people received mental and/or substance use disorder treatment last year, according to the Substance Abuse and Mental Health Services Administration.¹ Of those, a small but significant percentage chose support from a luxury type facility. This article intends to provide clinicians with guidance in addressing medically supervised luxury detox and/or rehabilitation programs for drug and alcohol abuse.

We recommend that individuals entering substance abuse services pursue these treatments with “eyes wide open.” A vast amount of literature indicates a rise in programs designed to attract vulnerable clients seeking treatment.² They offer an array of luxury services such as equine, massage, and yoga therapy, as well as holistic approaches. These services are all packaged in a five-star hotel–like environment in a desirable area (by the sea, mountains, etc.).

The guidelines that we are presenting do not take into account the diversity of regulations across the country that allow programs to avoid maintaining the appropriate rate of minimal clinical environment that is ideal.

The question is whether a $50,000-per-month treatment center is better at keeping its clients in remission than a facility that charges a fraction of the price per month. We believe that success rates may be less a function of financial cost and more a function of evidenced-based treatment strategies that are specific to recovery.

We would like to advise individuals to look for the following elements when reviewing a potential treatment center:

• Accredited and/or licensed by the Commission on Accreditation of Rehabilitation Facilities (CARF) and/or The Joint Commission.

• Accepted by major insurance companies such as Blue Cross/Blue Shield and United Healthcare, to name a few.

• No cookie-cutter approaches: Programs allowing for inter-individual flexibility regarding length of stay (not specifically 21, 30, or 45 days), as well as flexibility of services.

• Group therapy should have no more than 15 clients. Some individuals may not be appropriate for group therapy or may have a strong aversion to this modality.

• Licensed and/or certified staff (not peer coaching and/or paraprofessionals alone).

• Minimum of 20 hours per week, per client, of clinically supervised evidence-based methods, techniques, and/or practices including individual counseling, group therapies, and family involvement.

• Staff-to-client ratio of no more than 10 clients per one staff member, especially if the length of stay exceeds 21 days.

• If the length of stay is longer, fewer staff members may be more appropriate.

• Availability of higher level of professional staff, psychologists, psychiatrists, and other physicians to address all comorbid concerns.

• Adequate aftercare treatment.

After reviewing social media that rate treatment facilities, one common thread we noticed was the total absence of aftercare services.³ Aftercare services were something that clients may not think of at the initial intake.

Lastly, another often overlooked but important component of treatment is family support and/or direct involvement. Provision for child care may be a concern and necessary for some. Given the distant and isolated locations, this support is many times denied to the prospective client. As in other areas of life, “caveat emptor” (let the buyer beware). One should also be aware that many online searches for substance abuse facilities lead consumers to click on website ads paid for by the facility. As reported in the New York Times,⁴ companies paying for the most ads are the ones most likely to be seen in online searches. Nevertheless, we are seeing efforts by Google to set limits to these practices.
 

References

1 Substance Abuse and Mental Health Services Administration (SAMHSA). “Behavioral Health Treatments and Services.”

2 The Verge, Sept. 6, 2017

3 Rehabs.com

4. The New York Times, Sept. 14, 2017

Dr. Lesser is executive director of RANE, Medical & Mental Health, in New York City. In his recent positions as medical director for New York City and State, he was instrumental in developing and implementing nationally recognized emergency and response programs. Dr. Brenner is chief of Behavioral Health Service Line for Catholic Health Services of Long Island, in New York. He is a clinical professor of psychiatry for the State University of New York, Brooklyn, and medical director and CEO of Neurobehavioral Research Inc. Dr. Ferber is a licensed psychologist in New York and California. He has been the director of Behavioral Health Central Intake at Catholic Health Services of Long Island for the last 2 years. Dr. Ferber specializes in addiction treatment. Ms. Howard is a psychologist in training with specialization in clinical psychology. She currently treats numerous dual-diagnosed patients with comorbidities on an acute psychiatric ward.

 

About 2.5 million people received mental and/or substance use disorder treatment last year, according to the Substance Abuse and Mental Health Services Administration.¹ Of those, a small but significant percentage chose support from a luxury type facility. This article intends to provide clinicians with guidance in addressing medically supervised luxury detox and/or rehabilitation programs for drug and alcohol abuse.

We recommend that individuals entering substance abuse services pursue these treatments with “eyes wide open.” A vast amount of literature indicates a rise in programs designed to attract vulnerable clients seeking treatment.² They offer an array of luxury services such as equine, massage, and yoga therapy, as well as holistic approaches. These services are all packaged in a five-star hotel–like environment in a desirable area (by the sea, mountains, etc.).

The guidelines that we are presenting do not take into account the diversity of regulations across the country that allow programs to avoid maintaining the appropriate rate of minimal clinical environment that is ideal.

The question is whether a $50,000-per-month treatment center is better at keeping its clients in remission than a facility that charges a fraction of the price per month. We believe that success rates may be less a function of financial cost and more a function of evidenced-based treatment strategies that are specific to recovery.

We would like to advise individuals to look for the following elements when reviewing a potential treatment center:

• Accredited and/or licensed by the Commission on Accreditation of Rehabilitation Facilities (CARF) and/or The Joint Commission.

• Accepted by major insurance companies such as Blue Cross/Blue Shield and United Healthcare, to name a few.

• No cookie-cutter approaches: Programs allowing for inter-individual flexibility regarding length of stay (not specifically 21, 30, or 45 days), as well as flexibility of services.

• Group therapy should have no more than 15 clients. Some individuals may not be appropriate for group therapy or may have a strong aversion to this modality.

• Licensed and/or certified staff (not peer coaching and/or paraprofessionals alone).

• Minimum of 20 hours per week, per client, of clinically supervised evidence-based methods, techniques, and/or practices including individual counseling, group therapies, and family involvement.

• Staff-to-client ratio of no more than 10 clients per one staff member, especially if the length of stay exceeds 21 days.

• If the length of stay is longer, fewer staff members may be more appropriate.

• Availability of higher level of professional staff, psychologists, psychiatrists, and other physicians to address all comorbid concerns.

• Adequate aftercare treatment.

After reviewing social media that rate treatment facilities, one common thread we noticed was the total absence of aftercare services.³ Aftercare services were something that clients may not think of at the initial intake.

Lastly, another often overlooked but important component of treatment is family support and/or direct involvement. Provision for child care may be a concern and necessary for some. Given the distant and isolated locations, this support is many times denied to the prospective client. As in other areas of life, “caveat emptor” (let the buyer beware). One should also be aware that many online searches for substance abuse facilities lead consumers to click on website ads paid for by the facility. As reported in the New York Times,⁴ companies paying for the most ads are the ones most likely to be seen in online searches. Nevertheless, we are seeing efforts by Google to set limits to these practices.
 

References

1 Substance Abuse and Mental Health Services Administration (SAMHSA). “Behavioral Health Treatments and Services.”

2 The Verge, Sept. 6, 2017

3 Rehabs.com

4. The New York Times, Sept. 14, 2017

Dr. Lesser is executive director of RANE, Medical & Mental Health, in New York City. In his recent positions as medical director for New York City and State, he was instrumental in developing and implementing nationally recognized emergency and response programs. Dr. Brenner is chief of Behavioral Health Service Line for Catholic Health Services of Long Island, in New York. He is a clinical professor of psychiatry for the State University of New York, Brooklyn, and medical director and CEO of Neurobehavioral Research Inc. Dr. Ferber is a licensed psychologist in New York and California. He has been the director of Behavioral Health Central Intake at Catholic Health Services of Long Island for the last 2 years. Dr. Ferber specializes in addiction treatment. Ms. Howard is a psychologist in training with specialization in clinical psychology. She currently treats numerous dual-diagnosed patients with comorbidities on an acute psychiatric ward.

 

Confluent and reticulated papillomatosis of Gougerot and Carteaud, also known as Gougerot-Carteaud syndrome, is an uncommon skin disorder of young individuals characterized by hyperkeratotic or verrucous brown papules or plaques that coalesce centrally and by a reticulated pattern peripherally. It was first described by two French dermatologists, Gougerot and Carteaud, in 1927.¹ Initially, the distinct entity of CARP was contested, with some dermatologists believing it to be a variant of acanthosis nigricans. However, CARP is now recognized as a distinct, though rare, dermatosis.

Dr. Lawrence F. Eichenfield

CARP commonly affects teens and young adults, with a mean age of onset of 15 years and without gender predilection.²The most common skin findings of CARP are somewhat verrucous or slightly hyperkeratotic brown papules a few millimeters in diameter. They are closely set together to form plaques in the center of the involved area, while those on the periphery of the involved area form a characteristic reticulated pattern. Papules are often scaly, although verrucous papules, especially those found in intertriginous areas, may develop a velvety appearance. Macules and patches may be present as well. The most common areas of involvement include the central chest and back with lesions extending in a rhomboidal fashion superoinferiorly, as well as the neck and axillae.¹ Uncommonly, pubic and facial skin may be affected.² Skin lesions are frequently hyperpigmented; however, cases of hypopigmented variants have been reported in darker-skinned individuals, although these cases have often been misdiagnosed as tinea versicolor.³ The majority of patients are asymptomatic, although some report mild pruritus. Care often is sought for cosmetic concerns.

Histopathology reveals findings similar to those that may be found in acanthosis nigricans and epidermal nevi. Classic characteristics of CARP include hyperkeratosis, papillomatosis, increased basal melanin pigmentation, and mild acanthosis. Occasionally, there may be perivascular lymphocytic infiltrates in the superficial dermis.^3,4

The etiology of CARP is unknown. CARP’s resolution in response to antibiotics and the isolation of two bacterial actinomycetes, Rhodococcus and Dietzia papillomatosis, from skin scrapings of CARP patients have led some to believe that its etiology is bacterial. However, no bacterial species have been consistently isolated from CARP patients. The prevailing theory of the past was that CARP was an abnormal host response to the fungus Malassezia furfur. Inconsistent detection of the fungus in skin scrapings, as well as persistence of the skin lesions after fungal clearance with antifungal therapy, has debunked this theory. An underlying disorder of keratinization resulting in hyperproliferation also has been suggested given reports of familial CARP and electron microscopy studies demonstrating focal-enhanced expression of keratin-16 in the stratum granulosom.⁵ Other theories include a cutaneous response to underlying endocrinopathies, ultraviolet light, and localized amyloidosis.¹
 

Diagnosis and differential

CARP is poorly recognized by clinicians and frequently initially misdiagnosed due to its similar appearance to other disorders, most commonly tinea versicolor and acanthosis nigricans. Davis et al. proposed criteria for diagnosis of CARP requiring 1) presence of scaly, reticulated and papillomatous brown macules and patches; 2) distribution over the upper trunk and neck; 3) negative fungal staining of scales; 4) no improvement following antifungal treatment; and 5) improvement following minocycline.²

Tinea versicolor may appear similar to CARP, but unlike CARP, will respond to antifungal treatment and may demonstrate hyphae and yeast on KOH preparation. Acanthosis nigricans and CARP both may present with velvety, hyperpigmented plaques in individuals of obese habitus or with insulin resistance, but peripheral reticulation will be absent in acanthosis nigricans. However, acanthosis nigricans and CARP may coexist, and this coexistence is not uncommonly seen in individuals with obesity and/or insulin resistance. Darier’s disease may look similar to cases of CARP without pigmentary change, but it often will have accompanying nail changes. Macular or lichen amyloidosis may present with pruritic brown macules or papules, but skin biopsy will have positive amyloid staining. The use of 70% alcohol swabbing to diagnose terra firma-forme dermatosis, with lesions disappearing with swabbing, is classic and used to differentiate it from CARP. Other conditions to consider include seborrheic dermatitis, epidermal nevi, verruca plana, epidermodysplasia verruciformis, and acne vulgaris.^1,2,4
 

Treatment

Minocycline is the first-line treatment for CARP: 80% of patients may have complete resolution with minocycline, while the remainder experience at least 50% clearance of skin lesions.² However, recurrence after stopping minocycline treatment is not uncommon. The mechanism by which minocycline works is unknown. Second-line treatment for those who cannot tolerate minocycline are macrolide antibiotics.⁶ Other treatment options with reported success include oral isotretinoin and topical retinoids, including tretinoin gel and tazarotene cream.^3,7 Appropriate strength topical corticosteroids may be used for pruritus.

Ms. Han is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, as well as the vice chair of the department of dermatology and a professor of dermatology and pediatrics at UC San Diego. They report having no conflicts of interest or financial disclosures. Email them at pdnews@frontlinemedcom.com.

References

1. Clin Cosmet Investig Dermatol. 2016 Aug 25;9:217-23.

2. Br J Dermatol. 2006 Feb;154(2):287-93.

3. Arch Dermatol. 2012 Apr;148(4):505-8.

4. J Am Acad Dermatol. 2003 Dec;49(6):1182-4.

5. Arch Dermatol. 2002 Feb;138(2):276-7.

6. J Am Acad Dermatol. 2001;44(4):652-5.

7. Am J Clin Dermatol. 2006;7(5):305-13.
 

 

Confluent and reticulated papillomatosis of Gougerot and Carteaud, also known as Gougerot-Carteaud syndrome, is an uncommon skin disorder of young individuals characterized by hyperkeratotic or verrucous brown papules or plaques that coalesce centrally and by a reticulated pattern peripherally. It was first described by two French dermatologists, Gougerot and Carteaud, in 1927.¹ Initially, the distinct entity of CARP was contested, with some dermatologists believing it to be a variant of acanthosis nigricans. However, CARP is now recognized as a distinct, though rare, dermatosis.

Dr. Lawrence F. Eichenfield

CARP commonly affects teens and young adults, with a mean age of onset of 15 years and without gender predilection.²The most common skin findings of CARP are somewhat verrucous or slightly hyperkeratotic brown papules a few millimeters in diameter. They are closely set together to form plaques in the center of the involved area, while those on the periphery of the involved area form a characteristic reticulated pattern. Papules are often scaly, although verrucous papules, especially those found in intertriginous areas, may develop a velvety appearance. Macules and patches may be present as well. The most common areas of involvement include the central chest and back with lesions extending in a rhomboidal fashion superoinferiorly, as well as the neck and axillae.¹ Uncommonly, pubic and facial skin may be affected.² Skin lesions are frequently hyperpigmented; however, cases of hypopigmented variants have been reported in darker-skinned individuals, although these cases have often been misdiagnosed as tinea versicolor.³ The majority of patients are asymptomatic, although some report mild pruritus. Care often is sought for cosmetic concerns.

Histopathology reveals findings similar to those that may be found in acanthosis nigricans and epidermal nevi. Classic characteristics of CARP include hyperkeratosis, papillomatosis, increased basal melanin pigmentation, and mild acanthosis. Occasionally, there may be perivascular lymphocytic infiltrates in the superficial dermis.^3,4

The etiology of CARP is unknown. CARP’s resolution in response to antibiotics and the isolation of two bacterial actinomycetes, Rhodococcus and Dietzia papillomatosis, from skin scrapings of CARP patients have led some to believe that its etiology is bacterial. However, no bacterial species have been consistently isolated from CARP patients. The prevailing theory of the past was that CARP was an abnormal host response to the fungus Malassezia furfur. Inconsistent detection of the fungus in skin scrapings, as well as persistence of the skin lesions after fungal clearance with antifungal therapy, has debunked this theory. An underlying disorder of keratinization resulting in hyperproliferation also has been suggested given reports of familial CARP and electron microscopy studies demonstrating focal-enhanced expression of keratin-16 in the stratum granulosom.⁵ Other theories include a cutaneous response to underlying endocrinopathies, ultraviolet light, and localized amyloidosis.¹
 

Diagnosis and differential

CARP is poorly recognized by clinicians and frequently initially misdiagnosed due to its similar appearance to other disorders, most commonly tinea versicolor and acanthosis nigricans. Davis et al. proposed criteria for diagnosis of CARP requiring 1) presence of scaly, reticulated and papillomatous brown macules and patches; 2) distribution over the upper trunk and neck; 3) negative fungal staining of scales; 4) no improvement following antifungal treatment; and 5) improvement following minocycline.²

Tinea versicolor may appear similar to CARP, but unlike CARP, will respond to antifungal treatment and may demonstrate hyphae and yeast on KOH preparation. Acanthosis nigricans and CARP both may present with velvety, hyperpigmented plaques in individuals of obese habitus or with insulin resistance, but peripheral reticulation will be absent in acanthosis nigricans. However, acanthosis nigricans and CARP may coexist, and this coexistence is not uncommonly seen in individuals with obesity and/or insulin resistance. Darier’s disease may look similar to cases of CARP without pigmentary change, but it often will have accompanying nail changes. Macular or lichen amyloidosis may present with pruritic brown macules or papules, but skin biopsy will have positive amyloid staining. The use of 70% alcohol swabbing to diagnose terra firma-forme dermatosis, with lesions disappearing with swabbing, is classic and used to differentiate it from CARP. Other conditions to consider include seborrheic dermatitis, epidermal nevi, verruca plana, epidermodysplasia verruciformis, and acne vulgaris.^1,2,4
 

Treatment

Minocycline is the first-line treatment for CARP: 80% of patients may have complete resolution with minocycline, while the remainder experience at least 50% clearance of skin lesions.² However, recurrence after stopping minocycline treatment is not uncommon. The mechanism by which minocycline works is unknown. Second-line treatment for those who cannot tolerate minocycline are macrolide antibiotics.⁶ Other treatment options with reported success include oral isotretinoin and topical retinoids, including tretinoin gel and tazarotene cream.^3,7 Appropriate strength topical corticosteroids may be used for pruritus.

Ms. Han is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, as well as the vice chair of the department of dermatology and a professor of dermatology and pediatrics at UC San Diego. They report having no conflicts of interest or financial disclosures. Email them at pdnews@frontlinemedcom.com.

References

1. Clin Cosmet Investig Dermatol. 2016 Aug 25;9:217-23.

2. Br J Dermatol. 2006 Feb;154(2):287-93.

3. Arch Dermatol. 2012 Apr;148(4):505-8.

4. J Am Acad Dermatol. 2003 Dec;49(6):1182-4.

5. Arch Dermatol. 2002 Feb;138(2):276-7.

6. J Am Acad Dermatol. 2001;44(4):652-5.

7. Am J Clin Dermatol. 2006;7(5):305-13.
 

 

Confluent and reticulated papillomatosis of Gougerot and Carteaud, also known as Gougerot-Carteaud syndrome, is an uncommon skin disorder of young individuals characterized by hyperkeratotic or verrucous brown papules or plaques that coalesce centrally and by a reticulated pattern peripherally. It was first described by two French dermatologists, Gougerot and Carteaud, in 1927.¹ Initially, the distinct entity of CARP was contested, with some dermatologists believing it to be a variant of acanthosis nigricans. However, CARP is now recognized as a distinct, though rare, dermatosis.

Dr. Lawrence F. Eichenfield

CARP commonly affects teens and young adults, with a mean age of onset of 15 years and without gender predilection.²The most common skin findings of CARP are somewhat verrucous or slightly hyperkeratotic brown papules a few millimeters in diameter. They are closely set together to form plaques in the center of the involved area, while those on the periphery of the involved area form a characteristic reticulated pattern. Papules are often scaly, although verrucous papules, especially those found in intertriginous areas, may develop a velvety appearance. Macules and patches may be present as well. The most common areas of involvement include the central chest and back with lesions extending in a rhomboidal fashion superoinferiorly, as well as the neck and axillae.¹ Uncommonly, pubic and facial skin may be affected.² Skin lesions are frequently hyperpigmented; however, cases of hypopigmented variants have been reported in darker-skinned individuals, although these cases have often been misdiagnosed as tinea versicolor.³ The majority of patients are asymptomatic, although some report mild pruritus. Care often is sought for cosmetic concerns.

Histopathology reveals findings similar to those that may be found in acanthosis nigricans and epidermal nevi. Classic characteristics of CARP include hyperkeratosis, papillomatosis, increased basal melanin pigmentation, and mild acanthosis. Occasionally, there may be perivascular lymphocytic infiltrates in the superficial dermis.^3,4

The etiology of CARP is unknown. CARP’s resolution in response to antibiotics and the isolation of two bacterial actinomycetes, Rhodococcus and Dietzia papillomatosis, from skin scrapings of CARP patients have led some to believe that its etiology is bacterial. However, no bacterial species have been consistently isolated from CARP patients. The prevailing theory of the past was that CARP was an abnormal host response to the fungus Malassezia furfur. Inconsistent detection of the fungus in skin scrapings, as well as persistence of the skin lesions after fungal clearance with antifungal therapy, has debunked this theory. An underlying disorder of keratinization resulting in hyperproliferation also has been suggested given reports of familial CARP and electron microscopy studies demonstrating focal-enhanced expression of keratin-16 in the stratum granulosom.⁵ Other theories include a cutaneous response to underlying endocrinopathies, ultraviolet light, and localized amyloidosis.¹
 

Diagnosis and differential

CARP is poorly recognized by clinicians and frequently initially misdiagnosed due to its similar appearance to other disorders, most commonly tinea versicolor and acanthosis nigricans. Davis et al. proposed criteria for diagnosis of CARP requiring 1) presence of scaly, reticulated and papillomatous brown macules and patches; 2) distribution over the upper trunk and neck; 3) negative fungal staining of scales; 4) no improvement following antifungal treatment; and 5) improvement following minocycline.²

Tinea versicolor may appear similar to CARP, but unlike CARP, will respond to antifungal treatment and may demonstrate hyphae and yeast on KOH preparation. Acanthosis nigricans and CARP both may present with velvety, hyperpigmented plaques in individuals of obese habitus or with insulin resistance, but peripheral reticulation will be absent in acanthosis nigricans. However, acanthosis nigricans and CARP may coexist, and this coexistence is not uncommonly seen in individuals with obesity and/or insulin resistance. Darier’s disease may look similar to cases of CARP without pigmentary change, but it often will have accompanying nail changes. Macular or lichen amyloidosis may present with pruritic brown macules or papules, but skin biopsy will have positive amyloid staining. The use of 70% alcohol swabbing to diagnose terra firma-forme dermatosis, with lesions disappearing with swabbing, is classic and used to differentiate it from CARP. Other conditions to consider include seborrheic dermatitis, epidermal nevi, verruca plana, epidermodysplasia verruciformis, and acne vulgaris.^1,2,4
 

Treatment

Minocycline is the first-line treatment for CARP: 80% of patients may have complete resolution with minocycline, while the remainder experience at least 50% clearance of skin lesions.² However, recurrence after stopping minocycline treatment is not uncommon. The mechanism by which minocycline works is unknown. Second-line treatment for those who cannot tolerate minocycline are macrolide antibiotics.⁶ Other treatment options with reported success include oral isotretinoin and topical retinoids, including tretinoin gel and tazarotene cream.^3,7 Appropriate strength topical corticosteroids may be used for pruritus.

Ms. Han is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, as well as the vice chair of the department of dermatology and a professor of dermatology and pediatrics at UC San Diego. They report having no conflicts of interest or financial disclosures. Email them at pdnews@frontlinemedcom.com.

References

1. Clin Cosmet Investig Dermatol. 2016 Aug 25;9:217-23.

2. Br J Dermatol. 2006 Feb;154(2):287-93.

3. Arch Dermatol. 2012 Apr;148(4):505-8.

4. J Am Acad Dermatol. 2003 Dec;49(6):1182-4.

5. Arch Dermatol. 2002 Feb;138(2):276-7.

6. J Am Acad Dermatol. 2001;44(4):652-5.

7. Am J Clin Dermatol. 2006;7(5):305-13.
 

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I approach the end of my summer research project, my team and I have reflected on what we’ve learned from both the research itself and the experience of working on the project.

First, I am completely finished with the research and analysis portion of the project. In the last week, I’ve mostly been working on the abstract which we plan to submit to the Society of Hospital Medicine 2018 conference. While I would have liked to make more progress on the manuscript, I realize that writing almost always takes longer than I anticipate, and that I will need to continue working on the manuscript in the fall semester.

As work-life balance is important to me, I would usually I would balk at the idea of sacrificing my personal time, but in this case, I am driven by a sense of ownership and pride over the project that I haven’t felt with past projects. I truly believe the results of this research have the potential to change the way physicians think about and manage patients with osteomyelitis, and I am eager to publish our results and attend conferences where I can present and discuss the findings with the medical community.

We hypothesized that the use of image-guided bone biopsies in patients with non-vertebral osteomyelitis would not have a significant impact on antibiotic management. Our results showed that physicians usually do not trust culture data provided by bone biopsy results. Negative bone cultures almost never lead physicians to discontinue antibiotics due to the low yield and reliability of bone biopsy culture data. Similarly, positive cultures almost never lead physicians to prescribe targeted antibiotics. 75% of the patients in our study had contiguous osteomyelitis caused by an overlying ulcer (e.g., diabetic foot ulcers or sacral decubitus ulcers). Exposure of the wound to the outside world often results in polymicrobial infections, and as such physicians rarely narrowed antibiotic coverage when a single organism was cultured. We also found that empiric antibiotic therapy adequately treated cultured micro-organisms in 95% of cases.

While many questions remained unanswered by this study, our results are an important contribution to the body of evidence that image-guided bone biopsies have low utility in the management of contiguous non-vertebral osteomyelitis. I look forward to seeing how the results of future research will compare with our findings. I am grateful to have had the opportunity to work in such an exciting area of research and I hope to continue participating in research projects throughout my medical career.

Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I approach the end of my summer research project, my team and I have reflected on what we’ve learned from both the research itself and the experience of working on the project.

First, I am completely finished with the research and analysis portion of the project. In the last week, I’ve mostly been working on the abstract which we plan to submit to the Society of Hospital Medicine 2018 conference. While I would have liked to make more progress on the manuscript, I realize that writing almost always takes longer than I anticipate, and that I will need to continue working on the manuscript in the fall semester.

As work-life balance is important to me, I would usually I would balk at the idea of sacrificing my personal time, but in this case, I am driven by a sense of ownership and pride over the project that I haven’t felt with past projects. I truly believe the results of this research have the potential to change the way physicians think about and manage patients with osteomyelitis, and I am eager to publish our results and attend conferences where I can present and discuss the findings with the medical community.

We hypothesized that the use of image-guided bone biopsies in patients with non-vertebral osteomyelitis would not have a significant impact on antibiotic management. Our results showed that physicians usually do not trust culture data provided by bone biopsy results. Negative bone cultures almost never lead physicians to discontinue antibiotics due to the low yield and reliability of bone biopsy culture data. Similarly, positive cultures almost never lead physicians to prescribe targeted antibiotics. 75% of the patients in our study had contiguous osteomyelitis caused by an overlying ulcer (e.g., diabetic foot ulcers or sacral decubitus ulcers). Exposure of the wound to the outside world often results in polymicrobial infections, and as such physicians rarely narrowed antibiotic coverage when a single organism was cultured. We also found that empiric antibiotic therapy adequately treated cultured micro-organisms in 95% of cases.

While many questions remained unanswered by this study, our results are an important contribution to the body of evidence that image-guided bone biopsies have low utility in the management of contiguous non-vertebral osteomyelitis. I look forward to seeing how the results of future research will compare with our findings. I am grateful to have had the opportunity to work in such an exciting area of research and I hope to continue participating in research projects throughout my medical career.

Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I approach the end of my summer research project, my team and I have reflected on what we’ve learned from both the research itself and the experience of working on the project.

First, I am completely finished with the research and analysis portion of the project. In the last week, I’ve mostly been working on the abstract which we plan to submit to the Society of Hospital Medicine 2018 conference. While I would have liked to make more progress on the manuscript, I realize that writing almost always takes longer than I anticipate, and that I will need to continue working on the manuscript in the fall semester.

As work-life balance is important to me, I would usually I would balk at the idea of sacrificing my personal time, but in this case, I am driven by a sense of ownership and pride over the project that I haven’t felt with past projects. I truly believe the results of this research have the potential to change the way physicians think about and manage patients with osteomyelitis, and I am eager to publish our results and attend conferences where I can present and discuss the findings with the medical community.

We hypothesized that the use of image-guided bone biopsies in patients with non-vertebral osteomyelitis would not have a significant impact on antibiotic management. Our results showed that physicians usually do not trust culture data provided by bone biopsy results. Negative bone cultures almost never lead physicians to discontinue antibiotics due to the low yield and reliability of bone biopsy culture data. Similarly, positive cultures almost never lead physicians to prescribe targeted antibiotics. 75% of the patients in our study had contiguous osteomyelitis caused by an overlying ulcer (e.g., diabetic foot ulcers or sacral decubitus ulcers). Exposure of the wound to the outside world often results in polymicrobial infections, and as such physicians rarely narrowed antibiotic coverage when a single organism was cultured. We also found that empiric antibiotic therapy adequately treated cultured micro-organisms in 95% of cases.

While many questions remained unanswered by this study, our results are an important contribution to the body of evidence that image-guided bone biopsies have low utility in the management of contiguous non-vertebral osteomyelitis. I look forward to seeing how the results of future research will compare with our findings. I am grateful to have had the opportunity to work in such an exciting area of research and I hope to continue participating in research projects throughout my medical career.

Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.

Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. Some of the most effective and cost-effective interventions for substance abuse disorders are preventive ones, such as parent education and early recognition in pediatric practice.

Substance abuse risk

rez-art/Thinkstock

While the prevalence of substance use disorders has dropped in youth since the 1980s, an estimated 5% of youth aged 12-17 years suffered from a substance use disorder in 2014, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Epidemiologic studies have repeatedly demonstrated that earlier first use of alcohol (under 14 years old) or tobacco predicts use of illicit drugs and is associated with higher lifetime rates of alcohol and drug dependence. There is emerging evidence that early use of addictive substances such as tobacco and alcohol has distinct neurobiologic effects that increase the propensity toward dependence, rather than being simply a function of an underlying vulnerability to dependence.¹ While tobacco and alcohol use among youth have been trending down since the 1980s, rates are still high. The 2016 Monitoring the Future Survey found that 7% of 8th graders, 20% of 10th graders, and 33% of 12th graders reported having used alcohol in the 30 days prior to the study. Of particular concern is the recent upward trend in rates of binge drinking (five or more drinks in 2 hours), particularly among those enrolled in college, with rates as high as 43% in 2014, according to SAMHSA. Also notable is the strong shift in attitudes of youth toward marijuana, with fewer believing that “regular use” poses risks. Finally, rates of prescription opioid abuse among youth have started to decline, from more than 11% of 12th graders in 2013 to less than 8% in 2016. But there is evidence that those who regularly use marijuana in adolescence are more likely to abuse prescription opioids in their 20s. So interventions that can delay the first use of any substance, and discourage use of particularly addictive substances, can be a very effective way of preventing later substance use disorders.

We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.²
 

Prevention efforts you can make: To your patients

The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).

Be pragmatic. After learning about what is being used by their peers, think with them about how they could say no to trying a drink, a smoke, or something more without creating drama or drawing attention to themselves. Are they seeing worrisome problems at parties, or are their friends using substances? What should they do if they see a friend falling unconscious? Have they seen anyone in a dangerous situation? How do they handle driving? If an anxious or impulsive adolescent has a plan to respond in these situations, they are much more likely to follow their plan to delay or decline.

For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.

Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
 

 

Prevention efforts you can make: To the parents

Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.

Parents also benefit from practical strategies on how to talk about drugs and alcohol with their children. Letting parents know that 5th or 6th grade is not too early to have a conversation in which they introduce their rules around drugs and alcohol. Parents should look for opportunities to talk often with their kids in less proscriptive ways about drugs and alcohol. Such opportunities can arise around stories in the news about sports stars, musicians, or television stars and drug or alcohol use. Or they may occur when watching a favorite television show or movie together. Talking about these issues in a less confrontational way, when the subject is a celebrity or character rather than your child, can make the conversation more open, comfortable, and useful for everyone.

Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
 

References

1. Hum Genet. 2012 Jun;131(6):779-89.

2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.

Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. Some of the most effective and cost-effective interventions for substance abuse disorders are preventive ones, such as parent education and early recognition in pediatric practice.

Substance abuse risk

rez-art/Thinkstock

While the prevalence of substance use disorders has dropped in youth since the 1980s, an estimated 5% of youth aged 12-17 years suffered from a substance use disorder in 2014, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Epidemiologic studies have repeatedly demonstrated that earlier first use of alcohol (under 14 years old) or tobacco predicts use of illicit drugs and is associated with higher lifetime rates of alcohol and drug dependence. There is emerging evidence that early use of addictive substances such as tobacco and alcohol has distinct neurobiologic effects that increase the propensity toward dependence, rather than being simply a function of an underlying vulnerability to dependence.¹ While tobacco and alcohol use among youth have been trending down since the 1980s, rates are still high. The 2016 Monitoring the Future Survey found that 7% of 8th graders, 20% of 10th graders, and 33% of 12th graders reported having used alcohol in the 30 days prior to the study. Of particular concern is the recent upward trend in rates of binge drinking (five or more drinks in 2 hours), particularly among those enrolled in college, with rates as high as 43% in 2014, according to SAMHSA. Also notable is the strong shift in attitudes of youth toward marijuana, with fewer believing that “regular use” poses risks. Finally, rates of prescription opioid abuse among youth have started to decline, from more than 11% of 12th graders in 2013 to less than 8% in 2016. But there is evidence that those who regularly use marijuana in adolescence are more likely to abuse prescription opioids in their 20s. So interventions that can delay the first use of any substance, and discourage use of particularly addictive substances, can be a very effective way of preventing later substance use disorders.

We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.²
 

Prevention efforts you can make: To your patients

The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).

Be pragmatic. After learning about what is being used by their peers, think with them about how they could say no to trying a drink, a smoke, or something more without creating drama or drawing attention to themselves. Are they seeing worrisome problems at parties, or are their friends using substances? What should they do if they see a friend falling unconscious? Have they seen anyone in a dangerous situation? How do they handle driving? If an anxious or impulsive adolescent has a plan to respond in these situations, they are much more likely to follow their plan to delay or decline.

For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.

Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
 

 

Prevention efforts you can make: To the parents

Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.

Parents also benefit from practical strategies on how to talk about drugs and alcohol with their children. Letting parents know that 5th or 6th grade is not too early to have a conversation in which they introduce their rules around drugs and alcohol. Parents should look for opportunities to talk often with their kids in less proscriptive ways about drugs and alcohol. Such opportunities can arise around stories in the news about sports stars, musicians, or television stars and drug or alcohol use. Or they may occur when watching a favorite television show or movie together. Talking about these issues in a less confrontational way, when the subject is a celebrity or character rather than your child, can make the conversation more open, comfortable, and useful for everyone.

Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
 

References

1. Hum Genet. 2012 Jun;131(6):779-89.

2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.

Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. Some of the most effective and cost-effective interventions for substance abuse disorders are preventive ones, such as parent education and early recognition in pediatric practice.

Substance abuse risk

rez-art/Thinkstock

While the prevalence of substance use disorders has dropped in youth since the 1980s, an estimated 5% of youth aged 12-17 years suffered from a substance use disorder in 2014, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Epidemiologic studies have repeatedly demonstrated that earlier first use of alcohol (under 14 years old) or tobacco predicts use of illicit drugs and is associated with higher lifetime rates of alcohol and drug dependence. There is emerging evidence that early use of addictive substances such as tobacco and alcohol has distinct neurobiologic effects that increase the propensity toward dependence, rather than being simply a function of an underlying vulnerability to dependence.¹ While tobacco and alcohol use among youth have been trending down since the 1980s, rates are still high. The 2016 Monitoring the Future Survey found that 7% of 8th graders, 20% of 10th graders, and 33% of 12th graders reported having used alcohol in the 30 days prior to the study. Of particular concern is the recent upward trend in rates of binge drinking (five or more drinks in 2 hours), particularly among those enrolled in college, with rates as high as 43% in 2014, according to SAMHSA. Also notable is the strong shift in attitudes of youth toward marijuana, with fewer believing that “regular use” poses risks. Finally, rates of prescription opioid abuse among youth have started to decline, from more than 11% of 12th graders in 2013 to less than 8% in 2016. But there is evidence that those who regularly use marijuana in adolescence are more likely to abuse prescription opioids in their 20s. So interventions that can delay the first use of any substance, and discourage use of particularly addictive substances, can be a very effective way of preventing later substance use disorders.

We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.²
 

Prevention efforts you can make: To your patients

The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).

Be pragmatic. After learning about what is being used by their peers, think with them about how they could say no to trying a drink, a smoke, or something more without creating drama or drawing attention to themselves. Are they seeing worrisome problems at parties, or are their friends using substances? What should they do if they see a friend falling unconscious? Have they seen anyone in a dangerous situation? How do they handle driving? If an anxious or impulsive adolescent has a plan to respond in these situations, they are much more likely to follow their plan to delay or decline.

For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.

Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
 

 

Prevention efforts you can make: To the parents

Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.

Parents also benefit from practical strategies on how to talk about drugs and alcohol with their children. Letting parents know that 5th or 6th grade is not too early to have a conversation in which they introduce their rules around drugs and alcohol. Parents should look for opportunities to talk often with their kids in less proscriptive ways about drugs and alcohol. Such opportunities can arise around stories in the news about sports stars, musicians, or television stars and drug or alcohol use. Or they may occur when watching a favorite television show or movie together. Talking about these issues in a less confrontational way, when the subject is a celebrity or character rather than your child, can make the conversation more open, comfortable, and useful for everyone.

Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
 

References

1. Hum Genet. 2012 Jun;131(6):779-89.

2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.

Do you know we have record rates of physician burnout, dissatisfaction, and suicide? Ongoing shortages in primary care, without improvement in sight? Physicians exiting medicine earlier than in the past?

What about burnout? Do you know it affects patients as well as their doctors? Affects physicians’ families and friends? Increases mistakes and malpractice risk? Affects patient adherence and outcomes? Is costly to the entire system?

How do we start to fix this? The framework for a discussion on physician wellness begins with attention to three levels: personal wellness, organizational wellness, and wellness within the culture of medicine.

Darrin Klimek/Thinkstock

Physician wellness at the personal level includes what we all know and preach: Get adequate sleep. Eat healthy foods, mostly vegetables. Lead an active lifestyle. Surround yourself with healthy people. Set healthy boundaries. Develop a support network. Establish care with a primary care physician. Manage your finances. Care for your spiritual needs. Maintain intellectual pursuits across your lifetime. Physician wellness at this level focuses on life skills and habits that support our resiliency and promote our overall well-being.

The high level of physician burnout indicates that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters because it affects the bottom line.

Fixes at the institutional level have primarily focused on time. Physicians have too little time to do what we need to do and to do it well. The EMR is regularly blamed as a time sink. But what we do with our time also matters. We need systems that allow each person to work at the highest level of his or her training. Doctors can practice medicine while other team members do what they do best. Finally, we need to acknowledge the inherent conflict between the business of medicine and the practice of medicine – something physicians deal with every day as we work with our patients. Making these changes at the institutional level requires a refocusing of institutional values to include physician wellness.

Wellness within the culture of medicine is the third level of our framework. Western medicine has its own set of customs, traditions, and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice, and commitment also are included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.

When examining physician wellness at the cultural level, we also must address discrimination within medicine. Overt racism, misogyny, ageism, and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine. It’s difficult to experience wellness at the same time as discrimination.

At every level, physician wellness depends upon continuous, usually low-tech activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.
 

Dr. Stepien practices pediatrics in Juneau, Alaska. She is on the Pediatric News editorial advisory board. Email her at pdnews@frontlinemedcom.com

Do you know we have record rates of physician burnout, dissatisfaction, and suicide? Ongoing shortages in primary care, without improvement in sight? Physicians exiting medicine earlier than in the past?

What about burnout? Do you know it affects patients as well as their doctors? Affects physicians’ families and friends? Increases mistakes and malpractice risk? Affects patient adherence and outcomes? Is costly to the entire system?

How do we start to fix this? The framework for a discussion on physician wellness begins with attention to three levels: personal wellness, organizational wellness, and wellness within the culture of medicine.

Darrin Klimek/Thinkstock

Physician wellness at the personal level includes what we all know and preach: Get adequate sleep. Eat healthy foods, mostly vegetables. Lead an active lifestyle. Surround yourself with healthy people. Set healthy boundaries. Develop a support network. Establish care with a primary care physician. Manage your finances. Care for your spiritual needs. Maintain intellectual pursuits across your lifetime. Physician wellness at this level focuses on life skills and habits that support our resiliency and promote our overall well-being.

The high level of physician burnout indicates that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters because it affects the bottom line.

Fixes at the institutional level have primarily focused on time. Physicians have too little time to do what we need to do and to do it well. The EMR is regularly blamed as a time sink. But what we do with our time also matters. We need systems that allow each person to work at the highest level of his or her training. Doctors can practice medicine while other team members do what they do best. Finally, we need to acknowledge the inherent conflict between the business of medicine and the practice of medicine – something physicians deal with every day as we work with our patients. Making these changes at the institutional level requires a refocusing of institutional values to include physician wellness.

Wellness within the culture of medicine is the third level of our framework. Western medicine has its own set of customs, traditions, and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice, and commitment also are included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.

When examining physician wellness at the cultural level, we also must address discrimination within medicine. Overt racism, misogyny, ageism, and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine. It’s difficult to experience wellness at the same time as discrimination.

At every level, physician wellness depends upon continuous, usually low-tech activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.
 

Dr. Stepien practices pediatrics in Juneau, Alaska. She is on the Pediatric News editorial advisory board. Email her at pdnews@frontlinemedcom.com

Do you know we have record rates of physician burnout, dissatisfaction, and suicide? Ongoing shortages in primary care, without improvement in sight? Physicians exiting medicine earlier than in the past?

What about burnout? Do you know it affects patients as well as their doctors? Affects physicians’ families and friends? Increases mistakes and malpractice risk? Affects patient adherence and outcomes? Is costly to the entire system?

How do we start to fix this? The framework for a discussion on physician wellness begins with attention to three levels: personal wellness, organizational wellness, and wellness within the culture of medicine.

Darrin Klimek/Thinkstock

Physician wellness at the personal level includes what we all know and preach: Get adequate sleep. Eat healthy foods, mostly vegetables. Lead an active lifestyle. Surround yourself with healthy people. Set healthy boundaries. Develop a support network. Establish care with a primary care physician. Manage your finances. Care for your spiritual needs. Maintain intellectual pursuits across your lifetime. Physician wellness at this level focuses on life skills and habits that support our resiliency and promote our overall well-being.

The high level of physician burnout indicates that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters because it affects the bottom line.

Fixes at the institutional level have primarily focused on time. Physicians have too little time to do what we need to do and to do it well. The EMR is regularly blamed as a time sink. But what we do with our time also matters. We need systems that allow each person to work at the highest level of his or her training. Doctors can practice medicine while other team members do what they do best. Finally, we need to acknowledge the inherent conflict between the business of medicine and the practice of medicine – something physicians deal with every day as we work with our patients. Making these changes at the institutional level requires a refocusing of institutional values to include physician wellness.

Wellness within the culture of medicine is the third level of our framework. Western medicine has its own set of customs, traditions, and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice, and commitment also are included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.

When examining physician wellness at the cultural level, we also must address discrimination within medicine. Overt racism, misogyny, ageism, and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine. It’s difficult to experience wellness at the same time as discrimination.

At every level, physician wellness depends upon continuous, usually low-tech activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.
 

Dr. Stepien practices pediatrics in Juneau, Alaska. She is on the Pediatric News editorial advisory board. Email her at pdnews@frontlinemedcom.com

 

Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.

What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).

KrisCole/Thinkstock

My colleagues and I at the Massachusetts General Hospital (MGH) Ammon-Pinizzotto Center for Women’s Mental Health have made significant progress toward these goals with the development of a new iPhone application. The MGH Perinatal Depression Scale (MGHPDS) is an app that screens for postpartum depression during and after pregnancy, and is currently available at the iTunes App Store for iOS devices.

The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.

Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.

Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.

Equally as exciting as a precise and user-friendly digital screening tool for PPD is the opportunity that digital technology affords when identification of illness is coupled with delivery of evidence-based therapies via a smartphone or tablet. With almost no systematic evidence that initiatives to promote PPD screening have led to women getting referrals to treatment or to ultimate remission of PPD, there is now growing interest in developing evidence-based psychotherapies that can be delivered digitally, including cognitive-behavioral therapy, mindfulness-based cognitive therapy, and behavioral activation. Providing women with other information and resources about pharmacologic options for treatment all on one digital platform like a smartphone or tablet may help to bridge the distance from identification of those suffering from PPD to greater numbers of women recovering from a disabling disorder.

The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.

We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.

The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.

 

Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.

What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).

KrisCole/Thinkstock

My colleagues and I at the Massachusetts General Hospital (MGH) Ammon-Pinizzotto Center for Women’s Mental Health have made significant progress toward these goals with the development of a new iPhone application. The MGH Perinatal Depression Scale (MGHPDS) is an app that screens for postpartum depression during and after pregnancy, and is currently available at the iTunes App Store for iOS devices.

The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.

Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.

Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.

Equally as exciting as a precise and user-friendly digital screening tool for PPD is the opportunity that digital technology affords when identification of illness is coupled with delivery of evidence-based therapies via a smartphone or tablet. With almost no systematic evidence that initiatives to promote PPD screening have led to women getting referrals to treatment or to ultimate remission of PPD, there is now growing interest in developing evidence-based psychotherapies that can be delivered digitally, including cognitive-behavioral therapy, mindfulness-based cognitive therapy, and behavioral activation. Providing women with other information and resources about pharmacologic options for treatment all on one digital platform like a smartphone or tablet may help to bridge the distance from identification of those suffering from PPD to greater numbers of women recovering from a disabling disorder.

The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.

We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.

The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.

 

Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.

What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).

KrisCole/Thinkstock

My colleagues and I at the Massachusetts General Hospital (MGH) Ammon-Pinizzotto Center for Women’s Mental Health have made significant progress toward these goals with the development of a new iPhone application. The MGH Perinatal Depression Scale (MGHPDS) is an app that screens for postpartum depression during and after pregnancy, and is currently available at the iTunes App Store for iOS devices.

The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.

Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.

Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.

Equally as exciting as a precise and user-friendly digital screening tool for PPD is the opportunity that digital technology affords when identification of illness is coupled with delivery of evidence-based therapies via a smartphone or tablet. With almost no systematic evidence that initiatives to promote PPD screening have led to women getting referrals to treatment or to ultimate remission of PPD, there is now growing interest in developing evidence-based psychotherapies that can be delivered digitally, including cognitive-behavioral therapy, mindfulness-based cognitive therapy, and behavioral activation. Providing women with other information and resources about pharmacologic options for treatment all on one digital platform like a smartphone or tablet may help to bridge the distance from identification of those suffering from PPD to greater numbers of women recovering from a disabling disorder.

The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.

We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.

The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.

 

The benefits of integrating hysteroscopy into office practice have been compelling for some time. An in-office approach is patient centered, more efficient, and clinically valuable. It also has had the potential to be economically valuable for practices that are able to perform a mix of diagnostic and therapeutic/operative hysteroscopies.

Dramatic shifts within the Centers for Medicare & Medicaid Services fee schedule in 2017 – and commensurate changes in the private insurance market – have now ramped up this value, making it all the more important that physicians consider investing in equipment and adopting an in-office approach.

At the crux of this shift has been a 237% increase, effective at the start of 2017, in the physician office payment for hysteroscopic endometrial biopsy and/or polypectomy (CPT code 58558). According to national payment amounts, performing this procedure in the office earned an average of $1,382.07 in 2017, compared with $409.60 in 2016. This reimbursement will hold steady in the 2018 Medicare Physician Fee Schedule Final Rule published in November.

Central to this increase, in turn, is a significant increase in practice expense reimbursement. CMS has included the costs of equipment, including the costs of the hysteroscopic fluid management system and the hysteroscopic tissue resection system, in recalibrating the practice expense relative value unit. Clearly, physicians are being encouraged to move hysteroscopic procedures into the office.
 

Weighing an investment

In the Medicare resource-based relative value scale payment system, relative value units (RVUs) are calculated based on three elements: physician work, practice expenses, and malpractice cost. Each component is multiplied by a factor that accounts for geographic cost variations, and each total RVU is multiplied by a dollar amount known as the conversion factor.

This isn’t the first year that the payment system – a standard for many other payers in determining compensation – allows for higher reimbursement for some hysteroscopic procedures performed in the office. The practice expense relative units have been higher for some time for certain hysteroscopic procedures – such as diagnostic hysteroscopy (code 58555), removal of a foreign body (58562), endometrial ablation (58353), and biopsy/polypectomy (58558) – when these procedures are performed in the office, compared with the hospital or an ambulatory surgical center.

However, the new increase in physician office payment for 58558 changes the equation significantly and ensures a better return on investment. In 2017, CMS offered a 12% increase in the facility fee paid to hospitals and a 2% increase in the facility fee paid to outpatient surgery centers when a hysteroscopic biopsy/polypectomy is performed in these settings, but the physician reimbursement in these cases declined 11%-19%.

On the flip side, an in-office approach to hysteroscopic biopsy/polypectomy has been rewarded in 2017 through a significantly higher practice expense RVU and a “non-facility” total RVU of 38.51 – a 237% increase over the 2016 practice expense RVU of 11.4. Such dramatic differences between the practice RVUs – and total RVUs – for in-office and out-of-office hysteroscopic procedures will continue for 2018.

Private insurers are following suit, and some are increasing their reimbursement even more. As of June 2017 in metropolitan Chicago, Blue Cross Blue Shield has been reimbursing in-office hysteroscopic biopsy/polypectomy at approximately $2,424.00; prior to June, the allowable charge was $742.81.

Equipment costs for in-office hysteroscopy can range from $15,000 to $35,000, based on whether equipment is new or used, the number of trays, and the style of camera and monitor system. Ancillary equipment/disposables cost $10 or less, and $40-$50 or less for diagnostic and many operative procedures, respectively. The prices for handpiece mechanical resection disposables or tissue removal devices vary based on company and blade type, so these costs will need to be accounted for if such equipment is incorporated. Again, the CMS increase in reimbursement for offices accommodates for the inclusion of these disposables as well as fluid management disposable costs.

If diagnostic hysteroscopy (as a separate procedure) is the procedure that you perform most often, the investment will look less favorable. However, if you anticipate performing hysteroscopic biopsies and/or polypectomies as well, the investment will look significantly more favorable now than it has in past years.

Once you have established your in-office system, even those procedures that are weighted equally for the practice setting (non-facility) and hospital/surgery center setting, such as hysteroscopic lysis of adhesions (58559), can be easily incorporated from a financial point of view.

In addition to reimbursement levels, it’s important to consider the efficiencies of in-office hysteroscopy. The setup is relatively simple and requires a dedicated exam room, not a surgical suite. You can perform one or two annual exams while the assistant sets up the room and greets each patient, for instance, or see another established patient while the assistant discharges your patient and turns the room over. Hysteroscopy at the hospital, or even at an ambulatory surgical center, involves time driving, changing, and waiting for anesthesia.

For our patients, most importantly, an in-office approach offers less out-of-pocket expense (deductibles), less time away from family/work, avoidance of general anesthesia/intubation, and greater patient comfort from being within a familiar environment. For diagnostic procedures, the patient can be in and out in less than 30 minutes, and for operative procedures, she can be in and out in 1-2 hours, compared with more than 4 hours at the hospital.
 

 

Preparing the office

Physicians in Europe have been performing in-office hysteroscopy for years. But in the United States, it is a newer concept, with most gynecologic surgeons having been taught to perform surgical procedures in the operating room. Undoubtedly, our unfamiliarity with in-office surgery has played a role in the slow uptake of hysteroscopy in our practices.

Courtesy Dr. Amy Garcia

It requires a culture change. Performing surgery while the patient is awake forces us to be more alert to issues such as the room temperature, the lighting, and the noises that a patient may hear. All of these factors can affect a patient’s anxiety level. We need to train ourselves to be acutely aware of the surroundings and to incorporate a “vocal local” approach – a form of nonpharmacologic pain management that involves speaking directly and reassuringly with the patient in order to reduce anxiety and avoid/distract from pain.

Open communication about everything the patient will see hear and feel before, during and after the procedure is important. Focusing on these details can improve your patient’s experience and your professional relationship with her.

In an earlier edition of Master Class, I addressed instrumentation and technique, elements of pain control and anesthesia, and the value of a vaginoscopic approach to hysteroscopy. Vaginoscopy avoids the use of a vaginal speculum or cervical tenaculum, and is so tolerable to many patients that I use minimal premedication and only rarely use any local anesthetic and/or sedation, even for biopsies and polypectomies.

Preparing your practice for hysteroscopy is a multifaceted process involving not only the purchase and/or rental of equipment but also compliance with guidelines, regulatory considerations, patient rights, hospital transfer arrangements, and other issues. ACOG’s Report of the Presidential Task Force on Patient Safety in the Office Setting is a valuable resource for getting started. The report discusses anesthesia levels and the benefits and risks of a contract anesthesiologist, for instance, as well as the role of and processes for credentialing, privileging, and accreditation.

Checklists and drills are important for ensuring a safe practice, and the report discusses each of these elements and provides templates and examples. A sample “Office Surgical Safety Checklist” to be used for each procedure, for instance, has sections with preoperative steps (before anesthesia/analgesia, and before incision), intraoperative steps, postoperative steps, and discharge steps. Similar in format to checklists used in the aviation industry, each step has a box to be checked off to verify completion.

Mock drills help ensure that staff are knowledgeable about their roles and coordinated in their response to potential complications, such as vasovagal episodes, respiratory arrest caused by laryngospasm, and local anesthetic toxicity reactions. And, while not the focus of drills, we also must be prepared to manage cervical strictures and stenosis, cervical laceration, uterine perforation, and other complications.

Outpatient surgery guidelines from organizations such as the American College of Surgeons, the Joint Commission, state regulatory agencies, and professional liability insurers, can also be useful resources. With the use of ACOG’s report and other such resources, the set-up and the transition to in-office hysteroscopy need not be daunting. For most gynecologic surgeons, it will all feel comfortable after only a few procedures.
 

Dr. Cholkeri-Singh is with the University of Illinois at Chicago, and is director of gynecologic surgical education and associate director of minimally invasive gynecology at Advocate Lutheran General Hospital in Park Ridge, Ill. She is in private practice in Chicago. She is a consultant for Hologic, Bayer HealthCare, Olympus, Caldera Medical, Karl Storz, Medtronic, DYSIS Medical, and Channel Medsystems.

 

The benefits of integrating hysteroscopy into office practice have been compelling for some time. An in-office approach is patient centered, more efficient, and clinically valuable. It also has had the potential to be economically valuable for practices that are able to perform a mix of diagnostic and therapeutic/operative hysteroscopies.

Dramatic shifts within the Centers for Medicare & Medicaid Services fee schedule in 2017 – and commensurate changes in the private insurance market – have now ramped up this value, making it all the more important that physicians consider investing in equipment and adopting an in-office approach.

At the crux of this shift has been a 237% increase, effective at the start of 2017, in the physician office payment for hysteroscopic endometrial biopsy and/or polypectomy (CPT code 58558). According to national payment amounts, performing this procedure in the office earned an average of $1,382.07 in 2017, compared with $409.60 in 2016. This reimbursement will hold steady in the 2018 Medicare Physician Fee Schedule Final Rule published in November.

Central to this increase, in turn, is a significant increase in practice expense reimbursement. CMS has included the costs of equipment, including the costs of the hysteroscopic fluid management system and the hysteroscopic tissue resection system, in recalibrating the practice expense relative value unit. Clearly, physicians are being encouraged to move hysteroscopic procedures into the office.
 

Weighing an investment

In the Medicare resource-based relative value scale payment system, relative value units (RVUs) are calculated based on three elements: physician work, practice expenses, and malpractice cost. Each component is multiplied by a factor that accounts for geographic cost variations, and each total RVU is multiplied by a dollar amount known as the conversion factor.

This isn’t the first year that the payment system – a standard for many other payers in determining compensation – allows for higher reimbursement for some hysteroscopic procedures performed in the office. The practice expense relative units have been higher for some time for certain hysteroscopic procedures – such as diagnostic hysteroscopy (code 58555), removal of a foreign body (58562), endometrial ablation (58353), and biopsy/polypectomy (58558) – when these procedures are performed in the office, compared with the hospital or an ambulatory surgical center.

However, the new increase in physician office payment for 58558 changes the equation significantly and ensures a better return on investment. In 2017, CMS offered a 12% increase in the facility fee paid to hospitals and a 2% increase in the facility fee paid to outpatient surgery centers when a hysteroscopic biopsy/polypectomy is performed in these settings, but the physician reimbursement in these cases declined 11%-19%.

On the flip side, an in-office approach to hysteroscopic biopsy/polypectomy has been rewarded in 2017 through a significantly higher practice expense RVU and a “non-facility” total RVU of 38.51 – a 237% increase over the 2016 practice expense RVU of 11.4. Such dramatic differences between the practice RVUs – and total RVUs – for in-office and out-of-office hysteroscopic procedures will continue for 2018.

Private insurers are following suit, and some are increasing their reimbursement even more. As of June 2017 in metropolitan Chicago, Blue Cross Blue Shield has been reimbursing in-office hysteroscopic biopsy/polypectomy at approximately $2,424.00; prior to June, the allowable charge was $742.81.

Equipment costs for in-office hysteroscopy can range from $15,000 to $35,000, based on whether equipment is new or used, the number of trays, and the style of camera and monitor system. Ancillary equipment/disposables cost $10 or less, and $40-$50 or less for diagnostic and many operative procedures, respectively. The prices for handpiece mechanical resection disposables or tissue removal devices vary based on company and blade type, so these costs will need to be accounted for if such equipment is incorporated. Again, the CMS increase in reimbursement for offices accommodates for the inclusion of these disposables as well as fluid management disposable costs.

If diagnostic hysteroscopy (as a separate procedure) is the procedure that you perform most often, the investment will look less favorable. However, if you anticipate performing hysteroscopic biopsies and/or polypectomies as well, the investment will look significantly more favorable now than it has in past years.

Once you have established your in-office system, even those procedures that are weighted equally for the practice setting (non-facility) and hospital/surgery center setting, such as hysteroscopic lysis of adhesions (58559), can be easily incorporated from a financial point of view.

In addition to reimbursement levels, it’s important to consider the efficiencies of in-office hysteroscopy. The setup is relatively simple and requires a dedicated exam room, not a surgical suite. You can perform one or two annual exams while the assistant sets up the room and greets each patient, for instance, or see another established patient while the assistant discharges your patient and turns the room over. Hysteroscopy at the hospital, or even at an ambulatory surgical center, involves time driving, changing, and waiting for anesthesia.

For our patients, most importantly, an in-office approach offers less out-of-pocket expense (deductibles), less time away from family/work, avoidance of general anesthesia/intubation, and greater patient comfort from being within a familiar environment. For diagnostic procedures, the patient can be in and out in less than 30 minutes, and for operative procedures, she can be in and out in 1-2 hours, compared with more than 4 hours at the hospital.
 

 

Preparing the office

Physicians in Europe have been performing in-office hysteroscopy for years. But in the United States, it is a newer concept, with most gynecologic surgeons having been taught to perform surgical procedures in the operating room. Undoubtedly, our unfamiliarity with in-office surgery has played a role in the slow uptake of hysteroscopy in our practices.

Courtesy Dr. Amy Garcia

It requires a culture change. Performing surgery while the patient is awake forces us to be more alert to issues such as the room temperature, the lighting, and the noises that a patient may hear. All of these factors can affect a patient’s anxiety level. We need to train ourselves to be acutely aware of the surroundings and to incorporate a “vocal local” approach – a form of nonpharmacologic pain management that involves speaking directly and reassuringly with the patient in order to reduce anxiety and avoid/distract from pain.

Open communication about everything the patient will see hear and feel before, during and after the procedure is important. Focusing on these details can improve your patient’s experience and your professional relationship with her.

In an earlier edition of Master Class, I addressed instrumentation and technique, elements of pain control and anesthesia, and the value of a vaginoscopic approach to hysteroscopy. Vaginoscopy avoids the use of a vaginal speculum or cervical tenaculum, and is so tolerable to many patients that I use minimal premedication and only rarely use any local anesthetic and/or sedation, even for biopsies and polypectomies.

Preparing your practice for hysteroscopy is a multifaceted process involving not only the purchase and/or rental of equipment but also compliance with guidelines, regulatory considerations, patient rights, hospital transfer arrangements, and other issues. ACOG’s Report of the Presidential Task Force on Patient Safety in the Office Setting is a valuable resource for getting started. The report discusses anesthesia levels and the benefits and risks of a contract anesthesiologist, for instance, as well as the role of and processes for credentialing, privileging, and accreditation.

Checklists and drills are important for ensuring a safe practice, and the report discusses each of these elements and provides templates and examples. A sample “Office Surgical Safety Checklist” to be used for each procedure, for instance, has sections with preoperative steps (before anesthesia/analgesia, and before incision), intraoperative steps, postoperative steps, and discharge steps. Similar in format to checklists used in the aviation industry, each step has a box to be checked off to verify completion.

Mock drills help ensure that staff are knowledgeable about their roles and coordinated in their response to potential complications, such as vasovagal episodes, respiratory arrest caused by laryngospasm, and local anesthetic toxicity reactions. And, while not the focus of drills, we also must be prepared to manage cervical strictures and stenosis, cervical laceration, uterine perforation, and other complications.

Outpatient surgery guidelines from organizations such as the American College of Surgeons, the Joint Commission, state regulatory agencies, and professional liability insurers, can also be useful resources. With the use of ACOG’s report and other such resources, the set-up and the transition to in-office hysteroscopy need not be daunting. For most gynecologic surgeons, it will all feel comfortable after only a few procedures.
 

Dr. Cholkeri-Singh is with the University of Illinois at Chicago, and is director of gynecologic surgical education and associate director of minimally invasive gynecology at Advocate Lutheran General Hospital in Park Ridge, Ill. She is in private practice in Chicago. She is a consultant for Hologic, Bayer HealthCare, Olympus, Caldera Medical, Karl Storz, Medtronic, DYSIS Medical, and Channel Medsystems.

 

The benefits of integrating hysteroscopy into office practice have been compelling for some time. An in-office approach is patient centered, more efficient, and clinically valuable. It also has had the potential to be economically valuable for practices that are able to perform a mix of diagnostic and therapeutic/operative hysteroscopies.

Dramatic shifts within the Centers for Medicare & Medicaid Services fee schedule in 2017 – and commensurate changes in the private insurance market – have now ramped up this value, making it all the more important that physicians consider investing in equipment and adopting an in-office approach.

At the crux of this shift has been a 237% increase, effective at the start of 2017, in the physician office payment for hysteroscopic endometrial biopsy and/or polypectomy (CPT code 58558). According to national payment amounts, performing this procedure in the office earned an average of $1,382.07 in 2017, compared with $409.60 in 2016. This reimbursement will hold steady in the 2018 Medicare Physician Fee Schedule Final Rule published in November.

Central to this increase, in turn, is a significant increase in practice expense reimbursement. CMS has included the costs of equipment, including the costs of the hysteroscopic fluid management system and the hysteroscopic tissue resection system, in recalibrating the practice expense relative value unit. Clearly, physicians are being encouraged to move hysteroscopic procedures into the office.
 

Weighing an investment

In the Medicare resource-based relative value scale payment system, relative value units (RVUs) are calculated based on three elements: physician work, practice expenses, and malpractice cost. Each component is multiplied by a factor that accounts for geographic cost variations, and each total RVU is multiplied by a dollar amount known as the conversion factor.

This isn’t the first year that the payment system – a standard for many other payers in determining compensation – allows for higher reimbursement for some hysteroscopic procedures performed in the office. The practice expense relative units have been higher for some time for certain hysteroscopic procedures – such as diagnostic hysteroscopy (code 58555), removal of a foreign body (58562), endometrial ablation (58353), and biopsy/polypectomy (58558) – when these procedures are performed in the office, compared with the hospital or an ambulatory surgical center.

However, the new increase in physician office payment for 58558 changes the equation significantly and ensures a better return on investment. In 2017, CMS offered a 12% increase in the facility fee paid to hospitals and a 2% increase in the facility fee paid to outpatient surgery centers when a hysteroscopic biopsy/polypectomy is performed in these settings, but the physician reimbursement in these cases declined 11%-19%.

On the flip side, an in-office approach to hysteroscopic biopsy/polypectomy has been rewarded in 2017 through a significantly higher practice expense RVU and a “non-facility” total RVU of 38.51 – a 237% increase over the 2016 practice expense RVU of 11.4. Such dramatic differences between the practice RVUs – and total RVUs – for in-office and out-of-office hysteroscopic procedures will continue for 2018.

Private insurers are following suit, and some are increasing their reimbursement even more. As of June 2017 in metropolitan Chicago, Blue Cross Blue Shield has been reimbursing in-office hysteroscopic biopsy/polypectomy at approximately $2,424.00; prior to June, the allowable charge was $742.81.

Equipment costs for in-office hysteroscopy can range from $15,000 to $35,000, based on whether equipment is new or used, the number of trays, and the style of camera and monitor system. Ancillary equipment/disposables cost $10 or less, and $40-$50 or less for diagnostic and many operative procedures, respectively. The prices for handpiece mechanical resection disposables or tissue removal devices vary based on company and blade type, so these costs will need to be accounted for if such equipment is incorporated. Again, the CMS increase in reimbursement for offices accommodates for the inclusion of these disposables as well as fluid management disposable costs.

If diagnostic hysteroscopy (as a separate procedure) is the procedure that you perform most often, the investment will look less favorable. However, if you anticipate performing hysteroscopic biopsies and/or polypectomies as well, the investment will look significantly more favorable now than it has in past years.

Once you have established your in-office system, even those procedures that are weighted equally for the practice setting (non-facility) and hospital/surgery center setting, such as hysteroscopic lysis of adhesions (58559), can be easily incorporated from a financial point of view.

In addition to reimbursement levels, it’s important to consider the efficiencies of in-office hysteroscopy. The setup is relatively simple and requires a dedicated exam room, not a surgical suite. You can perform one or two annual exams while the assistant sets up the room and greets each patient, for instance, or see another established patient while the assistant discharges your patient and turns the room over. Hysteroscopy at the hospital, or even at an ambulatory surgical center, involves time driving, changing, and waiting for anesthesia.

For our patients, most importantly, an in-office approach offers less out-of-pocket expense (deductibles), less time away from family/work, avoidance of general anesthesia/intubation, and greater patient comfort from being within a familiar environment. For diagnostic procedures, the patient can be in and out in less than 30 minutes, and for operative procedures, she can be in and out in 1-2 hours, compared with more than 4 hours at the hospital.
 

 

Preparing the office

Physicians in Europe have been performing in-office hysteroscopy for years. But in the United States, it is a newer concept, with most gynecologic surgeons having been taught to perform surgical procedures in the operating room. Undoubtedly, our unfamiliarity with in-office surgery has played a role in the slow uptake of hysteroscopy in our practices.

Courtesy Dr. Amy Garcia

It requires a culture change. Performing surgery while the patient is awake forces us to be more alert to issues such as the room temperature, the lighting, and the noises that a patient may hear. All of these factors can affect a patient’s anxiety level. We need to train ourselves to be acutely aware of the surroundings and to incorporate a “vocal local” approach – a form of nonpharmacologic pain management that involves speaking directly and reassuringly with the patient in order to reduce anxiety and avoid/distract from pain.

Open communication about everything the patient will see hear and feel before, during and after the procedure is important. Focusing on these details can improve your patient’s experience and your professional relationship with her.

In an earlier edition of Master Class, I addressed instrumentation and technique, elements of pain control and anesthesia, and the value of a vaginoscopic approach to hysteroscopy. Vaginoscopy avoids the use of a vaginal speculum or cervical tenaculum, and is so tolerable to many patients that I use minimal premedication and only rarely use any local anesthetic and/or sedation, even for biopsies and polypectomies.

Preparing your practice for hysteroscopy is a multifaceted process involving not only the purchase and/or rental of equipment but also compliance with guidelines, regulatory considerations, patient rights, hospital transfer arrangements, and other issues. ACOG’s Report of the Presidential Task Force on Patient Safety in the Office Setting is a valuable resource for getting started. The report discusses anesthesia levels and the benefits and risks of a contract anesthesiologist, for instance, as well as the role of and processes for credentialing, privileging, and accreditation.

Checklists and drills are important for ensuring a safe practice, and the report discusses each of these elements and provides templates and examples. A sample “Office Surgical Safety Checklist” to be used for each procedure, for instance, has sections with preoperative steps (before anesthesia/analgesia, and before incision), intraoperative steps, postoperative steps, and discharge steps. Similar in format to checklists used in the aviation industry, each step has a box to be checked off to verify completion.

Mock drills help ensure that staff are knowledgeable about their roles and coordinated in their response to potential complications, such as vasovagal episodes, respiratory arrest caused by laryngospasm, and local anesthetic toxicity reactions. And, while not the focus of drills, we also must be prepared to manage cervical strictures and stenosis, cervical laceration, uterine perforation, and other complications.

Outpatient surgery guidelines from organizations such as the American College of Surgeons, the Joint Commission, state regulatory agencies, and professional liability insurers, can also be useful resources. With the use of ACOG’s report and other such resources, the set-up and the transition to in-office hysteroscopy need not be daunting. For most gynecologic surgeons, it will all feel comfortable after only a few procedures.
 

Dr. Cholkeri-Singh is with the University of Illinois at Chicago, and is director of gynecologic surgical education and associate director of minimally invasive gynecology at Advocate Lutheran General Hospital in Park Ridge, Ill. She is in private practice in Chicago. She is a consultant for Hologic, Bayer HealthCare, Olympus, Caldera Medical, Karl Storz, Medtronic, DYSIS Medical, and Channel Medsystems.

 

As a practicing reproductive endocrinologist and minimally invasive gynecologic surgeon, falling reimbursement has become routine. Furthermore, it was disadvantageous to perform in-office procedures while physician reimbursement was similar whether cases were performed in office, the hospital, or a surgery center. Higher procedural costs in the office, including reusable and disposable instrumentation and staffing, actually discouraged the physician who wanted to perform cases in the office, as it led to an overall reduction in reimbursement. Of course, certain outlying procedures have been reimbursed at a far greater rate in office and, as a result, global endometrial ablation and the Essure procedure now are generally performed in office.

As of January 2017, there has been a marked increase in the reimbursement for hysteroscopic endometrial biopsy and/or polypectomy. This creates a distinct monetary advantage, which along with increased physician efficiency and patient comfort, has led to more physicians bringing these surgeries to an in-office setting. Adding to the already robust reimbursement for saline-infused sonogram (especially 3-D) used in the diagnosis of abnormal uterine bleeding, endometrial polyps, retained products of conception and endometrial hyperplasia, hysteroscopic diagnosis and treatment offers overall very favorable compensation when performed in an in-office setting.

In order to help us all understand the “nuts and bolts” behind the changes in physician compensation for in-office hysteroscopic procedures, I have once again called upon internationally recognized expert in hysteroscopic surgery, Aarathi Cholkeri-Singh, MD. At the AAGL 45th Global Congress on Minimally Invasive Gynecologic Surgery in 2016, Dr. Cholkeri-Singh was the chair and faculty of the postgraduate course, “Hysteroscopy 360° Beyond the Basics: Maximize Treatment, Minimize Failures.” At this year’s Global Congress, Dr. Cholkeri-Singh is a cochair of the postgraduate course “Advanced Operative Hysteroscopy: Expect the Unexpected.”

I am sure after reading Dr. Cholkeri-Singh’s comments, many of our readers of the Master Class in Gynecologic Surgery will add hysteroscopic surgery to their surgical repertoire.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is a consultant for Medtronic.

 

As a practicing reproductive endocrinologist and minimally invasive gynecologic surgeon, falling reimbursement has become routine. Furthermore, it was disadvantageous to perform in-office procedures while physician reimbursement was similar whether cases were performed in office, the hospital, or a surgery center. Higher procedural costs in the office, including reusable and disposable instrumentation and staffing, actually discouraged the physician who wanted to perform cases in the office, as it led to an overall reduction in reimbursement. Of course, certain outlying procedures have been reimbursed at a far greater rate in office and, as a result, global endometrial ablation and the Essure procedure now are generally performed in office.

As of January 2017, there has been a marked increase in the reimbursement for hysteroscopic endometrial biopsy and/or polypectomy. This creates a distinct monetary advantage, which along with increased physician efficiency and patient comfort, has led to more physicians bringing these surgeries to an in-office setting. Adding to the already robust reimbursement for saline-infused sonogram (especially 3-D) used in the diagnosis of abnormal uterine bleeding, endometrial polyps, retained products of conception and endometrial hyperplasia, hysteroscopic diagnosis and treatment offers overall very favorable compensation when performed in an in-office setting.

In order to help us all understand the “nuts and bolts” behind the changes in physician compensation for in-office hysteroscopic procedures, I have once again called upon internationally recognized expert in hysteroscopic surgery, Aarathi Cholkeri-Singh, MD. At the AAGL 45th Global Congress on Minimally Invasive Gynecologic Surgery in 2016, Dr. Cholkeri-Singh was the chair and faculty of the postgraduate course, “Hysteroscopy 360° Beyond the Basics: Maximize Treatment, Minimize Failures.” At this year’s Global Congress, Dr. Cholkeri-Singh is a cochair of the postgraduate course “Advanced Operative Hysteroscopy: Expect the Unexpected.”

I am sure after reading Dr. Cholkeri-Singh’s comments, many of our readers of the Master Class in Gynecologic Surgery will add hysteroscopic surgery to their surgical repertoire.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is a consultant for Medtronic.

 

As a practicing reproductive endocrinologist and minimally invasive gynecologic surgeon, falling reimbursement has become routine. Furthermore, it was disadvantageous to perform in-office procedures while physician reimbursement was similar whether cases were performed in office, the hospital, or a surgery center. Higher procedural costs in the office, including reusable and disposable instrumentation and staffing, actually discouraged the physician who wanted to perform cases in the office, as it led to an overall reduction in reimbursement. Of course, certain outlying procedures have been reimbursed at a far greater rate in office and, as a result, global endometrial ablation and the Essure procedure now are generally performed in office.

As of January 2017, there has been a marked increase in the reimbursement for hysteroscopic endometrial biopsy and/or polypectomy. This creates a distinct monetary advantage, which along with increased physician efficiency and patient comfort, has led to more physicians bringing these surgeries to an in-office setting. Adding to the already robust reimbursement for saline-infused sonogram (especially 3-D) used in the diagnosis of abnormal uterine bleeding, endometrial polyps, retained products of conception and endometrial hyperplasia, hysteroscopic diagnosis and treatment offers overall very favorable compensation when performed in an in-office setting.

In order to help us all understand the “nuts and bolts” behind the changes in physician compensation for in-office hysteroscopic procedures, I have once again called upon internationally recognized expert in hysteroscopic surgery, Aarathi Cholkeri-Singh, MD. At the AAGL 45th Global Congress on Minimally Invasive Gynecologic Surgery in 2016, Dr. Cholkeri-Singh was the chair and faculty of the postgraduate course, “Hysteroscopy 360° Beyond the Basics: Maximize Treatment, Minimize Failures.” At this year’s Global Congress, Dr. Cholkeri-Singh is a cochair of the postgraduate course “Advanced Operative Hysteroscopy: Expect the Unexpected.”

I am sure after reading Dr. Cholkeri-Singh’s comments, many of our readers of the Master Class in Gynecologic Surgery will add hysteroscopic surgery to their surgical repertoire.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is a consultant for Medtronic.