Opinion

 

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

 

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

 

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

 

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

 

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

 

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.

Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.

In this column, we tend to favor the more optimistic view but also acknowledge that the proliferation of AI into our everyday existence has been alarmingly rapid in the past few years. Virtual assistants like “Siri,” “Alexa,” and “Cortana” (to name just a few) have become ubiquitous and are always listening, ready to receive our commands and find answers to our every question – even ones we don’t ask! For example, we are routinely amazed when our smartphones offer up unsolicited traffic updates or weather forecasts, anticipating our plans and behavior patterns. If you’re like most of us, you are more likely to find this helpful rather than terrifying, and actually welcome AI’s presence in your personal life without fear or concern. But are you ready for artificial intelligence to enter your practice and help you care for patients? Is the exam room too sacred a space to allow such an intrusion? The time has come for us to answer those questions and many more.

A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.

While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.

Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology¹ investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.

There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
 

 

Reference

1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.

Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.

In this column, we tend to favor the more optimistic view but also acknowledge that the proliferation of AI into our everyday existence has been alarmingly rapid in the past few years. Virtual assistants like “Siri,” “Alexa,” and “Cortana” (to name just a few) have become ubiquitous and are always listening, ready to receive our commands and find answers to our every question – even ones we don’t ask! For example, we are routinely amazed when our smartphones offer up unsolicited traffic updates or weather forecasts, anticipating our plans and behavior patterns. If you’re like most of us, you are more likely to find this helpful rather than terrifying, and actually welcome AI’s presence in your personal life without fear or concern. But are you ready for artificial intelligence to enter your practice and help you care for patients? Is the exam room too sacred a space to allow such an intrusion? The time has come for us to answer those questions and many more.

A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.

While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.

Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology¹ investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.

There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
 

 

Reference

1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.

Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.

In this column, we tend to favor the more optimistic view but also acknowledge that the proliferation of AI into our everyday existence has been alarmingly rapid in the past few years. Virtual assistants like “Siri,” “Alexa,” and “Cortana” (to name just a few) have become ubiquitous and are always listening, ready to receive our commands and find answers to our every question – even ones we don’t ask! For example, we are routinely amazed when our smartphones offer up unsolicited traffic updates or weather forecasts, anticipating our plans and behavior patterns. If you’re like most of us, you are more likely to find this helpful rather than terrifying, and actually welcome AI’s presence in your personal life without fear or concern. But are you ready for artificial intelligence to enter your practice and help you care for patients? Is the exam room too sacred a space to allow such an intrusion? The time has come for us to answer those questions and many more.

A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.

While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.

Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology¹ investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.

There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
 

 

Reference

1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

 

I’m burned out.

Heck, what doctor isn’t? Politicians say we get paid too much. Lawyers say we make too many mistakes. Insurance companies say we order too many tests and too many expensive treatments. And the patients, while generally good people looking for help, can also on occasion be angry and unreasonable. The bad apples may be in the minority, but it only takes one to ruin a day full of rewarding visits.

Milan Markovic/Thinkstock

On top of all that, a recent study found that the burnout rate among neurologists was one of the highest among physicians. This is driving many of us to consider early retirement or consider leaving the field and is keeping medical students away from neurology. This comes at a time when the projected future demand for our specialty is already 20% under what the population will need by 2025.

That can’t be good.

Some of the study’s listed reasons for burnout are very familiar: complaints about maintenance of certification and about calling insurances to authorize tests and medications, crappy reimbursement for time-consuming visits, having to spend more time at work just to break even, and the constant feeling of never being caught up. I leave work, come home, have dinner with my family, do dictations, go to bed, and do it over again. No matter where I am, I’ve never left the office.

Other common complaints aren’t as much an issue for me. I don’t have, or want, an electronic health record that qualifies for meaningful use; I designed the one I have, and it works fine for me. I don’t have a nonmedical administrator telling me how many patients I’m required to see each day, and my patient population is, overall, appreciative and polite.

There are always trade-offs. When my kids have school breaks, I take that time off from the office to be with them. I enjoy it – I mean, that’s what we’re here for as parents, isn’t it? Of course, the drawback comes a few weeks later when my income drops because I wasn’t working. In solo practice, cash flow is king. I may have more freedom and control than my employed colleagues, but the downside is that I have no guaranteed salary, either. I’m the last one here who gets paid.

I see plenty of columns on how to avoid burnout, none of which seem to be written by someone who’s in a real-world practice. They all recommend taking time off for yourself, maybe seeing a counselor, finding a hobby you enjoy ... Really?

All of those things involve taking time off work, and in my self-employed world, that’s money lost. What pays the bills (and barely, at that) is sitting in my office seeing patients. Even my colleagues who work for health care systems, with their guaranteed paychecks (at least, for the duration of their contracts), tell me similar things. A nonmedical administrative person quietly reminds them that their productivity is always under review and that there are new grads who’d be happy to replace them. So they shut up and keep spiraling down.

There’s no easy answer, either. We’re stuck with decreasing reimbursements, a gradual whittling away of our profession, a demand to keep putting time we don’t have into our jobs, and many other issues. It’s even worse for those who are coming out of training and are facing these same challenges with six-figure student loans over their heads and, often, the demands of young families. The idealism and energy of youth are all that seem to sustain them, and that can’t last.

I like being a doctor. I enjoy being a neurologist. I love being able to help people and have a sense of service in doing so. But the worsening financial picture for us, and the increasing demands on our often already nonexistent free time, are destroying the field. Like many other docs, I look at my savings here and there and wonder how long until I can retire. That is sad because, as we all gradually leave practice (for whatever reason), new people will need to come in and pick up the mantle. But current conditions are such that I suspect many will find something else to do unless things change.

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

cnnews@frontlinemedcom.com

 

I’m burned out.

Heck, what doctor isn’t? Politicians say we get paid too much. Lawyers say we make too many mistakes. Insurance companies say we order too many tests and too many expensive treatments. And the patients, while generally good people looking for help, can also on occasion be angry and unreasonable. The bad apples may be in the minority, but it only takes one to ruin a day full of rewarding visits.

Milan Markovic/Thinkstock

On top of all that, a recent study found that the burnout rate among neurologists was one of the highest among physicians. This is driving many of us to consider early retirement or consider leaving the field and is keeping medical students away from neurology. This comes at a time when the projected future demand for our specialty is already 20% under what the population will need by 2025.

That can’t be good.

Some of the study’s listed reasons for burnout are very familiar: complaints about maintenance of certification and about calling insurances to authorize tests and medications, crappy reimbursement for time-consuming visits, having to spend more time at work just to break even, and the constant feeling of never being caught up. I leave work, come home, have dinner with my family, do dictations, go to bed, and do it over again. No matter where I am, I’ve never left the office.

Other common complaints aren’t as much an issue for me. I don’t have, or want, an electronic health record that qualifies for meaningful use; I designed the one I have, and it works fine for me. I don’t have a nonmedical administrator telling me how many patients I’m required to see each day, and my patient population is, overall, appreciative and polite.

There are always trade-offs. When my kids have school breaks, I take that time off from the office to be with them. I enjoy it – I mean, that’s what we’re here for as parents, isn’t it? Of course, the drawback comes a few weeks later when my income drops because I wasn’t working. In solo practice, cash flow is king. I may have more freedom and control than my employed colleagues, but the downside is that I have no guaranteed salary, either. I’m the last one here who gets paid.

I see plenty of columns on how to avoid burnout, none of which seem to be written by someone who’s in a real-world practice. They all recommend taking time off for yourself, maybe seeing a counselor, finding a hobby you enjoy ... Really?

All of those things involve taking time off work, and in my self-employed world, that’s money lost. What pays the bills (and barely, at that) is sitting in my office seeing patients. Even my colleagues who work for health care systems, with their guaranteed paychecks (at least, for the duration of their contracts), tell me similar things. A nonmedical administrative person quietly reminds them that their productivity is always under review and that there are new grads who’d be happy to replace them. So they shut up and keep spiraling down.

There’s no easy answer, either. We’re stuck with decreasing reimbursements, a gradual whittling away of our profession, a demand to keep putting time we don’t have into our jobs, and many other issues. It’s even worse for those who are coming out of training and are facing these same challenges with six-figure student loans over their heads and, often, the demands of young families. The idealism and energy of youth are all that seem to sustain them, and that can’t last.

I like being a doctor. I enjoy being a neurologist. I love being able to help people and have a sense of service in doing so. But the worsening financial picture for us, and the increasing demands on our often already nonexistent free time, are destroying the field. Like many other docs, I look at my savings here and there and wonder how long until I can retire. That is sad because, as we all gradually leave practice (for whatever reason), new people will need to come in and pick up the mantle. But current conditions are such that I suspect many will find something else to do unless things change.

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

cnnews@frontlinemedcom.com

 

I’m burned out.

Heck, what doctor isn’t? Politicians say we get paid too much. Lawyers say we make too many mistakes. Insurance companies say we order too many tests and too many expensive treatments. And the patients, while generally good people looking for help, can also on occasion be angry and unreasonable. The bad apples may be in the minority, but it only takes one to ruin a day full of rewarding visits.

Milan Markovic/Thinkstock

On top of all that, a recent study found that the burnout rate among neurologists was one of the highest among physicians. This is driving many of us to consider early retirement or consider leaving the field and is keeping medical students away from neurology. This comes at a time when the projected future demand for our specialty is already 20% under what the population will need by 2025.

That can’t be good.

Some of the study’s listed reasons for burnout are very familiar: complaints about maintenance of certification and about calling insurances to authorize tests and medications, crappy reimbursement for time-consuming visits, having to spend more time at work just to break even, and the constant feeling of never being caught up. I leave work, come home, have dinner with my family, do dictations, go to bed, and do it over again. No matter where I am, I’ve never left the office.

Other common complaints aren’t as much an issue for me. I don’t have, or want, an electronic health record that qualifies for meaningful use; I designed the one I have, and it works fine for me. I don’t have a nonmedical administrator telling me how many patients I’m required to see each day, and my patient population is, overall, appreciative and polite.

There are always trade-offs. When my kids have school breaks, I take that time off from the office to be with them. I enjoy it – I mean, that’s what we’re here for as parents, isn’t it? Of course, the drawback comes a few weeks later when my income drops because I wasn’t working. In solo practice, cash flow is king. I may have more freedom and control than my employed colleagues, but the downside is that I have no guaranteed salary, either. I’m the last one here who gets paid.

I see plenty of columns on how to avoid burnout, none of which seem to be written by someone who’s in a real-world practice. They all recommend taking time off for yourself, maybe seeing a counselor, finding a hobby you enjoy ... Really?

All of those things involve taking time off work, and in my self-employed world, that’s money lost. What pays the bills (and barely, at that) is sitting in my office seeing patients. Even my colleagues who work for health care systems, with their guaranteed paychecks (at least, for the duration of their contracts), tell me similar things. A nonmedical administrative person quietly reminds them that their productivity is always under review and that there are new grads who’d be happy to replace them. So they shut up and keep spiraling down.

There’s no easy answer, either. We’re stuck with decreasing reimbursements, a gradual whittling away of our profession, a demand to keep putting time we don’t have into our jobs, and many other issues. It’s even worse for those who are coming out of training and are facing these same challenges with six-figure student loans over their heads and, often, the demands of young families. The idealism and energy of youth are all that seem to sustain them, and that can’t last.

I like being a doctor. I enjoy being a neurologist. I love being able to help people and have a sense of service in doing so. But the worsening financial picture for us, and the increasing demands on our often already nonexistent free time, are destroying the field. Like many other docs, I look at my savings here and there and wonder how long until I can retire. That is sad because, as we all gradually leave practice (for whatever reason), new people will need to come in and pick up the mantle. But current conditions are such that I suspect many will find something else to do unless things change.

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

cnnews@frontlinemedcom.com

 

One of the most difficult and unpleasant aspects of being middle-aged is beginning to experience the loss of friends and colleagues who have had a profound impact on one’s life. Those who have been, or continue to be, associated with the department of surgery of Maricopa Medical Center in Phoenix recently experienced such a loss with the passing of Daniel M. Caruso, MD, FACS, after a very determined and utterly courageous battle with cancer.

I first came to know Dan 9 years ago when Maricopa Medical Center’s need for a pediatric surgeon and my desire for a different practice situation in the Phoenix area converged, resulting in my becoming a member of his faculty. As my chairman and my friend, Dan had a significant positive impact on me, and though he was chronologically several years my junior, he taught and reinforced life lessons that I will forever carry forward. He was also a faithful reader of this column, and whenever I saw him in Arizona, he always had a kind word about my monthly efforts presented here.

Rather than write about his numerous accomplishments, I want to pay tribute to Dan by remembering some of his most admirable characteristics and the lessons he taught me during the time I was privileged to work with him. All were taught in his uniquely gentle, kind, and caring manner.

Perhaps Dan’s most admirable trait was his loyalty. He was fiercely loyal to me, his other faculty, the staff of the Arizona Burn Center, and his resident trainees. In turn, he instilled in all around him a profound sense of loyalty to both himself and our department. Nothing exemplifies this better than the “leave no stone unturned” care he received from current faculty, hospital staff, and his former trainees over the last months of his life. In short, he was the leader of his pack.

Dan’s loyalty was not of the “fair weather” sort; it prevailed even in the face of potential adverse circumstances that promised to actually cause him more grief. Nor was his loyalty blind and without limits, as all who were ever in contentious conversation with him have likely been reminded, “I am Sicilian. Don’t put a gun to my head.” That said, his loyalty was, like everything else about him, appropriately measured and extraordinarily genuine, providing for all of us an example toward which to strive.

Being measured in all one’s responses to the adversity presented by others is another valuable lesson Dan taught me. I can only imagine the headaches, anxiety, and stress of being the chair of a department largely made up of “passionate” mid-career surgeons during tumultuous times of continuous change. Despite the fact that many of us frequently urged him to be more forceful, just say “no,” or otherwise flex his or our collective muscle, Dan was forever the calm voice in the storm, reacting in a measured way that was much more reminiscent of honey than vinegar. Dan provided indisputable evidence that your grandmother was correct when she told you that you will catch more flies that way.

Nowhere were these qualities more preeminently displayed than in the administration of the surgical residency program at Maricopa. As is common to most academically affiliated, community-based surgery programs, much of our collective identity as a department was cloaked in the residency program and our trainees. Being a product of the program himself, Dan was the consummate “keeper of the flame.” He was also a superb judge of character and surgical aptitude and the unsurpassed prophet of future success. He was a passionate advocate for those residents in whom he saw promise even when his view was aggressively challenged by others in the department who felt otherwise.

In the case of residents whose flaws in the form of either “expressions of youth” or academic performance caused some faculty to have a negative opinion, Dan remained singularly focused on what he saw as their future potential. He not only protected them, but also saw to it that they were provided every resource available to succeed. He ensured that all trainees who met his muster by working hard and taking excellent care of the patients were given every opportunity to succeed. When appropriate and necessary, his profound insight into others’ talents combined with his compassionate demeanor made him particularly well suited to make suggestions, to the very few, that they might be happier and more successful in a specialty other than surgery. In sum, he had an unsurpassed passion for training the next generation of surgeons, paying it forward into the future as he went.

Dan had both a profound sense of justice and a keen political sense about how and when to strategically best use his position and influence to ensure fairness of outcomes. Amongst his faculty, he was particularly adept at discerning whose talents were best suited to specific tasks and thus, whom he should assign to ensure the optimal outcome for the department, our trainees, and our patients. When once I met with him to express my profound concerns relative to how members of our department were being treated by a certain hospital committee, his response was to act swiftly to ensure that I was appointed to that committee. By doing so, he showed that he trusted my judgment to look out for the interests of our department whilst simultaneously resolving my own concerns. He also gently reinforced the valuable life lesson of not going to your boss only with a problem. Take along that potential solution as well.

As I look forward to Clinical Congress and seeing familiar faces from the “Copa,” past and present, I anticipate many firm handshakes and warm embraces as well as a few tears shed in shared grief. Plain and simple, Dan was the consummate critical care/burn surgeon, a passionate surgical educator, and overall, epitomized the phrase, “great guy.” Our world is a far better place because of his 53 years of labor in the fields of this life.

Somewhere, a red Ferrari with a Detroit Lions license plate is humming down a flat stretch of highway at a clearly excessive rate of speed with Bob Seger blasting from the stereo ...

Well done, my friend. Very well done.

Until next month …
 

 

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.

 

One of the most difficult and unpleasant aspects of being middle-aged is beginning to experience the loss of friends and colleagues who have had a profound impact on one’s life. Those who have been, or continue to be, associated with the department of surgery of Maricopa Medical Center in Phoenix recently experienced such a loss with the passing of Daniel M. Caruso, MD, FACS, after a very determined and utterly courageous battle with cancer.

I first came to know Dan 9 years ago when Maricopa Medical Center’s need for a pediatric surgeon and my desire for a different practice situation in the Phoenix area converged, resulting in my becoming a member of his faculty. As my chairman and my friend, Dan had a significant positive impact on me, and though he was chronologically several years my junior, he taught and reinforced life lessons that I will forever carry forward. He was also a faithful reader of this column, and whenever I saw him in Arizona, he always had a kind word about my monthly efforts presented here.

Rather than write about his numerous accomplishments, I want to pay tribute to Dan by remembering some of his most admirable characteristics and the lessons he taught me during the time I was privileged to work with him. All were taught in his uniquely gentle, kind, and caring manner.

Perhaps Dan’s most admirable trait was his loyalty. He was fiercely loyal to me, his other faculty, the staff of the Arizona Burn Center, and his resident trainees. In turn, he instilled in all around him a profound sense of loyalty to both himself and our department. Nothing exemplifies this better than the “leave no stone unturned” care he received from current faculty, hospital staff, and his former trainees over the last months of his life. In short, he was the leader of his pack.

Dan’s loyalty was not of the “fair weather” sort; it prevailed even in the face of potential adverse circumstances that promised to actually cause him more grief. Nor was his loyalty blind and without limits, as all who were ever in contentious conversation with him have likely been reminded, “I am Sicilian. Don’t put a gun to my head.” That said, his loyalty was, like everything else about him, appropriately measured and extraordinarily genuine, providing for all of us an example toward which to strive.

Being measured in all one’s responses to the adversity presented by others is another valuable lesson Dan taught me. I can only imagine the headaches, anxiety, and stress of being the chair of a department largely made up of “passionate” mid-career surgeons during tumultuous times of continuous change. Despite the fact that many of us frequently urged him to be more forceful, just say “no,” or otherwise flex his or our collective muscle, Dan was forever the calm voice in the storm, reacting in a measured way that was much more reminiscent of honey than vinegar. Dan provided indisputable evidence that your grandmother was correct when she told you that you will catch more flies that way.

Nowhere were these qualities more preeminently displayed than in the administration of the surgical residency program at Maricopa. As is common to most academically affiliated, community-based surgery programs, much of our collective identity as a department was cloaked in the residency program and our trainees. Being a product of the program himself, Dan was the consummate “keeper of the flame.” He was also a superb judge of character and surgical aptitude and the unsurpassed prophet of future success. He was a passionate advocate for those residents in whom he saw promise even when his view was aggressively challenged by others in the department who felt otherwise.

In the case of residents whose flaws in the form of either “expressions of youth” or academic performance caused some faculty to have a negative opinion, Dan remained singularly focused on what he saw as their future potential. He not only protected them, but also saw to it that they were provided every resource available to succeed. He ensured that all trainees who met his muster by working hard and taking excellent care of the patients were given every opportunity to succeed. When appropriate and necessary, his profound insight into others’ talents combined with his compassionate demeanor made him particularly well suited to make suggestions, to the very few, that they might be happier and more successful in a specialty other than surgery. In sum, he had an unsurpassed passion for training the next generation of surgeons, paying it forward into the future as he went.

Dan had both a profound sense of justice and a keen political sense about how and when to strategically best use his position and influence to ensure fairness of outcomes. Amongst his faculty, he was particularly adept at discerning whose talents were best suited to specific tasks and thus, whom he should assign to ensure the optimal outcome for the department, our trainees, and our patients. When once I met with him to express my profound concerns relative to how members of our department were being treated by a certain hospital committee, his response was to act swiftly to ensure that I was appointed to that committee. By doing so, he showed that he trusted my judgment to look out for the interests of our department whilst simultaneously resolving my own concerns. He also gently reinforced the valuable life lesson of not going to your boss only with a problem. Take along that potential solution as well.

As I look forward to Clinical Congress and seeing familiar faces from the “Copa,” past and present, I anticipate many firm handshakes and warm embraces as well as a few tears shed in shared grief. Plain and simple, Dan was the consummate critical care/burn surgeon, a passionate surgical educator, and overall, epitomized the phrase, “great guy.” Our world is a far better place because of his 53 years of labor in the fields of this life.

Somewhere, a red Ferrari with a Detroit Lions license plate is humming down a flat stretch of highway at a clearly excessive rate of speed with Bob Seger blasting from the stereo ...

Well done, my friend. Very well done.

Until next month …
 

 

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.

 

One of the most difficult and unpleasant aspects of being middle-aged is beginning to experience the loss of friends and colleagues who have had a profound impact on one’s life. Those who have been, or continue to be, associated with the department of surgery of Maricopa Medical Center in Phoenix recently experienced such a loss with the passing of Daniel M. Caruso, MD, FACS, after a very determined and utterly courageous battle with cancer.

I first came to know Dan 9 years ago when Maricopa Medical Center’s need for a pediatric surgeon and my desire for a different practice situation in the Phoenix area converged, resulting in my becoming a member of his faculty. As my chairman and my friend, Dan had a significant positive impact on me, and though he was chronologically several years my junior, he taught and reinforced life lessons that I will forever carry forward. He was also a faithful reader of this column, and whenever I saw him in Arizona, he always had a kind word about my monthly efforts presented here.

Rather than write about his numerous accomplishments, I want to pay tribute to Dan by remembering some of his most admirable characteristics and the lessons he taught me during the time I was privileged to work with him. All were taught in his uniquely gentle, kind, and caring manner.

Perhaps Dan’s most admirable trait was his loyalty. He was fiercely loyal to me, his other faculty, the staff of the Arizona Burn Center, and his resident trainees. In turn, he instilled in all around him a profound sense of loyalty to both himself and our department. Nothing exemplifies this better than the “leave no stone unturned” care he received from current faculty, hospital staff, and his former trainees over the last months of his life. In short, he was the leader of his pack.

Dan’s loyalty was not of the “fair weather” sort; it prevailed even in the face of potential adverse circumstances that promised to actually cause him more grief. Nor was his loyalty blind and without limits, as all who were ever in contentious conversation with him have likely been reminded, “I am Sicilian. Don’t put a gun to my head.” That said, his loyalty was, like everything else about him, appropriately measured and extraordinarily genuine, providing for all of us an example toward which to strive.

Being measured in all one’s responses to the adversity presented by others is another valuable lesson Dan taught me. I can only imagine the headaches, anxiety, and stress of being the chair of a department largely made up of “passionate” mid-career surgeons during tumultuous times of continuous change. Despite the fact that many of us frequently urged him to be more forceful, just say “no,” or otherwise flex his or our collective muscle, Dan was forever the calm voice in the storm, reacting in a measured way that was much more reminiscent of honey than vinegar. Dan provided indisputable evidence that your grandmother was correct when she told you that you will catch more flies that way.

Nowhere were these qualities more preeminently displayed than in the administration of the surgical residency program at Maricopa. As is common to most academically affiliated, community-based surgery programs, much of our collective identity as a department was cloaked in the residency program and our trainees. Being a product of the program himself, Dan was the consummate “keeper of the flame.” He was also a superb judge of character and surgical aptitude and the unsurpassed prophet of future success. He was a passionate advocate for those residents in whom he saw promise even when his view was aggressively challenged by others in the department who felt otherwise.

In the case of residents whose flaws in the form of either “expressions of youth” or academic performance caused some faculty to have a negative opinion, Dan remained singularly focused on what he saw as their future potential. He not only protected them, but also saw to it that they were provided every resource available to succeed. He ensured that all trainees who met his muster by working hard and taking excellent care of the patients were given every opportunity to succeed. When appropriate and necessary, his profound insight into others’ talents combined with his compassionate demeanor made him particularly well suited to make suggestions, to the very few, that they might be happier and more successful in a specialty other than surgery. In sum, he had an unsurpassed passion for training the next generation of surgeons, paying it forward into the future as he went.

Dan had both a profound sense of justice and a keen political sense about how and when to strategically best use his position and influence to ensure fairness of outcomes. Amongst his faculty, he was particularly adept at discerning whose talents were best suited to specific tasks and thus, whom he should assign to ensure the optimal outcome for the department, our trainees, and our patients. When once I met with him to express my profound concerns relative to how members of our department were being treated by a certain hospital committee, his response was to act swiftly to ensure that I was appointed to that committee. By doing so, he showed that he trusted my judgment to look out for the interests of our department whilst simultaneously resolving my own concerns. He also gently reinforced the valuable life lesson of not going to your boss only with a problem. Take along that potential solution as well.

As I look forward to Clinical Congress and seeing familiar faces from the “Copa,” past and present, I anticipate many firm handshakes and warm embraces as well as a few tears shed in shared grief. Plain and simple, Dan was the consummate critical care/burn surgeon, a passionate surgical educator, and overall, epitomized the phrase, “great guy.” Our world is a far better place because of his 53 years of labor in the fields of this life.

Somewhere, a red Ferrari with a Detroit Lions license plate is humming down a flat stretch of highway at a clearly excessive rate of speed with Bob Seger blasting from the stereo ...

Well done, my friend. Very well done.

Until next month …
 

 

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.

 

Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.

The American College of Surgeons has hastened to recognize this problem as is evident in this year’s Clinical Congress symposia, PS407 Postoperative Pain Control: Strategies of Decreasing the Need for Narcotics: Part I and PS408 Surgeons’ Methods and Responses to Dealing with the Opioid Epidemic – Part II. Even with its collective experience with opioid use in hospice and palliative care, the palliative care community freely acknowledges its lack of preparation to meet the challenges resulting from the societal consequences of addiction, overdosage, and criminal activity stemming from the availability of opioids. A major concern for palliative care practitioners is to preserve the availability of opioid therapy without hindering reform of opioid use, a problem that will grow as more patients receive palliative care earlier in the course of life-limiting illness.

Although the liberal use of opioids is a common stereotype of palliative care, the use of opioids in the palliative care setting is part of a complex assessment and treatment process. Opioid use in this setting is analogous to palliative surgery in the surgical palliative care setting: It is one tool, and it is most effective and safe when based on an assessment of the more general picture. A fundamental concept of palliative care, “total pain,” provides a basis for improved pain management that goes far beyond the use and dependency on opioid therapy. Dame Cicely Saunders, who was mentored by a surgeon and later became a Fellow of the Royal College of Surgeons, defined the concept of total pain as the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles (BMJ. 2005 Jul 23;331[7510]:238). Blake Cady, a preeminent surgeon and surgical educator, once wrote that the day-to-day decisions in surgery are best made in the context of a surgical philosophy of care (J Am Coll Surg. 2005 Feb;200[2]:285-90). This applies to all interventions. Total-pain assessment provides us the opportunity to identify nonphysical factors associated with pain that might not indicate opioid use or even contraindicate their use. Existential distress or spiritual pain in a delirious or underassessed patient can be indistinguishable from physical distress. Socioeconomic factors, such as an inability to pay for medical care, can present as pain.

Surgeons are uniquely positioned as “listening posts” in the overall campaign to curb opioid misuse. They can identify patients at risk for or diagnosed with substance use disorder so they can be managed or referred for specialist treatment appropriately.

Awareness of other dimensions of pain will enhance their efficacy in this role.

Opioid sparing is a key tactic in the strategy for controlling opioid use and minimizing opioid-induced side effects. Occasionally surgical or interventional radiologic procedures are useful for this purpose.

There are immediate, specific actions surgeons can take in order to constructively participate in opioid use reform:

• Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
• Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
• Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
• Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
• Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.

Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.


 

Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

 

Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.

The American College of Surgeons has hastened to recognize this problem as is evident in this year’s Clinical Congress symposia, PS407 Postoperative Pain Control: Strategies of Decreasing the Need for Narcotics: Part I and PS408 Surgeons’ Methods and Responses to Dealing with the Opioid Epidemic – Part II. Even with its collective experience with opioid use in hospice and palliative care, the palliative care community freely acknowledges its lack of preparation to meet the challenges resulting from the societal consequences of addiction, overdosage, and criminal activity stemming from the availability of opioids. A major concern for palliative care practitioners is to preserve the availability of opioid therapy without hindering reform of opioid use, a problem that will grow as more patients receive palliative care earlier in the course of life-limiting illness.

Although the liberal use of opioids is a common stereotype of palliative care, the use of opioids in the palliative care setting is part of a complex assessment and treatment process. Opioid use in this setting is analogous to palliative surgery in the surgical palliative care setting: It is one tool, and it is most effective and safe when based on an assessment of the more general picture. A fundamental concept of palliative care, “total pain,” provides a basis for improved pain management that goes far beyond the use and dependency on opioid therapy. Dame Cicely Saunders, who was mentored by a surgeon and later became a Fellow of the Royal College of Surgeons, defined the concept of total pain as the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles (BMJ. 2005 Jul 23;331[7510]:238). Blake Cady, a preeminent surgeon and surgical educator, once wrote that the day-to-day decisions in surgery are best made in the context of a surgical philosophy of care (J Am Coll Surg. 2005 Feb;200[2]:285-90). This applies to all interventions. Total-pain assessment provides us the opportunity to identify nonphysical factors associated with pain that might not indicate opioid use or even contraindicate their use. Existential distress or spiritual pain in a delirious or underassessed patient can be indistinguishable from physical distress. Socioeconomic factors, such as an inability to pay for medical care, can present as pain.

Surgeons are uniquely positioned as “listening posts” in the overall campaign to curb opioid misuse. They can identify patients at risk for or diagnosed with substance use disorder so they can be managed or referred for specialist treatment appropriately.

Awareness of other dimensions of pain will enhance their efficacy in this role.

Opioid sparing is a key tactic in the strategy for controlling opioid use and minimizing opioid-induced side effects. Occasionally surgical or interventional radiologic procedures are useful for this purpose.

There are immediate, specific actions surgeons can take in order to constructively participate in opioid use reform:

• Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
• Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
• Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
• Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
• Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.

Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.


 

Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

 

Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.

The American College of Surgeons has hastened to recognize this problem as is evident in this year’s Clinical Congress symposia, PS407 Postoperative Pain Control: Strategies of Decreasing the Need for Narcotics: Part I and PS408 Surgeons’ Methods and Responses to Dealing with the Opioid Epidemic – Part II. Even with its collective experience with opioid use in hospice and palliative care, the palliative care community freely acknowledges its lack of preparation to meet the challenges resulting from the societal consequences of addiction, overdosage, and criminal activity stemming from the availability of opioids. A major concern for palliative care practitioners is to preserve the availability of opioid therapy without hindering reform of opioid use, a problem that will grow as more patients receive palliative care earlier in the course of life-limiting illness.

Although the liberal use of opioids is a common stereotype of palliative care, the use of opioids in the palliative care setting is part of a complex assessment and treatment process. Opioid use in this setting is analogous to palliative surgery in the surgical palliative care setting: It is one tool, and it is most effective and safe when based on an assessment of the more general picture. A fundamental concept of palliative care, “total pain,” provides a basis for improved pain management that goes far beyond the use and dependency on opioid therapy. Dame Cicely Saunders, who was mentored by a surgeon and later became a Fellow of the Royal College of Surgeons, defined the concept of total pain as the suffering that encompasses all of a person’s physical, psychological, social, spiritual, and practical struggles (BMJ. 2005 Jul 23;331[7510]:238). Blake Cady, a preeminent surgeon and surgical educator, once wrote that the day-to-day decisions in surgery are best made in the context of a surgical philosophy of care (J Am Coll Surg. 2005 Feb;200[2]:285-90). This applies to all interventions. Total-pain assessment provides us the opportunity to identify nonphysical factors associated with pain that might not indicate opioid use or even contraindicate their use. Existential distress or spiritual pain in a delirious or underassessed patient can be indistinguishable from physical distress. Socioeconomic factors, such as an inability to pay for medical care, can present as pain.

Surgeons are uniquely positioned as “listening posts” in the overall campaign to curb opioid misuse. They can identify patients at risk for or diagnosed with substance use disorder so they can be managed or referred for specialist treatment appropriately.

Awareness of other dimensions of pain will enhance their efficacy in this role.

Opioid sparing is a key tactic in the strategy for controlling opioid use and minimizing opioid-induced side effects. Occasionally surgical or interventional radiologic procedures are useful for this purpose.

There are immediate, specific actions surgeons can take in order to constructively participate in opioid use reform:

• Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
• Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
• Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
• Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
• Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.

Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.


 

Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

 

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

The surgical resident’s assessment was that, despite the unremarkable abdominal exam and the resolution of the patient’s pain, surgery was indicated. The resident discussed the patient’s case with the attending surgeon on call that night, and the attending agreed: The patient should have an abdominal exploration to rule out a midgut volvulus and the potential for an abdominal catastrophe.

When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.

The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?

These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.

There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.

Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.
 

 

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

 

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

The surgical resident’s assessment was that, despite the unremarkable abdominal exam and the resolution of the patient’s pain, surgery was indicated. The resident discussed the patient’s case with the attending surgeon on call that night, and the attending agreed: The patient should have an abdominal exploration to rule out a midgut volvulus and the potential for an abdominal catastrophe.

When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.

The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?

These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.

There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.

Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.
 

 

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

 

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

The surgical resident’s assessment was that, despite the unremarkable abdominal exam and the resolution of the patient’s pain, surgery was indicated. The resident discussed the patient’s case with the attending surgeon on call that night, and the attending agreed: The patient should have an abdominal exploration to rule out a midgut volvulus and the potential for an abdominal catastrophe.

When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.

The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?

These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.

There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.

Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.
 

 

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

 

Is it not ironic that in a profession that is always seeking answers – What does this patient have? Is that mass malignant? What’s the best way to make a diagnosis? – too much information has become a major problem?

Unlike William Stewart Halsted or Theodor Billroth, who blazed surgical trails in an age when much was unknown, today’s surgeons face a jungle of information obscuring the trail ahead. Every morning we wake up to another 30 or 40 unread emails. Journals multiply on our desks. The books we need to read pile up and spill over onto our desks, bookshelves, and side tables. Sometimes, it makes one long for the old days when definitive answers might not be found in the literature. These days, we know it is likely that someone has published exactly what we need at any particular moment, and yet finding it in the jungle of information can be a great challenge.

S_Lew/Thinkstock

The Internet was formally hailed as the “information superhighway.” Are you old enough to remember the first time you googled a question and got the answer in a flash? It was a revelation. What you may have missed that day is the little information tab that said, “1 of 100,653.” The answer you sought was brought to you by an algorithm that prioritized the rank order. Answer #1 may have satisfied the algorithm, but in fact, answer #62,500 was what you needed. It was the one not sponsored by a certain company, yet it was hidden among the search results because the wrong keywords or some other characteristic may have baffled the algorithm.

Another outcome of too much information is the accumulation in our brains of unsorted bits of medical/surgical knowledge. Some of those bits are pearls, and others are just gum wrappers that take up space. It becomes an overwhelming task of ranking, sorting, prioritizing, and discarding.

A friend of mine years of ago called his brain an iceberg on which thousands of penguins stand. The penguins just kept coming and, finally, in order to learn anything new, he had to push some penguins off the iceberg. We have a lot of penguins on our icebergs these days.

This brings to mind many doctors’ favorite fictional character, Sherlock Holmes. That denizen of 221B Baker Street was a master at data management. He always had the right information available in his head relevant for the mystery at hand. How did he do it? Recall that Dr. Watson (a surgeon, I might add) was intermittently shocked by what Holmes didn’t know, to which the tobacco- and opiate-addicted hero would reply that he purposely forgot things that did not help him solve his cases.

And so, what is the modern surgeon – who must keep in the forefront of his or her mind every best practice, algorithm, and guideline – to do in this age of too much information? Like Holmes, we need to sort what is critical from what is not and let go of those items that no longer are germane. We then need to triage the vast amount of information delivered to us yearly, weekly, monthly, daily, hourly. The stream of little notes flashing at you from your black mirror (the screen of your mobile device) needs to be controlled lest it control you.

So, might I suggest a few strategies I have used to triage the flow of information? For hourly and daily information, I tend to ignore everything except ACS NewsScope and the ACS Communities items I find most interesting. For monthly information, I tend to use ACS Surgery News (plug intended) because it is “news” – the stuff that just happened in the meeting sphere or has not yet hit print (sorry, e-publication). The Journal of the American College of Surgeons is another monthly source that is reliable.

For a yearly update of information, filtered for significance, there’s nothing like the Clinical Congress. The Clinical Congress program is your filter, and the amount of solid information gained there through direct contact with the authors and leaders can’t be beat. For the huge picture, my final filter is Selected Readings in General Surgery and the Surgical Education and Self-Assessment Program (SESAP).

You may see a theme here. I’ve used the American College of Surgeons as my main filter. What gets through the editors of these outlets generally is viable and useful information. That’s what I need to know for right now. Such knowledge allows me to push those penguins no longer needed off my iceberg and greet the new ones with joy. We often wonder what the benefit of membership in the College may be. For me, these filters are worth the price of admission.
 

 

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

 

Is it not ironic that in a profession that is always seeking answers – What does this patient have? Is that mass malignant? What’s the best way to make a diagnosis? – too much information has become a major problem?

Unlike William Stewart Halsted or Theodor Billroth, who blazed surgical trails in an age when much was unknown, today’s surgeons face a jungle of information obscuring the trail ahead. Every morning we wake up to another 30 or 40 unread emails. Journals multiply on our desks. The books we need to read pile up and spill over onto our desks, bookshelves, and side tables. Sometimes, it makes one long for the old days when definitive answers might not be found in the literature. These days, we know it is likely that someone has published exactly what we need at any particular moment, and yet finding it in the jungle of information can be a great challenge.

S_Lew/Thinkstock

The Internet was formally hailed as the “information superhighway.” Are you old enough to remember the first time you googled a question and got the answer in a flash? It was a revelation. What you may have missed that day is the little information tab that said, “1 of 100,653.” The answer you sought was brought to you by an algorithm that prioritized the rank order. Answer #1 may have satisfied the algorithm, but in fact, answer #62,500 was what you needed. It was the one not sponsored by a certain company, yet it was hidden among the search results because the wrong keywords or some other characteristic may have baffled the algorithm.

Another outcome of too much information is the accumulation in our brains of unsorted bits of medical/surgical knowledge. Some of those bits are pearls, and others are just gum wrappers that take up space. It becomes an overwhelming task of ranking, sorting, prioritizing, and discarding.

A friend of mine years of ago called his brain an iceberg on which thousands of penguins stand. The penguins just kept coming and, finally, in order to learn anything new, he had to push some penguins off the iceberg. We have a lot of penguins on our icebergs these days.

This brings to mind many doctors’ favorite fictional character, Sherlock Holmes. That denizen of 221B Baker Street was a master at data management. He always had the right information available in his head relevant for the mystery at hand. How did he do it? Recall that Dr. Watson (a surgeon, I might add) was intermittently shocked by what Holmes didn’t know, to which the tobacco- and opiate-addicted hero would reply that he purposely forgot things that did not help him solve his cases.

And so, what is the modern surgeon – who must keep in the forefront of his or her mind every best practice, algorithm, and guideline – to do in this age of too much information? Like Holmes, we need to sort what is critical from what is not and let go of those items that no longer are germane. We then need to triage the vast amount of information delivered to us yearly, weekly, monthly, daily, hourly. The stream of little notes flashing at you from your black mirror (the screen of your mobile device) needs to be controlled lest it control you.

So, might I suggest a few strategies I have used to triage the flow of information? For hourly and daily information, I tend to ignore everything except ACS NewsScope and the ACS Communities items I find most interesting. For monthly information, I tend to use ACS Surgery News (plug intended) because it is “news” – the stuff that just happened in the meeting sphere or has not yet hit print (sorry, e-publication). The Journal of the American College of Surgeons is another monthly source that is reliable.

For a yearly update of information, filtered for significance, there’s nothing like the Clinical Congress. The Clinical Congress program is your filter, and the amount of solid information gained there through direct contact with the authors and leaders can’t be beat. For the huge picture, my final filter is Selected Readings in General Surgery and the Surgical Education and Self-Assessment Program (SESAP).

You may see a theme here. I’ve used the American College of Surgeons as my main filter. What gets through the editors of these outlets generally is viable and useful information. That’s what I need to know for right now. Such knowledge allows me to push those penguins no longer needed off my iceberg and greet the new ones with joy. We often wonder what the benefit of membership in the College may be. For me, these filters are worth the price of admission.
 

 

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

 

Is it not ironic that in a profession that is always seeking answers – What does this patient have? Is that mass malignant? What’s the best way to make a diagnosis? – too much information has become a major problem?

Unlike William Stewart Halsted or Theodor Billroth, who blazed surgical trails in an age when much was unknown, today’s surgeons face a jungle of information obscuring the trail ahead. Every morning we wake up to another 30 or 40 unread emails. Journals multiply on our desks. The books we need to read pile up and spill over onto our desks, bookshelves, and side tables. Sometimes, it makes one long for the old days when definitive answers might not be found in the literature. These days, we know it is likely that someone has published exactly what we need at any particular moment, and yet finding it in the jungle of information can be a great challenge.

S_Lew/Thinkstock

The Internet was formally hailed as the “information superhighway.” Are you old enough to remember the first time you googled a question and got the answer in a flash? It was a revelation. What you may have missed that day is the little information tab that said, “1 of 100,653.” The answer you sought was brought to you by an algorithm that prioritized the rank order. Answer #1 may have satisfied the algorithm, but in fact, answer #62,500 was what you needed. It was the one not sponsored by a certain company, yet it was hidden among the search results because the wrong keywords or some other characteristic may have baffled the algorithm.

Another outcome of too much information is the accumulation in our brains of unsorted bits of medical/surgical knowledge. Some of those bits are pearls, and others are just gum wrappers that take up space. It becomes an overwhelming task of ranking, sorting, prioritizing, and discarding.

A friend of mine years of ago called his brain an iceberg on which thousands of penguins stand. The penguins just kept coming and, finally, in order to learn anything new, he had to push some penguins off the iceberg. We have a lot of penguins on our icebergs these days.

This brings to mind many doctors’ favorite fictional character, Sherlock Holmes. That denizen of 221B Baker Street was a master at data management. He always had the right information available in his head relevant for the mystery at hand. How did he do it? Recall that Dr. Watson (a surgeon, I might add) was intermittently shocked by what Holmes didn’t know, to which the tobacco- and opiate-addicted hero would reply that he purposely forgot things that did not help him solve his cases.

And so, what is the modern surgeon – who must keep in the forefront of his or her mind every best practice, algorithm, and guideline – to do in this age of too much information? Like Holmes, we need to sort what is critical from what is not and let go of those items that no longer are germane. We then need to triage the vast amount of information delivered to us yearly, weekly, monthly, daily, hourly. The stream of little notes flashing at you from your black mirror (the screen of your mobile device) needs to be controlled lest it control you.

So, might I suggest a few strategies I have used to triage the flow of information? For hourly and daily information, I tend to ignore everything except ACS NewsScope and the ACS Communities items I find most interesting. For monthly information, I tend to use ACS Surgery News (plug intended) because it is “news” – the stuff that just happened in the meeting sphere or has not yet hit print (sorry, e-publication). The Journal of the American College of Surgeons is another monthly source that is reliable.

For a yearly update of information, filtered for significance, there’s nothing like the Clinical Congress. The Clinical Congress program is your filter, and the amount of solid information gained there through direct contact with the authors and leaders can’t be beat. For the huge picture, my final filter is Selected Readings in General Surgery and the Surgical Education and Self-Assessment Program (SESAP).

You may see a theme here. I’ve used the American College of Surgeons as my main filter. What gets through the editors of these outlets generally is viable and useful information. That’s what I need to know for right now. Such knowledge allows me to push those penguins no longer needed off my iceberg and greet the new ones with joy. We often wonder what the benefit of membership in the College may be. For me, these filters are worth the price of admission.
 

 

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

 

Angiosarcoma is also known as malignant hemangioendothelioma, hemangiosarcoma, and lymphangiosarcoma. It is an uncommon, high-grade malignant vascular neoplasm of the inner lining of blood vessels. Unlike most sarcomas, it occurs more superficially, most often on the head and neck (particularly on the scalp). This neoplasm occurs twice as often in males as it does in females. Angiosarcomas can occur in the breast after radiation therapy, as well as in the liver and spleen, but 60% are cutaneous.
 

Courtesy Parteek Singla, MD, and Susannah McClain, MD

Most commonly, angiosarcomas are seen in the elderly on sun-damaged sites, such as the head and neck, without lymphedema. Other risk factors include radiation therapy, with lesions typically occurring 5-10 years after treatment. Also, chronic lymphedema (Stewart-Treves syndrome), most commonly following after breast cancer treatment with axillary node dissection, increases the risk of angiosarcomas. This condition has a poor prognosis, with metastases to the lung as the most frequent cause of death.

Clinical exam findings may show a violaceous lesion similar to a bruise on the head and neck that does not heal or bleeds when scratched; this is of particular concern when the lesion has appeared in an area of prior radiation therapy. Deeper tumors may be felt as a soft nodule. Ulceration may be present. Biopsy of the lesion will show hyperchromatic, pleomorphic tumor cells that dissect between collagen bundles with endothelial cells that are multilayered along with hemorrhage. Malignant cells stain positive for CD31, CD34, ERG, and FLI1.

For localized disease, surgery with wide local excision plus adjuvant radiation therapy can be used. For metastatic disease, chemotherapy is the treatment modality of choice. Unfortunately, prognosis is poor, with a 5-year survival rate of about 35% in nonmetastatic angiosarcoma cases. The majority of recurrences – approximately 75% – occur within 24 months of local treatment.

This case and photo were submitted by Parteek Singla, MD, of the division of dermatology at Washington University and at Barnes-Jewish Hospital, both in St. Louis, and by Susannah McClain, MD, of Three Rivers Dermatology, Coraopolis, Pa.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to dermnews@frontlinemedcom.com.

 

Angiosarcoma is also known as malignant hemangioendothelioma, hemangiosarcoma, and lymphangiosarcoma. It is an uncommon, high-grade malignant vascular neoplasm of the inner lining of blood vessels. Unlike most sarcomas, it occurs more superficially, most often on the head and neck (particularly on the scalp). This neoplasm occurs twice as often in males as it does in females. Angiosarcomas can occur in the breast after radiation therapy, as well as in the liver and spleen, but 60% are cutaneous.
 

Courtesy Parteek Singla, MD, and Susannah McClain, MD

Most commonly, angiosarcomas are seen in the elderly on sun-damaged sites, such as the head and neck, without lymphedema. Other risk factors include radiation therapy, with lesions typically occurring 5-10 years after treatment. Also, chronic lymphedema (Stewart-Treves syndrome), most commonly following after breast cancer treatment with axillary node dissection, increases the risk of angiosarcomas. This condition has a poor prognosis, with metastases to the lung as the most frequent cause of death.

Clinical exam findings may show a violaceous lesion similar to a bruise on the head and neck that does not heal or bleeds when scratched; this is of particular concern when the lesion has appeared in an area of prior radiation therapy. Deeper tumors may be felt as a soft nodule. Ulceration may be present. Biopsy of the lesion will show hyperchromatic, pleomorphic tumor cells that dissect between collagen bundles with endothelial cells that are multilayered along with hemorrhage. Malignant cells stain positive for CD31, CD34, ERG, and FLI1.

For localized disease, surgery with wide local excision plus adjuvant radiation therapy can be used. For metastatic disease, chemotherapy is the treatment modality of choice. Unfortunately, prognosis is poor, with a 5-year survival rate of about 35% in nonmetastatic angiosarcoma cases. The majority of recurrences – approximately 75% – occur within 24 months of local treatment.

This case and photo were submitted by Parteek Singla, MD, of the division of dermatology at Washington University and at Barnes-Jewish Hospital, both in St. Louis, and by Susannah McClain, MD, of Three Rivers Dermatology, Coraopolis, Pa.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to dermnews@frontlinemedcom.com.

 

Angiosarcoma is also known as malignant hemangioendothelioma, hemangiosarcoma, and lymphangiosarcoma. It is an uncommon, high-grade malignant vascular neoplasm of the inner lining of blood vessels. Unlike most sarcomas, it occurs more superficially, most often on the head and neck (particularly on the scalp). This neoplasm occurs twice as often in males as it does in females. Angiosarcomas can occur in the breast after radiation therapy, as well as in the liver and spleen, but 60% are cutaneous.
 

Courtesy Parteek Singla, MD, and Susannah McClain, MD

Most commonly, angiosarcomas are seen in the elderly on sun-damaged sites, such as the head and neck, without lymphedema. Other risk factors include radiation therapy, with lesions typically occurring 5-10 years after treatment. Also, chronic lymphedema (Stewart-Treves syndrome), most commonly following after breast cancer treatment with axillary node dissection, increases the risk of angiosarcomas. This condition has a poor prognosis, with metastases to the lung as the most frequent cause of death.

Clinical exam findings may show a violaceous lesion similar to a bruise on the head and neck that does not heal or bleeds when scratched; this is of particular concern when the lesion has appeared in an area of prior radiation therapy. Deeper tumors may be felt as a soft nodule. Ulceration may be present. Biopsy of the lesion will show hyperchromatic, pleomorphic tumor cells that dissect between collagen bundles with endothelial cells that are multilayered along with hemorrhage. Malignant cells stain positive for CD31, CD34, ERG, and FLI1.

For localized disease, surgery with wide local excision plus adjuvant radiation therapy can be used. For metastatic disease, chemotherapy is the treatment modality of choice. Unfortunately, prognosis is poor, with a 5-year survival rate of about 35% in nonmetastatic angiosarcoma cases. The majority of recurrences – approximately 75% – occur within 24 months of local treatment.

This case and photo were submitted by Parteek Singla, MD, of the division of dermatology at Washington University and at Barnes-Jewish Hospital, both in St. Louis, and by Susannah McClain, MD, of Three Rivers Dermatology, Coraopolis, Pa.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to dermnews@frontlinemedcom.com.

 

Much has been written over the past year about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and its primary vehicle, the Merit-Based Incentive System (MIPS); but many small practices seem reluctant to take it seriously, despite the fact that it puts yet another significant percentage of our Medicare reimbursements at risk.

Those much-publicized attempts to “repeal and replace” the Affordable Care Act earlier this year undoubtedly contributed to the apathy; but the ACA is apparently here to stay, and the first MIPS “performance period” ends on Dec. 31, so now would be an excellent time to get up to speed. Herewith, the basics:

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU), and it adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC). While the new system won’t be implemented until 2019, performance reporting began in January, and your 2017 reporting will affect your 2019 reimbursements.

Each practice must choose between two payment tracks: either MIPS or one of the so-called Alternate Payment Models (APM). The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries (QCDRs), such as Approved Quality Improvement (AQI); total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The final MACRA regulations, issued last October, allow a more gradual MIPS implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty in 2019 – but not qualify for a bonus – by reporting your performance in only one quality-of-care or practice-improvement category by the end of this year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss, as very few models have been presented – or even defined – to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most of those have failed miserably in real-world settings. The Episode of Care (EOC) model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but this remains untested and in the end may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as APMs that are better and more efficient become available, as it appears that there will be more financial security there, with less risk of penalties; but you will probably need to start in the MIPS program, since most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do so.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of the Center for Medicare & Medicaid Services’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov).

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

 

Much has been written over the past year about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and its primary vehicle, the Merit-Based Incentive System (MIPS); but many small practices seem reluctant to take it seriously, despite the fact that it puts yet another significant percentage of our Medicare reimbursements at risk.

Those much-publicized attempts to “repeal and replace” the Affordable Care Act earlier this year undoubtedly contributed to the apathy; but the ACA is apparently here to stay, and the first MIPS “performance period” ends on Dec. 31, so now would be an excellent time to get up to speed. Herewith, the basics:

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU), and it adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC). While the new system won’t be implemented until 2019, performance reporting began in January, and your 2017 reporting will affect your 2019 reimbursements.

Each practice must choose between two payment tracks: either MIPS or one of the so-called Alternate Payment Models (APM). The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries (QCDRs), such as Approved Quality Improvement (AQI); total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The final MACRA regulations, issued last October, allow a more gradual MIPS implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty in 2019 – but not qualify for a bonus – by reporting your performance in only one quality-of-care or practice-improvement category by the end of this year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss, as very few models have been presented – or even defined – to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most of those have failed miserably in real-world settings. The Episode of Care (EOC) model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but this remains untested and in the end may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as APMs that are better and more efficient become available, as it appears that there will be more financial security there, with less risk of penalties; but you will probably need to start in the MIPS program, since most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do so.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of the Center for Medicare & Medicaid Services’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov).

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

 

Much has been written over the past year about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and its primary vehicle, the Merit-Based Incentive System (MIPS); but many small practices seem reluctant to take it seriously, despite the fact that it puts yet another significant percentage of our Medicare reimbursements at risk.

Those much-publicized attempts to “repeal and replace” the Affordable Care Act earlier this year undoubtedly contributed to the apathy; but the ACA is apparently here to stay, and the first MIPS “performance period” ends on Dec. 31, so now would be an excellent time to get up to speed. Herewith, the basics:

MACRA consolidates three existing quality reporting programs, all of which I have discussed in previous columns: the Physician Quality Reporting System (PQRS); the Value-Based Payment Modifier (VBM), and Meaningful Use (MU), and it adds a “new” program called Clinical Practice Improvement Activities (CPIA), which is actually just another iteration of Maintenance of Certification (MOC). While the new system won’t be implemented until 2019, performance reporting began in January, and your 2017 reporting will affect your 2019 reimbursements.

Each practice must choose between two payment tracks: either MIPS or one of the so-called Alternate Payment Models (APM). The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries (QCDRs), such as Approved Quality Improvement (AQI); total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.

The final MACRA regulations, issued last October, allow a more gradual MIPS implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty in 2019 – but not qualify for a bonus – by reporting your performance in only one quality-of-care or practice-improvement category by the end of this year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.

The alternative, APM, is difficult to discuss, as very few models have been presented – or even defined – to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most of those have failed miserably in real-world settings. The Episode of Care (EOC) model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but this remains untested and in the end may turn out to be just another variant of capitation.

So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as APMs that are better and more efficient become available, as it appears that there will be more financial security there, with less risk of penalties; but you will probably need to start in the MIPS program, since most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do so.

While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of the Center for Medicare & Medicaid Services’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.

First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov).

If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

 

For the final installment of this series, we “flashback” to our April 2016 issue, which featured a study examining 30-day complications among commercially insured adults undergoing colonoscopy with and without anesthesia-assisted sedation using Marketscan data (2008-2011).

While the costs of utilizing anesthesia assistance for an ever-increasing proportion of routine GI procedures are significant, the effect of endoscopic sedation type on patient outcomes provides the most compelling evidence for or against this practice. In this study, use of anesthesia-assisted sedation (generally with propofol) was associated with a 13% increased risk of any 30-day complication, and specifically with an increased perforation risk in those undergoing polypectomy, hemorrhage, abdominal pain, anesthesia-associated complications, and stroke (range of ORs = 1.04-1.28). However, the existence and clinical significance of this differential complication rate remains controversial. For example, a subsequent systematic review and meta-analysis (Clin Gastro Hepatol. 2017;15[12]:194-206), pooling the results of 27 studies including 2,518 patients, concluded that propofol-based sedation had a risk of cardiopulmonary adverse events similar to that of traditional agents, and a decreased risk of overall complications when used for routine GI procedures.

Several letters to the editor challenged the methods used in this systematic review/meta-analysis, such that this question remains largely unresolved. What is clear is that we continue to lack an adequate understanding of which patients are most likely to benefit from anesthesia-assisted sedation, whether due to increased risk of failing standard sedation or increased risk of complications with standard sedation. This lack of clarity, as manifested in poorly specified guidelines, has fueled likely inappropriate allocation of monitored anesthesia care to low risk-patients (driven by a complex interplay of patient, provider, organizational, and economic factors), which has contributed to ballooning health care costs

and potentially impaired access for higher-risk patients in resource-limited settings. Enhanced understanding of which patients are most likely to benefit from anesthesia-assisted sedation is an essential first step in helping to define high-value use of this resource and developing more refined clinical criteria to guide sedation decision making.
 

Megan A. Adams, MS, JD, MSc, is a clinical lecturer in the division of gastroenterology at the University of Michigan, a gastroenterologist at the Ann Arbor Mich, VA, and an investigator in the VA Ann Arbor Center for Clinical Management Research. She is an associate editor of GI & Hepatology News.

 

For the final installment of this series, we “flashback” to our April 2016 issue, which featured a study examining 30-day complications among commercially insured adults undergoing colonoscopy with and without anesthesia-assisted sedation using Marketscan data (2008-2011).

While the costs of utilizing anesthesia assistance for an ever-increasing proportion of routine GI procedures are significant, the effect of endoscopic sedation type on patient outcomes provides the most compelling evidence for or against this practice. In this study, use of anesthesia-assisted sedation (generally with propofol) was associated with a 13% increased risk of any 30-day complication, and specifically with an increased perforation risk in those undergoing polypectomy, hemorrhage, abdominal pain, anesthesia-associated complications, and stroke (range of ORs = 1.04-1.28). However, the existence and clinical significance of this differential complication rate remains controversial. For example, a subsequent systematic review and meta-analysis (Clin Gastro Hepatol. 2017;15[12]:194-206), pooling the results of 27 studies including 2,518 patients, concluded that propofol-based sedation had a risk of cardiopulmonary adverse events similar to that of traditional agents, and a decreased risk of overall complications when used for routine GI procedures.

Several letters to the editor challenged the methods used in this systematic review/meta-analysis, such that this question remains largely unresolved. What is clear is that we continue to lack an adequate understanding of which patients are most likely to benefit from anesthesia-assisted sedation, whether due to increased risk of failing standard sedation or increased risk of complications with standard sedation. This lack of clarity, as manifested in poorly specified guidelines, has fueled likely inappropriate allocation of monitored anesthesia care to low risk-patients (driven by a complex interplay of patient, provider, organizational, and economic factors), which has contributed to ballooning health care costs

and potentially impaired access for higher-risk patients in resource-limited settings. Enhanced understanding of which patients are most likely to benefit from anesthesia-assisted sedation is an essential first step in helping to define high-value use of this resource and developing more refined clinical criteria to guide sedation decision making.
 

Megan A. Adams, MS, JD, MSc, is a clinical lecturer in the division of gastroenterology at the University of Michigan, a gastroenterologist at the Ann Arbor Mich, VA, and an investigator in the VA Ann Arbor Center for Clinical Management Research. She is an associate editor of GI & Hepatology News.

 

For the final installment of this series, we “flashback” to our April 2016 issue, which featured a study examining 30-day complications among commercially insured adults undergoing colonoscopy with and without anesthesia-assisted sedation using Marketscan data (2008-2011).

While the costs of utilizing anesthesia assistance for an ever-increasing proportion of routine GI procedures are significant, the effect of endoscopic sedation type on patient outcomes provides the most compelling evidence for or against this practice. In this study, use of anesthesia-assisted sedation (generally with propofol) was associated with a 13% increased risk of any 30-day complication, and specifically with an increased perforation risk in those undergoing polypectomy, hemorrhage, abdominal pain, anesthesia-associated complications, and stroke (range of ORs = 1.04-1.28). However, the existence and clinical significance of this differential complication rate remains controversial. For example, a subsequent systematic review and meta-analysis (Clin Gastro Hepatol. 2017;15[12]:194-206), pooling the results of 27 studies including 2,518 patients, concluded that propofol-based sedation had a risk of cardiopulmonary adverse events similar to that of traditional agents, and a decreased risk of overall complications when used for routine GI procedures.

Several letters to the editor challenged the methods used in this systematic review/meta-analysis, such that this question remains largely unresolved. What is clear is that we continue to lack an adequate understanding of which patients are most likely to benefit from anesthesia-assisted sedation, whether due to increased risk of failing standard sedation or increased risk of complications with standard sedation. This lack of clarity, as manifested in poorly specified guidelines, has fueled likely inappropriate allocation of monitored anesthesia care to low risk-patients (driven by a complex interplay of patient, provider, organizational, and economic factors), which has contributed to ballooning health care costs

and potentially impaired access for higher-risk patients in resource-limited settings. Enhanced understanding of which patients are most likely to benefit from anesthesia-assisted sedation is an essential first step in helping to define high-value use of this resource and developing more refined clinical criteria to guide sedation decision making.
 

Megan A. Adams, MS, JD, MSc, is a clinical lecturer in the division of gastroenterology at the University of Michigan, a gastroenterologist at the Ann Arbor Mich, VA, and an investigator in the VA Ann Arbor Center for Clinical Management Research. She is an associate editor of GI & Hepatology News.