Managing Editor

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.

As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?

For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.

“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”

If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”

However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”

The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”

Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”

For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.

Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”

Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.

Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”

Hospitals and large health care systems often have an interpreter services department that offers coverage in the most commonly encountered languages. Massachusetts General Hospital, for example, has staff interpreters who speak Spanish, French, and Italian, as well as Arabic, Chinese (two dialects), French Creole, Khmer, Portuguese, Russian, and Vietnamese.

For smaller practices, it may not be practical to have staff interpreters. “To have in-house interpreters, you have to have a good number of patients who speak [a particular language] to warrant having someone on your payroll who needs to be busy all the time,” Fernandez says. “If you only have this issue once in a while, it’s probably worth it to contact a language service over the telephone or video.”

Arocha also touts the benefits of remote interpreting for situations when in-person services are not available. “Remote interpreting [provides] 24/7 access in over 150 languages,” she says, “something that no city, no hospital, is ever going to get, even if they’re in a metropolitan area. There will be a day and a time and a language for which they can’t provide face-to-face services.”

Fernandez cautions that remote interpreting services can be expensive. Arocha says the average rate is around $2 per minute. However, even if a 15-minute call adds up to a $30 bill, “you will take a lot longer not having a professional interpreter there to assist.” There could also be a cost to your patient’s health and well-being if you are unable to provide appropriate care.

Flores encourages clinicians to explore more creative mechanisms to improve language access when traditional interpreter services are unavailable or cost-prohibitive. One clinic in Ohio, for example, “had the creative strategy of training Romance-language majors from the local college as interpreters” and having them volunteer at the clinic. Another option would be to work with local community-based groups that may have bilingual members; these individuals could be trained to provide interpreter services.

Working Together
What you should avoid is falling back on the misconception that anyone who can speak the language is better than no interpreter at all. “There’s now good evidence that the so-called ad hoc interpreters—family, friends, children, people pulled from the waiting room, people actually pulled from the streets—that’s a suboptimal situation and probably endangers patients more,” Flores says. “We know, for example, that they’re more likely to make not only errors but errors of clinical consequence.”

In one of the many studies that Flores has published on this topic (Pediatrics. 2003;111[1]:6-14), a total of 396 interpreter errors were identified in 13 pediatric clinical encounters. Of these, 63% were determined to have clinical consequences, such as the omission of questions about drug allergies and the omission of key information from the medical history.

Ad hoc interpreters—particularly family members—are also prone to editorializing or interjecting their own opinions into the encounter. This is something a professional interpreter is trained not to do. Interpreters do more than translate words from one language to another; they must understand what they are interpreting and provide a context if the patient or provider is confused. But they do not take sides in an encounter.

So how can clinicians guarantee that they are working with a properly trained medical interpreter? Arocha says the bare minimum of training that medical interpreters should have is 40 hours. There is already a trend in the growth of one-year college-based programs across the United States, and since spoken-language interpreters have tended to follow the path of sign-language interpreters, she anticipates the eventual development of Associate’s-degree or even Bachelor’s-degree programs.

“It’s a really highly specialized field,” Arocha points out. “People don’t realize that a medical interpreter needs to have a pretty deep knowledge of medical terminology.” Interpreters who are placed in large medical centers or hospitals, for example, may have to interpret during a primary care session with a patient, then switch to a clinical trial, then move on to a specific department, such as oncology.

“Interpreters really have to be incredibly versatile to be able to accurately interpret,” Arocha says. “That’s important for patient safety.”

In October 2009, the field of medical interpretation got a boost from the launch of the first national certification examination, which will result in a “Certified Medical Interpreter” credential. The Spanish-language exam was the first available; additional languages will be added this year.

“It’s important for health care providers to know about that,” Arocha says. “If they’re ever going to hire an interpreter, they should ask if the person is a certified medical interpreter. If not, they should say, ‘Well, go get certified and come back.’”

When working with an interpreter, it can be helpful to briefly prepare him or her for the upcoming patient encounter—particularly if you will be delivering bad news or if the patient is notoriously difficult. Also, introduce the patient and interpreter, so everyone is clear on what each person’s role is. Train yourself to maintain eye contact with the patient, even when the interpreter is speaking, and use short sentences to allow the interpreter time to comprehend and translate what you say. Remember that while medical interpreters do not take the patient’s or the provider’s side, they are there to help both.

“If we’re going to have a team that makes sure a patient stays healthy,” Arocha says, “the medical interpreter has to be included in that team.”                            

Just two weeks after Breast Cancer Awareness Month ended, the US Preventive Services Task Force (USPSTF) dropped a bombshell on patients and health care providers across the country. The Task Force now recommends against routine screening mammography for breast cancer in average-risk women ages 40 to 49.

The American Cancer Society (ACS) promptly issued a statement from Chief Medical Officer Otis W. Brawley, MD: "The [ACS]continues to recommend annual screening using mammography ... for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. "

Almost instantly, the debate began. Which set of guidelines will clinicians follow? How confusing will the conflicting recommendations be for patients? And perhaps most alarming—and least controllable—which guidelines will insurers base their coverage on?

USPSTF Assessment
"The decision to start regular, biennial screening mammography before the age of 50," the USPSTF says, "should be an individual one and [should] take patient context into account, including the patient's values regarding specific benefits and harms." The Task Force based its recommendation on "convincing evidence" that while mammography reduces breast cancer mortality, the absolute reduction is greater in women ages 50 to 74 than in those ages 40 to 49. Furthermore, the USPSTF says there is "moderate certainty" that the net benefit of mammography screening in the younger age-group is small.

Nelson et al performed a systematic literature review for the USPSTF (Ann Intern Med. 2009; 151[10]:727-737). This analysis revealed a pooled relative risk for breast cancer mortality among women screened with mammography of 0.85 in those ages 40 to 49 and 0.86 in those ages 50 to 59. The researchers also found a "number needed to invite [for screening] to prevent one breast cancer death" of 1,904 for women ages 39 to 49 and 1,339 for those ages 50 to 59. The latter data show, according to the USPSTF, that "the absolute risk reduction ... is greater" for women in the older age-group.

Also published in the same issue of Annals of Internal Medicine were results from a related study by the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009;151[10]:738-747). Mandelblatt et al used six models to predict the benefits and harms of 20 different mammography screening strategies (with various ages of initiation and cessation, as well as different screening frequencies [annual or biennial]).

The Working Group found that "screening every other year from ages 50 to 69 ... is an efficient strategy for reducing breast cancer mortality." Beginning to screen at age 40 provided "additional, albeit small, reductions" that equated to a median one additional breast cancer–related death averted per 1,000 women screened on an annual basis. Annual screening beginning at age 40 also provided a median 33 life-years gained per 1,000 women screened. The Working Group also reported, however, that the rate of false-positive results for annual screening of women from age 40 through 69 was 2,250 per 1,000 women screened.

Based on these and other findings, the USPSTF concluded that "the additional benefit gained by starting screening at age 40 ... rather than at age 50 ... is small, and that moderate harms from screening remain at any age."

The Backlash
According to Brawley's statement, the ACS is aware that "the overall effectiveness of mammography increases with increasing age." However, he added, screening women starting at age 40 does save lives.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age[s] 40 to 49 saves lives; just not enough of them," Brawley stated.

The ACS statement cites recent data indicating that about 17% of breast cancer deaths occur in women diagnosed during their 40s, and 22% occur in those diagnosed during their 50s. Brawley said that ACS staff, members, and supporters "overwhelmingly believe the benefits of screening women ages 40 to 49 outweigh its limitations."

In his online cancer blog (www .cancer.org/aspx/blog), J. Leonard Lichtenfeld, MD, MACP, Deputy Chief Medical Officer of ACS, wrote at length about the new recommendations from USPSTF. He referenced the modeling study by Mandelblatt and colleagues (among other research), noting that depending on which model was used, breast cancer mortality was reduced by as much as 54% when women were screened annually between ages 40 and 84; by comparison, the reduction was 28% when women ages 50 to 74 were screened every two years. Other models revealed little or no difference, he acknowledged.

Lichtenfeld summarized the research this way: "You could get somewhere between 70% and 99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years, as compared to starting at age 40 and doing it every year."

However, he added, ACS "[does not] agree that 70% of the benefit from screening mammograms is the right way to go.... We should not forget that the 'benefit' in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives in not acceptable."

Several patients posted comments to Lichtenfeld's blog, writing in essence that if they had followed what these guidelines propose, they "would be dead at 50." While the USPSTF has stated that the decision to screen at earlier ages should be based on the patient's and provider's judgment, there is concern that insurance companies will adhere to these guidelines, making it more difficult, or more expensive, for women to receive mammograms in their 40s, or on an annual rather than biennial basis.

One patient also expressed frustration with the lack of attention to women who are diagnosed with breast cancer in their 20s and 30s, saying, "If it's going to become more difficult for women in their 40s to get a mammogram, what is that going to do for women in their 20s and 30s, who already get blown off by their health care providers when they come in with a lump?"

There will undoubtedly be ongoing debate and discussion as to what impact the USPSTF recommendations will have, and clinicians will need to be prepared to answer questions from concerned (or even angry) patients. Lichtenfeld perhaps said it best in this blog posting: "These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing, since the experts can't seem to make up their minds."

Just two weeks after Breast Cancer Awareness Month ended, the US Preventive Services Task Force (USPSTF) dropped a bombshell on patients and health care providers across the country. The Task Force now recommends against routine screening mammography for breast cancer in average-risk women ages 40 to 49.

The American Cancer Society (ACS) promptly issued a statement from Chief Medical Officer Otis W. Brawley, MD: "The [ACS]continues to recommend annual screening using mammography ... for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. "

Almost instantly, the debate began. Which set of guidelines will clinicians follow? How confusing will the conflicting recommendations be for patients? And perhaps most alarming—and least controllable—which guidelines will insurers base their coverage on?

USPSTF Assessment
"The decision to start regular, biennial screening mammography before the age of 50," the USPSTF says, "should be an individual one and [should] take patient context into account, including the patient's values regarding specific benefits and harms." The Task Force based its recommendation on "convincing evidence" that while mammography reduces breast cancer mortality, the absolute reduction is greater in women ages 50 to 74 than in those ages 40 to 49. Furthermore, the USPSTF says there is "moderate certainty" that the net benefit of mammography screening in the younger age-group is small.

Nelson et al performed a systematic literature review for the USPSTF (Ann Intern Med. 2009; 151[10]:727-737). This analysis revealed a pooled relative risk for breast cancer mortality among women screened with mammography of 0.85 in those ages 40 to 49 and 0.86 in those ages 50 to 59. The researchers also found a "number needed to invite [for screening] to prevent one breast cancer death" of 1,904 for women ages 39 to 49 and 1,339 for those ages 50 to 59. The latter data show, according to the USPSTF, that "the absolute risk reduction ... is greater" for women in the older age-group.

Also published in the same issue of Annals of Internal Medicine were results from a related study by the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009;151[10]:738-747). Mandelblatt et al used six models to predict the benefits and harms of 20 different mammography screening strategies (with various ages of initiation and cessation, as well as different screening frequencies [annual or biennial]).

The Working Group found that "screening every other year from ages 50 to 69 ... is an efficient strategy for reducing breast cancer mortality." Beginning to screen at age 40 provided "additional, albeit small, reductions" that equated to a median one additional breast cancer–related death averted per 1,000 women screened on an annual basis. Annual screening beginning at age 40 also provided a median 33 life-years gained per 1,000 women screened. The Working Group also reported, however, that the rate of false-positive results for annual screening of women from age 40 through 69 was 2,250 per 1,000 women screened.

Based on these and other findings, the USPSTF concluded that "the additional benefit gained by starting screening at age 40 ... rather than at age 50 ... is small, and that moderate harms from screening remain at any age."

The Backlash
According to Brawley's statement, the ACS is aware that "the overall effectiveness of mammography increases with increasing age." However, he added, screening women starting at age 40 does save lives.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age[s] 40 to 49 saves lives; just not enough of them," Brawley stated.

The ACS statement cites recent data indicating that about 17% of breast cancer deaths occur in women diagnosed during their 40s, and 22% occur in those diagnosed during their 50s. Brawley said that ACS staff, members, and supporters "overwhelmingly believe the benefits of screening women ages 40 to 49 outweigh its limitations."

In his online cancer blog (www .cancer.org/aspx/blog), J. Leonard Lichtenfeld, MD, MACP, Deputy Chief Medical Officer of ACS, wrote at length about the new recommendations from USPSTF. He referenced the modeling study by Mandelblatt and colleagues (among other research), noting that depending on which model was used, breast cancer mortality was reduced by as much as 54% when women were screened annually between ages 40 and 84; by comparison, the reduction was 28% when women ages 50 to 74 were screened every two years. Other models revealed little or no difference, he acknowledged.

Lichtenfeld summarized the research this way: "You could get somewhere between 70% and 99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years, as compared to starting at age 40 and doing it every year."

However, he added, ACS "[does not] agree that 70% of the benefit from screening mammograms is the right way to go.... We should not forget that the 'benefit' in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives in not acceptable."

Several patients posted comments to Lichtenfeld's blog, writing in essence that if they had followed what these guidelines propose, they "would be dead at 50." While the USPSTF has stated that the decision to screen at earlier ages should be based on the patient's and provider's judgment, there is concern that insurance companies will adhere to these guidelines, making it more difficult, or more expensive, for women to receive mammograms in their 40s, or on an annual rather than biennial basis.

One patient also expressed frustration with the lack of attention to women who are diagnosed with breast cancer in their 20s and 30s, saying, "If it's going to become more difficult for women in their 40s to get a mammogram, what is that going to do for women in their 20s and 30s, who already get blown off by their health care providers when they come in with a lump?"

There will undoubtedly be ongoing debate and discussion as to what impact the USPSTF recommendations will have, and clinicians will need to be prepared to answer questions from concerned (or even angry) patients. Lichtenfeld perhaps said it best in this blog posting: "These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing, since the experts can't seem to make up their minds."

Just two weeks after Breast Cancer Awareness Month ended, the US Preventive Services Task Force (USPSTF) dropped a bombshell on patients and health care providers across the country. The Task Force now recommends against routine screening mammography for breast cancer in average-risk women ages 40 to 49.

The American Cancer Society (ACS) promptly issued a statement from Chief Medical Officer Otis W. Brawley, MD: "The [ACS]continues to recommend annual screening using mammography ... for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. "

Almost instantly, the debate began. Which set of guidelines will clinicians follow? How confusing will the conflicting recommendations be for patients? And perhaps most alarming—and least controllable—which guidelines will insurers base their coverage on?

USPSTF Assessment
"The decision to start regular, biennial screening mammography before the age of 50," the USPSTF says, "should be an individual one and [should] take patient context into account, including the patient's values regarding specific benefits and harms." The Task Force based its recommendation on "convincing evidence" that while mammography reduces breast cancer mortality, the absolute reduction is greater in women ages 50 to 74 than in those ages 40 to 49. Furthermore, the USPSTF says there is "moderate certainty" that the net benefit of mammography screening in the younger age-group is small.

Nelson et al performed a systematic literature review for the USPSTF (Ann Intern Med. 2009; 151[10]:727-737). This analysis revealed a pooled relative risk for breast cancer mortality among women screened with mammography of 0.85 in those ages 40 to 49 and 0.86 in those ages 50 to 59. The researchers also found a "number needed to invite [for screening] to prevent one breast cancer death" of 1,904 for women ages 39 to 49 and 1,339 for those ages 50 to 59. The latter data show, according to the USPSTF, that "the absolute risk reduction ... is greater" for women in the older age-group.

Also published in the same issue of Annals of Internal Medicine were results from a related study by the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009;151[10]:738-747). Mandelblatt et al used six models to predict the benefits and harms of 20 different mammography screening strategies (with various ages of initiation and cessation, as well as different screening frequencies [annual or biennial]).

The Working Group found that "screening every other year from ages 50 to 69 ... is an efficient strategy for reducing breast cancer mortality." Beginning to screen at age 40 provided "additional, albeit small, reductions" that equated to a median one additional breast cancer–related death averted per 1,000 women screened on an annual basis. Annual screening beginning at age 40 also provided a median 33 life-years gained per 1,000 women screened. The Working Group also reported, however, that the rate of false-positive results for annual screening of women from age 40 through 69 was 2,250 per 1,000 women screened.

Based on these and other findings, the USPSTF concluded that "the additional benefit gained by starting screening at age 40 ... rather than at age 50 ... is small, and that moderate harms from screening remain at any age."

The Backlash
According to Brawley's statement, the ACS is aware that "the overall effectiveness of mammography increases with increasing age." However, he added, screening women starting at age 40 does save lives.

"With its new recommendations, the USPSTF is essentially telling women that mammography at age[s] 40 to 49 saves lives; just not enough of them," Brawley stated.

The ACS statement cites recent data indicating that about 17% of breast cancer deaths occur in women diagnosed during their 40s, and 22% occur in those diagnosed during their 50s. Brawley said that ACS staff, members, and supporters "overwhelmingly believe the benefits of screening women ages 40 to 49 outweigh its limitations."

In his online cancer blog (www .cancer.org/aspx/blog), J. Leonard Lichtenfeld, MD, MACP, Deputy Chief Medical Officer of ACS, wrote at length about the new recommendations from USPSTF. He referenced the modeling study by Mandelblatt and colleagues (among other research), noting that depending on which model was used, breast cancer mortality was reduced by as much as 54% when women were screened annually between ages 40 and 84; by comparison, the reduction was 28% when women ages 50 to 74 were screened every two years. Other models revealed little or no difference, he acknowledged.

Lichtenfeld summarized the research this way: "You could get somewhere between 70% and 99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years, as compared to starting at age 40 and doing it every year."

However, he added, ACS "[does not] agree that 70% of the benefit from screening mammograms is the right way to go.... We should not forget that the 'benefit' in this situation is reducing deaths from breast cancer. A 30% reduction in saving lives in not acceptable."

Several patients posted comments to Lichtenfeld's blog, writing in essence that if they had followed what these guidelines propose, they "would be dead at 50." While the USPSTF has stated that the decision to screen at earlier ages should be based on the patient's and provider's judgment, there is concern that insurance companies will adhere to these guidelines, making it more difficult, or more expensive, for women to receive mammograms in their 40s, or on an annual rather than biennial basis.

One patient also expressed frustration with the lack of attention to women who are diagnosed with breast cancer in their 20s and 30s, saying, "If it's going to become more difficult for women in their 40s to get a mammogram, what is that going to do for women in their 20s and 30s, who already get blown off by their health care providers when they come in with a lump?"

There will undoubtedly be ongoing debate and discussion as to what impact the USPSTF recommendations will have, and clinicians will need to be prepared to answer questions from concerned (or even angry) patients. Lichtenfeld perhaps said it best in this blog posting: "These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow. The worst outcome would be if the confusion leads women to do nothing, since the experts can't seem to make up their minds."

When The Journal of Family Practice asked family physicians across the country whether access to primary care was a serious problem in their communities, the answer was a unanimous Yes. Each of the physicians we interviewed is taking steps to increase access. But all agree that the problems contributing to the growing crisis—including a shrinking pool of primary care physicians (PCPs)—are too big to be solved without a national policy shift.

“Physicians owe so much by the time they finish medical school that unless reimbursement is substantially increased, deciding on primary care will be a very difficult decision to make,” says KAROL DAVIS, MD, a family physician (FP) at Heartland Primary Care in Kansas City, Kan.

STANLEY KOZAKOWSKI, MD, director of the Hunterdon Medical Center Family Medicine Residency in Flemington, NJ, echoes Davis’s concern. “We need to address the inequities between the earnings of primary care and non-primary care physicians,” he says, adding that by some accounts, what’s needed is an increase in PCP salaries in the order of 60%.

But money is neither the sole problem, nor the sole solution. An advocate of the patient-centered medical home, Kozakowski would end the “hamster wheel model” of practice—in which PCPs squeeze more and more patients into shorter and shorter time slots, but can never catch up. To enable FPs to partner with and coordinate care for their patients, he maintains, “We need to redesign our system to support an advanced primary care model.” In the model he envisions, a PCP’s panel might be closer to 1000 than 2300.

That’s in sharp contrast to the 3300-patient panel of DAVID SWITZER, MD. An FP with Page Healthcare Associates in rural Luray, Va, Switzer has spent the last 12 years in this community, a designated primary care shortage area. “As the population ages and fewer doctors go into primary care,” he says, “the problem is only going to get worse.”

Improving access, 1 practice at a time

While Switzer agrees that “as a society, we need to figure out ways to make it more attractive for physicians to enter primary care disciplines,” he also believes—as do the other FPs we spoke to—that increasing access is the responsibility of individual physicians, too.

With that in mind, his rural practice added 1 full-time and 1 half-time physician a year ago. That increased access in terms of “warm bodies,” Switzer notes, “but we were hampered by space constraints because we had no additional exam rooms.” The solution? The practice instituted staggered schedules, which resulted in opening up earlier in the morning and remaining open a little later in the day.

To further improve access, Switzer and his colleagues implemented an open-access scheduling system. “That has certainly made us more accessible than the conventional scheduling system we previously used,” he acknowledges. “But when you’re limited in terms of capacity, as we are, open access can only go so far.”

If Switzer is not counting on health care reform to fix the PCP access problem, he is hopeful that the recent affliation of his employer, Page Memorial Hospital, with a larger regional health system will make the group more attractive to recruits over the next year or 2. “We now have access to capital to expand the office space, which will help increase our capacity,” he says. Equally helpful is the hospital’s new “convenient care” clinic, adjacent to the emergency department (ED), where patients can go for after-hours care at primary care—not ED—prices.

Heartland Primary Care in Kansas City runs its own urgent care clinic, which is open until 8 pm during the week and until 2 pm on Saturdays and Sundays. Although Davis rotates with several other physicians and nurse practitioners (NPs) in the practice (she works 1 evening a week and 1 weekend a month), after-hours care outside of the hospital is not the norm in their area.

“We routinely see patients at the clinic who have their own PCP, but their doctors close their doors at the end of the day and tell them if they’re sick to go to the ED or to our urgent care clinic, “Davis says. Those who choose the clinic, according to Davis, fare considerably better, in terms of convenience as well as costs: “We’ve gotten the wait down to a point where it’s usually less than 20 minutes,” she says. “At the ED down the street, I’m told, patients can wait as long as 3 hours.”

Davis has taken additional steps to improve patient access. After having a closed panel for 2 years, she hired an NP to help her work down the backlog and see more patients. Now she’s able to accommodate 2 new patients every workday. “I love meeting new people and would like to accept more new patients,” says Davis. But her panel size—now at 2700—is approaching the point where she may have to close it again.

While some FPs are frustrated by the focus of reform efforts, Davis sees the proposed legislation as an important first step. Another step in the right direction would be to institute reimbursement for electronic patient interactions, she adds, such as those supported by the patient portal Heartland is about to launch. Another key step: Require public and private health plans alike to pay higher fees for after-hours care.

“Plumbers get paid extra for working on Sundays,” Davis points out. “Why shouldn’t we?”

KATE ROWLAND, MD, an FP at Advocate Illinois Masonic Family Medicine Residency in Chicago, says that the residency clinic where she works has taken another step toward increasing access: The group has instituted formal walk-in hours. Between 8 and 10 am, established patients with acute care needs can come in without an appointment and be guaranteed that they’ll be seen by noon.

The new approach—a modified version of same-day scheduling—has been tremendously successful, she says, and relieved a good deal of pressure. Still, “We see some 3000 patients per month, and have just gotten busier and busier.”

What else can be done?

Rowland favors taking small steps, 1 at a time: extending clinic hours (it is now open until 7 pm 2 evenings a week and from 8 am until noon on Saturdays); reallocating physician duties, as needed; and establishing classes for patients with similar issues, such as asthma and diabetes, among other innovations.

She maintains, however, that the US health system is devoted to curing disease and prolonging life rather than on keeping the population healthy. A major refocus is needed for lasting change to occur, Rowland says. But will governmental policy changes and physician culture shift in the right direction?

“Medicine is incredibly stagnant,” the 31-year-old Rowland says. “I wonder whether we’ll still have the same chaotic system when I’m ready to retire.”

When The Journal of Family Practice asked family physicians across the country whether access to primary care was a serious problem in their communities, the answer was a unanimous Yes. Each of the physicians we interviewed is taking steps to increase access. But all agree that the problems contributing to the growing crisis—including a shrinking pool of primary care physicians (PCPs)—are too big to be solved without a national policy shift.

“Physicians owe so much by the time they finish medical school that unless reimbursement is substantially increased, deciding on primary care will be a very difficult decision to make,” says KAROL DAVIS, MD, a family physician (FP) at Heartland Primary Care in Kansas City, Kan.

STANLEY KOZAKOWSKI, MD, director of the Hunterdon Medical Center Family Medicine Residency in Flemington, NJ, echoes Davis’s concern. “We need to address the inequities between the earnings of primary care and non-primary care physicians,” he says, adding that by some accounts, what’s needed is an increase in PCP salaries in the order of 60%.

But money is neither the sole problem, nor the sole solution. An advocate of the patient-centered medical home, Kozakowski would end the “hamster wheel model” of practice—in which PCPs squeeze more and more patients into shorter and shorter time slots, but can never catch up. To enable FPs to partner with and coordinate care for their patients, he maintains, “We need to redesign our system to support an advanced primary care model.” In the model he envisions, a PCP’s panel might be closer to 1000 than 2300.

That’s in sharp contrast to the 3300-patient panel of DAVID SWITZER, MD. An FP with Page Healthcare Associates in rural Luray, Va, Switzer has spent the last 12 years in this community, a designated primary care shortage area. “As the population ages and fewer doctors go into primary care,” he says, “the problem is only going to get worse.”

Improving access, 1 practice at a time

While Switzer agrees that “as a society, we need to figure out ways to make it more attractive for physicians to enter primary care disciplines,” he also believes—as do the other FPs we spoke to—that increasing access is the responsibility of individual physicians, too.

With that in mind, his rural practice added 1 full-time and 1 half-time physician a year ago. That increased access in terms of “warm bodies,” Switzer notes, “but we were hampered by space constraints because we had no additional exam rooms.” The solution? The practice instituted staggered schedules, which resulted in opening up earlier in the morning and remaining open a little later in the day.

To further improve access, Switzer and his colleagues implemented an open-access scheduling system. “That has certainly made us more accessible than the conventional scheduling system we previously used,” he acknowledges. “But when you’re limited in terms of capacity, as we are, open access can only go so far.”

If Switzer is not counting on health care reform to fix the PCP access problem, he is hopeful that the recent affliation of his employer, Page Memorial Hospital, with a larger regional health system will make the group more attractive to recruits over the next year or 2. “We now have access to capital to expand the office space, which will help increase our capacity,” he says. Equally helpful is the hospital’s new “convenient care” clinic, adjacent to the emergency department (ED), where patients can go for after-hours care at primary care—not ED—prices.

Heartland Primary Care in Kansas City runs its own urgent care clinic, which is open until 8 pm during the week and until 2 pm on Saturdays and Sundays. Although Davis rotates with several other physicians and nurse practitioners (NPs) in the practice (she works 1 evening a week and 1 weekend a month), after-hours care outside of the hospital is not the norm in their area.

“We routinely see patients at the clinic who have their own PCP, but their doctors close their doors at the end of the day and tell them if they’re sick to go to the ED or to our urgent care clinic, “Davis says. Those who choose the clinic, according to Davis, fare considerably better, in terms of convenience as well as costs: “We’ve gotten the wait down to a point where it’s usually less than 20 minutes,” she says. “At the ED down the street, I’m told, patients can wait as long as 3 hours.”

Davis has taken additional steps to improve patient access. After having a closed panel for 2 years, she hired an NP to help her work down the backlog and see more patients. Now she’s able to accommodate 2 new patients every workday. “I love meeting new people and would like to accept more new patients,” says Davis. But her panel size—now at 2700—is approaching the point where she may have to close it again.

While some FPs are frustrated by the focus of reform efforts, Davis sees the proposed legislation as an important first step. Another step in the right direction would be to institute reimbursement for electronic patient interactions, she adds, such as those supported by the patient portal Heartland is about to launch. Another key step: Require public and private health plans alike to pay higher fees for after-hours care.

“Plumbers get paid extra for working on Sundays,” Davis points out. “Why shouldn’t we?”

KATE ROWLAND, MD, an FP at Advocate Illinois Masonic Family Medicine Residency in Chicago, says that the residency clinic where she works has taken another step toward increasing access: The group has instituted formal walk-in hours. Between 8 and 10 am, established patients with acute care needs can come in without an appointment and be guaranteed that they’ll be seen by noon.

The new approach—a modified version of same-day scheduling—has been tremendously successful, she says, and relieved a good deal of pressure. Still, “We see some 3000 patients per month, and have just gotten busier and busier.”

What else can be done?

Rowland favors taking small steps, 1 at a time: extending clinic hours (it is now open until 7 pm 2 evenings a week and from 8 am until noon on Saturdays); reallocating physician duties, as needed; and establishing classes for patients with similar issues, such as asthma and diabetes, among other innovations.

She maintains, however, that the US health system is devoted to curing disease and prolonging life rather than on keeping the population healthy. A major refocus is needed for lasting change to occur, Rowland says. But will governmental policy changes and physician culture shift in the right direction?

“Medicine is incredibly stagnant,” the 31-year-old Rowland says. “I wonder whether we’ll still have the same chaotic system when I’m ready to retire.”

When The Journal of Family Practice asked family physicians across the country whether access to primary care was a serious problem in their communities, the answer was a unanimous Yes. Each of the physicians we interviewed is taking steps to increase access. But all agree that the problems contributing to the growing crisis—including a shrinking pool of primary care physicians (PCPs)—are too big to be solved without a national policy shift.

“Physicians owe so much by the time they finish medical school that unless reimbursement is substantially increased, deciding on primary care will be a very difficult decision to make,” says KAROL DAVIS, MD, a family physician (FP) at Heartland Primary Care in Kansas City, Kan.

STANLEY KOZAKOWSKI, MD, director of the Hunterdon Medical Center Family Medicine Residency in Flemington, NJ, echoes Davis’s concern. “We need to address the inequities between the earnings of primary care and non-primary care physicians,” he says, adding that by some accounts, what’s needed is an increase in PCP salaries in the order of 60%.

But money is neither the sole problem, nor the sole solution. An advocate of the patient-centered medical home, Kozakowski would end the “hamster wheel model” of practice—in which PCPs squeeze more and more patients into shorter and shorter time slots, but can never catch up. To enable FPs to partner with and coordinate care for their patients, he maintains, “We need to redesign our system to support an advanced primary care model.” In the model he envisions, a PCP’s panel might be closer to 1000 than 2300.

That’s in sharp contrast to the 3300-patient panel of DAVID SWITZER, MD. An FP with Page Healthcare Associates in rural Luray, Va, Switzer has spent the last 12 years in this community, a designated primary care shortage area. “As the population ages and fewer doctors go into primary care,” he says, “the problem is only going to get worse.”

Improving access, 1 practice at a time

While Switzer agrees that “as a society, we need to figure out ways to make it more attractive for physicians to enter primary care disciplines,” he also believes—as do the other FPs we spoke to—that increasing access is the responsibility of individual physicians, too.

With that in mind, his rural practice added 1 full-time and 1 half-time physician a year ago. That increased access in terms of “warm bodies,” Switzer notes, “but we were hampered by space constraints because we had no additional exam rooms.” The solution? The practice instituted staggered schedules, which resulted in opening up earlier in the morning and remaining open a little later in the day.

To further improve access, Switzer and his colleagues implemented an open-access scheduling system. “That has certainly made us more accessible than the conventional scheduling system we previously used,” he acknowledges. “But when you’re limited in terms of capacity, as we are, open access can only go so far.”

If Switzer is not counting on health care reform to fix the PCP access problem, he is hopeful that the recent affliation of his employer, Page Memorial Hospital, with a larger regional health system will make the group more attractive to recruits over the next year or 2. “We now have access to capital to expand the office space, which will help increase our capacity,” he says. Equally helpful is the hospital’s new “convenient care” clinic, adjacent to the emergency department (ED), where patients can go for after-hours care at primary care—not ED—prices.

Heartland Primary Care in Kansas City runs its own urgent care clinic, which is open until 8 pm during the week and until 2 pm on Saturdays and Sundays. Although Davis rotates with several other physicians and nurse practitioners (NPs) in the practice (she works 1 evening a week and 1 weekend a month), after-hours care outside of the hospital is not the norm in their area.

“We routinely see patients at the clinic who have their own PCP, but their doctors close their doors at the end of the day and tell them if they’re sick to go to the ED or to our urgent care clinic, “Davis says. Those who choose the clinic, according to Davis, fare considerably better, in terms of convenience as well as costs: “We’ve gotten the wait down to a point where it’s usually less than 20 minutes,” she says. “At the ED down the street, I’m told, patients can wait as long as 3 hours.”

Davis has taken additional steps to improve patient access. After having a closed panel for 2 years, she hired an NP to help her work down the backlog and see more patients. Now she’s able to accommodate 2 new patients every workday. “I love meeting new people and would like to accept more new patients,” says Davis. But her panel size—now at 2700—is approaching the point where she may have to close it again.

While some FPs are frustrated by the focus of reform efforts, Davis sees the proposed legislation as an important first step. Another step in the right direction would be to institute reimbursement for electronic patient interactions, she adds, such as those supported by the patient portal Heartland is about to launch. Another key step: Require public and private health plans alike to pay higher fees for after-hours care.

“Plumbers get paid extra for working on Sundays,” Davis points out. “Why shouldn’t we?”

KATE ROWLAND, MD, an FP at Advocate Illinois Masonic Family Medicine Residency in Chicago, says that the residency clinic where she works has taken another step toward increasing access: The group has instituted formal walk-in hours. Between 8 and 10 am, established patients with acute care needs can come in without an appointment and be guaranteed that they’ll be seen by noon.

The new approach—a modified version of same-day scheduling—has been tremendously successful, she says, and relieved a good deal of pressure. Still, “We see some 3000 patients per month, and have just gotten busier and busier.”

What else can be done?

Rowland favors taking small steps, 1 at a time: extending clinic hours (it is now open until 7 pm 2 evenings a week and from 8 am until noon on Saturdays); reallocating physician duties, as needed; and establishing classes for patients with similar issues, such as asthma and diabetes, among other innovations.

She maintains, however, that the US health system is devoted to curing disease and prolonging life rather than on keeping the population healthy. A major refocus is needed for lasting change to occur, Rowland says. But will governmental policy changes and physician culture shift in the right direction?

“Medicine is incredibly stagnant,” the 31-year-old Rowland says. “I wonder whether we’ll still have the same chaotic system when I’m ready to retire.”

Regular readers of “Malpractice Chronicle” know that all types of cases—from instances of clear-cut negligence to those of obvious noncompliance by the patient—find their way into the legal system. It often seems that there is no rhyme or reason to how a verdict is decided or how high the judgment or settlement is. In light of this unpredictability, protecting yourself—with liability insurance acquired through your practice or on your own—seems like a no-brainer.

Always There for You
It’s hard to imagine any clinician “going bare” and having no liability coverage at all. At the very least, most will be covered by their employer’s policy. But there are advantages to having your own malpractice insurance.

For one thing, it’s portable—wherever you practice, the policy goes with you—and it covers all aspects of professional liability. “It protects you 24 hours a day, so if you’re moonlighting, if you’re volunteering, you’re protected,” says Rebecca S. Crosby, Vice President of Marsh, the insurance brokerage for the American Academy of Nurse Practitioners (AANP). “It also protects you if you give advice—friends and family sue, too.” The policies offered through AANP and the American Academy of Physician Assistants (AAPA) also provide coverage for policyholders who are called before their state licensing board.

The policy is also 100% yours. “You are the only named person on the policy, so the limits are not shared,” says Ellen Rathfon, Senior Director of Professional Affairs for AAPA. “If you’re covered by your employer, the limits may be shared among several people—or a lot of people, depending on what kind of policy it is.”

In the event of a lawsuit, you will have your own legal representation. “There can be conflicts of interest between an employer or a supervising physician and the PA; they could be pointing fingers at each other,” says Gary M. McCammon, President of Professional Risk Advisors, Inc, the AAPA’s insurance broker. “And when a case is ultimately settled, or maybe it even goes to trial, the apportionment of liability can be greater if the PA is not in a position to negotiate his own liability.”

This can be important, because settlement information is reported to the National Practitioner Data Bank. Cases are often settled because it is ultimately less costly than taking a case to trial. Even a successful defense costs money, after all. But if a group of providers is named in the settlement, and they are covered by a single employer policy, the individual clinician may not be in a position to decide what portion of the settlement is his or her responsibility.

“Now, it doesn’t come out of their pocket, it comes out of the insurance,” Rathfon acknowledges. “But in the Data Bank, that clinician might have a high payment value.”

 ow Risk, High Cost?
You may think that PAs and NPs don’t get sued. Actually, they do. Not as often as physicians do, certainly, but even a small risk can carry a big price tag.

An analysis of data from the National Practitioner Data Bank, published earlier this year in the Journal of Medical Licensure and Discipline (a publication of the Federation of State Medical Boards), indicated that approximately 3% of active PAs and at least 1.5% of active APNs made a payment during the 17-year study period. However, while PAs and APNs accounted for 0.003% and 0.007%, respectively, of the $74 billion in malpractice payments made from 1991 to 2008, the mean/median payments for these providers were $173,128/$80,003 and $350,540/$190,898, respectively. The risk may be small, but is it one clinicians can afford?

“If you look at the spread of payments, some of them are really high,” Rathfon says. “And I think most people look at that and say, ‘I don’t want to take that risk.’”

In some cases, verdicts are exceeding even the limits of the defendant’s insurance, says Michele Kauffman, JD, PA-C, Chair of the Physician Assistant Department at Gannon University in Erie, Pennsylvania. This can open clinicians up to personal liability; while this hasn’t really happened yet, it’s a sobering possibility.

“Some states—Pennsylvania is one of them—now require PAs and NPs to have a minimum insurance, whether it’s through their employer or on their own,” Kauffman says. “In order to get their license, they have to prove that they have that insurance.”

Oh, and that old “deep pocket” argument—the idea that having liability insurance will just make you a target for litigation—is “a fallacy,” according to Crosby. “They’re going after everybody who even said ‘good morning’ to the patient. They don’t know if you have insurance until you’re in the discovery phase of the case.” By then, it’s too late to think about obtaining malpractice coverage.

Know Your Limits
Whether or not you opt for your own policy, know what coverage you do have. If you’re covered through your employer, make sure you have (at the very least) a copy of the declarations page, which will provide the name of the insurance company, the policy number, and the terms of coverage. McCammon suggests making it a condition of your employment that your employer will provide this information every year.

“People need to know their limits and know that they are individually named under those limits,” Rathfon says. “And they need to feel confident that there’s enough coverage, whatever the policy is, whether it’s their own or through their employer.”

Familiarize yourself with the type of policy you have: Is it occurrence-based or claims-made coverage? The former applies to any incident that occurs during the period of coverage, even if the claim is made years later. The latter covers claims filed during the life of the policy; people with this type of policy often purchase tail coverage to close any gaps that may occur. McCammon, who has authored a series of articles on liability insurance that can be found in the “Advocacy and Practice Resources” section on the AAPA Web site (www.aapa.org), says one type is not better than the other.

Occurrence-based coverage may be easier to manage; you file a copy for your records and hope you never need it. As Crosby says, “You can be retired and lying on the beach in Florida, and if there’s a lawsuit over something that happened in your last year of work, you would be covered.”

However, the economic downturn has highlighted one drawback to occurrence-based coverage: The company that covered you 10 or 20 years ago may not be in business by the time you have a claim. “Ten or 20 years ago, that was not a real issue,” McCammon says, “because companies just didn’t go under. But in this day and age, companies are getting out of the business or going out of business.”

That doesn’t mean you should avoid occurrence-based policies. But you might do a little extra homework on a company’s financial stability and longevity.

Rates depend on a number of factors, including geographic location and specialty of practice. AANP members can find information at www.proliability.com. AAPA members can contact AAPA Insurance Services at (877) 356-2272.

Regular readers of “Malpractice Chronicle” know that all types of cases—from instances of clear-cut negligence to those of obvious noncompliance by the patient—find their way into the legal system. It often seems that there is no rhyme or reason to how a verdict is decided or how high the judgment or settlement is. In light of this unpredictability, protecting yourself—with liability insurance acquired through your practice or on your own—seems like a no-brainer.

Always There for You
It’s hard to imagine any clinician “going bare” and having no liability coverage at all. At the very least, most will be covered by their employer’s policy. But there are advantages to having your own malpractice insurance.

For one thing, it’s portable—wherever you practice, the policy goes with you—and it covers all aspects of professional liability. “It protects you 24 hours a day, so if you’re moonlighting, if you’re volunteering, you’re protected,” says Rebecca S. Crosby, Vice President of Marsh, the insurance brokerage for the American Academy of Nurse Practitioners (AANP). “It also protects you if you give advice—friends and family sue, too.” The policies offered through AANP and the American Academy of Physician Assistants (AAPA) also provide coverage for policyholders who are called before their state licensing board.

The policy is also 100% yours. “You are the only named person on the policy, so the limits are not shared,” says Ellen Rathfon, Senior Director of Professional Affairs for AAPA. “If you’re covered by your employer, the limits may be shared among several people—or a lot of people, depending on what kind of policy it is.”

In the event of a lawsuit, you will have your own legal representation. “There can be conflicts of interest between an employer or a supervising physician and the PA; they could be pointing fingers at each other,” says Gary M. McCammon, President of Professional Risk Advisors, Inc, the AAPA’s insurance broker. “And when a case is ultimately settled, or maybe it even goes to trial, the apportionment of liability can be greater if the PA is not in a position to negotiate his own liability.”

This can be important, because settlement information is reported to the National Practitioner Data Bank. Cases are often settled because it is ultimately less costly than taking a case to trial. Even a successful defense costs money, after all. But if a group of providers is named in the settlement, and they are covered by a single employer policy, the individual clinician may not be in a position to decide what portion of the settlement is his or her responsibility.

“Now, it doesn’t come out of their pocket, it comes out of the insurance,” Rathfon acknowledges. “But in the Data Bank, that clinician might have a high payment value.”

 ow Risk, High Cost?
You may think that PAs and NPs don’t get sued. Actually, they do. Not as often as physicians do, certainly, but even a small risk can carry a big price tag.

An analysis of data from the National Practitioner Data Bank, published earlier this year in the Journal of Medical Licensure and Discipline (a publication of the Federation of State Medical Boards), indicated that approximately 3% of active PAs and at least 1.5% of active APNs made a payment during the 17-year study period. However, while PAs and APNs accounted for 0.003% and 0.007%, respectively, of the $74 billion in malpractice payments made from 1991 to 2008, the mean/median payments for these providers were $173,128/$80,003 and $350,540/$190,898, respectively. The risk may be small, but is it one clinicians can afford?

“If you look at the spread of payments, some of them are really high,” Rathfon says. “And I think most people look at that and say, ‘I don’t want to take that risk.’”

In some cases, verdicts are exceeding even the limits of the defendant’s insurance, says Michele Kauffman, JD, PA-C, Chair of the Physician Assistant Department at Gannon University in Erie, Pennsylvania. This can open clinicians up to personal liability; while this hasn’t really happened yet, it’s a sobering possibility.

“Some states—Pennsylvania is one of them—now require PAs and NPs to have a minimum insurance, whether it’s through their employer or on their own,” Kauffman says. “In order to get their license, they have to prove that they have that insurance.”

Oh, and that old “deep pocket” argument—the idea that having liability insurance will just make you a target for litigation—is “a fallacy,” according to Crosby. “They’re going after everybody who even said ‘good morning’ to the patient. They don’t know if you have insurance until you’re in the discovery phase of the case.” By then, it’s too late to think about obtaining malpractice coverage.

Know Your Limits
Whether or not you opt for your own policy, know what coverage you do have. If you’re covered through your employer, make sure you have (at the very least) a copy of the declarations page, which will provide the name of the insurance company, the policy number, and the terms of coverage. McCammon suggests making it a condition of your employment that your employer will provide this information every year.

“People need to know their limits and know that they are individually named under those limits,” Rathfon says. “And they need to feel confident that there’s enough coverage, whatever the policy is, whether it’s their own or through their employer.”

Familiarize yourself with the type of policy you have: Is it occurrence-based or claims-made coverage? The former applies to any incident that occurs during the period of coverage, even if the claim is made years later. The latter covers claims filed during the life of the policy; people with this type of policy often purchase tail coverage to close any gaps that may occur. McCammon, who has authored a series of articles on liability insurance that can be found in the “Advocacy and Practice Resources” section on the AAPA Web site (www.aapa.org), says one type is not better than the other.

Occurrence-based coverage may be easier to manage; you file a copy for your records and hope you never need it. As Crosby says, “You can be retired and lying on the beach in Florida, and if there’s a lawsuit over something that happened in your last year of work, you would be covered.”

However, the economic downturn has highlighted one drawback to occurrence-based coverage: The company that covered you 10 or 20 years ago may not be in business by the time you have a claim. “Ten or 20 years ago, that was not a real issue,” McCammon says, “because companies just didn’t go under. But in this day and age, companies are getting out of the business or going out of business.”

That doesn’t mean you should avoid occurrence-based policies. But you might do a little extra homework on a company’s financial stability and longevity.

Rates depend on a number of factors, including geographic location and specialty of practice. AANP members can find information at www.proliability.com. AAPA members can contact AAPA Insurance Services at (877) 356-2272.

Regular readers of “Malpractice Chronicle” know that all types of cases—from instances of clear-cut negligence to those of obvious noncompliance by the patient—find their way into the legal system. It often seems that there is no rhyme or reason to how a verdict is decided or how high the judgment or settlement is. In light of this unpredictability, protecting yourself—with liability insurance acquired through your practice or on your own—seems like a no-brainer.

Always There for You
It’s hard to imagine any clinician “going bare” and having no liability coverage at all. At the very least, most will be covered by their employer’s policy. But there are advantages to having your own malpractice insurance.

For one thing, it’s portable—wherever you practice, the policy goes with you—and it covers all aspects of professional liability. “It protects you 24 hours a day, so if you’re moonlighting, if you’re volunteering, you’re protected,” says Rebecca S. Crosby, Vice President of Marsh, the insurance brokerage for the American Academy of Nurse Practitioners (AANP). “It also protects you if you give advice—friends and family sue, too.” The policies offered through AANP and the American Academy of Physician Assistants (AAPA) also provide coverage for policyholders who are called before their state licensing board.

The policy is also 100% yours. “You are the only named person on the policy, so the limits are not shared,” says Ellen Rathfon, Senior Director of Professional Affairs for AAPA. “If you’re covered by your employer, the limits may be shared among several people—or a lot of people, depending on what kind of policy it is.”

In the event of a lawsuit, you will have your own legal representation. “There can be conflicts of interest between an employer or a supervising physician and the PA; they could be pointing fingers at each other,” says Gary M. McCammon, President of Professional Risk Advisors, Inc, the AAPA’s insurance broker. “And when a case is ultimately settled, or maybe it even goes to trial, the apportionment of liability can be greater if the PA is not in a position to negotiate his own liability.”

This can be important, because settlement information is reported to the National Practitioner Data Bank. Cases are often settled because it is ultimately less costly than taking a case to trial. Even a successful defense costs money, after all. But if a group of providers is named in the settlement, and they are covered by a single employer policy, the individual clinician may not be in a position to decide what portion of the settlement is his or her responsibility.

“Now, it doesn’t come out of their pocket, it comes out of the insurance,” Rathfon acknowledges. “But in the Data Bank, that clinician might have a high payment value.”

 ow Risk, High Cost?
You may think that PAs and NPs don’t get sued. Actually, they do. Not as often as physicians do, certainly, but even a small risk can carry a big price tag.

An analysis of data from the National Practitioner Data Bank, published earlier this year in the Journal of Medical Licensure and Discipline (a publication of the Federation of State Medical Boards), indicated that approximately 3% of active PAs and at least 1.5% of active APNs made a payment during the 17-year study period. However, while PAs and APNs accounted for 0.003% and 0.007%, respectively, of the $74 billion in malpractice payments made from 1991 to 2008, the mean/median payments for these providers were $173,128/$80,003 and $350,540/$190,898, respectively. The risk may be small, but is it one clinicians can afford?

“If you look at the spread of payments, some of them are really high,” Rathfon says. “And I think most people look at that and say, ‘I don’t want to take that risk.’”

In some cases, verdicts are exceeding even the limits of the defendant’s insurance, says Michele Kauffman, JD, PA-C, Chair of the Physician Assistant Department at Gannon University in Erie, Pennsylvania. This can open clinicians up to personal liability; while this hasn’t really happened yet, it’s a sobering possibility.

“Some states—Pennsylvania is one of them—now require PAs and NPs to have a minimum insurance, whether it’s through their employer or on their own,” Kauffman says. “In order to get their license, they have to prove that they have that insurance.”

Oh, and that old “deep pocket” argument—the idea that having liability insurance will just make you a target for litigation—is “a fallacy,” according to Crosby. “They’re going after everybody who even said ‘good morning’ to the patient. They don’t know if you have insurance until you’re in the discovery phase of the case.” By then, it’s too late to think about obtaining malpractice coverage.

Know Your Limits
Whether or not you opt for your own policy, know what coverage you do have. If you’re covered through your employer, make sure you have (at the very least) a copy of the declarations page, which will provide the name of the insurance company, the policy number, and the terms of coverage. McCammon suggests making it a condition of your employment that your employer will provide this information every year.

“People need to know their limits and know that they are individually named under those limits,” Rathfon says. “And they need to feel confident that there’s enough coverage, whatever the policy is, whether it’s their own or through their employer.”

Familiarize yourself with the type of policy you have: Is it occurrence-based or claims-made coverage? The former applies to any incident that occurs during the period of coverage, even if the claim is made years later. The latter covers claims filed during the life of the policy; people with this type of policy often purchase tail coverage to close any gaps that may occur. McCammon, who has authored a series of articles on liability insurance that can be found in the “Advocacy and Practice Resources” section on the AAPA Web site (www.aapa.org), says one type is not better than the other.

Occurrence-based coverage may be easier to manage; you file a copy for your records and hope you never need it. As Crosby says, “You can be retired and lying on the beach in Florida, and if there’s a lawsuit over something that happened in your last year of work, you would be covered.”

However, the economic downturn has highlighted one drawback to occurrence-based coverage: The company that covered you 10 or 20 years ago may not be in business by the time you have a claim. “Ten or 20 years ago, that was not a real issue,” McCammon says, “because companies just didn’t go under. But in this day and age, companies are getting out of the business or going out of business.”

That doesn’t mean you should avoid occurrence-based policies. But you might do a little extra homework on a company’s financial stability and longevity.

Rates depend on a number of factors, including geographic location and specialty of practice. AANP members can find information at www.proliability.com. AAPA members can contact AAPA Insurance Services at (877) 356-2272.

Call it the New Age of Transparency and Accountability: So far this year, two states—Massachusetts and Vermont—have enacted strict laws that codify and regulate the interactions between health care providers and pharmaceutical sales and marketing representatives. Whether you consider such legislation “draconian” (as some critics do) or essential, it appears to be part of a trend that advocates hope will continue.

While lauding Massachusetts and Vermont for “taking the lead” in these matters—going beyond other states’ laws that allow gifts and payments from pharmaceutical and device manufacturers to health care providers, as long as they are disclosed—Howard Brody, MD, PhD, Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, laments that legislation has been necessary.

“I think it would really be ideal if professionally, we just decided among ourselves—doctors, nurse practitioners, physician assistants, and so on—that we would not accept this money,” Brody says. “Because it’s tainted money, really, and it compromises our commitment to our patients.”

Massachusetts: The Microcosm
The Massachusetts code of conduct—officially designated “105 CMR 970.000: Pharmaceutical and Medical Device Manufacturer Conduct”—is outlined in a 13-page document available at the Web site for the state’s Department of Public Health (www.mass.gov/dph). The code applies to industry interactions with any health care provider licensed to practice in Massachusetts—even if the encounter occurs in another state (say, at a national conference). Helpfully, there are three “frequently asked questions” sections in which the finer points of the regulations are explained, often with specific examples.

In a nutshell, the code prohibits gifts of entertainment or recreation (eg, trips, tickets to concerts or sporting events); complimentary branded items (eg, pens, mugs, calendars); and meals, unless certain circumstances are met. All provided meals must be “modest” and “occasional,” must take place in the practitioner’s office or hospital setting, and must be accompanied by an informational presentation. Items that have potential benefit to patients—such as drug samples or demonstration models of medical devices—are permissible under the new regulations.

With regard to sponsorship of continuing medical education (CME) programs, the code stipulates that pharmaceutical and medical device manufacturers may not provide financial support for travel, lodging, meals, or personal expenses to nonfaculty health care providers attending such events. They are also prohibited from sponsoring or paying for CME that does not comply with the Standards for Commercial Support set forth by the Accreditation Council for Continuing Medical Education or an equivalent accrediting body. Further, companies are also barred from providing “any advice or guidance to the CME provider regarding the content or faculty for a particular CME program funded by the company.”

Pharmaceutical and medical device manufacturers are required to disclose “the value, nature, purpose, and particular recipient of any fee, payment, subsidy, or other economic benefit with a value of at least $50 to any covered recipient in connection with the company’s sales and marketing activities.” Disclosure reports must be filed by July 1 each year, beginning in 2010, and must be accompanied by a $2,000 fee. The first reports will cover the six-month period from the regulations’ implementation on July 1, 2009, through December 31, 2009. Subsequent annual reports will cover the entire previous calendar year.

While the demise of the “free lunch” has received the most media attention, it is the CME restrictions that may pose the biggest challenges to clinicians in Massachusetts. Both the NP and PA professional organizations in the state have already started planning how they will continue to provide CME opportunities to their members while complying with the code.

“Since the change in attitude toward pharmaceutical company funding of CME events, we have had to be more creative in how we provide CME to our members,” says David Probert, PA-C, the Massachusetts Association of Physician Assistants (MAPA) Delegate to the American Academy of Physician Assistants, who has served on MAPA’s CME committee. “The continued operation of our professional organization will rely more on member support—ie, dues—than in the past.” MAPA is applying for grants from nonpharmaceutical sources, including the AAPA, local hospitals, and other employers of PAs.

The Massachusetts Coalition of Nurse Practitioners (MCNP) is also working to develop educational programs in partnership with larger institutions and universities. “We’re looking at how we can develop quarterly educational offerings … that we could open to our members for a small fee,” says MCNP President Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP. “We haven’t had to charge them anything for their educational opportunities, but at this point, we’re going to have to start. It’s probably going to be a nominal fee, but it still has to cover the cost of putting on the program. Speakers for these programs typically get a large honorarium, and that’s where the pharmaceutical companies were helping us—paying that honorarium.”

O’Rourke also points out that the location restrictions, while understandable, may pose challenges for those who are not in major urban areas such as Boston. “If you’re practicing out in central or western Massachusetts, you might be 100 miles from the nearest hospital setting,” she points out. But the law is the law, as she observes, and “there are still ways that you can provide education—you just have to work within that structure.”

Industry, Police Thyself?
The Massachusetts code mirrors, to a large extent, the voluntary code established by the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA actually updated its code last year, and the changes took effect on January 1, 2009. Among them was the banning of gifts that are either “reminder items” (eg, the pens and preprinted notepads that everyone used to collect in the exhibit halls at conferences) or items that are of benefit to the prescriber. The updated PhRMA code is also more explicit about the situations in which provision of meals is appropriate and about the need for disclosure of any relationship between a pharmaceutical company and a health care provider if the latter is involved in the development of CME programs, clinical practice guidelines, or formulary decisions.

This industry-wide code is part of the reason that PhRMA opposed the Massachusetts legislation. “We’ve said consistently that it is the most draconian law in the country,” says Marjorie Powell, Senior Assistant General Counsel for PhRMA. “We think it’s not necessary—in part, because of the PhRMA code. We think it doesn’t do anything to improve patient care. It simply involves everybody in the health care system in much more recordkeeping and potential disputes over potential violations.”

 All PhRMA member companies and some nonmember companies have agreed to comply with the organization’s code; the names of all the companies’ compliance officers are listed on the PhRMA Web site (www.phrma.org), making it easy, Powell says, for a clinician to report a potential violation to the appropriate party. She adds that this provides “a great deal of both peer pressure and public pressure” for company representatives to comply with the code of conduct.

There are those who would suggest that a voluntary code administered by a leading industry organization may not be effective enough; that’s why laws like the ones in Massachusetts and Vermont become necessary. While it is not an apples-to-apples comparison, no one has been very impressed with the financial industry’s efforts at policing itself.

Brody, who authored the book Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, says the effectiveness of the more robust PhRMA code will be proven if marketing expenses decrease. “If they’re not doing all those things anymore—the lavish dinners, giving out pens and notepads and so on—shouldn’t there be a reduction in cost somewhere?” he asks. “Until I see some hard numbers, I’m going to be skeptical. I’m going to look for some evidence that it actually is working. And I can see why a state would say, ‘Well, the track record being what it is, maybe your voluntary code will work, but maybe it won’t. Just in case, we’re going to have this law on the books.’”

But Powell points out that pharmaceutical and medical device manufacturers, like all health care companies, are subject to the federal Anti-Kickback Statute. The FDA reviews all materials that are presented to prescribers and surveys health care providers to determine what types of information sales reps have provided about medications and devices. And the Centers for Medicare and Medicaid Services, the Department of Justice, and state attorneys general all have enforcement authority.

“Frankly, they have very strong enforcement authority,” Powell says, “and they bring actions if they think companies either have been failing to abide by the federal requirements or have been lax in their own enforcement…. It’s sort of a misunderstanding to say that the only thing that regulates the industry is this voluntary code. 

And while other states—including Oregon, Texas, Connecticut, Colorado, Illinois, and Maryland—are considering legislation that would either ban gift-giving or require public disclosure of it, the real battleground on this issue may be the US Congress. The devil may end up being in the details, but all parties are watching to see what progress the Physician Payments Sunshine Act will make at the federal level.

“We have consistently said that we think transparency has a place in the health care system, but that if there is going to be that kind of transparency, national reporting—one uniform standard—makes much more sense than 55 different standards,” Powell says. “So we in fact supported last year’s [version of the bill] because it had a national uniformity provision. This year, [that] provision is much weaker; it allows states to have their own additional reporting requirements.”

Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”

Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?

“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”

The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”

MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”

But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”

“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”

Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”

Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”

Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”

Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.

Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”

O’Rourke also sees more effective ways to use the thousands of dollars that would, in the past, have been spent to take a group of 20 or 25 NPs to dinner at a fancy restaurant in Boston and provide an expert speaker. “It’s an expensive proposition, and if you’re doing that across the country for many, many groups, you’re talking millions of dollars,” she says. “That money could absolutely go into research and development. It could clearly go to supporting the indigent drug programs for patients who don’t have any health insurance. Instead of being able to give them a sample pack of five pills, maybe they could get a month’s supply of their prescription.

“It has to come back to the patient. In health care, at some point, you lose sight of what’s right and what’s wrong for the patient.We have to bring health care back to that and have to focus on what’s good for patients and not necessarily what’s good for us.”        

Call it the New Age of Transparency and Accountability: So far this year, two states—Massachusetts and Vermont—have enacted strict laws that codify and regulate the interactions between health care providers and pharmaceutical sales and marketing representatives. Whether you consider such legislation “draconian” (as some critics do) or essential, it appears to be part of a trend that advocates hope will continue.

While lauding Massachusetts and Vermont for “taking the lead” in these matters—going beyond other states’ laws that allow gifts and payments from pharmaceutical and device manufacturers to health care providers, as long as they are disclosed—Howard Brody, MD, PhD, Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, laments that legislation has been necessary.

“I think it would really be ideal if professionally, we just decided among ourselves—doctors, nurse practitioners, physician assistants, and so on—that we would not accept this money,” Brody says. “Because it’s tainted money, really, and it compromises our commitment to our patients.”

Massachusetts: The Microcosm
The Massachusetts code of conduct—officially designated “105 CMR 970.000: Pharmaceutical and Medical Device Manufacturer Conduct”—is outlined in a 13-page document available at the Web site for the state’s Department of Public Health (www.mass.gov/dph). The code applies to industry interactions with any health care provider licensed to practice in Massachusetts—even if the encounter occurs in another state (say, at a national conference). Helpfully, there are three “frequently asked questions” sections in which the finer points of the regulations are explained, often with specific examples.

In a nutshell, the code prohibits gifts of entertainment or recreation (eg, trips, tickets to concerts or sporting events); complimentary branded items (eg, pens, mugs, calendars); and meals, unless certain circumstances are met. All provided meals must be “modest” and “occasional,” must take place in the practitioner’s office or hospital setting, and must be accompanied by an informational presentation. Items that have potential benefit to patients—such as drug samples or demonstration models of medical devices—are permissible under the new regulations.

With regard to sponsorship of continuing medical education (CME) programs, the code stipulates that pharmaceutical and medical device manufacturers may not provide financial support for travel, lodging, meals, or personal expenses to nonfaculty health care providers attending such events. They are also prohibited from sponsoring or paying for CME that does not comply with the Standards for Commercial Support set forth by the Accreditation Council for Continuing Medical Education or an equivalent accrediting body. Further, companies are also barred from providing “any advice or guidance to the CME provider regarding the content or faculty for a particular CME program funded by the company.”

Pharmaceutical and medical device manufacturers are required to disclose “the value, nature, purpose, and particular recipient of any fee, payment, subsidy, or other economic benefit with a value of at least $50 to any covered recipient in connection with the company’s sales and marketing activities.” Disclosure reports must be filed by July 1 each year, beginning in 2010, and must be accompanied by a $2,000 fee. The first reports will cover the six-month period from the regulations’ implementation on July 1, 2009, through December 31, 2009. Subsequent annual reports will cover the entire previous calendar year.

While the demise of the “free lunch” has received the most media attention, it is the CME restrictions that may pose the biggest challenges to clinicians in Massachusetts. Both the NP and PA professional organizations in the state have already started planning how they will continue to provide CME opportunities to their members while complying with the code.

“Since the change in attitude toward pharmaceutical company funding of CME events, we have had to be more creative in how we provide CME to our members,” says David Probert, PA-C, the Massachusetts Association of Physician Assistants (MAPA) Delegate to the American Academy of Physician Assistants, who has served on MAPA’s CME committee. “The continued operation of our professional organization will rely more on member support—ie, dues—than in the past.” MAPA is applying for grants from nonpharmaceutical sources, including the AAPA, local hospitals, and other employers of PAs.

The Massachusetts Coalition of Nurse Practitioners (MCNP) is also working to develop educational programs in partnership with larger institutions and universities. “We’re looking at how we can develop quarterly educational offerings … that we could open to our members for a small fee,” says MCNP President Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP. “We haven’t had to charge them anything for their educational opportunities, but at this point, we’re going to have to start. It’s probably going to be a nominal fee, but it still has to cover the cost of putting on the program. Speakers for these programs typically get a large honorarium, and that’s where the pharmaceutical companies were helping us—paying that honorarium.”

O’Rourke also points out that the location restrictions, while understandable, may pose challenges for those who are not in major urban areas such as Boston. “If you’re practicing out in central or western Massachusetts, you might be 100 miles from the nearest hospital setting,” she points out. But the law is the law, as she observes, and “there are still ways that you can provide education—you just have to work within that structure.”

Industry, Police Thyself?
The Massachusetts code mirrors, to a large extent, the voluntary code established by the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA actually updated its code last year, and the changes took effect on January 1, 2009. Among them was the banning of gifts that are either “reminder items” (eg, the pens and preprinted notepads that everyone used to collect in the exhibit halls at conferences) or items that are of benefit to the prescriber. The updated PhRMA code is also more explicit about the situations in which provision of meals is appropriate and about the need for disclosure of any relationship between a pharmaceutical company and a health care provider if the latter is involved in the development of CME programs, clinical practice guidelines, or formulary decisions.

This industry-wide code is part of the reason that PhRMA opposed the Massachusetts legislation. “We’ve said consistently that it is the most draconian law in the country,” says Marjorie Powell, Senior Assistant General Counsel for PhRMA. “We think it’s not necessary—in part, because of the PhRMA code. We think it doesn’t do anything to improve patient care. It simply involves everybody in the health care system in much more recordkeeping and potential disputes over potential violations.”

 All PhRMA member companies and some nonmember companies have agreed to comply with the organization’s code; the names of all the companies’ compliance officers are listed on the PhRMA Web site (www.phrma.org), making it easy, Powell says, for a clinician to report a potential violation to the appropriate party. She adds that this provides “a great deal of both peer pressure and public pressure” for company representatives to comply with the code of conduct.

There are those who would suggest that a voluntary code administered by a leading industry organization may not be effective enough; that’s why laws like the ones in Massachusetts and Vermont become necessary. While it is not an apples-to-apples comparison, no one has been very impressed with the financial industry’s efforts at policing itself.

Brody, who authored the book Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, says the effectiveness of the more robust PhRMA code will be proven if marketing expenses decrease. “If they’re not doing all those things anymore—the lavish dinners, giving out pens and notepads and so on—shouldn’t there be a reduction in cost somewhere?” he asks. “Until I see some hard numbers, I’m going to be skeptical. I’m going to look for some evidence that it actually is working. And I can see why a state would say, ‘Well, the track record being what it is, maybe your voluntary code will work, but maybe it won’t. Just in case, we’re going to have this law on the books.’”

But Powell points out that pharmaceutical and medical device manufacturers, like all health care companies, are subject to the federal Anti-Kickback Statute. The FDA reviews all materials that are presented to prescribers and surveys health care providers to determine what types of information sales reps have provided about medications and devices. And the Centers for Medicare and Medicaid Services, the Department of Justice, and state attorneys general all have enforcement authority.

“Frankly, they have very strong enforcement authority,” Powell says, “and they bring actions if they think companies either have been failing to abide by the federal requirements or have been lax in their own enforcement…. It’s sort of a misunderstanding to say that the only thing that regulates the industry is this voluntary code. 

And while other states—including Oregon, Texas, Connecticut, Colorado, Illinois, and Maryland—are considering legislation that would either ban gift-giving or require public disclosure of it, the real battleground on this issue may be the US Congress. The devil may end up being in the details, but all parties are watching to see what progress the Physician Payments Sunshine Act will make at the federal level.

“We have consistently said that we think transparency has a place in the health care system, but that if there is going to be that kind of transparency, national reporting—one uniform standard—makes much more sense than 55 different standards,” Powell says. “So we in fact supported last year’s [version of the bill] because it had a national uniformity provision. This year, [that] provision is much weaker; it allows states to have their own additional reporting requirements.”

Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”

Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?

“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”

The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”

MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”

But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”

“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”

Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”

Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”

Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”

Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.

Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”

O’Rourke also sees more effective ways to use the thousands of dollars that would, in the past, have been spent to take a group of 20 or 25 NPs to dinner at a fancy restaurant in Boston and provide an expert speaker. “It’s an expensive proposition, and if you’re doing that across the country for many, many groups, you’re talking millions of dollars,” she says. “That money could absolutely go into research and development. It could clearly go to supporting the indigent drug programs for patients who don’t have any health insurance. Instead of being able to give them a sample pack of five pills, maybe they could get a month’s supply of their prescription.

“It has to come back to the patient. In health care, at some point, you lose sight of what’s right and what’s wrong for the patient.We have to bring health care back to that and have to focus on what’s good for patients and not necessarily what’s good for us.”        

Call it the New Age of Transparency and Accountability: So far this year, two states—Massachusetts and Vermont—have enacted strict laws that codify and regulate the interactions between health care providers and pharmaceutical sales and marketing representatives. Whether you consider such legislation “draconian” (as some critics do) or essential, it appears to be part of a trend that advocates hope will continue.

While lauding Massachusetts and Vermont for “taking the lead” in these matters—going beyond other states’ laws that allow gifts and payments from pharmaceutical and device manufacturers to health care providers, as long as they are disclosed—Howard Brody, MD, PhD, Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, laments that legislation has been necessary.

“I think it would really be ideal if professionally, we just decided among ourselves—doctors, nurse practitioners, physician assistants, and so on—that we would not accept this money,” Brody says. “Because it’s tainted money, really, and it compromises our commitment to our patients.”

Massachusetts: The Microcosm
The Massachusetts code of conduct—officially designated “105 CMR 970.000: Pharmaceutical and Medical Device Manufacturer Conduct”—is outlined in a 13-page document available at the Web site for the state’s Department of Public Health (www.mass.gov/dph). The code applies to industry interactions with any health care provider licensed to practice in Massachusetts—even if the encounter occurs in another state (say, at a national conference). Helpfully, there are three “frequently asked questions” sections in which the finer points of the regulations are explained, often with specific examples.

In a nutshell, the code prohibits gifts of entertainment or recreation (eg, trips, tickets to concerts or sporting events); complimentary branded items (eg, pens, mugs, calendars); and meals, unless certain circumstances are met. All provided meals must be “modest” and “occasional,” must take place in the practitioner’s office or hospital setting, and must be accompanied by an informational presentation. Items that have potential benefit to patients—such as drug samples or demonstration models of medical devices—are permissible under the new regulations.

With regard to sponsorship of continuing medical education (CME) programs, the code stipulates that pharmaceutical and medical device manufacturers may not provide financial support for travel, lodging, meals, or personal expenses to nonfaculty health care providers attending such events. They are also prohibited from sponsoring or paying for CME that does not comply with the Standards for Commercial Support set forth by the Accreditation Council for Continuing Medical Education or an equivalent accrediting body. Further, companies are also barred from providing “any advice or guidance to the CME provider regarding the content or faculty for a particular CME program funded by the company.”

Pharmaceutical and medical device manufacturers are required to disclose “the value, nature, purpose, and particular recipient of any fee, payment, subsidy, or other economic benefit with a value of at least $50 to any covered recipient in connection with the company’s sales and marketing activities.” Disclosure reports must be filed by July 1 each year, beginning in 2010, and must be accompanied by a $2,000 fee. The first reports will cover the six-month period from the regulations’ implementation on July 1, 2009, through December 31, 2009. Subsequent annual reports will cover the entire previous calendar year.

While the demise of the “free lunch” has received the most media attention, it is the CME restrictions that may pose the biggest challenges to clinicians in Massachusetts. Both the NP and PA professional organizations in the state have already started planning how they will continue to provide CME opportunities to their members while complying with the code.

“Since the change in attitude toward pharmaceutical company funding of CME events, we have had to be more creative in how we provide CME to our members,” says David Probert, PA-C, the Massachusetts Association of Physician Assistants (MAPA) Delegate to the American Academy of Physician Assistants, who has served on MAPA’s CME committee. “The continued operation of our professional organization will rely more on member support—ie, dues—than in the past.” MAPA is applying for grants from nonpharmaceutical sources, including the AAPA, local hospitals, and other employers of PAs.

The Massachusetts Coalition of Nurse Practitioners (MCNP) is also working to develop educational programs in partnership with larger institutions and universities. “We’re looking at how we can develop quarterly educational offerings … that we could open to our members for a small fee,” says MCNP President Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP. “We haven’t had to charge them anything for their educational opportunities, but at this point, we’re going to have to start. It’s probably going to be a nominal fee, but it still has to cover the cost of putting on the program. Speakers for these programs typically get a large honorarium, and that’s where the pharmaceutical companies were helping us—paying that honorarium.”

O’Rourke also points out that the location restrictions, while understandable, may pose challenges for those who are not in major urban areas such as Boston. “If you’re practicing out in central or western Massachusetts, you might be 100 miles from the nearest hospital setting,” she points out. But the law is the law, as she observes, and “there are still ways that you can provide education—you just have to work within that structure.”

Industry, Police Thyself?
The Massachusetts code mirrors, to a large extent, the voluntary code established by the Pharmaceutical Research and Manufacturers of America (PhRMA). PhRMA actually updated its code last year, and the changes took effect on January 1, 2009. Among them was the banning of gifts that are either “reminder items” (eg, the pens and preprinted notepads that everyone used to collect in the exhibit halls at conferences) or items that are of benefit to the prescriber. The updated PhRMA code is also more explicit about the situations in which provision of meals is appropriate and about the need for disclosure of any relationship between a pharmaceutical company and a health care provider if the latter is involved in the development of CME programs, clinical practice guidelines, or formulary decisions.

This industry-wide code is part of the reason that PhRMA opposed the Massachusetts legislation. “We’ve said consistently that it is the most draconian law in the country,” says Marjorie Powell, Senior Assistant General Counsel for PhRMA. “We think it’s not necessary—in part, because of the PhRMA code. We think it doesn’t do anything to improve patient care. It simply involves everybody in the health care system in much more recordkeeping and potential disputes over potential violations.”

 All PhRMA member companies and some nonmember companies have agreed to comply with the organization’s code; the names of all the companies’ compliance officers are listed on the PhRMA Web site (www.phrma.org), making it easy, Powell says, for a clinician to report a potential violation to the appropriate party. She adds that this provides “a great deal of both peer pressure and public pressure” for company representatives to comply with the code of conduct.

There are those who would suggest that a voluntary code administered by a leading industry organization may not be effective enough; that’s why laws like the ones in Massachusetts and Vermont become necessary. While it is not an apples-to-apples comparison, no one has been very impressed with the financial industry’s efforts at policing itself.

Brody, who authored the book Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, says the effectiveness of the more robust PhRMA code will be proven if marketing expenses decrease. “If they’re not doing all those things anymore—the lavish dinners, giving out pens and notepads and so on—shouldn’t there be a reduction in cost somewhere?” he asks. “Until I see some hard numbers, I’m going to be skeptical. I’m going to look for some evidence that it actually is working. And I can see why a state would say, ‘Well, the track record being what it is, maybe your voluntary code will work, but maybe it won’t. Just in case, we’re going to have this law on the books.’”

But Powell points out that pharmaceutical and medical device manufacturers, like all health care companies, are subject to the federal Anti-Kickback Statute. The FDA reviews all materials that are presented to prescribers and surveys health care providers to determine what types of information sales reps have provided about medications and devices. And the Centers for Medicare and Medicaid Services, the Department of Justice, and state attorneys general all have enforcement authority.

“Frankly, they have very strong enforcement authority,” Powell says, “and they bring actions if they think companies either have been failing to abide by the federal requirements or have been lax in their own enforcement…. It’s sort of a misunderstanding to say that the only thing that regulates the industry is this voluntary code. 

And while other states—including Oregon, Texas, Connecticut, Colorado, Illinois, and Maryland—are considering legislation that would either ban gift-giving or require public disclosure of it, the real battleground on this issue may be the US Congress. The devil may end up being in the details, but all parties are watching to see what progress the Physician Payments Sunshine Act will make at the federal level.

“We have consistently said that we think transparency has a place in the health care system, but that if there is going to be that kind of transparency, national reporting—one uniform standard—makes much more sense than 55 different standards,” Powell says. “So we in fact supported last year’s [version of the bill] because it had a national uniformity provision. This year, [that] provision is much weaker; it allows states to have their own additional reporting requirements.”

Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”

Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?

“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”

The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”

MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”

But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”

“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”

Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”

Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”

Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”

Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.

Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”

O’Rourke also sees more effective ways to use the thousands of dollars that would, in the past, have been spent to take a group of 20 or 25 NPs to dinner at a fancy restaurant in Boston and provide an expert speaker. “It’s an expensive proposition, and if you’re doing that across the country for many, many groups, you’re talking millions of dollars,” she says. “That money could absolutely go into research and development. It could clearly go to supporting the indigent drug programs for patients who don’t have any health insurance. Instead of being able to give them a sample pack of five pills, maybe they could get a month’s supply of their prescription.

“It has to come back to the patient. In health care, at some point, you lose sight of what’s right and what’s wrong for the patient.We have to bring health care back to that and have to focus on what’s good for patients and not necessarily what’s good for us.”        

Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”

The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”

“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.” 

Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.

“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.

NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.

“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.

Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”

That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?

“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”

Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.

“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.

Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”

Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”

The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.

As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.

“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.

“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”          

Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”

The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”

“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.” 

Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.

“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.

NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.

“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.

Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”

That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?

“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”

Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.

“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.

Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”

Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”

The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.

As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.

“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.

“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”          

Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”

The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”

“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.” 

Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.

“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.

NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.

“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.

Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”

That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?

“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”

Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.

“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.

Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”

Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”

The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.

As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.

“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.

“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”          

An international expert panel assembled by three leading diabetes organizations has recommended the use of the A1C assay for the diagnosis of diabetes. In its report, the committee states its hope that the recommendation “will serve as a stimulus” to the discussion of appropriate screening for and diagnosis of this prevalent metabolic condition.

But what impact would this recommendation—if widely implemented—have on primary care practice? And will it be widely implemented, as has largely been assumed? As Sandra Drozdz Burke, PhD, APRN, CDE, BC-ADN, a member of the board of directors of the American Association of Diabetes Educators, points out, “It’s a report. And nothing is going to be done about it until after the constituent groups have a chance to review it and make some decisions…. We generally don’t change practice based on an article. 

The Case for A1C
Currently, the standard for the diagnosis of type 2 diabetes is a fasting plasma glucose (FPG) of 126 mg/dL or higher or a random oral glucose tolerance test (OGTT) of more than 200 mg/dL. While these tests have been validated, endorsed, and standardized, they provide a snapshot of a patient’s glycemic control—and not in entirely “real world” conditions. 

The FPG test requires the patient to fast for at least eight hours prior to testing. Besides that inconvenience, there are also variances in FPG. “If you’re fasting, you haven’t been challenged for an extended period,” says Scott Urquhart, PA-C, President of the American Society of Endocrine PAs, who practices at Diabetes and Thyroid Associates in Fredericksburg, Virginia. “And the day-to-day variation is roughly 12%. So a patient could be at 112 one day and 98 the next. They were ‘prediabetic,’ and now they’re not.”

For the OGTT, patients must consume 75 grams of sweet drink in five minutes. “Most of us can’t even consume that,” Urquhart points out. By his calculation, the preparation is equivalent to drinking a 20-ounce bottle of soda in five minutes. “That gives you an indication of why it’s often called a glucose stress test—it is quite stressful. And is that a fair comparison to how most people consume daily calories? The answer is, probably not. So maybe that uncovers too many people who wouldn’t be facing that challenge every day.”

By contrast, the A1C assay, as the expert panel notes, “can be obtained at any time [and] requires no patient preparation.” Besides ease of use, a more important argument in favor of the A1C assay for diagnosis of diabetes is the fact that it provides a long-term overview of a patient’s glycemic state.

“It doesn’t give a one-day look at the blood sugar,” says Geralyn R. Spollett, MSN, ANP, CDE, an adult nurse practitioner and Associate Director of the Yale Diabetes Center. “It’s an accumulation of two to three months’ averaging of blood sugar. Hopefully, it would catch those patients who come in and their blood sugar looks OK that day but for whom there is some kind of symptomology suggestive of diabetes.”

A Matter for Debate
One prevailing theory is that these benefits might encourage clinicians to use the A1C assay, resulting in the identification of more patients who are currently diabetic but unaware of it. Statistics indicate that approximately 25% of persons in the United States with type 2 diabetes are undiagnosed.

“It very well could be that this is a nice alternative to what we’re already doing,” Burke says, “since what we’re already doing is only capturing 75% to 80% [of diabetes cases].”

But can the health care system accommodate those additional patients, who will require treatment not only for their glycemic issues but also for comorbidities such as hypertension and dyslipidemia?

“This is going to help us catch those that need to be diagnosed,” Urquhart says. “But are we going to be able to handle the 50% [of diabetic patients] who aren’t being managed properly now, and then throw these [new cases] on top of them?”

It’s one of many debating points that the recommendation has raised. The committee acknowledges that the A1C assay will not be an accurate measure for patients with hemoglobinopathies; will providers always know which patients have such traits? While some assay methods can correct for these factors, will clinicians—particularly in primary care—have access to them?

Other questions relate to A1C values and how clinicians will interpret them. Burke, who is vice-chair of the Older Adults Working Group of the National Diabetes Education Program, points out that there are not currently age-specific A1C targets. “Even though we know that A1C increases with age, they’re still recommending a universal target of 6.5% as a diagnostic value,” she says. “Is that going to give us false-positives in some populations?”

At a more basic level, what does that 6.5% mean? “If you look at a mean average for A1C, 6% is around 130 mg/dL and 7% is around 165 mg/dL, ” Spollett says. “If people are diagnosed between 6% and 6.5%, they’re going to be called ‘at risk.’ So I think there will be some confusion about what those numbers mean and how to interpret them.”

Better Screening Needed
For now, the questions are theoretical. Until it is widely adopted, so is the recommendation. (The American Diabetes Association has assembled a task force to review the report and may issue its own commentary by the end of the summer.) But the discussion the report has generated provides an opportunity to focus attention on the problem of diabetes in this country.

“Even though we’re improving, we’re still not at a point where we can say that most of our patients have achieved really good control,” Burke adds. “So, using the A1C more appropriately to guide clinical decision-making in terms of medication management, referral to educators or dietitians—a paper like this really brings that into very clear relief.”

The consensus among Burke, Spollett, and Urquhart seems to be that clinicians simply are not screening enough for diabetes. “It still isn’t as widely known as the other screenings for cancer and heart disease,” Spollett says. “Even if it’s not [with] the A1C, clinicians should be screening patients appropriately and really asking the questions that patients need to hear about their weight gain and their exercise and sedentary level.”

“An A1C is just a number,” as Urquhart says. “That number corresponds to other things that are going on in the body. We need to tackle those things, all the different entities of dyslipidemia and hypertension and glucose and obesity.”

An international expert panel assembled by three leading diabetes organizations has recommended the use of the A1C assay for the diagnosis of diabetes. In its report, the committee states its hope that the recommendation “will serve as a stimulus” to the discussion of appropriate screening for and diagnosis of this prevalent metabolic condition.

But what impact would this recommendation—if widely implemented—have on primary care practice? And will it be widely implemented, as has largely been assumed? As Sandra Drozdz Burke, PhD, APRN, CDE, BC-ADN, a member of the board of directors of the American Association of Diabetes Educators, points out, “It’s a report. And nothing is going to be done about it until after the constituent groups have a chance to review it and make some decisions…. We generally don’t change practice based on an article. 

The Case for A1C
Currently, the standard for the diagnosis of type 2 diabetes is a fasting plasma glucose (FPG) of 126 mg/dL or higher or a random oral glucose tolerance test (OGTT) of more than 200 mg/dL. While these tests have been validated, endorsed, and standardized, they provide a snapshot of a patient’s glycemic control—and not in entirely “real world” conditions. 

The FPG test requires the patient to fast for at least eight hours prior to testing. Besides that inconvenience, there are also variances in FPG. “If you’re fasting, you haven’t been challenged for an extended period,” says Scott Urquhart, PA-C, President of the American Society of Endocrine PAs, who practices at Diabetes and Thyroid Associates in Fredericksburg, Virginia. “And the day-to-day variation is roughly 12%. So a patient could be at 112 one day and 98 the next. They were ‘prediabetic,’ and now they’re not.”

For the OGTT, patients must consume 75 grams of sweet drink in five minutes. “Most of us can’t even consume that,” Urquhart points out. By his calculation, the preparation is equivalent to drinking a 20-ounce bottle of soda in five minutes. “That gives you an indication of why it’s often called a glucose stress test—it is quite stressful. And is that a fair comparison to how most people consume daily calories? The answer is, probably not. So maybe that uncovers too many people who wouldn’t be facing that challenge every day.”

By contrast, the A1C assay, as the expert panel notes, “can be obtained at any time [and] requires no patient preparation.” Besides ease of use, a more important argument in favor of the A1C assay for diagnosis of diabetes is the fact that it provides a long-term overview of a patient’s glycemic state.

“It doesn’t give a one-day look at the blood sugar,” says Geralyn R. Spollett, MSN, ANP, CDE, an adult nurse practitioner and Associate Director of the Yale Diabetes Center. “It’s an accumulation of two to three months’ averaging of blood sugar. Hopefully, it would catch those patients who come in and their blood sugar looks OK that day but for whom there is some kind of symptomology suggestive of diabetes.”

A Matter for Debate
One prevailing theory is that these benefits might encourage clinicians to use the A1C assay, resulting in the identification of more patients who are currently diabetic but unaware of it. Statistics indicate that approximately 25% of persons in the United States with type 2 diabetes are undiagnosed.

“It very well could be that this is a nice alternative to what we’re already doing,” Burke says, “since what we’re already doing is only capturing 75% to 80% [of diabetes cases].”

But can the health care system accommodate those additional patients, who will require treatment not only for their glycemic issues but also for comorbidities such as hypertension and dyslipidemia?

“This is going to help us catch those that need to be diagnosed,” Urquhart says. “But are we going to be able to handle the 50% [of diabetic patients] who aren’t being managed properly now, and then throw these [new cases] on top of them?”

It’s one of many debating points that the recommendation has raised. The committee acknowledges that the A1C assay will not be an accurate measure for patients with hemoglobinopathies; will providers always know which patients have such traits? While some assay methods can correct for these factors, will clinicians—particularly in primary care—have access to them?

Other questions relate to A1C values and how clinicians will interpret them. Burke, who is vice-chair of the Older Adults Working Group of the National Diabetes Education Program, points out that there are not currently age-specific A1C targets. “Even though we know that A1C increases with age, they’re still recommending a universal target of 6.5% as a diagnostic value,” she says. “Is that going to give us false-positives in some populations?”

At a more basic level, what does that 6.5% mean? “If you look at a mean average for A1C, 6% is around 130 mg/dL and 7% is around 165 mg/dL, ” Spollett says. “If people are diagnosed between 6% and 6.5%, they’re going to be called ‘at risk.’ So I think there will be some confusion about what those numbers mean and how to interpret them.”

Better Screening Needed
For now, the questions are theoretical. Until it is widely adopted, so is the recommendation. (The American Diabetes Association has assembled a task force to review the report and may issue its own commentary by the end of the summer.) But the discussion the report has generated provides an opportunity to focus attention on the problem of diabetes in this country.

“Even though we’re improving, we’re still not at a point where we can say that most of our patients have achieved really good control,” Burke adds. “So, using the A1C more appropriately to guide clinical decision-making in terms of medication management, referral to educators or dietitians—a paper like this really brings that into very clear relief.”

The consensus among Burke, Spollett, and Urquhart seems to be that clinicians simply are not screening enough for diabetes. “It still isn’t as widely known as the other screenings for cancer and heart disease,” Spollett says. “Even if it’s not [with] the A1C, clinicians should be screening patients appropriately and really asking the questions that patients need to hear about their weight gain and their exercise and sedentary level.”

“An A1C is just a number,” as Urquhart says. “That number corresponds to other things that are going on in the body. We need to tackle those things, all the different entities of dyslipidemia and hypertension and glucose and obesity.”

An international expert panel assembled by three leading diabetes organizations has recommended the use of the A1C assay for the diagnosis of diabetes. In its report, the committee states its hope that the recommendation “will serve as a stimulus” to the discussion of appropriate screening for and diagnosis of this prevalent metabolic condition.

But what impact would this recommendation—if widely implemented—have on primary care practice? And will it be widely implemented, as has largely been assumed? As Sandra Drozdz Burke, PhD, APRN, CDE, BC-ADN, a member of the board of directors of the American Association of Diabetes Educators, points out, “It’s a report. And nothing is going to be done about it until after the constituent groups have a chance to review it and make some decisions…. We generally don’t change practice based on an article. 

The Case for A1C
Currently, the standard for the diagnosis of type 2 diabetes is a fasting plasma glucose (FPG) of 126 mg/dL or higher or a random oral glucose tolerance test (OGTT) of more than 200 mg/dL. While these tests have been validated, endorsed, and standardized, they provide a snapshot of a patient’s glycemic control—and not in entirely “real world” conditions. 

The FPG test requires the patient to fast for at least eight hours prior to testing. Besides that inconvenience, there are also variances in FPG. “If you’re fasting, you haven’t been challenged for an extended period,” says Scott Urquhart, PA-C, President of the American Society of Endocrine PAs, who practices at Diabetes and Thyroid Associates in Fredericksburg, Virginia. “And the day-to-day variation is roughly 12%. So a patient could be at 112 one day and 98 the next. They were ‘prediabetic,’ and now they’re not.”

For the OGTT, patients must consume 75 grams of sweet drink in five minutes. “Most of us can’t even consume that,” Urquhart points out. By his calculation, the preparation is equivalent to drinking a 20-ounce bottle of soda in five minutes. “That gives you an indication of why it’s often called a glucose stress test—it is quite stressful. And is that a fair comparison to how most people consume daily calories? The answer is, probably not. So maybe that uncovers too many people who wouldn’t be facing that challenge every day.”

By contrast, the A1C assay, as the expert panel notes, “can be obtained at any time [and] requires no patient preparation.” Besides ease of use, a more important argument in favor of the A1C assay for diagnosis of diabetes is the fact that it provides a long-term overview of a patient’s glycemic state.

“It doesn’t give a one-day look at the blood sugar,” says Geralyn R. Spollett, MSN, ANP, CDE, an adult nurse practitioner and Associate Director of the Yale Diabetes Center. “It’s an accumulation of two to three months’ averaging of blood sugar. Hopefully, it would catch those patients who come in and their blood sugar looks OK that day but for whom there is some kind of symptomology suggestive of diabetes.”

A Matter for Debate
One prevailing theory is that these benefits might encourage clinicians to use the A1C assay, resulting in the identification of more patients who are currently diabetic but unaware of it. Statistics indicate that approximately 25% of persons in the United States with type 2 diabetes are undiagnosed.

“It very well could be that this is a nice alternative to what we’re already doing,” Burke says, “since what we’re already doing is only capturing 75% to 80% [of diabetes cases].”

But can the health care system accommodate those additional patients, who will require treatment not only for their glycemic issues but also for comorbidities such as hypertension and dyslipidemia?

“This is going to help us catch those that need to be diagnosed,” Urquhart says. “But are we going to be able to handle the 50% [of diabetic patients] who aren’t being managed properly now, and then throw these [new cases] on top of them?”

It’s one of many debating points that the recommendation has raised. The committee acknowledges that the A1C assay will not be an accurate measure for patients with hemoglobinopathies; will providers always know which patients have such traits? While some assay methods can correct for these factors, will clinicians—particularly in primary care—have access to them?

Other questions relate to A1C values and how clinicians will interpret them. Burke, who is vice-chair of the Older Adults Working Group of the National Diabetes Education Program, points out that there are not currently age-specific A1C targets. “Even though we know that A1C increases with age, they’re still recommending a universal target of 6.5% as a diagnostic value,” she says. “Is that going to give us false-positives in some populations?”

At a more basic level, what does that 6.5% mean? “If you look at a mean average for A1C, 6% is around 130 mg/dL and 7% is around 165 mg/dL, ” Spollett says. “If people are diagnosed between 6% and 6.5%, they’re going to be called ‘at risk.’ So I think there will be some confusion about what those numbers mean and how to interpret them.”

Better Screening Needed
For now, the questions are theoretical. Until it is widely adopted, so is the recommendation. (The American Diabetes Association has assembled a task force to review the report and may issue its own commentary by the end of the summer.) But the discussion the report has generated provides an opportunity to focus attention on the problem of diabetes in this country.

“Even though we’re improving, we’re still not at a point where we can say that most of our patients have achieved really good control,” Burke adds. “So, using the A1C more appropriately to guide clinical decision-making in terms of medication management, referral to educators or dietitians—a paper like this really brings that into very clear relief.”

The consensus among Burke, Spollett, and Urquhart seems to be that clinicians simply are not screening enough for diabetes. “It still isn’t as widely known as the other screenings for cancer and heart disease,” Spollett says. “Even if it’s not [with] the A1C, clinicians should be screening patients appropriately and really asking the questions that patients need to hear about their weight gain and their exercise and sedentary level.”

“An A1C is just a number,” as Urquhart says. “That number corresponds to other things that are going on in the body. We need to tackle those things, all the different entities of dyslipidemia and hypertension and glucose and obesity.”

When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious. 

“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”

Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.

A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.

When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.

“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”

Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.

Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”

“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”

Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.

Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”

“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.

Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.

Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.

“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”

The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.

The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.

“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”

Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”

Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”

Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.

“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”

Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.

“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”

For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.

Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.

“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”

Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”

Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.

“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”

Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)

And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."

When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious. 

“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”

Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.

A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.

When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.

“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”

Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.

Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”

“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”

Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.

Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”

“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.

Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.

Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.

“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”

The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.

The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.

“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”

Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”

Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”

Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.

“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”

Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.

“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”

For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.

Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.

“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”

Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”

Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.

“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”

Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)

And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."

When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious. 

“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”

Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.

A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.

When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.

“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”

Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.

Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”

“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”

Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.

Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”

“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.

Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.

Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.

“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”

The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.

The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.

“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”

Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”

Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”

Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.

“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”

Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.

“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”

For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.

Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.

“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”

Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”

Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.

“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”

Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)

And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

By now, the story of Nadya Suleman is well known. The 33-year-old California woman gave birth to octuplets—only the second set born in the United States—on January 26. Within a few weeks, what was initially reported as a heartwarming story of medicine’s finest hour had ignited a nationwide backlash as details of Suleman’s situation became known. The divorced single mom already had six children younger than 8 when she underwent the fertility treatments that led to an eight-baby bonanza.

Should Suleman have been allowed to undergo the additional treatments? Did her medical team violate guidelines by implanting more than the generally accepted number of embryos? Is it fair to burden taxpayers with the costs of raising her large family—particularly in the current economic climate?

Clinician Reviews does not profess to have the answers to these questions. But we did ask a panel of editorial board members and other experts for their take on the thorny ethical questions Suleman’s case has raised.

How do you feel about a woman with six children younger than 8 receiving fertility treatments and delivering another eight babies?

Stephen Nunn, MPAS, PA-C, a founding member of the Association of PAs in Ob-Gyn, who worked with the first successful in vitro fertilization program in Arizona for 18 years: The issue for me isn’t so much that she already has six children, but the real and serious risks to both the mother and fetuses with multiple gestation. The American Society of Reproductive Medicine has established guidelines for the number of embryos to be transferred, which for this patient would be three. It appears these guidelines were not used in this case. This would not have generated the same response had Ms. Suleman received fertility treatment in an effort to achieve a singleton or, at most, twin gestation.

Obviously, we do not know all the details; however, I wonder why so many embryos were placed. If there were a total of seven, as the press has stated, then there would have been more than one opportunity to achieve a single pregnancy. Even if the mother did not want the other embryos destroyed, she could have donated them to another woman.

Rebecca Scott, PhD, PA-C, Clinical Coordinator in the Physician Assistant Program at Northeastern University, Boston, and an elected member of the Board of Health in Sandwich, Massachusetts: I have been thinking about how this really illustrates a tension that we’ve had in our history of the rights of the individual versus the rights of the whole community. We have this long tradition of saying, “Everybody ought to be able to have children.” This seems to fit into that continuum of the individual’s right being very strongly upheld in this country over, perhaps, what is best for the good of society.

This is so interesting because other societies are quite up-front about their goals for their population. I remember traveling in Hungary at one point, where the people were not reproducing enough to replace the population. So the government said, “It’s in our best interests to have enough people to support the society,” and they actually subsidized moms with the equivalent of a factory worker’s wage to stay home with children for three years, up to three children’s worth.

The big thing that troubles me about this is where do the rights of the group get accounted for? Should we be paying tax dollars to subsidize people who want to have children?

Austin D. Potenza II, JD, a Phoenix-based attorney and Adjunct Professor at the Arizona School of Health Sciences, where he has taught a course on medical ethics for 10 years: I think in our society everything has to be open for discussion, but we have to realize that at some point it’s just discussion. Under current ethical thinking, the most important perspective is that of a competent patient. We as a society don’t make these kinds of decisions—whether it is getting fertility treatment or having multiple births—for people.

A close second is the perspective of the infants, but it is problematic to base a societal response on what is right for children when it comes to fertility and multiple birth. Is being born into a family of 14 somehow worse than not being born at all? If we’re trying to save children, what exactly are we saving them from? And why look at just these children? If we try to have a responsible answer to these questions, it is myopic to look only at this family.

Think about the thousands of children who are born into horrible poverty, hunger, abuse, and neglect. We don’t regulate their parents’ reproductive decisions. And that’s just considering our own country; if we really want to be concerned about children, think about places like Sierra Leone, where the infant mortality rate is about 25%. Although the consideration of the children is compelling, it is much more important to consider how to help them once they are born, rather than thinking of the solution in terms of fertility and multiple births.     

The next important ethical perspective is that of the caregiver [discussed in depth later]. 

Finally, society is a stakeholder, and this seems to be the perspective from which most people are approaching the issue. The typical questions you’re going to hear are, “Is the cost of care for this mother and these children going to fall on the rest of us as taxpayers? Is this part of what’s straining the health care and social support systems?” These are all valid questions, but they beg an awful lot of other questions that we have to answer first. For example, what should we spend our collective money on? Who decides?  

While it is understandable why the public is upset by this story, at the same time, does anyone have the right to impose restrictions on someone’s procreation? Where, if at all, do we draw a line in the sand? 

Marie-Eileen Onieal, PhD, CPNP, FAANP, Director of Medical Services for the Massachusetts Department of Youth Services and Clinician Reviews NP Editor-in-Chief: I think the line between moral soundness and legal rights was crossed when the woman put her desires to have more children above the needs of the children she already bore. Before the octup-let pregnancy, she needed more than minimal assistance to care for the six children she already had; at least two have special needs requiring more attention and care.  

I think, especially in the face of the fact that she is almost totally dependent on others to help her provide for her family, we as a society have a moral and legal obligation to impose restrictions on procreation (especially when one’s procreating consumes as many resources as this woman consumed).

Rebecca Scott: I don’t think sending hate mail and death threats is any way to respond in a civil society. But I think we do need to say, “No, it is not all right for somebody to be using taxpayer dollars to subsidize,” you know, whatever it is that the individual wants to do that is way above and beyond what most of us would consider reasonable. 

If we look at the welfare-to-work initiatives that took place under the Clinton administration, that’s a start on an answer. We made the decision at that point that it was OK to say to people, “You have to get off welfare. You must go to work.” But we also enabled people to do that by saying, “We will subsidize Medicaid so that you can continue to get coverage at these low-paying jobs where you don’t earn enough money to be able to pay for health care.”

Stephen Nunn: To me, the principle here is Primum non nocere or “First, do no harm.” A twin pregnancy is considered high risk just because it’s a twin pregnancy. Those risks skyrocket with each additional fetus. The main risk here is to the fetuses, their individual and collective survival, and the potential for future problems after birth, such as cerebral palsy, blindness, and learning disabilities. So, the risks and benefits have to be weighed on an individual basis.

Personally, I can see no circumstance to justify transferring more than four embryos—ever! Holding to this guideline is not restricting a woman’s right to procreation. It’s not saying “No,” it’s saying, “Not this many.”

Although the obstetrician’s patient is the mother, not the fetus, I believe the fertility specialist can’t take such a narrow view of his or her responsibilities. Ordinarily, an obstetrician becomes involved after pregnancy has occurred, while the fertility specialist is involved prior and thus has a greater duty in regard to the potential eventual outcome. Too much success can lead ultimately to failure.

Moving forward, where do we go from here? How might these issues be addressed?

Rebecca Scott: What I’m afraid is going to happen is that we’re going to react in a heavy-handed way and set up all kinds of oversight and come at it with a legislative approach—you know, somebody in the state legislature’s going to say, “Well, we’re going to make a rule about this.”

What I hope will happen is that we’ll have a good deal of dialogue about what’s appropriate and that that dialogue will include fertility specialists, public health experts, citizens in general, and government/public health departments and that the dialogue will try to come out with some policies and procedures to guide thinking in this kind of situation.

Austin Potenza: It’s very difficult for me to imagine any legislature taking on this issue. It would be politically impossible to attempt to regulate who can have children, and how many. Think back to the Terri Schiavo case, which was such a travesty in Congress. Everybody was trying to get involved, and it was obviously completely beyond the scope of their expertise and their ability. It was just a political nightmare. This is similar because it is government involvement in an intensely personal decision, in a country dedicated to personal freedoms. If we get involved in birth regulation, we’re repeating China’s mistakes and going against the fundamentally individual-rights focus of our society.

The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions. 

The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.

What role can and should health care providers play in situations such as this? Where do their responsibilities end?

Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.   

All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).

Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision. 

I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.

Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.

Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.

The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.

What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?

Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.

Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.

Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.

At the same time, I really have a horror of setting up a situation where individual health care providers refuse to provide appropriate care because of individual beliefs. I think if we start going down that road, we’re really asking for trouble…. Medical decision-making is rarely clear-cut. The interaction between patient and provider is so much of a negotiation, tinged with so many “shades of gray,” that I believe we really have to think very carefully about whether making decisions for patients is appropriate.

Stephen Nunn: I doubt the notoriety of an octuplet birth held any sway over the decision. In fact, it probably was a negative factor. I am aware of a professed fertility specialist who became famous—or rather infamous—for being responsible for the largest number of quad births in the nation. For various reasons, the state medical board investigated, and the doctor agreed to stop the practices that led to this.

The remarkable thing seems to be that multiple gestations survive, not that they happen. I suspect that in the coming years, we will start hearing more about various learning and other disabilities as these children enter the school system.

Austin Potenza: It’s a very relevant question, and it really goes to the heart of ethical thinking. Whose interests is the caregiver really serving? The caregiver’s, by making a medical breakthrough, or the patient’s? I certainly can’t define whether such considerations had an influence in this case, but they clearly shouldn’t….

The truth is our medical abilities are advancing at just an amazing rate, and I think it’s sometimes hard to tell the difference between doing something because we can do it and doing something because it’s the right thing to do for a particular patient in a particular circumstance. Medical ethics is fighting to catch up with the medical advances that are being made, and we always have to be thinking about these things.

By now, the story of Nadya Suleman is well known. The 33-year-old California woman gave birth to octuplets—only the second set born in the United States—on January 26. Within a few weeks, what was initially reported as a heartwarming story of medicine’s finest hour had ignited a nationwide backlash as details of Suleman’s situation became known. The divorced single mom already had six children younger than 8 when she underwent the fertility treatments that led to an eight-baby bonanza.

Should Suleman have been allowed to undergo the additional treatments? Did her medical team violate guidelines by implanting more than the generally accepted number of embryos? Is it fair to burden taxpayers with the costs of raising her large family—particularly in the current economic climate?

Clinician Reviews does not profess to have the answers to these questions. But we did ask a panel of editorial board members and other experts for their take on the thorny ethical questions Suleman’s case has raised.

How do you feel about a woman with six children younger than 8 receiving fertility treatments and delivering another eight babies?

Stephen Nunn, MPAS, PA-C, a founding member of the Association of PAs in Ob-Gyn, who worked with the first successful in vitro fertilization program in Arizona for 18 years: The issue for me isn’t so much that she already has six children, but the real and serious risks to both the mother and fetuses with multiple gestation. The American Society of Reproductive Medicine has established guidelines for the number of embryos to be transferred, which for this patient would be three. It appears these guidelines were not used in this case. This would not have generated the same response had Ms. Suleman received fertility treatment in an effort to achieve a singleton or, at most, twin gestation.

Obviously, we do not know all the details; however, I wonder why so many embryos were placed. If there were a total of seven, as the press has stated, then there would have been more than one opportunity to achieve a single pregnancy. Even if the mother did not want the other embryos destroyed, she could have donated them to another woman.

Rebecca Scott, PhD, PA-C, Clinical Coordinator in the Physician Assistant Program at Northeastern University, Boston, and an elected member of the Board of Health in Sandwich, Massachusetts: I have been thinking about how this really illustrates a tension that we’ve had in our history of the rights of the individual versus the rights of the whole community. We have this long tradition of saying, “Everybody ought to be able to have children.” This seems to fit into that continuum of the individual’s right being very strongly upheld in this country over, perhaps, what is best for the good of society.

This is so interesting because other societies are quite up-front about their goals for their population. I remember traveling in Hungary at one point, where the people were not reproducing enough to replace the population. So the government said, “It’s in our best interests to have enough people to support the society,” and they actually subsidized moms with the equivalent of a factory worker’s wage to stay home with children for three years, up to three children’s worth.

The big thing that troubles me about this is where do the rights of the group get accounted for? Should we be paying tax dollars to subsidize people who want to have children?

Austin D. Potenza II, JD, a Phoenix-based attorney and Adjunct Professor at the Arizona School of Health Sciences, where he has taught a course on medical ethics for 10 years: I think in our society everything has to be open for discussion, but we have to realize that at some point it’s just discussion. Under current ethical thinking, the most important perspective is that of a competent patient. We as a society don’t make these kinds of decisions—whether it is getting fertility treatment or having multiple births—for people.

A close second is the perspective of the infants, but it is problematic to base a societal response on what is right for children when it comes to fertility and multiple birth. Is being born into a family of 14 somehow worse than not being born at all? If we’re trying to save children, what exactly are we saving them from? And why look at just these children? If we try to have a responsible answer to these questions, it is myopic to look only at this family.

Think about the thousands of children who are born into horrible poverty, hunger, abuse, and neglect. We don’t regulate their parents’ reproductive decisions. And that’s just considering our own country; if we really want to be concerned about children, think about places like Sierra Leone, where the infant mortality rate is about 25%. Although the consideration of the children is compelling, it is much more important to consider how to help them once they are born, rather than thinking of the solution in terms of fertility and multiple births.     

The next important ethical perspective is that of the caregiver [discussed in depth later]. 

Finally, society is a stakeholder, and this seems to be the perspective from which most people are approaching the issue. The typical questions you’re going to hear are, “Is the cost of care for this mother and these children going to fall on the rest of us as taxpayers? Is this part of what’s straining the health care and social support systems?” These are all valid questions, but they beg an awful lot of other questions that we have to answer first. For example, what should we spend our collective money on? Who decides?  

While it is understandable why the public is upset by this story, at the same time, does anyone have the right to impose restrictions on someone’s procreation? Where, if at all, do we draw a line in the sand? 

Marie-Eileen Onieal, PhD, CPNP, FAANP, Director of Medical Services for the Massachusetts Department of Youth Services and Clinician Reviews NP Editor-in-Chief: I think the line between moral soundness and legal rights was crossed when the woman put her desires to have more children above the needs of the children she already bore. Before the octup-let pregnancy, she needed more than minimal assistance to care for the six children she already had; at least two have special needs requiring more attention and care.  

I think, especially in the face of the fact that she is almost totally dependent on others to help her provide for her family, we as a society have a moral and legal obligation to impose restrictions on procreation (especially when one’s procreating consumes as many resources as this woman consumed).

Rebecca Scott: I don’t think sending hate mail and death threats is any way to respond in a civil society. But I think we do need to say, “No, it is not all right for somebody to be using taxpayer dollars to subsidize,” you know, whatever it is that the individual wants to do that is way above and beyond what most of us would consider reasonable. 

If we look at the welfare-to-work initiatives that took place under the Clinton administration, that’s a start on an answer. We made the decision at that point that it was OK to say to people, “You have to get off welfare. You must go to work.” But we also enabled people to do that by saying, “We will subsidize Medicaid so that you can continue to get coverage at these low-paying jobs where you don’t earn enough money to be able to pay for health care.”

Stephen Nunn: To me, the principle here is Primum non nocere or “First, do no harm.” A twin pregnancy is considered high risk just because it’s a twin pregnancy. Those risks skyrocket with each additional fetus. The main risk here is to the fetuses, their individual and collective survival, and the potential for future problems after birth, such as cerebral palsy, blindness, and learning disabilities. So, the risks and benefits have to be weighed on an individual basis.

Personally, I can see no circumstance to justify transferring more than four embryos—ever! Holding to this guideline is not restricting a woman’s right to procreation. It’s not saying “No,” it’s saying, “Not this many.”

Although the obstetrician’s patient is the mother, not the fetus, I believe the fertility specialist can’t take such a narrow view of his or her responsibilities. Ordinarily, an obstetrician becomes involved after pregnancy has occurred, while the fertility specialist is involved prior and thus has a greater duty in regard to the potential eventual outcome. Too much success can lead ultimately to failure.

Moving forward, where do we go from here? How might these issues be addressed?

Rebecca Scott: What I’m afraid is going to happen is that we’re going to react in a heavy-handed way and set up all kinds of oversight and come at it with a legislative approach—you know, somebody in the state legislature’s going to say, “Well, we’re going to make a rule about this.”

What I hope will happen is that we’ll have a good deal of dialogue about what’s appropriate and that that dialogue will include fertility specialists, public health experts, citizens in general, and government/public health departments and that the dialogue will try to come out with some policies and procedures to guide thinking in this kind of situation.

Austin Potenza: It’s very difficult for me to imagine any legislature taking on this issue. It would be politically impossible to attempt to regulate who can have children, and how many. Think back to the Terri Schiavo case, which was such a travesty in Congress. Everybody was trying to get involved, and it was obviously completely beyond the scope of their expertise and their ability. It was just a political nightmare. This is similar because it is government involvement in an intensely personal decision, in a country dedicated to personal freedoms. If we get involved in birth regulation, we’re repeating China’s mistakes and going against the fundamentally individual-rights focus of our society.

The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions. 

The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.

What role can and should health care providers play in situations such as this? Where do their responsibilities end?

Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.   

All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).

Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision. 

I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.

Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.

Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.

The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.

What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?

Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.

Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.

Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.

At the same time, I really have a horror of setting up a situation where individual health care providers refuse to provide appropriate care because of individual beliefs. I think if we start going down that road, we’re really asking for trouble…. Medical decision-making is rarely clear-cut. The interaction between patient and provider is so much of a negotiation, tinged with so many “shades of gray,” that I believe we really have to think very carefully about whether making decisions for patients is appropriate.

Stephen Nunn: I doubt the notoriety of an octuplet birth held any sway over the decision. In fact, it probably was a negative factor. I am aware of a professed fertility specialist who became famous—or rather infamous—for being responsible for the largest number of quad births in the nation. For various reasons, the state medical board investigated, and the doctor agreed to stop the practices that led to this.

The remarkable thing seems to be that multiple gestations survive, not that they happen. I suspect that in the coming years, we will start hearing more about various learning and other disabilities as these children enter the school system.

Austin Potenza: It’s a very relevant question, and it really goes to the heart of ethical thinking. Whose interests is the caregiver really serving? The caregiver’s, by making a medical breakthrough, or the patient’s? I certainly can’t define whether such considerations had an influence in this case, but they clearly shouldn’t….

The truth is our medical abilities are advancing at just an amazing rate, and I think it’s sometimes hard to tell the difference between doing something because we can do it and doing something because it’s the right thing to do for a particular patient in a particular circumstance. Medical ethics is fighting to catch up with the medical advances that are being made, and we always have to be thinking about these things.

By now, the story of Nadya Suleman is well known. The 33-year-old California woman gave birth to octuplets—only the second set born in the United States—on January 26. Within a few weeks, what was initially reported as a heartwarming story of medicine’s finest hour had ignited a nationwide backlash as details of Suleman’s situation became known. The divorced single mom already had six children younger than 8 when she underwent the fertility treatments that led to an eight-baby bonanza.

Should Suleman have been allowed to undergo the additional treatments? Did her medical team violate guidelines by implanting more than the generally accepted number of embryos? Is it fair to burden taxpayers with the costs of raising her large family—particularly in the current economic climate?

Clinician Reviews does not profess to have the answers to these questions. But we did ask a panel of editorial board members and other experts for their take on the thorny ethical questions Suleman’s case has raised.

How do you feel about a woman with six children younger than 8 receiving fertility treatments and delivering another eight babies?

Stephen Nunn, MPAS, PA-C, a founding member of the Association of PAs in Ob-Gyn, who worked with the first successful in vitro fertilization program in Arizona for 18 years: The issue for me isn’t so much that she already has six children, but the real and serious risks to both the mother and fetuses with multiple gestation. The American Society of Reproductive Medicine has established guidelines for the number of embryos to be transferred, which for this patient would be three. It appears these guidelines were not used in this case. This would not have generated the same response had Ms. Suleman received fertility treatment in an effort to achieve a singleton or, at most, twin gestation.

Obviously, we do not know all the details; however, I wonder why so many embryos were placed. If there were a total of seven, as the press has stated, then there would have been more than one opportunity to achieve a single pregnancy. Even if the mother did not want the other embryos destroyed, she could have donated them to another woman.

Rebecca Scott, PhD, PA-C, Clinical Coordinator in the Physician Assistant Program at Northeastern University, Boston, and an elected member of the Board of Health in Sandwich, Massachusetts: I have been thinking about how this really illustrates a tension that we’ve had in our history of the rights of the individual versus the rights of the whole community. We have this long tradition of saying, “Everybody ought to be able to have children.” This seems to fit into that continuum of the individual’s right being very strongly upheld in this country over, perhaps, what is best for the good of society.

This is so interesting because other societies are quite up-front about their goals for their population. I remember traveling in Hungary at one point, where the people were not reproducing enough to replace the population. So the government said, “It’s in our best interests to have enough people to support the society,” and they actually subsidized moms with the equivalent of a factory worker’s wage to stay home with children for three years, up to three children’s worth.

The big thing that troubles me about this is where do the rights of the group get accounted for? Should we be paying tax dollars to subsidize people who want to have children?

Austin D. Potenza II, JD, a Phoenix-based attorney and Adjunct Professor at the Arizona School of Health Sciences, where he has taught a course on medical ethics for 10 years: I think in our society everything has to be open for discussion, but we have to realize that at some point it’s just discussion. Under current ethical thinking, the most important perspective is that of a competent patient. We as a society don’t make these kinds of decisions—whether it is getting fertility treatment or having multiple births—for people.

A close second is the perspective of the infants, but it is problematic to base a societal response on what is right for children when it comes to fertility and multiple birth. Is being born into a family of 14 somehow worse than not being born at all? If we’re trying to save children, what exactly are we saving them from? And why look at just these children? If we try to have a responsible answer to these questions, it is myopic to look only at this family.

Think about the thousands of children who are born into horrible poverty, hunger, abuse, and neglect. We don’t regulate their parents’ reproductive decisions. And that’s just considering our own country; if we really want to be concerned about children, think about places like Sierra Leone, where the infant mortality rate is about 25%. Although the consideration of the children is compelling, it is much more important to consider how to help them once they are born, rather than thinking of the solution in terms of fertility and multiple births.     

The next important ethical perspective is that of the caregiver [discussed in depth later]. 

Finally, society is a stakeholder, and this seems to be the perspective from which most people are approaching the issue. The typical questions you’re going to hear are, “Is the cost of care for this mother and these children going to fall on the rest of us as taxpayers? Is this part of what’s straining the health care and social support systems?” These are all valid questions, but they beg an awful lot of other questions that we have to answer first. For example, what should we spend our collective money on? Who decides?  

While it is understandable why the public is upset by this story, at the same time, does anyone have the right to impose restrictions on someone’s procreation? Where, if at all, do we draw a line in the sand? 

Marie-Eileen Onieal, PhD, CPNP, FAANP, Director of Medical Services for the Massachusetts Department of Youth Services and Clinician Reviews NP Editor-in-Chief: I think the line between moral soundness and legal rights was crossed when the woman put her desires to have more children above the needs of the children she already bore. Before the octup-let pregnancy, she needed more than minimal assistance to care for the six children she already had; at least two have special needs requiring more attention and care.  

I think, especially in the face of the fact that she is almost totally dependent on others to help her provide for her family, we as a society have a moral and legal obligation to impose restrictions on procreation (especially when one’s procreating consumes as many resources as this woman consumed).

Rebecca Scott: I don’t think sending hate mail and death threats is any way to respond in a civil society. But I think we do need to say, “No, it is not all right for somebody to be using taxpayer dollars to subsidize,” you know, whatever it is that the individual wants to do that is way above and beyond what most of us would consider reasonable. 

If we look at the welfare-to-work initiatives that took place under the Clinton administration, that’s a start on an answer. We made the decision at that point that it was OK to say to people, “You have to get off welfare. You must go to work.” But we also enabled people to do that by saying, “We will subsidize Medicaid so that you can continue to get coverage at these low-paying jobs where you don’t earn enough money to be able to pay for health care.”

Stephen Nunn: To me, the principle here is Primum non nocere or “First, do no harm.” A twin pregnancy is considered high risk just because it’s a twin pregnancy. Those risks skyrocket with each additional fetus. The main risk here is to the fetuses, their individual and collective survival, and the potential for future problems after birth, such as cerebral palsy, blindness, and learning disabilities. So, the risks and benefits have to be weighed on an individual basis.

Personally, I can see no circumstance to justify transferring more than four embryos—ever! Holding to this guideline is not restricting a woman’s right to procreation. It’s not saying “No,” it’s saying, “Not this many.”

Although the obstetrician’s patient is the mother, not the fetus, I believe the fertility specialist can’t take such a narrow view of his or her responsibilities. Ordinarily, an obstetrician becomes involved after pregnancy has occurred, while the fertility specialist is involved prior and thus has a greater duty in regard to the potential eventual outcome. Too much success can lead ultimately to failure.

Moving forward, where do we go from here? How might these issues be addressed?

Rebecca Scott: What I’m afraid is going to happen is that we’re going to react in a heavy-handed way and set up all kinds of oversight and come at it with a legislative approach—you know, somebody in the state legislature’s going to say, “Well, we’re going to make a rule about this.”

What I hope will happen is that we’ll have a good deal of dialogue about what’s appropriate and that that dialogue will include fertility specialists, public health experts, citizens in general, and government/public health departments and that the dialogue will try to come out with some policies and procedures to guide thinking in this kind of situation.

Austin Potenza: It’s very difficult for me to imagine any legislature taking on this issue. It would be politically impossible to attempt to regulate who can have children, and how many. Think back to the Terri Schiavo case, which was such a travesty in Congress. Everybody was trying to get involved, and it was obviously completely beyond the scope of their expertise and their ability. It was just a political nightmare. This is similar because it is government involvement in an intensely personal decision, in a country dedicated to personal freedoms. If we get involved in birth regulation, we’re repeating China’s mistakes and going against the fundamentally individual-rights focus of our society.

The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions. 

The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.

What role can and should health care providers play in situations such as this? Where do their responsibilities end?

Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.   

All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).

Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision. 

I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.

Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.

Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.

The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.

What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?

Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.

Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.

Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.

At the same time, I really have a horror of setting up a situation where individual health care providers refuse to provide appropriate care because of individual beliefs. I think if we start going down that road, we’re really asking for trouble…. Medical decision-making is rarely clear-cut. The interaction between patient and provider is so much of a negotiation, tinged with so many “shades of gray,” that I believe we really have to think very carefully about whether making decisions for patients is appropriate.

Stephen Nunn: I doubt the notoriety of an octuplet birth held any sway over the decision. In fact, it probably was a negative factor. I am aware of a professed fertility specialist who became famous—or rather infamous—for being responsible for the largest number of quad births in the nation. For various reasons, the state medical board investigated, and the doctor agreed to stop the practices that led to this.

The remarkable thing seems to be that multiple gestations survive, not that they happen. I suspect that in the coming years, we will start hearing more about various learning and other disabilities as these children enter the school system.

Austin Potenza: It’s a very relevant question, and it really goes to the heart of ethical thinking. Whose interests is the caregiver really serving? The caregiver’s, by making a medical breakthrough, or the patient’s? I certainly can’t define whether such considerations had an influence in this case, but they clearly shouldn’t….

The truth is our medical abilities are advancing at just an amazing rate, and I think it’s sometimes hard to tell the difference between doing something because we can do it and doing something because it’s the right thing to do for a particular patient in a particular circumstance. Medical ethics is fighting to catch up with the medical advances that are being made, and we always have to be thinking about these things.