At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

A nurse and a doctor

caring for a patient in

an intensive care unit

The American Association of Critical-Care Nurses (AACN) has released updated resources aimed at helping nurses prevent serious complications facing critically ill patients.

The resources, or “practice alerts,” address venous thromboembolism (VTE), delirium, and catheter-associated urinary tract infections (CAUTIs).

Each alert outlines the scope of the problem, summarizes the expected nursing practice, and provides supporting evidence and research.

These documents are available on the AACN website.

The VTE practice alert, “Preventing Venous Thromboembolism in Adults,” notes that VTE affects approximately 900,000 adult patients in the US annually and results in an estimated 300,000 deaths. Furthermore, VTE prevalence is predicted to more than double in the next 35 years.

The document also reviews risk factors for VTE and methods of VTE prophylaxis, including medications and compression devices.

The CAUTI practice alert, “Prevention of Catheter-Associated Urinary Tract Infections in Adults,” notes that urinary tract infections are the most common healthcare-associated infection, and prolonged indwelling catheterization is the major risk factor for CAUTIs.

The document outlines preliminary and ongoing assessment, documentation, and adherence to infection control protocols.

The delirium practice alert, “Assessment and Management of Delirium Across the Life Span,” states that delirium affects up to 80% of critically ill patients in the US, with associated annual costs between $4 billion and $16 billion.

The document reviews risk factors for pediatric and adult patients and the use of validated tools to assess for delirium.

According to AACN, each practice alert is supported by authoritative evidence and seeks to ensure excellence in practice along with promotion of a safe and humane work environment.

Topics address both nursing and interprofessional activities of importance for patients in acute and critical care environments. Some alerts include additional resources for staff education and performance-improvement activities.

A nurse and a doctor

caring for a patient in

an intensive care unit

The American Association of Critical-Care Nurses (AACN) has released updated resources aimed at helping nurses prevent serious complications facing critically ill patients.

The resources, or “practice alerts,” address venous thromboembolism (VTE), delirium, and catheter-associated urinary tract infections (CAUTIs).

Each alert outlines the scope of the problem, summarizes the expected nursing practice, and provides supporting evidence and research.

These documents are available on the AACN website.

The VTE practice alert, “Preventing Venous Thromboembolism in Adults,” notes that VTE affects approximately 900,000 adult patients in the US annually and results in an estimated 300,000 deaths. Furthermore, VTE prevalence is predicted to more than double in the next 35 years.

The document also reviews risk factors for VTE and methods of VTE prophylaxis, including medications and compression devices.

The CAUTI practice alert, “Prevention of Catheter-Associated Urinary Tract Infections in Adults,” notes that urinary tract infections are the most common healthcare-associated infection, and prolonged indwelling catheterization is the major risk factor for CAUTIs.

The document outlines preliminary and ongoing assessment, documentation, and adherence to infection control protocols.

The delirium practice alert, “Assessment and Management of Delirium Across the Life Span,” states that delirium affects up to 80% of critically ill patients in the US, with associated annual costs between $4 billion and $16 billion.

The document reviews risk factors for pediatric and adult patients and the use of validated tools to assess for delirium.

According to AACN, each practice alert is supported by authoritative evidence and seeks to ensure excellence in practice along with promotion of a safe and humane work environment.

Topics address both nursing and interprofessional activities of importance for patients in acute and critical care environments. Some alerts include additional resources for staff education and performance-improvement activities.

A nurse and a doctor

caring for a patient in

an intensive care unit

The American Association of Critical-Care Nurses (AACN) has released updated resources aimed at helping nurses prevent serious complications facing critically ill patients.

The resources, or “practice alerts,” address venous thromboembolism (VTE), delirium, and catheter-associated urinary tract infections (CAUTIs).

Each alert outlines the scope of the problem, summarizes the expected nursing practice, and provides supporting evidence and research.

These documents are available on the AACN website.

The VTE practice alert, “Preventing Venous Thromboembolism in Adults,” notes that VTE affects approximately 900,000 adult patients in the US annually and results in an estimated 300,000 deaths. Furthermore, VTE prevalence is predicted to more than double in the next 35 years.

The document also reviews risk factors for VTE and methods of VTE prophylaxis, including medications and compression devices.

The CAUTI practice alert, “Prevention of Catheter-Associated Urinary Tract Infections in Adults,” notes that urinary tract infections are the most common healthcare-associated infection, and prolonged indwelling catheterization is the major risk factor for CAUTIs.

The document outlines preliminary and ongoing assessment, documentation, and adherence to infection control protocols.

The delirium practice alert, “Assessment and Management of Delirium Across the Life Span,” states that delirium affects up to 80% of critically ill patients in the US, with associated annual costs between $4 billion and $16 billion.

The document reviews risk factors for pediatric and adult patients and the use of validated tools to assess for delirium.

According to AACN, each practice alert is supported by authoritative evidence and seeks to ensure excellence in practice along with promotion of a safe and humane work environment.

Topics address both nursing and interprofessional activities of importance for patients in acute and critical care environments. Some alerts include additional resources for staff education and performance-improvement activities.

Warfarin tablets

NEW ORLEANS—Many US patients who are candidates for treatment with oral anticoagulants (OACs) are not actually receiving these drugs, a large study suggests.

Investigators analyzed information on nearly 1.6 million hospital admissions of patients with atrial fibrillation who were candidates for OAC treatment according to guideline recommendations.

The data showed that only 46% of these patients actually received an OAC at discharge.

“This low rate of OAC use in hospitalized patients highlights an important opportunity to improve care in atrial fibrillation patients,” said Sean Pokorney, MD, of Duke University School of Medicine in Durham, North Carolina.

Dr Pokorney and his colleagues presented this research at the American Heart Association Scientific Sessions (abstract 17636).

The study was supported by Janssen Scientific Affairs, and some of the study’s investigators reported financial relationships with Janssen.

The investigators analyzed data on 1,579,456 hospital admissions across the US, occurring between January 2010 and June 2015, in which patients were treated for atrial fibrillation. The information was taken from the Premier Healthcare Database, which includes data for 1 in 5 hospital discharges in the US.

The patients analyzed were at least 40 years old and stayed in the hospital for at least 1 day. They also had a CHA₂DS₂-VASc stroke risk score of 2 or higher and were therefore candidates for treatment with an OAC, according to guideline recommendations from the American Heart Association and American College of Cardiology.

The CHA₂DS₂-VASc stroke risk score considers several factors, including age, sex, and history of congestive heart failure, stroke, diabetes, hypertension, and vascular disease.

“[I]n certain cases, it may not be safe for patients with a high stroke risk score to take blood thinners because of complications that could arise,” Dr Pokorney noted. “Still, we think 50% is too low and that there are thousands of preventable strokes happening in the United States each year because of the low rates of OAC usage.”

Dr Pokorney noted that use of OACs hovered just below 50% across several subgroups in the study.

OAC use by subgroup

The proportion of OAC use was:

• 46% overall
• 47% for patients with prior stroke
• 45% for females
• 46% for non-whites
• 47% for patients with hypertension
• 49% for those with diabetes
• 45% for patients with chronic kidney disease
• 35% for those with dementia
• 38% for patients with a history of falls
• 47% for those younger than 55
• 50% for ages 55-64 and 65-74
• 49% for ages 75-84
• 38% for patients 85 and older.

“This study identified a gap in care and is a critical first step in raising questions about how we can optimize the OAC decision-making process that atrial fibrillation patients and their providers are engaging in during a hospital stay and at the point of discharge,” Dr Pokorney said.

Barriers to OAC use

Dr Pokorney and his colleagues hope to conduct further research to determine what barriers to OAC use might exist. Dr Pokorney said possible barriers could include:

• A lack of understanding about atrial fibrillation and the risk of stroke or fear of using OACs among patients
• Knowledge deficits about stroke prevention or overemphasis of the risks of OACs among healthcare providers
• A view that OAC use is an outpatient issue, rather than an inpatient issue, among healthcare providers and systems.

Study limitations

The data showed whether patients were provided an OAC during their hospital stays. For the purposes of the study, the investigators assumed that those inpatients who were on an OAC within 24 hours of hospital discharge were also prescribed an OAC upon discharge.

However, there was no way to verify that a prescription was indeed made or filled after discharge. Additionally, although the investigators tried to exclude patients who were not candidates for OACs because of the risk of complications, there is the possibility that some remained in the study’s sample.

Warfarin tablets

NEW ORLEANS—Many US patients who are candidates for treatment with oral anticoagulants (OACs) are not actually receiving these drugs, a large study suggests.

Investigators analyzed information on nearly 1.6 million hospital admissions of patients with atrial fibrillation who were candidates for OAC treatment according to guideline recommendations.

The data showed that only 46% of these patients actually received an OAC at discharge.

“This low rate of OAC use in hospitalized patients highlights an important opportunity to improve care in atrial fibrillation patients,” said Sean Pokorney, MD, of Duke University School of Medicine in Durham, North Carolina.

Dr Pokorney and his colleagues presented this research at the American Heart Association Scientific Sessions (abstract 17636).

The study was supported by Janssen Scientific Affairs, and some of the study’s investigators reported financial relationships with Janssen.

The investigators analyzed data on 1,579,456 hospital admissions across the US, occurring between January 2010 and June 2015, in which patients were treated for atrial fibrillation. The information was taken from the Premier Healthcare Database, which includes data for 1 in 5 hospital discharges in the US.

The patients analyzed were at least 40 years old and stayed in the hospital for at least 1 day. They also had a CHA₂DS₂-VASc stroke risk score of 2 or higher and were therefore candidates for treatment with an OAC, according to guideline recommendations from the American Heart Association and American College of Cardiology.

The CHA₂DS₂-VASc stroke risk score considers several factors, including age, sex, and history of congestive heart failure, stroke, diabetes, hypertension, and vascular disease.

“[I]n certain cases, it may not be safe for patients with a high stroke risk score to take blood thinners because of complications that could arise,” Dr Pokorney noted. “Still, we think 50% is too low and that there are thousands of preventable strokes happening in the United States each year because of the low rates of OAC usage.”

Dr Pokorney noted that use of OACs hovered just below 50% across several subgroups in the study.

OAC use by subgroup

The proportion of OAC use was:

• 46% overall
• 47% for patients with prior stroke
• 45% for females
• 46% for non-whites
• 47% for patients with hypertension
• 49% for those with diabetes
• 45% for patients with chronic kidney disease
• 35% for those with dementia
• 38% for patients with a history of falls
• 47% for those younger than 55
• 50% for ages 55-64 and 65-74
• 49% for ages 75-84
• 38% for patients 85 and older.

“This study identified a gap in care and is a critical first step in raising questions about how we can optimize the OAC decision-making process that atrial fibrillation patients and their providers are engaging in during a hospital stay and at the point of discharge,” Dr Pokorney said.

Barriers to OAC use

Dr Pokorney and his colleagues hope to conduct further research to determine what barriers to OAC use might exist. Dr Pokorney said possible barriers could include:

• A lack of understanding about atrial fibrillation and the risk of stroke or fear of using OACs among patients
• Knowledge deficits about stroke prevention or overemphasis of the risks of OACs among healthcare providers
• A view that OAC use is an outpatient issue, rather than an inpatient issue, among healthcare providers and systems.

Study limitations

The data showed whether patients were provided an OAC during their hospital stays. For the purposes of the study, the investigators assumed that those inpatients who were on an OAC within 24 hours of hospital discharge were also prescribed an OAC upon discharge.

However, there was no way to verify that a prescription was indeed made or filled after discharge. Additionally, although the investigators tried to exclude patients who were not candidates for OACs because of the risk of complications, there is the possibility that some remained in the study’s sample.

Warfarin tablets

NEW ORLEANS—Many US patients who are candidates for treatment with oral anticoagulants (OACs) are not actually receiving these drugs, a large study suggests.

Investigators analyzed information on nearly 1.6 million hospital admissions of patients with atrial fibrillation who were candidates for OAC treatment according to guideline recommendations.

The data showed that only 46% of these patients actually received an OAC at discharge.

“This low rate of OAC use in hospitalized patients highlights an important opportunity to improve care in atrial fibrillation patients,” said Sean Pokorney, MD, of Duke University School of Medicine in Durham, North Carolina.

Dr Pokorney and his colleagues presented this research at the American Heart Association Scientific Sessions (abstract 17636).

The study was supported by Janssen Scientific Affairs, and some of the study’s investigators reported financial relationships with Janssen.

The investigators analyzed data on 1,579,456 hospital admissions across the US, occurring between January 2010 and June 2015, in which patients were treated for atrial fibrillation. The information was taken from the Premier Healthcare Database, which includes data for 1 in 5 hospital discharges in the US.

The patients analyzed were at least 40 years old and stayed in the hospital for at least 1 day. They also had a CHA₂DS₂-VASc stroke risk score of 2 or higher and were therefore candidates for treatment with an OAC, according to guideline recommendations from the American Heart Association and American College of Cardiology.

The CHA₂DS₂-VASc stroke risk score considers several factors, including age, sex, and history of congestive heart failure, stroke, diabetes, hypertension, and vascular disease.

“[I]n certain cases, it may not be safe for patients with a high stroke risk score to take blood thinners because of complications that could arise,” Dr Pokorney noted. “Still, we think 50% is too low and that there are thousands of preventable strokes happening in the United States each year because of the low rates of OAC usage.”

Dr Pokorney noted that use of OACs hovered just below 50% across several subgroups in the study.

OAC use by subgroup

The proportion of OAC use was:

• 46% overall
• 47% for patients with prior stroke
• 45% for females
• 46% for non-whites
• 47% for patients with hypertension
• 49% for those with diabetes
• 45% for patients with chronic kidney disease
• 35% for those with dementia
• 38% for patients with a history of falls
• 47% for those younger than 55
• 50% for ages 55-64 and 65-74
• 49% for ages 75-84
• 38% for patients 85 and older.

“This study identified a gap in care and is a critical first step in raising questions about how we can optimize the OAC decision-making process that atrial fibrillation patients and their providers are engaging in during a hospital stay and at the point of discharge,” Dr Pokorney said.

Barriers to OAC use

Dr Pokorney and his colleagues hope to conduct further research to determine what barriers to OAC use might exist. Dr Pokorney said possible barriers could include:

• A lack of understanding about atrial fibrillation and the risk of stroke or fear of using OACs among patients
• Knowledge deficits about stroke prevention or overemphasis of the risks of OACs among healthcare providers
• A view that OAC use is an outpatient issue, rather than an inpatient issue, among healthcare providers and systems.

Study limitations

The data showed whether patients were provided an OAC during their hospital stays. For the purposes of the study, the investigators assumed that those inpatients who were on an OAC within 24 hours of hospital discharge were also prescribed an OAC upon discharge.

However, there was no way to verify that a prescription was indeed made or filled after discharge. Additionally, although the investigators tried to exclude patients who were not candidates for OACs because of the risk of complications, there is the possibility that some remained in the study’s sample.

AGA has expanded the Patient INFO Center with a new resource that covers the common questions from patients with IBD who are looking to conceive. This easy-to-access and easy-to-read fact sheet covers frequently asked questions from both women and men, and includes information on staying on medications while trying to get pregnant, precautions pregnant women should be aware of, and much more.

The resource guide was written with Sunanda V. Kane, MD, from Mayo Clinic, Rochester, Minn. View, download, print, or share the IBD & Pregnancy FAQ fact sheet with your IBD patients today.

Visit the Patient INFO Center for all patient education on IBD and more.

AGA has expanded the Patient INFO Center with a new resource that covers the common questions from patients with IBD who are looking to conceive. This easy-to-access and easy-to-read fact sheet covers frequently asked questions from both women and men, and includes information on staying on medications while trying to get pregnant, precautions pregnant women should be aware of, and much more.

The resource guide was written with Sunanda V. Kane, MD, from Mayo Clinic, Rochester, Minn. View, download, print, or share the IBD & Pregnancy FAQ fact sheet with your IBD patients today.

Visit the Patient INFO Center for all patient education on IBD and more.

AGA has expanded the Patient INFO Center with a new resource that covers the common questions from patients with IBD who are looking to conceive. This easy-to-access and easy-to-read fact sheet covers frequently asked questions from both women and men, and includes information on staying on medications while trying to get pregnant, precautions pregnant women should be aware of, and much more.

The resource guide was written with Sunanda V. Kane, MD, from Mayo Clinic, Rochester, Minn. View, download, print, or share the IBD & Pregnancy FAQ fact sheet with your IBD patients today.

Visit the Patient INFO Center for all patient education on IBD and more.

BOSTON – Patients with primary biliary cholangitis (PBC) who have compensated cirrhosis fared just as well on obeticholic acid (OCA) as did PBC patients without cirrhosis, according to an analysis of data from POISE, the pivotal clinical trial for approval of OCA for PBC.

The POISE trial included 36 individuals with PBC and compensated cirrhosis, since cirrhosis “is an endpoint for virtually all liver diseases,” John Vierling, MD, said in a video interview at the meeting.

“Significantly more OCA-treated patients with cirrhosis achieved the primary composite endpoint compared to placebo,” Dr. Vierling and his coauthors wrote in a poster presented at the annual meeting for the American Association for the Study of Liver Diseases. The difference was individually significant for all three values that made up the composite primary endpoint as well.

Secondary endpoints included gamma-glutamyltransferase, alanine aminotrasferase, and aspartate aminotransferase, all of which were significantly reduced among patients taking OCA. Patients on placebo saw these values rise over the time period of the study.

There were no new safety signals seen in the post hoc analysis of the group with cirrhosis that were not seen in the trial at large, said Dr. Vierling. Two individuals in the subgroup dropped out of the trial because of pruritis, a similar proportion to that seen in the full trial population.

The drug’s manufacturer, Intercept Pharmaceuticals, is working with the Food and Drug Administration to establish appropriate doses and intervals for obeticholic acid so it may be used safely in individuals with decompensated cirrhosis, said Dr. Vierling.

Obeticholic acid, a farnesoid-X receptor agonist, is an approved agent to use as add-on therapy to ursodeoxycholic acid (UDCA), or as monotherapy for patients who can’t tolerate UDCA.

Dr. Vierling disclosed financial relationships with Intercept Pharmaceuticals and with several other pharmaceutical companies. The study was funded by Intercept Pharmaceuticals.

koakes@frontlinemedcom.com

On Twitter @karioakes

BOSTON – Patients with primary biliary cholangitis (PBC) who have compensated cirrhosis fared just as well on obeticholic acid (OCA) as did PBC patients without cirrhosis, according to an analysis of data from POISE, the pivotal clinical trial for approval of OCA for PBC.

The POISE trial included 36 individuals with PBC and compensated cirrhosis, since cirrhosis “is an endpoint for virtually all liver diseases,” John Vierling, MD, said in a video interview at the meeting.

“Significantly more OCA-treated patients with cirrhosis achieved the primary composite endpoint compared to placebo,” Dr. Vierling and his coauthors wrote in a poster presented at the annual meeting for the American Association for the Study of Liver Diseases. The difference was individually significant for all three values that made up the composite primary endpoint as well.

Secondary endpoints included gamma-glutamyltransferase, alanine aminotrasferase, and aspartate aminotransferase, all of which were significantly reduced among patients taking OCA. Patients on placebo saw these values rise over the time period of the study.

There were no new safety signals seen in the post hoc analysis of the group with cirrhosis that were not seen in the trial at large, said Dr. Vierling. Two individuals in the subgroup dropped out of the trial because of pruritis, a similar proportion to that seen in the full trial population.

The drug’s manufacturer, Intercept Pharmaceuticals, is working with the Food and Drug Administration to establish appropriate doses and intervals for obeticholic acid so it may be used safely in individuals with decompensated cirrhosis, said Dr. Vierling.

Obeticholic acid, a farnesoid-X receptor agonist, is an approved agent to use as add-on therapy to ursodeoxycholic acid (UDCA), or as monotherapy for patients who can’t tolerate UDCA.

Dr. Vierling disclosed financial relationships with Intercept Pharmaceuticals and with several other pharmaceutical companies. The study was funded by Intercept Pharmaceuticals.

koakes@frontlinemedcom.com

On Twitter @karioakes

BOSTON – Patients with primary biliary cholangitis (PBC) who have compensated cirrhosis fared just as well on obeticholic acid (OCA) as did PBC patients without cirrhosis, according to an analysis of data from POISE, the pivotal clinical trial for approval of OCA for PBC.

The POISE trial included 36 individuals with PBC and compensated cirrhosis, since cirrhosis “is an endpoint for virtually all liver diseases,” John Vierling, MD, said in a video interview at the meeting.

“Significantly more OCA-treated patients with cirrhosis achieved the primary composite endpoint compared to placebo,” Dr. Vierling and his coauthors wrote in a poster presented at the annual meeting for the American Association for the Study of Liver Diseases. The difference was individually significant for all three values that made up the composite primary endpoint as well.

Secondary endpoints included gamma-glutamyltransferase, alanine aminotrasferase, and aspartate aminotransferase, all of which were significantly reduced among patients taking OCA. Patients on placebo saw these values rise over the time period of the study.

There were no new safety signals seen in the post hoc analysis of the group with cirrhosis that were not seen in the trial at large, said Dr. Vierling. Two individuals in the subgroup dropped out of the trial because of pruritis, a similar proportion to that seen in the full trial population.

The drug’s manufacturer, Intercept Pharmaceuticals, is working with the Food and Drug Administration to establish appropriate doses and intervals for obeticholic acid so it may be used safely in individuals with decompensated cirrhosis, said Dr. Vierling.

Obeticholic acid, a farnesoid-X receptor agonist, is an approved agent to use as add-on therapy to ursodeoxycholic acid (UDCA), or as monotherapy for patients who can’t tolerate UDCA.

Dr. Vierling disclosed financial relationships with Intercept Pharmaceuticals and with several other pharmaceutical companies. The study was funded by Intercept Pharmaceuticals.

koakes@frontlinemedcom.com

On Twitter @karioakes

The following opinions are my own and not those of the U.S. Department of Defense.

Job insecurity can have a powerful impact on health, particularly mental health.

A recent study of almost 17,500 U.S. working adults found that 33% of the workers thought that their jobs were insecure, and those who reported job insecurity were more likely to be obese, sleep less than 6 hours a day, report pain conditions, and smoke every day. When it came to mental health, those who were job insecure had a likelihood of serious mental illness within the last 30 days almost five times higher than those who were not job insecure (J Community Health. 2016 Sep 10. doi: 10.1007/s10900-016-0249-8). This study is one of many that highlights the importance of what I call “financial mental health.”

The notion of financial mental health merges two distinct, yet interrelated aspects of patients’ lives into a single construct that can be used to inform resiliency-building behaviors and identify gaps in institutional approaches to supportive services. Patients with strong financial mental health are able to build, maintain, sustain, and revitalize their resiliency across several domains, which include mind, body, spirit, and social indicators.

Financial mental health and mortality

According to the World Bank, “Mental health issues impose an enormous disease burden on societies across the world. Depression alone affects 350 million people globally and is the leading cause of disability worldwide. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, and fear. The issue is becoming ever more urgent in light of the forced migration and sustained conflict we are seeing in many countries around the world.”¹ In the United States alone, the Consumer Financial Protection Bureau (CFPB) reports that almost one-third of Americans are touched by poverty and advocates for financial literacy and empowerment for our most vulnerable citizens.

Unfortunately, mental health clinicians rarely discuss a depressed patient’s financial planning aside from occasional referrals for housing, disability benefits, or subsistence allowances. Based on observations from the World Health Organization, mental health is tied to satisfaction with quality of life. Furthermore, it relates to the ability to cope with life’s stressors, to engage in meaningful and productive activities, and to have a sense of community belonging.

When Abraham Maslow, PhD, described psychological health through the lens of human motivation, he constructed a “hierarchy of needs”² that at the base lies the physiological requirements for food, shelter, and clothing. Those items represent our most physical necessities, protect us from harm, and determine our survival. They also are related to our need for safety (i.e., job security), which is the second rung on Dr. Maslow’s hierarchy of needs. In many ways, our ability to feel safe is predicated on our ability to secure our environment with proper housing, healthy nutrition, and appropriate wardrobe (and the accouterments thereof), which, in turn, align us and our families to our culture, community, and socioeconomic status. But it costs money to stay healthy and protected. The CFPB recognized the intersection of these issues and developed a toolkit³ for social service and related agencies aimed at enhancing financial literacy and education within the populations they serve so that those individuals can become more skilled and empowered.

The consequences of poor financial mental health are found in data related to mortality. The Centers for Disease Control and Prevention documents that lower socioeconomic status is related to higher rates of mortality.⁴ For Americans living in poverty, their social network, lifestyle, and access to medical care contribute to their inability to live longer lives. Without access to quality and timely medical care, and appropriately funded services, the impacts from trauma, depression, substance abuse, and suicide are more widely experienced. For example, the Department of Defense Suicide Event Report since 2008 has linked suicide and suicide attempts among Service members to failed relationships along with financial and legal problems.

Several of the economic issues relate to conflicts in the workplace that can determine promotions in rank/increases in pay, retention, or transition to civilian employment/unemployment, retirement pay and benefits, or disability compensation. Service members and their families also are subject to divorce and alimony, child support payments, student loan repayments, mortgage defaults, and other liens or judgments. As veterans, this younger cohort must secure new housing, enroll in college or gain employment. This means (often for the first time) financing a mortgage, hunting for a job, filing for GI Bill or other Department of Veterans Affairs (VA) benefits, updating insurance, and family budgeting, while also dealing with the stress of military separation and loss of service identity, and postdeployment health issues. The VA has studied increases in suicide rates, depression, and post-traumatic stress disorder within this population – which is not surprising given the level of social instability that they are experiencing.

Furthermore, for veterans who seek treatment, which can mean long inpatient hospitalization or rehabilitation stays, numerous outpatient appointments, and/or medication management, there will be an impact on their finances, because they will be limited in their ability to maintain gainful employment or enroll in classes. This, in turn, complicates family dynamics. Sometimes, spouses have to assume caregiver roles or become the primary breadwinner, which can have an effect on veterans’ self-esteem, sense of belongingness, and burdensomeness – factors associated with suicide.

Mental health also is affected by financial abuse. According to the National Network to End Domestic Violence, financial abuse is a means by which perpetrators can control their victims who are elderly, disabled, subjects of human trafficking, or their partners. Although financial abuse occurs across all socioeconomic classes, usually victims who are experiencing physical and emotional abuse also are being controlled by having their finances or assets taken or withheld from them. Survivors able to extricate themselves from an abuser often are dealing with depression, anxiety, substance abuse, or suicidality. Under that state of mind, they also must find ways to repair their employability and insurability, recover from debt or identity theft, restore their credit and rebuild assets, file for divorce or protective orders, or claim unpaid alimony or child support from the perpetrator and secure safe housing – all while managing their symptoms.

Concrete steps

Individuals can take steps to ensure their financial mental health. Looking at Dr. Maslow’s hierarchy, the pinnacle of the pyramid centers on activities that relate to self-efficacy and esteem. Financial planning is an activity that can foster those feelings but requires the right blend of knowledge and information. Investing in the market has been described as an emotional experience. When the market is up and risk is high, emotions are positive; but when it is low, despondency over a portfolio can set in, and emotions may run scared. Investing comes with its risks and rewards. The receptiveness that individuals have for financial planning and investing will depend upon their views about tolerating risk, as well as their lifestyle goals and objectives, retirement plans, and health concerns.

Trauma survivors who tend to experience anxiety, depression, guilt, or emotional numbing – and have a foreshortened sense of future – may find it difficult to focus on a long-term financial plan. In the early stages of therapy and recovery, finance efforts may need to be concentrated primarily on obtaining a job with benefits and proper housing. Reducing debt and restoring credit become secondary challenges, and investing and retirement planning may take an even further backseat. However, for those experiencing psychological challenges, financial planning can be empowering and reassuring, because it provides a sense of structure, identifies goals, and restores hope for a better future.

Communities and organizations that support individuals with psychiatric conditions may need to further consider embedding financial planning into a case management approach that is more holistic and concentrates on all domains of social resilience as recommended by the CFPB. Training clinicians about financial planning can be useful because of the tools it can offer patients who are working on their recovery and rebuilding their futures.

People contemplating suicide are known to first get their affairs in order and often will update their beneficiary status, sometime making multiple changes depending on their emotional state within a month of their death, so agents should be aware of these habits. When working with veterans, abuse survivors, or those with more serious mental illness, ensuring that they are knowledgeable about available government benefits and pairing them with private sector products can help people who might seem like they are in denial or procrastinating about investing but are actually feeling overwhelmed, confused, and lack confidence in their own decision making. Partitioning these goals into short- and long-term steps and providing more attentive case management that builds trust and addresses concerns can help people stay engaged in reaching their goals.

Financial mental health is a concept rooted in individual resilience and the approaches needed to maximize it. As mental health professionals, we can leverage our own knowledge with that of personal finance experts to help our patients build resilience skills and tools. As result, patients in the most disadvantaged and disenfranchised communities will not only survive but thrive.

References

1 “Out of the Shadows: Making Mental Health a Global Priority,” April 13-14, 2016.
2 Psychological Rev. 1943;50:370-96. “A Theory of Human Motivation” is represented as a pyramid with the most fundamental needs at the base. Those needs are physiological, safety, love/belonging, esteem, and self-actualization in descending order.
3 “Your Money, Your Goals: A financial empowerment toolkit for Social Services programs,” April 2015.
4 National Vital Statistics Report, “Deaths: Final Data for 2014,” Vol. 65 No. 4, June 30, 2016.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and, suicide prevention and peer support programs; worked with Gulf War veterans as an Army social work officer; and provided individual, group, and family therapy to Vietnam veterans their families dealing with post-traumatic stress disorder.

The following opinions are my own and not those of the U.S. Department of Defense.

Job insecurity can have a powerful impact on health, particularly mental health.

A recent study of almost 17,500 U.S. working adults found that 33% of the workers thought that their jobs were insecure, and those who reported job insecurity were more likely to be obese, sleep less than 6 hours a day, report pain conditions, and smoke every day. When it came to mental health, those who were job insecure had a likelihood of serious mental illness within the last 30 days almost five times higher than those who were not job insecure (J Community Health. 2016 Sep 10. doi: 10.1007/s10900-016-0249-8). This study is one of many that highlights the importance of what I call “financial mental health.”

The notion of financial mental health merges two distinct, yet interrelated aspects of patients’ lives into a single construct that can be used to inform resiliency-building behaviors and identify gaps in institutional approaches to supportive services. Patients with strong financial mental health are able to build, maintain, sustain, and revitalize their resiliency across several domains, which include mind, body, spirit, and social indicators.

Financial mental health and mortality

According to the World Bank, “Mental health issues impose an enormous disease burden on societies across the world. Depression alone affects 350 million people globally and is the leading cause of disability worldwide. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, and fear. The issue is becoming ever more urgent in light of the forced migration and sustained conflict we are seeing in many countries around the world.”¹ In the United States alone, the Consumer Financial Protection Bureau (CFPB) reports that almost one-third of Americans are touched by poverty and advocates for financial literacy and empowerment for our most vulnerable citizens.

Unfortunately, mental health clinicians rarely discuss a depressed patient’s financial planning aside from occasional referrals for housing, disability benefits, or subsistence allowances. Based on observations from the World Health Organization, mental health is tied to satisfaction with quality of life. Furthermore, it relates to the ability to cope with life’s stressors, to engage in meaningful and productive activities, and to have a sense of community belonging.

When Abraham Maslow, PhD, described psychological health through the lens of human motivation, he constructed a “hierarchy of needs”² that at the base lies the physiological requirements for food, shelter, and clothing. Those items represent our most physical necessities, protect us from harm, and determine our survival. They also are related to our need for safety (i.e., job security), which is the second rung on Dr. Maslow’s hierarchy of needs. In many ways, our ability to feel safe is predicated on our ability to secure our environment with proper housing, healthy nutrition, and appropriate wardrobe (and the accouterments thereof), which, in turn, align us and our families to our culture, community, and socioeconomic status. But it costs money to stay healthy and protected. The CFPB recognized the intersection of these issues and developed a toolkit³ for social service and related agencies aimed at enhancing financial literacy and education within the populations they serve so that those individuals can become more skilled and empowered.

The consequences of poor financial mental health are found in data related to mortality. The Centers for Disease Control and Prevention documents that lower socioeconomic status is related to higher rates of mortality.⁴ For Americans living in poverty, their social network, lifestyle, and access to medical care contribute to their inability to live longer lives. Without access to quality and timely medical care, and appropriately funded services, the impacts from trauma, depression, substance abuse, and suicide are more widely experienced. For example, the Department of Defense Suicide Event Report since 2008 has linked suicide and suicide attempts among Service members to failed relationships along with financial and legal problems.

Several of the economic issues relate to conflicts in the workplace that can determine promotions in rank/increases in pay, retention, or transition to civilian employment/unemployment, retirement pay and benefits, or disability compensation. Service members and their families also are subject to divorce and alimony, child support payments, student loan repayments, mortgage defaults, and other liens or judgments. As veterans, this younger cohort must secure new housing, enroll in college or gain employment. This means (often for the first time) financing a mortgage, hunting for a job, filing for GI Bill or other Department of Veterans Affairs (VA) benefits, updating insurance, and family budgeting, while also dealing with the stress of military separation and loss of service identity, and postdeployment health issues. The VA has studied increases in suicide rates, depression, and post-traumatic stress disorder within this population – which is not surprising given the level of social instability that they are experiencing.

Furthermore, for veterans who seek treatment, which can mean long inpatient hospitalization or rehabilitation stays, numerous outpatient appointments, and/or medication management, there will be an impact on their finances, because they will be limited in their ability to maintain gainful employment or enroll in classes. This, in turn, complicates family dynamics. Sometimes, spouses have to assume caregiver roles or become the primary breadwinner, which can have an effect on veterans’ self-esteem, sense of belongingness, and burdensomeness – factors associated with suicide.

Mental health also is affected by financial abuse. According to the National Network to End Domestic Violence, financial abuse is a means by which perpetrators can control their victims who are elderly, disabled, subjects of human trafficking, or their partners. Although financial abuse occurs across all socioeconomic classes, usually victims who are experiencing physical and emotional abuse also are being controlled by having their finances or assets taken or withheld from them. Survivors able to extricate themselves from an abuser often are dealing with depression, anxiety, substance abuse, or suicidality. Under that state of mind, they also must find ways to repair their employability and insurability, recover from debt or identity theft, restore their credit and rebuild assets, file for divorce or protective orders, or claim unpaid alimony or child support from the perpetrator and secure safe housing – all while managing their symptoms.

Concrete steps

Individuals can take steps to ensure their financial mental health. Looking at Dr. Maslow’s hierarchy, the pinnacle of the pyramid centers on activities that relate to self-efficacy and esteem. Financial planning is an activity that can foster those feelings but requires the right blend of knowledge and information. Investing in the market has been described as an emotional experience. When the market is up and risk is high, emotions are positive; but when it is low, despondency over a portfolio can set in, and emotions may run scared. Investing comes with its risks and rewards. The receptiveness that individuals have for financial planning and investing will depend upon their views about tolerating risk, as well as their lifestyle goals and objectives, retirement plans, and health concerns.

Trauma survivors who tend to experience anxiety, depression, guilt, or emotional numbing – and have a foreshortened sense of future – may find it difficult to focus on a long-term financial plan. In the early stages of therapy and recovery, finance efforts may need to be concentrated primarily on obtaining a job with benefits and proper housing. Reducing debt and restoring credit become secondary challenges, and investing and retirement planning may take an even further backseat. However, for those experiencing psychological challenges, financial planning can be empowering and reassuring, because it provides a sense of structure, identifies goals, and restores hope for a better future.

Communities and organizations that support individuals with psychiatric conditions may need to further consider embedding financial planning into a case management approach that is more holistic and concentrates on all domains of social resilience as recommended by the CFPB. Training clinicians about financial planning can be useful because of the tools it can offer patients who are working on their recovery and rebuilding their futures.

People contemplating suicide are known to first get their affairs in order and often will update their beneficiary status, sometime making multiple changes depending on their emotional state within a month of their death, so agents should be aware of these habits. When working with veterans, abuse survivors, or those with more serious mental illness, ensuring that they are knowledgeable about available government benefits and pairing them with private sector products can help people who might seem like they are in denial or procrastinating about investing but are actually feeling overwhelmed, confused, and lack confidence in their own decision making. Partitioning these goals into short- and long-term steps and providing more attentive case management that builds trust and addresses concerns can help people stay engaged in reaching their goals.

Financial mental health is a concept rooted in individual resilience and the approaches needed to maximize it. As mental health professionals, we can leverage our own knowledge with that of personal finance experts to help our patients build resilience skills and tools. As result, patients in the most disadvantaged and disenfranchised communities will not only survive but thrive.

References

1 “Out of the Shadows: Making Mental Health a Global Priority,” April 13-14, 2016.
2 Psychological Rev. 1943;50:370-96. “A Theory of Human Motivation” is represented as a pyramid with the most fundamental needs at the base. Those needs are physiological, safety, love/belonging, esteem, and self-actualization in descending order.
3 “Your Money, Your Goals: A financial empowerment toolkit for Social Services programs,” April 2015.
4 National Vital Statistics Report, “Deaths: Final Data for 2014,” Vol. 65 No. 4, June 30, 2016.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and, suicide prevention and peer support programs; worked with Gulf War veterans as an Army social work officer; and provided individual, group, and family therapy to Vietnam veterans their families dealing with post-traumatic stress disorder.

The following opinions are my own and not those of the U.S. Department of Defense.

Job insecurity can have a powerful impact on health, particularly mental health.

A recent study of almost 17,500 U.S. working adults found that 33% of the workers thought that their jobs were insecure, and those who reported job insecurity were more likely to be obese, sleep less than 6 hours a day, report pain conditions, and smoke every day. When it came to mental health, those who were job insecure had a likelihood of serious mental illness within the last 30 days almost five times higher than those who were not job insecure (J Community Health. 2016 Sep 10. doi: 10.1007/s10900-016-0249-8). This study is one of many that highlights the importance of what I call “financial mental health.”

The notion of financial mental health merges two distinct, yet interrelated aspects of patients’ lives into a single construct that can be used to inform resiliency-building behaviors and identify gaps in institutional approaches to supportive services. Patients with strong financial mental health are able to build, maintain, sustain, and revitalize their resiliency across several domains, which include mind, body, spirit, and social indicators.

Financial mental health and mortality

According to the World Bank, “Mental health issues impose an enormous disease burden on societies across the world. Depression alone affects 350 million people globally and is the leading cause of disability worldwide. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, and fear. The issue is becoming ever more urgent in light of the forced migration and sustained conflict we are seeing in many countries around the world.”¹ In the United States alone, the Consumer Financial Protection Bureau (CFPB) reports that almost one-third of Americans are touched by poverty and advocates for financial literacy and empowerment for our most vulnerable citizens.

Unfortunately, mental health clinicians rarely discuss a depressed patient’s financial planning aside from occasional referrals for housing, disability benefits, or subsistence allowances. Based on observations from the World Health Organization, mental health is tied to satisfaction with quality of life. Furthermore, it relates to the ability to cope with life’s stressors, to engage in meaningful and productive activities, and to have a sense of community belonging.

When Abraham Maslow, PhD, described psychological health through the lens of human motivation, he constructed a “hierarchy of needs”² that at the base lies the physiological requirements for food, shelter, and clothing. Those items represent our most physical necessities, protect us from harm, and determine our survival. They also are related to our need for safety (i.e., job security), which is the second rung on Dr. Maslow’s hierarchy of needs. In many ways, our ability to feel safe is predicated on our ability to secure our environment with proper housing, healthy nutrition, and appropriate wardrobe (and the accouterments thereof), which, in turn, align us and our families to our culture, community, and socioeconomic status. But it costs money to stay healthy and protected. The CFPB recognized the intersection of these issues and developed a toolkit³ for social service and related agencies aimed at enhancing financial literacy and education within the populations they serve so that those individuals can become more skilled and empowered.

The consequences of poor financial mental health are found in data related to mortality. The Centers for Disease Control and Prevention documents that lower socioeconomic status is related to higher rates of mortality.⁴ For Americans living in poverty, their social network, lifestyle, and access to medical care contribute to their inability to live longer lives. Without access to quality and timely medical care, and appropriately funded services, the impacts from trauma, depression, substance abuse, and suicide are more widely experienced. For example, the Department of Defense Suicide Event Report since 2008 has linked suicide and suicide attempts among Service members to failed relationships along with financial and legal problems.

Several of the economic issues relate to conflicts in the workplace that can determine promotions in rank/increases in pay, retention, or transition to civilian employment/unemployment, retirement pay and benefits, or disability compensation. Service members and their families also are subject to divorce and alimony, child support payments, student loan repayments, mortgage defaults, and other liens or judgments. As veterans, this younger cohort must secure new housing, enroll in college or gain employment. This means (often for the first time) financing a mortgage, hunting for a job, filing for GI Bill or other Department of Veterans Affairs (VA) benefits, updating insurance, and family budgeting, while also dealing with the stress of military separation and loss of service identity, and postdeployment health issues. The VA has studied increases in suicide rates, depression, and post-traumatic stress disorder within this population – which is not surprising given the level of social instability that they are experiencing.

Furthermore, for veterans who seek treatment, which can mean long inpatient hospitalization or rehabilitation stays, numerous outpatient appointments, and/or medication management, there will be an impact on their finances, because they will be limited in their ability to maintain gainful employment or enroll in classes. This, in turn, complicates family dynamics. Sometimes, spouses have to assume caregiver roles or become the primary breadwinner, which can have an effect on veterans’ self-esteem, sense of belongingness, and burdensomeness – factors associated with suicide.

Mental health also is affected by financial abuse. According to the National Network to End Domestic Violence, financial abuse is a means by which perpetrators can control their victims who are elderly, disabled, subjects of human trafficking, or their partners. Although financial abuse occurs across all socioeconomic classes, usually victims who are experiencing physical and emotional abuse also are being controlled by having their finances or assets taken or withheld from them. Survivors able to extricate themselves from an abuser often are dealing with depression, anxiety, substance abuse, or suicidality. Under that state of mind, they also must find ways to repair their employability and insurability, recover from debt or identity theft, restore their credit and rebuild assets, file for divorce or protective orders, or claim unpaid alimony or child support from the perpetrator and secure safe housing – all while managing their symptoms.

Concrete steps

Individuals can take steps to ensure their financial mental health. Looking at Dr. Maslow’s hierarchy, the pinnacle of the pyramid centers on activities that relate to self-efficacy and esteem. Financial planning is an activity that can foster those feelings but requires the right blend of knowledge and information. Investing in the market has been described as an emotional experience. When the market is up and risk is high, emotions are positive; but when it is low, despondency over a portfolio can set in, and emotions may run scared. Investing comes with its risks and rewards. The receptiveness that individuals have for financial planning and investing will depend upon their views about tolerating risk, as well as their lifestyle goals and objectives, retirement plans, and health concerns.

Trauma survivors who tend to experience anxiety, depression, guilt, or emotional numbing – and have a foreshortened sense of future – may find it difficult to focus on a long-term financial plan. In the early stages of therapy and recovery, finance efforts may need to be concentrated primarily on obtaining a job with benefits and proper housing. Reducing debt and restoring credit become secondary challenges, and investing and retirement planning may take an even further backseat. However, for those experiencing psychological challenges, financial planning can be empowering and reassuring, because it provides a sense of structure, identifies goals, and restores hope for a better future.

Communities and organizations that support individuals with psychiatric conditions may need to further consider embedding financial planning into a case management approach that is more holistic and concentrates on all domains of social resilience as recommended by the CFPB. Training clinicians about financial planning can be useful because of the tools it can offer patients who are working on their recovery and rebuilding their futures.

People contemplating suicide are known to first get their affairs in order and often will update their beneficiary status, sometime making multiple changes depending on their emotional state within a month of their death, so agents should be aware of these habits. When working with veterans, abuse survivors, or those with more serious mental illness, ensuring that they are knowledgeable about available government benefits and pairing them with private sector products can help people who might seem like they are in denial or procrastinating about investing but are actually feeling overwhelmed, confused, and lack confidence in their own decision making. Partitioning these goals into short- and long-term steps and providing more attentive case management that builds trust and addresses concerns can help people stay engaged in reaching their goals.

Financial mental health is a concept rooted in individual resilience and the approaches needed to maximize it. As mental health professionals, we can leverage our own knowledge with that of personal finance experts to help our patients build resilience skills and tools. As result, patients in the most disadvantaged and disenfranchised communities will not only survive but thrive.

References

1 “Out of the Shadows: Making Mental Health a Global Priority,” April 13-14, 2016.
2 Psychological Rev. 1943;50:370-96. “A Theory of Human Motivation” is represented as a pyramid with the most fundamental needs at the base. Those needs are physiological, safety, love/belonging, esteem, and self-actualization in descending order.
3 “Your Money, Your Goals: A financial empowerment toolkit for Social Services programs,” April 2015.
4 National Vital Statistics Report, “Deaths: Final Data for 2014,” Vol. 65 No. 4, June 30, 2016.

Ms. Garrick is a special assistant, manpower and reserve affairs for the U.S. Department of Defense. Previously, she served as the director of the Defense Suicide Prevention Office. She has been a leader in veterans’ disability policy and, suicide prevention and peer support programs; worked with Gulf War veterans as an Army social work officer; and provided individual, group, and family therapy to Vietnam veterans their families dealing with post-traumatic stress disorder.

BOSTON – rs4836493, a single nucleotide polymorphism of the gene encoding chondroitin sulfate synthase-3, significantly predicted hepatocellular carcinoma among patients with HCV even when they achieved sustained virologic response on pegylated interferon, according to a genome-wide association study.

The next step is to determine whether rs4836493 predicts liver cancer after SVR on the new direct-acting antiviral regimens, Basile Njei, MD, MPH, said during an oral presentation at the annual meeting of the American Association for the Study of Liver Diseases.

copyright Eraxion/Thinkstock

BOSTON – rs4836493, a single nucleotide polymorphism of the gene encoding chondroitin sulfate synthase-3, significantly predicted hepatocellular carcinoma among patients with HCV even when they achieved sustained virologic response on pegylated interferon, according to a genome-wide association study.

The next step is to determine whether rs4836493 predicts liver cancer after SVR on the new direct-acting antiviral regimens, Basile Njei, MD, MPH, said during an oral presentation at the annual meeting of the American Association for the Study of Liver Diseases.

copyright Eraxion/Thinkstock

BOSTON – rs4836493, a single nucleotide polymorphism of the gene encoding chondroitin sulfate synthase-3, significantly predicted hepatocellular carcinoma among patients with HCV even when they achieved sustained virologic response on pegylated interferon, according to a genome-wide association study.

The next step is to determine whether rs4836493 predicts liver cancer after SVR on the new direct-acting antiviral regimens, Basile Njei, MD, MPH, said during an oral presentation at the annual meeting of the American Association for the Study of Liver Diseases.

copyright Eraxion/Thinkstock

WASHINGTON – Tumor necrosis factor inhibitors don’t appear to confer any additional cancer risk upon children with juvenile idiopathic arthritis above the increased incidence of cancer that comes hand in hand with the disease itself.

In 2009, the drugs came under suspicion of boosting the already-known increased cancer risk in these patients, Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology. But the large database review that he conducted with his colleagues doesn’t validate those fears.

“I feel fairly confident now that I can stand in front of parents and say that we can treat their child effectively without putting that child at an even higher risk of a malignancy,” he said in a video interview.

WASHINGTON – Tumor necrosis factor inhibitors don’t appear to confer any additional cancer risk upon children with juvenile idiopathic arthritis above the increased incidence of cancer that comes hand in hand with the disease itself.

In 2009, the drugs came under suspicion of boosting the already-known increased cancer risk in these patients, Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology. But the large database review that he conducted with his colleagues doesn’t validate those fears.

“I feel fairly confident now that I can stand in front of parents and say that we can treat their child effectively without putting that child at an even higher risk of a malignancy,” he said in a video interview.

WASHINGTON – Tumor necrosis factor inhibitors don’t appear to confer any additional cancer risk upon children with juvenile idiopathic arthritis above the increased incidence of cancer that comes hand in hand with the disease itself.

In 2009, the drugs came under suspicion of boosting the already-known increased cancer risk in these patients, Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology. But the large database review that he conducted with his colleagues doesn’t validate those fears.

“I feel fairly confident now that I can stand in front of parents and say that we can treat their child effectively without putting that child at an even higher risk of a malignancy,” he said in a video interview.

The training model for orthopedic resident education has been transformed. Surgeon factors, patient expectations, financial and legal concerns, associated costs, and work hour restrictions have put pressure on resident autonomy in the operating room.^1,2 At the end of resident training, the expectation is that board-eligible surgeons will have the surgical skills necessary to perform a wide range of surgical procedures.^3,4 Helping residents become proficient for independent practice requires a multidisciplinary approach.⁵ This approach, regardless of its details, requires investment in time, resources, expertise, and funding.

Many residency programs are trying to bridge the gap between observation and autonomy with surgical simulation. According to one study, 76% of residency programs have a surgical skills laboratory, and 46% have a structured surgical skills curriculum.⁶Surgical skills preparation is available in different modalities. Synthetic bones, virtual reality, and arthroscopic simulators represent potential opportunities for practice. Through these modalities, residents become more comfortable with the tools used in orthopedic procedures. Cadaveric dissection allows them to practice surgical approaches in the setting of real anatomy.¹ Independent dissection helps them appreciate the planes, layers, and proximity of crucial body structures and understand important surgical anatomy.⁴Surgical simulation can be expensive, and funding comes in many forms. Cadaver laboratories require investment in specimens, facilities, and time away from clinical obligations.⁴ Cadaver availability varies with regional resources, and the cost of a cadaver ranges from $1000 to $2000.^7,8 Arthroscopic simulators and virtual reality programs are expensive as well. These modalities range from a less expensive video box (with standard arthroscopic equipment) to a virtual reality haptic simulation costing a residency program as much as $80,000.⁹ Synthetic bone simulations are less expensive but require investment in faculty time and outside implants and instrumentation.¹⁰ The cost of simulation raises the question of funding sources.

Funding surgical simulation is a challenge. In a national survey of program directors, conducted by Karam and colleagues,⁶ 87.3% of residencies cited lack of funding as the most significant barrier to a formal surgical skills program. Simulation can be residency-sponsored, industry-sponsored, or specialty-sponsored. Karam and colleagues⁶ found that department, hospital, and industry funding were the 3 main sponsors of surgical simulation. Each funding mechanism brings its own set of challenges and opportunities. Industry-sponsored simulation provides a cost-effective outlet for residency programs. However, this type of funding is under scrutiny, as industry funding for education becomes more transparent. In addition, industry funding typically limits the technology that can be used during the simulation to the sponsor’s technology. Courses offered by the American Academy of Orthopaedic Surgeons (AAOS) and a number of subspecialty societies provide less conflicted simulation at reasonable cost.

If residents, residency programs, hospitals, industry, subspecialty societies, and the AAOS are going to invest in resident education through simulation, then the effect of simulation on resident education must be understood. Intuitively, simulation as a modality for improving resident skills makes sense. For residency programs to invest in simulation and surgical skills, different modalities must be objectively evaluated and their utility validated. If simulation is to become valuable, first it must be done correctly.

Kneebone¹¹ proposed a framework for evaluating simulation. In this framework, simulation should allow for sustained, deliberate practice in a safe environment. It should provide access to expert tutors when appropriate. It should map onto real-life clinical experience. Last, it should provide a supportive, motivational, learner-centered milieu. Residents and program directors should consider this framework when deciding which simulation exercises to engage in and which resources to supply for exercises. Having supportive supervision during simulation can lead to a positive outcome. Likewise, learning incorrect techniques or bad habits or having inexperienced teachers can have the opposite effect.

Several authors have reviewed the evidence and found simulation to be an important part of orthopedic resident education.^{1,2,4,9,12,13} They have evaluated cadaveric simulation, synthetic bone simulation, arthroscopic simulation, and virtual reality simulation. Their studies demonstrated that simulation is an effective tool and provided objective criteria for evaluating residents on a larger scale. In a blinded, randomized study by Howells and colleagues,¹⁴ junior residents were either trained on a knee simulator or received no training before evaluation. Those who received the training scored significantly better than their peers on validated assessment measures.

The literature on different modalities shows simulation is an effective teaching tool for general orthopedic surgical skills⁵; knee, shoulder, and ankle arthroscopy^14-21; spine surgery²²; and orthopedic trauma surgery.^23-26 Investigators in several other surgical specialties have studied the utility of simulation, and many are incorporating simulation into their resident curricula.

More effective simulation seems correlated with a yearlong structured curriculum rather than with intermittent, isolated experiences.³ Dunn and colleagues²⁷ evaluated arthroscopic shoulder simulation 1 year after a training exercise. The group that received formal training did better than the control group on an initial arthroscopic surgery skill evaluation tool. At 1 year, however, the gains made through training were lost.

Simulation is a new paradigm for resident education. It offers multiple opportunities and challenges for residents, residency programs, industry partners, specialty and subspecialty societies, and medical examiners. The Accreditation Council for Graduate Medical Education’s ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery requires of residency programs a didactic curriculum dedicated to basic motor skills in addition to a dedicated space for facilitating basic surgical skills training.²⁸ Residency programs must demonstrate to ACGME their commitment to surgical skills training and simulation. Implementation of simulation for resident education has many variables, including funding, type of simulation, demonstrated efficacy, provision of supervision, resident time, and establishment of a formal curriculum. Residents and residency programs should embrace this changing paradigm to bridge the gap between observation and autonomy in orthopedic surgical and arthroscopic technique.

Am J Orthop. 2016;45(7):E426-E428. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

The training model for orthopedic resident education has been transformed. Surgeon factors, patient expectations, financial and legal concerns, associated costs, and work hour restrictions have put pressure on resident autonomy in the operating room.^1,2 At the end of resident training, the expectation is that board-eligible surgeons will have the surgical skills necessary to perform a wide range of surgical procedures.^3,4 Helping residents become proficient for independent practice requires a multidisciplinary approach.⁵ This approach, regardless of its details, requires investment in time, resources, expertise, and funding.

Many residency programs are trying to bridge the gap between observation and autonomy with surgical simulation. According to one study, 76% of residency programs have a surgical skills laboratory, and 46% have a structured surgical skills curriculum.⁶Surgical skills preparation is available in different modalities. Synthetic bones, virtual reality, and arthroscopic simulators represent potential opportunities for practice. Through these modalities, residents become more comfortable with the tools used in orthopedic procedures. Cadaveric dissection allows them to practice surgical approaches in the setting of real anatomy.¹ Independent dissection helps them appreciate the planes, layers, and proximity of crucial body structures and understand important surgical anatomy.⁴Surgical simulation can be expensive, and funding comes in many forms. Cadaver laboratories require investment in specimens, facilities, and time away from clinical obligations.⁴ Cadaver availability varies with regional resources, and the cost of a cadaver ranges from $1000 to $2000.^7,8 Arthroscopic simulators and virtual reality programs are expensive as well. These modalities range from a less expensive video box (with standard arthroscopic equipment) to a virtual reality haptic simulation costing a residency program as much as $80,000.⁹ Synthetic bone simulations are less expensive but require investment in faculty time and outside implants and instrumentation.¹⁰ The cost of simulation raises the question of funding sources.

Funding surgical simulation is a challenge. In a national survey of program directors, conducted by Karam and colleagues,⁶ 87.3% of residencies cited lack of funding as the most significant barrier to a formal surgical skills program. Simulation can be residency-sponsored, industry-sponsored, or specialty-sponsored. Karam and colleagues⁶ found that department, hospital, and industry funding were the 3 main sponsors of surgical simulation. Each funding mechanism brings its own set of challenges and opportunities. Industry-sponsored simulation provides a cost-effective outlet for residency programs. However, this type of funding is under scrutiny, as industry funding for education becomes more transparent. In addition, industry funding typically limits the technology that can be used during the simulation to the sponsor’s technology. Courses offered by the American Academy of Orthopaedic Surgeons (AAOS) and a number of subspecialty societies provide less conflicted simulation at reasonable cost.

If residents, residency programs, hospitals, industry, subspecialty societies, and the AAOS are going to invest in resident education through simulation, then the effect of simulation on resident education must be understood. Intuitively, simulation as a modality for improving resident skills makes sense. For residency programs to invest in simulation and surgical skills, different modalities must be objectively evaluated and their utility validated. If simulation is to become valuable, first it must be done correctly.

Kneebone¹¹ proposed a framework for evaluating simulation. In this framework, simulation should allow for sustained, deliberate practice in a safe environment. It should provide access to expert tutors when appropriate. It should map onto real-life clinical experience. Last, it should provide a supportive, motivational, learner-centered milieu. Residents and program directors should consider this framework when deciding which simulation exercises to engage in and which resources to supply for exercises. Having supportive supervision during simulation can lead to a positive outcome. Likewise, learning incorrect techniques or bad habits or having inexperienced teachers can have the opposite effect.

Several authors have reviewed the evidence and found simulation to be an important part of orthopedic resident education.^{1,2,4,9,12,13} They have evaluated cadaveric simulation, synthetic bone simulation, arthroscopic simulation, and virtual reality simulation. Their studies demonstrated that simulation is an effective tool and provided objective criteria for evaluating residents on a larger scale. In a blinded, randomized study by Howells and colleagues,¹⁴ junior residents were either trained on a knee simulator or received no training before evaluation. Those who received the training scored significantly better than their peers on validated assessment measures.

The literature on different modalities shows simulation is an effective teaching tool for general orthopedic surgical skills⁵; knee, shoulder, and ankle arthroscopy^14-21; spine surgery²²; and orthopedic trauma surgery.^23-26 Investigators in several other surgical specialties have studied the utility of simulation, and many are incorporating simulation into their resident curricula.

More effective simulation seems correlated with a yearlong structured curriculum rather than with intermittent, isolated experiences.³ Dunn and colleagues²⁷ evaluated arthroscopic shoulder simulation 1 year after a training exercise. The group that received formal training did better than the control group on an initial arthroscopic surgery skill evaluation tool. At 1 year, however, the gains made through training were lost.

Simulation is a new paradigm for resident education. It offers multiple opportunities and challenges for residents, residency programs, industry partners, specialty and subspecialty societies, and medical examiners. The Accreditation Council for Graduate Medical Education’s ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery requires of residency programs a didactic curriculum dedicated to basic motor skills in addition to a dedicated space for facilitating basic surgical skills training.²⁸ Residency programs must demonstrate to ACGME their commitment to surgical skills training and simulation. Implementation of simulation for resident education has many variables, including funding, type of simulation, demonstrated efficacy, provision of supervision, resident time, and establishment of a formal curriculum. Residents and residency programs should embrace this changing paradigm to bridge the gap between observation and autonomy in orthopedic surgical and arthroscopic technique.

Am J Orthop. 2016;45(7):E426-E428. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

The training model for orthopedic resident education has been transformed. Surgeon factors, patient expectations, financial and legal concerns, associated costs, and work hour restrictions have put pressure on resident autonomy in the operating room.^1,2 At the end of resident training, the expectation is that board-eligible surgeons will have the surgical skills necessary to perform a wide range of surgical procedures.^3,4 Helping residents become proficient for independent practice requires a multidisciplinary approach.⁵ This approach, regardless of its details, requires investment in time, resources, expertise, and funding.

Many residency programs are trying to bridge the gap between observation and autonomy with surgical simulation. According to one study, 76% of residency programs have a surgical skills laboratory, and 46% have a structured surgical skills curriculum.⁶Surgical skills preparation is available in different modalities. Synthetic bones, virtual reality, and arthroscopic simulators represent potential opportunities for practice. Through these modalities, residents become more comfortable with the tools used in orthopedic procedures. Cadaveric dissection allows them to practice surgical approaches in the setting of real anatomy.¹ Independent dissection helps them appreciate the planes, layers, and proximity of crucial body structures and understand important surgical anatomy.⁴Surgical simulation can be expensive, and funding comes in many forms. Cadaver laboratories require investment in specimens, facilities, and time away from clinical obligations.⁴ Cadaver availability varies with regional resources, and the cost of a cadaver ranges from $1000 to $2000.^7,8 Arthroscopic simulators and virtual reality programs are expensive as well. These modalities range from a less expensive video box (with standard arthroscopic equipment) to a virtual reality haptic simulation costing a residency program as much as $80,000.⁹ Synthetic bone simulations are less expensive but require investment in faculty time and outside implants and instrumentation.¹⁰ The cost of simulation raises the question of funding sources.

Funding surgical simulation is a challenge. In a national survey of program directors, conducted by Karam and colleagues,⁶ 87.3% of residencies cited lack of funding as the most significant barrier to a formal surgical skills program. Simulation can be residency-sponsored, industry-sponsored, or specialty-sponsored. Karam and colleagues⁶ found that department, hospital, and industry funding were the 3 main sponsors of surgical simulation. Each funding mechanism brings its own set of challenges and opportunities. Industry-sponsored simulation provides a cost-effective outlet for residency programs. However, this type of funding is under scrutiny, as industry funding for education becomes more transparent. In addition, industry funding typically limits the technology that can be used during the simulation to the sponsor’s technology. Courses offered by the American Academy of Orthopaedic Surgeons (AAOS) and a number of subspecialty societies provide less conflicted simulation at reasonable cost.

If residents, residency programs, hospitals, industry, subspecialty societies, and the AAOS are going to invest in resident education through simulation, then the effect of simulation on resident education must be understood. Intuitively, simulation as a modality for improving resident skills makes sense. For residency programs to invest in simulation and surgical skills, different modalities must be objectively evaluated and their utility validated. If simulation is to become valuable, first it must be done correctly.

Kneebone¹¹ proposed a framework for evaluating simulation. In this framework, simulation should allow for sustained, deliberate practice in a safe environment. It should provide access to expert tutors when appropriate. It should map onto real-life clinical experience. Last, it should provide a supportive, motivational, learner-centered milieu. Residents and program directors should consider this framework when deciding which simulation exercises to engage in and which resources to supply for exercises. Having supportive supervision during simulation can lead to a positive outcome. Likewise, learning incorrect techniques or bad habits or having inexperienced teachers can have the opposite effect.

Several authors have reviewed the evidence and found simulation to be an important part of orthopedic resident education.^{1,2,4,9,12,13} They have evaluated cadaveric simulation, synthetic bone simulation, arthroscopic simulation, and virtual reality simulation. Their studies demonstrated that simulation is an effective tool and provided objective criteria for evaluating residents on a larger scale. In a blinded, randomized study by Howells and colleagues,¹⁴ junior residents were either trained on a knee simulator or received no training before evaluation. Those who received the training scored significantly better than their peers on validated assessment measures.

The literature on different modalities shows simulation is an effective teaching tool for general orthopedic surgical skills⁵; knee, shoulder, and ankle arthroscopy^14-21; spine surgery²²; and orthopedic trauma surgery.^23-26 Investigators in several other surgical specialties have studied the utility of simulation, and many are incorporating simulation into their resident curricula.

More effective simulation seems correlated with a yearlong structured curriculum rather than with intermittent, isolated experiences.³ Dunn and colleagues²⁷ evaluated arthroscopic shoulder simulation 1 year after a training exercise. The group that received formal training did better than the control group on an initial arthroscopic surgery skill evaluation tool. At 1 year, however, the gains made through training were lost.

Simulation is a new paradigm for resident education. It offers multiple opportunities and challenges for residents, residency programs, industry partners, specialty and subspecialty societies, and medical examiners. The Accreditation Council for Graduate Medical Education’s ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery requires of residency programs a didactic curriculum dedicated to basic motor skills in addition to a dedicated space for facilitating basic surgical skills training.²⁸ Residency programs must demonstrate to ACGME their commitment to surgical skills training and simulation. Implementation of simulation for resident education has many variables, including funding, type of simulation, demonstrated efficacy, provision of supervision, resident time, and establishment of a formal curriculum. Residents and residency programs should embrace this changing paradigm to bridge the gap between observation and autonomy in orthopedic surgical and arthroscopic technique.

Am J Orthop. 2016;45(7):E426-E428. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.