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Give me an occupation, Miss Dashwood
“I’ve been watching YouTube videos on how to set a ventilator,” said one of our dermatologists. The absurdity, levity, and gravity of that statement captures in a single sentence where we are today.
None of us alive have experience with such a crisis. It is as if our planet passed through a wormhole and we’ve been transported to the late medieval period: We doctors fighting the Black Death donned in beaked masks filled with juniper berries, mint, and clove to protect us from the miasma. Now, though, we spray store-bought lavender disinfectant on surgical masks.
“A crisis shows you a person’s soul,” said New York Governor Andrew Cuomo, adding: “It shows you what they’re made of, the weaknesses explode and the strengths ... emboldened.” Most of us have traveled through life with no experience of peril. Such mortal danger explodes and emboldens us, dividing us in two, the fearful or the phlegmatic.
When President Trump proclaimed that plaquenil was a promising treatment for the virus, prescriptions for the drug soared so quickly that four of eight manufacturers reported being in shortage by the end of the day. Many of those prescriptions were written by physicians for themselves and their families. Private Facebook physician groups shared insider tips for how to get around constraints and find the drug – as hoardable as toilet paper. As a department chief and fellow human being, I understand why some of us might behave this way. We didn’t sign up to be dermatologists or nephrologists or surgeons or pulmonologists agreeing that, to do so, we might die. We are all afraid.
The track of this epic storm became clear last week and now, terrifyingly, it appears it will be a direct hit. I braced for an onslaught of anxiety from our doctors and staff. But as the forecast became more grim, the courage began to well up and creativity climbed. Doctors went to local stores and bought all the masks and shields on their own. Rolls of toilet paper and diapers began magically appearing in our mom-doctors’ offices, delivered by angels in scrubs. I’ve practically had to install a velvet rope at my door to organize the queue of people wanting to talk to me about their ideas to help – keep 6 feet apart please! Stories like this abound. Even at the EvergreenHealth hospital in Washington they’ve not had shortages of staff. Rather than calling out sick, they called in: “If you need me, I’m available.”
Doctors are afraid and frustrated. Some of the things we will do in the coming weeks will first do no good, perhaps even harm. But I believe it’s because we’ve yet to embolden our strengths. It’s our job as leaders, attendings, administrators to inform and enable them.
When Marianne fell deathly ill in “Sense and Sensibility,” Colonel Branden wrung his hands and paced the floor. “Give me an occupation, Miss Dashwood, or I shall run mad.” Doctors are running, mad. And, just in case, some dermatologists are relearning how to intubate, waiting for that occupation to be given.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no relevant conflicts of interest related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
“I’ve been watching YouTube videos on how to set a ventilator,” said one of our dermatologists. The absurdity, levity, and gravity of that statement captures in a single sentence where we are today.
None of us alive have experience with such a crisis. It is as if our planet passed through a wormhole and we’ve been transported to the late medieval period: We doctors fighting the Black Death donned in beaked masks filled with juniper berries, mint, and clove to protect us from the miasma. Now, though, we spray store-bought lavender disinfectant on surgical masks.
“A crisis shows you a person’s soul,” said New York Governor Andrew Cuomo, adding: “It shows you what they’re made of, the weaknesses explode and the strengths ... emboldened.” Most of us have traveled through life with no experience of peril. Such mortal danger explodes and emboldens us, dividing us in two, the fearful or the phlegmatic.
When President Trump proclaimed that plaquenil was a promising treatment for the virus, prescriptions for the drug soared so quickly that four of eight manufacturers reported being in shortage by the end of the day. Many of those prescriptions were written by physicians for themselves and their families. Private Facebook physician groups shared insider tips for how to get around constraints and find the drug – as hoardable as toilet paper. As a department chief and fellow human being, I understand why some of us might behave this way. We didn’t sign up to be dermatologists or nephrologists or surgeons or pulmonologists agreeing that, to do so, we might die. We are all afraid.
The track of this epic storm became clear last week and now, terrifyingly, it appears it will be a direct hit. I braced for an onslaught of anxiety from our doctors and staff. But as the forecast became more grim, the courage began to well up and creativity climbed. Doctors went to local stores and bought all the masks and shields on their own. Rolls of toilet paper and diapers began magically appearing in our mom-doctors’ offices, delivered by angels in scrubs. I’ve practically had to install a velvet rope at my door to organize the queue of people wanting to talk to me about their ideas to help – keep 6 feet apart please! Stories like this abound. Even at the EvergreenHealth hospital in Washington they’ve not had shortages of staff. Rather than calling out sick, they called in: “If you need me, I’m available.”
Doctors are afraid and frustrated. Some of the things we will do in the coming weeks will first do no good, perhaps even harm. But I believe it’s because we’ve yet to embolden our strengths. It’s our job as leaders, attendings, administrators to inform and enable them.
When Marianne fell deathly ill in “Sense and Sensibility,” Colonel Branden wrung his hands and paced the floor. “Give me an occupation, Miss Dashwood, or I shall run mad.” Doctors are running, mad. And, just in case, some dermatologists are relearning how to intubate, waiting for that occupation to be given.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no relevant conflicts of interest related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
“I’ve been watching YouTube videos on how to set a ventilator,” said one of our dermatologists. The absurdity, levity, and gravity of that statement captures in a single sentence where we are today.
None of us alive have experience with such a crisis. It is as if our planet passed through a wormhole and we’ve been transported to the late medieval period: We doctors fighting the Black Death donned in beaked masks filled with juniper berries, mint, and clove to protect us from the miasma. Now, though, we spray store-bought lavender disinfectant on surgical masks.
“A crisis shows you a person’s soul,” said New York Governor Andrew Cuomo, adding: “It shows you what they’re made of, the weaknesses explode and the strengths ... emboldened.” Most of us have traveled through life with no experience of peril. Such mortal danger explodes and emboldens us, dividing us in two, the fearful or the phlegmatic.
When President Trump proclaimed that plaquenil was a promising treatment for the virus, prescriptions for the drug soared so quickly that four of eight manufacturers reported being in shortage by the end of the day. Many of those prescriptions were written by physicians for themselves and their families. Private Facebook physician groups shared insider tips for how to get around constraints and find the drug – as hoardable as toilet paper. As a department chief and fellow human being, I understand why some of us might behave this way. We didn’t sign up to be dermatologists or nephrologists or surgeons or pulmonologists agreeing that, to do so, we might die. We are all afraid.
The track of this epic storm became clear last week and now, terrifyingly, it appears it will be a direct hit. I braced for an onslaught of anxiety from our doctors and staff. But as the forecast became more grim, the courage began to well up and creativity climbed. Doctors went to local stores and bought all the masks and shields on their own. Rolls of toilet paper and diapers began magically appearing in our mom-doctors’ offices, delivered by angels in scrubs. I’ve practically had to install a velvet rope at my door to organize the queue of people wanting to talk to me about their ideas to help – keep 6 feet apart please! Stories like this abound. Even at the EvergreenHealth hospital in Washington they’ve not had shortages of staff. Rather than calling out sick, they called in: “If you need me, I’m available.”
Doctors are afraid and frustrated. Some of the things we will do in the coming weeks will first do no good, perhaps even harm. But I believe it’s because we’ve yet to embolden our strengths. It’s our job as leaders, attendings, administrators to inform and enable them.
When Marianne fell deathly ill in “Sense and Sensibility,” Colonel Branden wrung his hands and paced the floor. “Give me an occupation, Miss Dashwood, or I shall run mad.” Doctors are running, mad. And, just in case, some dermatologists are relearning how to intubate, waiting for that occupation to be given.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. He has no relevant conflicts of interest related to this column. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Preventable diseases could gain a foothold because of COVID-19
There is a highly infectious virus spreading around the world and it is targeting the most vulnerable among us. It is among the most contagious of human diseases, spreading through the air unseen. No, it isn’t the novel coronavirus, COVID-19. It’s measles.
Remember measles? Outbreaks in recent years have brought the disease, which once was declared eliminated in the United States, back into the news and public awareness, but measles never has really gone away. Every year there are millions of cases worldwide – in 2018 alone there were nearly 10 million estimated cases and 142,300 deaths, according to the World Health Organization. The good news is that measles vaccination is highly effective, at about 97% after the recommended two doses. According to the Centers for Disease Control and Prevention, “because of vaccination, more than 21 million lives have been saved and measles deaths have been reduced by 80% since 2000.” This is a tremendous public health success and a cause for celebration. But our work is not done. The recent increases in vaccine hesitancy and refusal in many countries has contributed to the resurgence of measles worldwide.
Influenza still is in full swing with the CDC reporting high activity in 1 states for the week ending April 4th. Seasonal influenza, according to currently available data, has a lower fatality rate than COVID-19, but that doesn’t mean it is harmless. Thus far in the 2019-2020 flu season, there have been at least 24,000 deaths because of influenza in the United States alone, 166 of which were among pediatric patients.*
Like many pediatricians, I have seen firsthand the impact of vaccine-preventable illnesses like influenza, pertussis, and varicella. I have personally cared for an infant with pertussis who had to be intubated and on a ventilator for nearly a week. I have told the family of a child with cancer that they would have to be admitted to the hospital yet again for intravenous antiviral medication because that little rash turned out to be varicella. I have performed CPR on a previously healthy teenager with the flu whose heart was failing despite maximum ventilator support. All these illnesses might have been prevented had these patients or those around them been appropriately vaccinated.
Right now, the United States and governments around the world are taking unprecedented public health measures to prevent the spread of COVID-19, directing the public to stay home, avoid unnecessary contact with other people, practice good hand-washing and infection-control techniques. In order to promote social distancing, many primary care clinics are canceling nonurgent appointments or converting them to virtual visits, including some visits for routine vaccinations for older children, teens, and adults. This is a responsible choice to keep potentially asymptomatic people from spreading COVID-19, but once restrictions begin to lift, we all will need to act to help our patients catch up on these missing vaccinations.
This pandemic has made it more apparent than ever that we all rely upon each other to stay healthy. While this pandemic has disrupted nearly every aspect of daily life, we can’t let it disrupt one of the great successes in health care today: the prevention of serious illnesses. As soon as it is safe to do so, we must help and encourage patients to catch up on missing vaccinations. It’s rare that preventative public health measures and vaccine developments are in the nightly news, so we should use this increased public awareness to ensure patients are well educated and protected from every disease. As part of this, we must continue our efforts to share accurate information on the safety and efficacy of routine vaccination. And when there is a vaccine for COVID-19? Let’s make sure everyone gets that too.
Dr. Leighton is a pediatrician in the ED at Children’s National Hospital and currently is completing her MPH in health policy at George Washington University, both in Washington. She had no relevant financial disclosures.*
* This article was updated 4/10/2020.
There is a highly infectious virus spreading around the world and it is targeting the most vulnerable among us. It is among the most contagious of human diseases, spreading through the air unseen. No, it isn’t the novel coronavirus, COVID-19. It’s measles.
Remember measles? Outbreaks in recent years have brought the disease, which once was declared eliminated in the United States, back into the news and public awareness, but measles never has really gone away. Every year there are millions of cases worldwide – in 2018 alone there were nearly 10 million estimated cases and 142,300 deaths, according to the World Health Organization. The good news is that measles vaccination is highly effective, at about 97% after the recommended two doses. According to the Centers for Disease Control and Prevention, “because of vaccination, more than 21 million lives have been saved and measles deaths have been reduced by 80% since 2000.” This is a tremendous public health success and a cause for celebration. But our work is not done. The recent increases in vaccine hesitancy and refusal in many countries has contributed to the resurgence of measles worldwide.
Influenza still is in full swing with the CDC reporting high activity in 1 states for the week ending April 4th. Seasonal influenza, according to currently available data, has a lower fatality rate than COVID-19, but that doesn’t mean it is harmless. Thus far in the 2019-2020 flu season, there have been at least 24,000 deaths because of influenza in the United States alone, 166 of which were among pediatric patients.*
Like many pediatricians, I have seen firsthand the impact of vaccine-preventable illnesses like influenza, pertussis, and varicella. I have personally cared for an infant with pertussis who had to be intubated and on a ventilator for nearly a week. I have told the family of a child with cancer that they would have to be admitted to the hospital yet again for intravenous antiviral medication because that little rash turned out to be varicella. I have performed CPR on a previously healthy teenager with the flu whose heart was failing despite maximum ventilator support. All these illnesses might have been prevented had these patients or those around them been appropriately vaccinated.
Right now, the United States and governments around the world are taking unprecedented public health measures to prevent the spread of COVID-19, directing the public to stay home, avoid unnecessary contact with other people, practice good hand-washing and infection-control techniques. In order to promote social distancing, many primary care clinics are canceling nonurgent appointments or converting them to virtual visits, including some visits for routine vaccinations for older children, teens, and adults. This is a responsible choice to keep potentially asymptomatic people from spreading COVID-19, but once restrictions begin to lift, we all will need to act to help our patients catch up on these missing vaccinations.
This pandemic has made it more apparent than ever that we all rely upon each other to stay healthy. While this pandemic has disrupted nearly every aspect of daily life, we can’t let it disrupt one of the great successes in health care today: the prevention of serious illnesses. As soon as it is safe to do so, we must help and encourage patients to catch up on missing vaccinations. It’s rare that preventative public health measures and vaccine developments are in the nightly news, so we should use this increased public awareness to ensure patients are well educated and protected from every disease. As part of this, we must continue our efforts to share accurate information on the safety and efficacy of routine vaccination. And when there is a vaccine for COVID-19? Let’s make sure everyone gets that too.
Dr. Leighton is a pediatrician in the ED at Children’s National Hospital and currently is completing her MPH in health policy at George Washington University, both in Washington. She had no relevant financial disclosures.*
* This article was updated 4/10/2020.
There is a highly infectious virus spreading around the world and it is targeting the most vulnerable among us. It is among the most contagious of human diseases, spreading through the air unseen. No, it isn’t the novel coronavirus, COVID-19. It’s measles.
Remember measles? Outbreaks in recent years have brought the disease, which once was declared eliminated in the United States, back into the news and public awareness, but measles never has really gone away. Every year there are millions of cases worldwide – in 2018 alone there were nearly 10 million estimated cases and 142,300 deaths, according to the World Health Organization. The good news is that measles vaccination is highly effective, at about 97% after the recommended two doses. According to the Centers for Disease Control and Prevention, “because of vaccination, more than 21 million lives have been saved and measles deaths have been reduced by 80% since 2000.” This is a tremendous public health success and a cause for celebration. But our work is not done. The recent increases in vaccine hesitancy and refusal in many countries has contributed to the resurgence of measles worldwide.
Influenza still is in full swing with the CDC reporting high activity in 1 states for the week ending April 4th. Seasonal influenza, according to currently available data, has a lower fatality rate than COVID-19, but that doesn’t mean it is harmless. Thus far in the 2019-2020 flu season, there have been at least 24,000 deaths because of influenza in the United States alone, 166 of which were among pediatric patients.*
Like many pediatricians, I have seen firsthand the impact of vaccine-preventable illnesses like influenza, pertussis, and varicella. I have personally cared for an infant with pertussis who had to be intubated and on a ventilator for nearly a week. I have told the family of a child with cancer that they would have to be admitted to the hospital yet again for intravenous antiviral medication because that little rash turned out to be varicella. I have performed CPR on a previously healthy teenager with the flu whose heart was failing despite maximum ventilator support. All these illnesses might have been prevented had these patients or those around them been appropriately vaccinated.
Right now, the United States and governments around the world are taking unprecedented public health measures to prevent the spread of COVID-19, directing the public to stay home, avoid unnecessary contact with other people, practice good hand-washing and infection-control techniques. In order to promote social distancing, many primary care clinics are canceling nonurgent appointments or converting them to virtual visits, including some visits for routine vaccinations for older children, teens, and adults. This is a responsible choice to keep potentially asymptomatic people from spreading COVID-19, but once restrictions begin to lift, we all will need to act to help our patients catch up on these missing vaccinations.
This pandemic has made it more apparent than ever that we all rely upon each other to stay healthy. While this pandemic has disrupted nearly every aspect of daily life, we can’t let it disrupt one of the great successes in health care today: the prevention of serious illnesses. As soon as it is safe to do so, we must help and encourage patients to catch up on missing vaccinations. It’s rare that preventative public health measures and vaccine developments are in the nightly news, so we should use this increased public awareness to ensure patients are well educated and protected from every disease. As part of this, we must continue our efforts to share accurate information on the safety and efficacy of routine vaccination. And when there is a vaccine for COVID-19? Let’s make sure everyone gets that too.
Dr. Leighton is a pediatrician in the ED at Children’s National Hospital and currently is completing her MPH in health policy at George Washington University, both in Washington. She had no relevant financial disclosures.*
* This article was updated 4/10/2020.
Emergency Rule: Docs can bill for telehealth and COVID-19 tests. Here’s how
Many medical practices have long wanted to use telehealth to perform office visits and other evaluation and management (E/M) services. The technology readily exists and many electronic health records are set up to do telehealth visits. The problem has been getting paid for those visits. Medicare limited telehealth services to patients in underserved areas, and commercial insurances wouldn’t pay. But amid the COVID-19 crisis, things have changed.
On March 17, Congress passed a law allowing Medicare to waive some telehealth restrictions during a government state of emergency only, which we are in now. Specifically, the patient no longer needs to be in a medically underserved area and no longer needs to go to an originating site, such as a hospital. The patient can be located anywhere in the country and be in their own home.
Further, the Centers for Medicare & Medicaid is waiving the requirement that the practitioner use a HIPAA-compliant platform for the telehealth service. The service must still be provided using a real-time audiovisual platform, but that could be via FaceTime or Skype, both of which are readily available via a patient’s smartphone or home computer. Audio alone – that is, phone calls between physician and patient – is still insufficient.
Billing for telemedicine
There are two lists of services that you can bill for telehealth. One of the lists is in Medicare’s telehealth fact sheet and includes both CPT and HCPCS codes. The second is in your CPT book, Appendix P, and lists only CPT codes.
Practices may bill all of the Medicare-covered telehealth services using these new rules. This includes new and established patient visits 99201–99215. It includes inpatient and skilled nursing services, for which CMS uses HCPCS codes in place of CPT codes.
Some notable additional services that you may bill via telehealth are: smoking cessation, transitional care management, advanced care planning, psychiatric diagnostic interviews and psychotherapy, and initial and subsequent Medicare wellness visits. The Welcome to Medicare visit is not on the list.
Report these services to Medicare with the correct CPT code and use place of service 02 (telehealth) on the claim. There is a CPT modifier for telehealth (Modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) but Medicare does not require it.
If you perform an office visit and also do smoking cessation, document those just as you would if you saw the patient in person. Document the history; observational exam, if relevant; and the assessment and plan. Note the additional time spent in smoking cessation counseling. If it was a level three established patient, code 99213-25 and 99406 (smoking and tobacco use cessation counseling visit, intermediate, 3-10 minutes).
The Office of Inspector General is allowing practices to reduce or waive copays and patient due amounts. However, a practice is not required to waive the copay or patient due amount for a telehealth service.
Medicare Advantage plans are required to cover all services that original Medicare covers. State Medicaid plans and Medicaid managed care organizations can set their own rules.
What about commercial payers?
While CMS has issued its Medicare guidelines, commercial insurance companies can also set their own rules about covering telehealth services. Many of them have rushed to update their policies to allow office visits to be billed via telehealth.
Unfortunately, each payer can set its own rules about whether to cover telehealth and if the place of service 02 and/or modifier -95 is needed. UnitedHealthcare is covering telehealth visits for all of its Medicare Advantage, Medicaid, and commercial accounts.
Humana also is covering telemedicine for urgent care needs. Some private insurers are continuing to offer virtual visits with their contracted telehealth provider, not with the patient’s own physician. It is likely that this will change in the days ahead, but it means practices must check their payer policies and pay attention to the emails they receive from the payers. If patient foot traffic is slow, this may be a good time to call each payer to not only find out their telehealth rules, but to also learn what else is being suspended during the COVID-19 pandemic.
This would also be a good job for an employee to do from home versus coming into the practice.
None of the payers are limiting the diagnosis code for telemedicine services. The patient does not need to have a cough or fever to have telemedicine covered. Any diagnosis or condition is eligible to be billed via telehealth.
The waived restrictions by Medicare are in place only as long as the government state of emergency. Commercial payers are also describing these as temporary. However, it may be hard to put the genie back in the bottle. Medical practices and patients may find that these visits are just what the doctor ordered.
COVID-19 testing
Although testing is still not widely available, the American Medical Association has developed a CPT code for the test:
- 87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
CMS has also developed codes for testing for this new coronavirus. One (U0001) is specifically for tests done in the CDC lab. The second (U0002) was for other labs, but it seems likely that the CPT code will replace it.
In February, the U.S. Food and Drug Administration issued a new policy for certain labs to develop their own validated COVID-19 diagnostics. This second HCPCS code could be used for such tests when submitting claims to Medicare or other insurers.
The hope by CMS is that having these specific codes will encourage further testing and improve tracking of the virus.
This article first appeared on Medscape.com.
Many medical practices have long wanted to use telehealth to perform office visits and other evaluation and management (E/M) services. The technology readily exists and many electronic health records are set up to do telehealth visits. The problem has been getting paid for those visits. Medicare limited telehealth services to patients in underserved areas, and commercial insurances wouldn’t pay. But amid the COVID-19 crisis, things have changed.
On March 17, Congress passed a law allowing Medicare to waive some telehealth restrictions during a government state of emergency only, which we are in now. Specifically, the patient no longer needs to be in a medically underserved area and no longer needs to go to an originating site, such as a hospital. The patient can be located anywhere in the country and be in their own home.
Further, the Centers for Medicare & Medicaid is waiving the requirement that the practitioner use a HIPAA-compliant platform for the telehealth service. The service must still be provided using a real-time audiovisual platform, but that could be via FaceTime or Skype, both of which are readily available via a patient’s smartphone or home computer. Audio alone – that is, phone calls between physician and patient – is still insufficient.
Billing for telemedicine
There are two lists of services that you can bill for telehealth. One of the lists is in Medicare’s telehealth fact sheet and includes both CPT and HCPCS codes. The second is in your CPT book, Appendix P, and lists only CPT codes.
Practices may bill all of the Medicare-covered telehealth services using these new rules. This includes new and established patient visits 99201–99215. It includes inpatient and skilled nursing services, for which CMS uses HCPCS codes in place of CPT codes.
Some notable additional services that you may bill via telehealth are: smoking cessation, transitional care management, advanced care planning, psychiatric diagnostic interviews and psychotherapy, and initial and subsequent Medicare wellness visits. The Welcome to Medicare visit is not on the list.
Report these services to Medicare with the correct CPT code and use place of service 02 (telehealth) on the claim. There is a CPT modifier for telehealth (Modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) but Medicare does not require it.
If you perform an office visit and also do smoking cessation, document those just as you would if you saw the patient in person. Document the history; observational exam, if relevant; and the assessment and plan. Note the additional time spent in smoking cessation counseling. If it was a level three established patient, code 99213-25 and 99406 (smoking and tobacco use cessation counseling visit, intermediate, 3-10 minutes).
The Office of Inspector General is allowing practices to reduce or waive copays and patient due amounts. However, a practice is not required to waive the copay or patient due amount for a telehealth service.
Medicare Advantage plans are required to cover all services that original Medicare covers. State Medicaid plans and Medicaid managed care organizations can set their own rules.
What about commercial payers?
While CMS has issued its Medicare guidelines, commercial insurance companies can also set their own rules about covering telehealth services. Many of them have rushed to update their policies to allow office visits to be billed via telehealth.
Unfortunately, each payer can set its own rules about whether to cover telehealth and if the place of service 02 and/or modifier -95 is needed. UnitedHealthcare is covering telehealth visits for all of its Medicare Advantage, Medicaid, and commercial accounts.
Humana also is covering telemedicine for urgent care needs. Some private insurers are continuing to offer virtual visits with their contracted telehealth provider, not with the patient’s own physician. It is likely that this will change in the days ahead, but it means practices must check their payer policies and pay attention to the emails they receive from the payers. If patient foot traffic is slow, this may be a good time to call each payer to not only find out their telehealth rules, but to also learn what else is being suspended during the COVID-19 pandemic.
This would also be a good job for an employee to do from home versus coming into the practice.
None of the payers are limiting the diagnosis code for telemedicine services. The patient does not need to have a cough or fever to have telemedicine covered. Any diagnosis or condition is eligible to be billed via telehealth.
The waived restrictions by Medicare are in place only as long as the government state of emergency. Commercial payers are also describing these as temporary. However, it may be hard to put the genie back in the bottle. Medical practices and patients may find that these visits are just what the doctor ordered.
COVID-19 testing
Although testing is still not widely available, the American Medical Association has developed a CPT code for the test:
- 87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
CMS has also developed codes for testing for this new coronavirus. One (U0001) is specifically for tests done in the CDC lab. The second (U0002) was for other labs, but it seems likely that the CPT code will replace it.
In February, the U.S. Food and Drug Administration issued a new policy for certain labs to develop their own validated COVID-19 diagnostics. This second HCPCS code could be used for such tests when submitting claims to Medicare or other insurers.
The hope by CMS is that having these specific codes will encourage further testing and improve tracking of the virus.
This article first appeared on Medscape.com.
Many medical practices have long wanted to use telehealth to perform office visits and other evaluation and management (E/M) services. The technology readily exists and many electronic health records are set up to do telehealth visits. The problem has been getting paid for those visits. Medicare limited telehealth services to patients in underserved areas, and commercial insurances wouldn’t pay. But amid the COVID-19 crisis, things have changed.
On March 17, Congress passed a law allowing Medicare to waive some telehealth restrictions during a government state of emergency only, which we are in now. Specifically, the patient no longer needs to be in a medically underserved area and no longer needs to go to an originating site, such as a hospital. The patient can be located anywhere in the country and be in their own home.
Further, the Centers for Medicare & Medicaid is waiving the requirement that the practitioner use a HIPAA-compliant platform for the telehealth service. The service must still be provided using a real-time audiovisual platform, but that could be via FaceTime or Skype, both of which are readily available via a patient’s smartphone or home computer. Audio alone – that is, phone calls between physician and patient – is still insufficient.
Billing for telemedicine
There are two lists of services that you can bill for telehealth. One of the lists is in Medicare’s telehealth fact sheet and includes both CPT and HCPCS codes. The second is in your CPT book, Appendix P, and lists only CPT codes.
Practices may bill all of the Medicare-covered telehealth services using these new rules. This includes new and established patient visits 99201–99215. It includes inpatient and skilled nursing services, for which CMS uses HCPCS codes in place of CPT codes.
Some notable additional services that you may bill via telehealth are: smoking cessation, transitional care management, advanced care planning, psychiatric diagnostic interviews and psychotherapy, and initial and subsequent Medicare wellness visits. The Welcome to Medicare visit is not on the list.
Report these services to Medicare with the correct CPT code and use place of service 02 (telehealth) on the claim. There is a CPT modifier for telehealth (Modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) but Medicare does not require it.
If you perform an office visit and also do smoking cessation, document those just as you would if you saw the patient in person. Document the history; observational exam, if relevant; and the assessment and plan. Note the additional time spent in smoking cessation counseling. If it was a level three established patient, code 99213-25 and 99406 (smoking and tobacco use cessation counseling visit, intermediate, 3-10 minutes).
The Office of Inspector General is allowing practices to reduce or waive copays and patient due amounts. However, a practice is not required to waive the copay or patient due amount for a telehealth service.
Medicare Advantage plans are required to cover all services that original Medicare covers. State Medicaid plans and Medicaid managed care organizations can set their own rules.
What about commercial payers?
While CMS has issued its Medicare guidelines, commercial insurance companies can also set their own rules about covering telehealth services. Many of them have rushed to update their policies to allow office visits to be billed via telehealth.
Unfortunately, each payer can set its own rules about whether to cover telehealth and if the place of service 02 and/or modifier -95 is needed. UnitedHealthcare is covering telehealth visits for all of its Medicare Advantage, Medicaid, and commercial accounts.
Humana also is covering telemedicine for urgent care needs. Some private insurers are continuing to offer virtual visits with their contracted telehealth provider, not with the patient’s own physician. It is likely that this will change in the days ahead, but it means practices must check their payer policies and pay attention to the emails they receive from the payers. If patient foot traffic is slow, this may be a good time to call each payer to not only find out their telehealth rules, but to also learn what else is being suspended during the COVID-19 pandemic.
This would also be a good job for an employee to do from home versus coming into the practice.
None of the payers are limiting the diagnosis code for telemedicine services. The patient does not need to have a cough or fever to have telemedicine covered. Any diagnosis or condition is eligible to be billed via telehealth.
The waived restrictions by Medicare are in place only as long as the government state of emergency. Commercial payers are also describing these as temporary. However, it may be hard to put the genie back in the bottle. Medical practices and patients may find that these visits are just what the doctor ordered.
COVID-19 testing
Although testing is still not widely available, the American Medical Association has developed a CPT code for the test:
- 87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
CMS has also developed codes for testing for this new coronavirus. One (U0001) is specifically for tests done in the CDC lab. The second (U0002) was for other labs, but it seems likely that the CPT code will replace it.
In February, the U.S. Food and Drug Administration issued a new policy for certain labs to develop their own validated COVID-19 diagnostics. This second HCPCS code could be used for such tests when submitting claims to Medicare or other insurers.
The hope by CMS is that having these specific codes will encourage further testing and improve tracking of the virus.
This article first appeared on Medscape.com.
The apricot tree
My apricot tree has bloomed. It is a foolish tree planted by a foolish man since it blossoms, with beautiful pink then white flowers, at least 3 weeks too early in Northern Kentucky. Nonetheless, I am hopeful that it will produce fruit, maybe this year.
The apricot tree takes me back to my early childhood in Oklahoma City. We had a small apricot tree in the backyard of our rental house, and my dad would talk about how there was nothing finer than a sun ripened apricot. Those were happy times. My dad was a milkman and was home every day by late afternoon, though he was still taking classes at night to try to finish his degree. My mother was at home and my older brother in first grade down the street. My little sister was small and tried to keep up.
My time was unstructured, and I reveled in the backyard. In retrospect, the backyard was an open display of broken and hoped for dreams. There was a junked car my best friend Alvin and I would sit in, there was a huge tree stump we sat on and played around, we had an old slow dog named Pooch, gifted to us when my mom’s sister moved to Alaska. We ran around with no shirts or shoes, played and pretended, and carefully watched the apricot tree.
I remember one time when the apricots finally ripened. My father climbed up and got me one, and it was so sweet I did not notice that the juice ran down my face and my bare chest. It was the sweetest and most wonderful thing I have ever tasted. All the better for having to wait for it.
. I have had four major meetings canceled and though my livelihood and life are at risk, I feel oddly free and happy. I am no longer under those pressures to research, write, and present, and am spending at lot of time at home with my wife and daughter. I think I will clean out the garage (who knows what I will find?) and work in the backyard – and keep a close watch on the apricot tree.
As many of you have, I have awkwardly embraced telemedicine in the past. It is interesting now, how HIPAA regulations and state licensing requirements have finally been tossed aside, making it possible to practice telemedicine. I suspect things will stay that way if it is demonstrated they are unnecessary.
In my office, we are depopulating the waiting room and autoclaving face masks. I am cleaning out the stockroom and donating extra gloves, gowns, and masks to the local hospital. We may shut down altogether. There is little more I can do unless called to man a ventilator. I hope it doesn’t come to that, but I will serve if called.
I suggest you embrace your current unstructured time and use it to let your mind roam. It is a reprieve from today’s hyperconnected, hurly burly world. I also suggest you check COVID-19 news updates only once a day and turn off television news altogether. Other than following the recommendations and guidance of public health authorities, there is nothing you can do to speed up the resolution of this pandemic.
No matter how awful, this will pass. It is a warm spring and it is possible the apricot tree will not be bitten by frost, and we may have fruit this year. We should know in about 2 months. I am going to keep a close watch on it.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
My apricot tree has bloomed. It is a foolish tree planted by a foolish man since it blossoms, with beautiful pink then white flowers, at least 3 weeks too early in Northern Kentucky. Nonetheless, I am hopeful that it will produce fruit, maybe this year.
The apricot tree takes me back to my early childhood in Oklahoma City. We had a small apricot tree in the backyard of our rental house, and my dad would talk about how there was nothing finer than a sun ripened apricot. Those were happy times. My dad was a milkman and was home every day by late afternoon, though he was still taking classes at night to try to finish his degree. My mother was at home and my older brother in first grade down the street. My little sister was small and tried to keep up.
My time was unstructured, and I reveled in the backyard. In retrospect, the backyard was an open display of broken and hoped for dreams. There was a junked car my best friend Alvin and I would sit in, there was a huge tree stump we sat on and played around, we had an old slow dog named Pooch, gifted to us when my mom’s sister moved to Alaska. We ran around with no shirts or shoes, played and pretended, and carefully watched the apricot tree.
I remember one time when the apricots finally ripened. My father climbed up and got me one, and it was so sweet I did not notice that the juice ran down my face and my bare chest. It was the sweetest and most wonderful thing I have ever tasted. All the better for having to wait for it.
. I have had four major meetings canceled and though my livelihood and life are at risk, I feel oddly free and happy. I am no longer under those pressures to research, write, and present, and am spending at lot of time at home with my wife and daughter. I think I will clean out the garage (who knows what I will find?) and work in the backyard – and keep a close watch on the apricot tree.
As many of you have, I have awkwardly embraced telemedicine in the past. It is interesting now, how HIPAA regulations and state licensing requirements have finally been tossed aside, making it possible to practice telemedicine. I suspect things will stay that way if it is demonstrated they are unnecessary.
In my office, we are depopulating the waiting room and autoclaving face masks. I am cleaning out the stockroom and donating extra gloves, gowns, and masks to the local hospital. We may shut down altogether. There is little more I can do unless called to man a ventilator. I hope it doesn’t come to that, but I will serve if called.
I suggest you embrace your current unstructured time and use it to let your mind roam. It is a reprieve from today’s hyperconnected, hurly burly world. I also suggest you check COVID-19 news updates only once a day and turn off television news altogether. Other than following the recommendations and guidance of public health authorities, there is nothing you can do to speed up the resolution of this pandemic.
No matter how awful, this will pass. It is a warm spring and it is possible the apricot tree will not be bitten by frost, and we may have fruit this year. We should know in about 2 months. I am going to keep a close watch on it.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
My apricot tree has bloomed. It is a foolish tree planted by a foolish man since it blossoms, with beautiful pink then white flowers, at least 3 weeks too early in Northern Kentucky. Nonetheless, I am hopeful that it will produce fruit, maybe this year.
The apricot tree takes me back to my early childhood in Oklahoma City. We had a small apricot tree in the backyard of our rental house, and my dad would talk about how there was nothing finer than a sun ripened apricot. Those were happy times. My dad was a milkman and was home every day by late afternoon, though he was still taking classes at night to try to finish his degree. My mother was at home and my older brother in first grade down the street. My little sister was small and tried to keep up.
My time was unstructured, and I reveled in the backyard. In retrospect, the backyard was an open display of broken and hoped for dreams. There was a junked car my best friend Alvin and I would sit in, there was a huge tree stump we sat on and played around, we had an old slow dog named Pooch, gifted to us when my mom’s sister moved to Alaska. We ran around with no shirts or shoes, played and pretended, and carefully watched the apricot tree.
I remember one time when the apricots finally ripened. My father climbed up and got me one, and it was so sweet I did not notice that the juice ran down my face and my bare chest. It was the sweetest and most wonderful thing I have ever tasted. All the better for having to wait for it.
. I have had four major meetings canceled and though my livelihood and life are at risk, I feel oddly free and happy. I am no longer under those pressures to research, write, and present, and am spending at lot of time at home with my wife and daughter. I think I will clean out the garage (who knows what I will find?) and work in the backyard – and keep a close watch on the apricot tree.
As many of you have, I have awkwardly embraced telemedicine in the past. It is interesting now, how HIPAA regulations and state licensing requirements have finally been tossed aside, making it possible to practice telemedicine. I suspect things will stay that way if it is demonstrated they are unnecessary.
In my office, we are depopulating the waiting room and autoclaving face masks. I am cleaning out the stockroom and donating extra gloves, gowns, and masks to the local hospital. We may shut down altogether. There is little more I can do unless called to man a ventilator. I hope it doesn’t come to that, but I will serve if called.
I suggest you embrace your current unstructured time and use it to let your mind roam. It is a reprieve from today’s hyperconnected, hurly burly world. I also suggest you check COVID-19 news updates only once a day and turn off television news altogether. Other than following the recommendations and guidance of public health authorities, there is nothing you can do to speed up the resolution of this pandemic.
No matter how awful, this will pass. It is a warm spring and it is possible the apricot tree will not be bitten by frost, and we may have fruit this year. We should know in about 2 months. I am going to keep a close watch on it.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
Responsible use of breast cancer screening
In this edition of “Applying research to practice,” I examine a study suggesting that annual screening mammography does not reduce the risk of death from breast cancer in women aged 75 years and older. I also highlight a related editorial noting that we should optimize treatment as well as screening for breast cancer.
Regular screening mammography in women aged 50-69 years prevents 21.3 breast cancer deaths among 10,000 women over a 10-year time period (Ann Intern Med. 2016 Feb 16;164[4]:244-55). However, in the published screening trials, few participants were older than 70 years of age.
More than half of women above age 74 receive annual mammograms (Health, United States, 2018. www.cdc.gov/nchs/data/hus/hus18.pdf). And more than a third of breast cancer deaths occur in women aged 70 years or older (CA Cancer J Clin. 2016 Mar-Apr;66[2]:96-114).
Do older women benefit from annual mammography to the same extent as younger women? Is there a point at which benefit ends?
To answer these questions, Xabier García-Albéniz, MD, PhD, of Harvard Medical School in Boston, and colleagues studied 1,058,013 women enrolled in Medicare during 2000-2008 (Ann Intern Med. 2020 Feb 25. doi: 10.7326/M18-1199).
The researchers examined data on patients aged 70-84 years who had a life expectancy of at least 10 years, at least one recent mammogram, and no history of breast cancer. The team emulated a prospective trial by examining deaths over an 8-year period for women aged 70 years and older who either continued or stopped screening mammography. The researchers conducted separate analyses for women aged 70-74 years and those aged 75-84 years.
Diagnoses of breast cancer were, not surprisingly, higher in the continued-screening group, but there were no major reductions in breast cancer–related deaths.
Among women aged 70-74 years, the estimated 8-year risk for breast cancer death was reduced for women who continued screening versus those who stopped it by one death per 1,000 women (hazard ratio, 0.78). Among women aged 75-84 years, the 8-year risk reduction was 0.07 deaths per 1,000 women (HR, 1.00).
The authors concluded that continuing mammographic screening past age 75 years resulted in no material difference in cancer-specific mortality over an 8-year time period, in comparison with stopping regular screening examinations.
Considering treatment as well as screening
For a variety of reasons (ethical, economic, methodologic), it is unreasonable to expect a randomized, clinical trial examining the value of mammography in older women. An informative alternative would be a well-designed, large-scale, population-based, observational study that takes into consideration potentially confounding variables of the binary strategies of continuing screening versus stopping it.
Although the 8-year risk of breast cancer in older women is not low among screened women – 5.5% in women aged 70-74 years and 5.8% in women aged 75-84 years – and mammography remains an effective screening tool, the effect of screening on breast cancer mortality appears to decline as women age.
In the editorial that accompanies the study by Dr. García-Albéniz and colleagues, Otis Brawley, MD, of Johns Hopkins University, Baltimore, highlighted the role of inadequate, ineffective, inconvenient, or poorly tolerated treatment in older women (Ann Intern Med. 2020 Feb 25. doi: 10.7326/M20-0429).
Dr. Brawley illustrated that focusing too much on screening diverts attention from the major driver of cancer mortality in older women: suboptimal treatment. That certainly has been the case for the dramatic impact of improved lung cancer treatment on mortality, despite a statistically significant impact of screening on lung cancer mortality as well.
As with lung cancer screening, Dr. Brawley describes the goal of defining “personalized screening recommendations” in breast cancer, or screening that is targeted to the highest-risk women and those who stand a high chance of benefiting from treatment if they are diagnosed with breast cancer.
As our population ages and health care expenditures continue to rise, there can be little disagreement that responsible use of cancer diagnostics will be as vital as judicious application of treatment.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations.
In this edition of “Applying research to practice,” I examine a study suggesting that annual screening mammography does not reduce the risk of death from breast cancer in women aged 75 years and older. I also highlight a related editorial noting that we should optimize treatment as well as screening for breast cancer.
Regular screening mammography in women aged 50-69 years prevents 21.3 breast cancer deaths among 10,000 women over a 10-year time period (Ann Intern Med. 2016 Feb 16;164[4]:244-55). However, in the published screening trials, few participants were older than 70 years of age.
More than half of women above age 74 receive annual mammograms (Health, United States, 2018. www.cdc.gov/nchs/data/hus/hus18.pdf). And more than a third of breast cancer deaths occur in women aged 70 years or older (CA Cancer J Clin. 2016 Mar-Apr;66[2]:96-114).
Do older women benefit from annual mammography to the same extent as younger women? Is there a point at which benefit ends?
To answer these questions, Xabier García-Albéniz, MD, PhD, of Harvard Medical School in Boston, and colleagues studied 1,058,013 women enrolled in Medicare during 2000-2008 (Ann Intern Med. 2020 Feb 25. doi: 10.7326/M18-1199).
The researchers examined data on patients aged 70-84 years who had a life expectancy of at least 10 years, at least one recent mammogram, and no history of breast cancer. The team emulated a prospective trial by examining deaths over an 8-year period for women aged 70 years and older who either continued or stopped screening mammography. The researchers conducted separate analyses for women aged 70-74 years and those aged 75-84 years.
Diagnoses of breast cancer were, not surprisingly, higher in the continued-screening group, but there were no major reductions in breast cancer–related deaths.
Among women aged 70-74 years, the estimated 8-year risk for breast cancer death was reduced for women who continued screening versus those who stopped it by one death per 1,000 women (hazard ratio, 0.78). Among women aged 75-84 years, the 8-year risk reduction was 0.07 deaths per 1,000 women (HR, 1.00).
The authors concluded that continuing mammographic screening past age 75 years resulted in no material difference in cancer-specific mortality over an 8-year time period, in comparison with stopping regular screening examinations.
Considering treatment as well as screening
For a variety of reasons (ethical, economic, methodologic), it is unreasonable to expect a randomized, clinical trial examining the value of mammography in older women. An informative alternative would be a well-designed, large-scale, population-based, observational study that takes into consideration potentially confounding variables of the binary strategies of continuing screening versus stopping it.
Although the 8-year risk of breast cancer in older women is not low among screened women – 5.5% in women aged 70-74 years and 5.8% in women aged 75-84 years – and mammography remains an effective screening tool, the effect of screening on breast cancer mortality appears to decline as women age.
In the editorial that accompanies the study by Dr. García-Albéniz and colleagues, Otis Brawley, MD, of Johns Hopkins University, Baltimore, highlighted the role of inadequate, ineffective, inconvenient, or poorly tolerated treatment in older women (Ann Intern Med. 2020 Feb 25. doi: 10.7326/M20-0429).
Dr. Brawley illustrated that focusing too much on screening diverts attention from the major driver of cancer mortality in older women: suboptimal treatment. That certainly has been the case for the dramatic impact of improved lung cancer treatment on mortality, despite a statistically significant impact of screening on lung cancer mortality as well.
As with lung cancer screening, Dr. Brawley describes the goal of defining “personalized screening recommendations” in breast cancer, or screening that is targeted to the highest-risk women and those who stand a high chance of benefiting from treatment if they are diagnosed with breast cancer.
As our population ages and health care expenditures continue to rise, there can be little disagreement that responsible use of cancer diagnostics will be as vital as judicious application of treatment.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations.
In this edition of “Applying research to practice,” I examine a study suggesting that annual screening mammography does not reduce the risk of death from breast cancer in women aged 75 years and older. I also highlight a related editorial noting that we should optimize treatment as well as screening for breast cancer.
Regular screening mammography in women aged 50-69 years prevents 21.3 breast cancer deaths among 10,000 women over a 10-year time period (Ann Intern Med. 2016 Feb 16;164[4]:244-55). However, in the published screening trials, few participants were older than 70 years of age.
More than half of women above age 74 receive annual mammograms (Health, United States, 2018. www.cdc.gov/nchs/data/hus/hus18.pdf). And more than a third of breast cancer deaths occur in women aged 70 years or older (CA Cancer J Clin. 2016 Mar-Apr;66[2]:96-114).
Do older women benefit from annual mammography to the same extent as younger women? Is there a point at which benefit ends?
To answer these questions, Xabier García-Albéniz, MD, PhD, of Harvard Medical School in Boston, and colleagues studied 1,058,013 women enrolled in Medicare during 2000-2008 (Ann Intern Med. 2020 Feb 25. doi: 10.7326/M18-1199).
The researchers examined data on patients aged 70-84 years who had a life expectancy of at least 10 years, at least one recent mammogram, and no history of breast cancer. The team emulated a prospective trial by examining deaths over an 8-year period for women aged 70 years and older who either continued or stopped screening mammography. The researchers conducted separate analyses for women aged 70-74 years and those aged 75-84 years.
Diagnoses of breast cancer were, not surprisingly, higher in the continued-screening group, but there were no major reductions in breast cancer–related deaths.
Among women aged 70-74 years, the estimated 8-year risk for breast cancer death was reduced for women who continued screening versus those who stopped it by one death per 1,000 women (hazard ratio, 0.78). Among women aged 75-84 years, the 8-year risk reduction was 0.07 deaths per 1,000 women (HR, 1.00).
The authors concluded that continuing mammographic screening past age 75 years resulted in no material difference in cancer-specific mortality over an 8-year time period, in comparison with stopping regular screening examinations.
Considering treatment as well as screening
For a variety of reasons (ethical, economic, methodologic), it is unreasonable to expect a randomized, clinical trial examining the value of mammography in older women. An informative alternative would be a well-designed, large-scale, population-based, observational study that takes into consideration potentially confounding variables of the binary strategies of continuing screening versus stopping it.
Although the 8-year risk of breast cancer in older women is not low among screened women – 5.5% in women aged 70-74 years and 5.8% in women aged 75-84 years – and mammography remains an effective screening tool, the effect of screening on breast cancer mortality appears to decline as women age.
In the editorial that accompanies the study by Dr. García-Albéniz and colleagues, Otis Brawley, MD, of Johns Hopkins University, Baltimore, highlighted the role of inadequate, ineffective, inconvenient, or poorly tolerated treatment in older women (Ann Intern Med. 2020 Feb 25. doi: 10.7326/M20-0429).
Dr. Brawley illustrated that focusing too much on screening diverts attention from the major driver of cancer mortality in older women: suboptimal treatment. That certainly has been the case for the dramatic impact of improved lung cancer treatment on mortality, despite a statistically significant impact of screening on lung cancer mortality as well.
As with lung cancer screening, Dr. Brawley describes the goal of defining “personalized screening recommendations” in breast cancer, or screening that is targeted to the highest-risk women and those who stand a high chance of benefiting from treatment if they are diagnosed with breast cancer.
As our population ages and health care expenditures continue to rise, there can be little disagreement that responsible use of cancer diagnostics will be as vital as judicious application of treatment.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations.
April 2020
Shiitake mushroom flagellate dermatitis
that resemble whiplash marks. The lesions may be extremely pruritic, and petechiae may be present in the streaks. The trunk is most commonly affected, although lesions can occur on the limbs. Mucosa is not affected. Sun exposure may exacerbate the condition. The dermatitis has been described in all ages and races, and males seem to be more affected than females.
Shiitake mushroom flagellate dermatitis typically occurs following the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). The mushrooms contain a polysaccharide called lentinan. Ingestion of lentinan activates interleukin-1 (IL-1), resulting in vasodilation and the subsequent dermatitis that can occur within a few hours and up to 5 days post ingestion. Associated gastrointestinal symptoms, fever, and localized swelling have been reported. The rash will resolve spontaneously over a few days to weeks.
Flagellate erythema has been described with bleomycin treatment. Other reported associations include peplomycin (a bleomycin derivative) and docetaxel. The rash may appear following administration of bleomycin by any route and has been shown to be dose independent. Onset occurs anywhere from 1 day to several months after exposure. Over time, the erythema will develop into postinflammatory hyperpigmentation.
Dermatomyositis may present with flagellate erythema. Other symptoms include muscle weakness and an inflammatory myopathy. A heliotrope rash on the eyelids, Gottron’s papules on the hands, ragged cuticles with prominent vessels on nail folds may be seen. Blood work may reveal elevated antinuclear antibodies (ANA), anti–Mi-2 and anti–Jo-1. Adult-onset Still disease is characterized by fever, arthritis, and salmon-colored patches.
Our patient’s dermatitis resolved spontaneously without treatment.
This case and photo were provided by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
Shiitake mushroom flagellate dermatitis
that resemble whiplash marks. The lesions may be extremely pruritic, and petechiae may be present in the streaks. The trunk is most commonly affected, although lesions can occur on the limbs. Mucosa is not affected. Sun exposure may exacerbate the condition. The dermatitis has been described in all ages and races, and males seem to be more affected than females.
Shiitake mushroom flagellate dermatitis typically occurs following the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). The mushrooms contain a polysaccharide called lentinan. Ingestion of lentinan activates interleukin-1 (IL-1), resulting in vasodilation and the subsequent dermatitis that can occur within a few hours and up to 5 days post ingestion. Associated gastrointestinal symptoms, fever, and localized swelling have been reported. The rash will resolve spontaneously over a few days to weeks.
Flagellate erythema has been described with bleomycin treatment. Other reported associations include peplomycin (a bleomycin derivative) and docetaxel. The rash may appear following administration of bleomycin by any route and has been shown to be dose independent. Onset occurs anywhere from 1 day to several months after exposure. Over time, the erythema will develop into postinflammatory hyperpigmentation.
Dermatomyositis may present with flagellate erythema. Other symptoms include muscle weakness and an inflammatory myopathy. A heliotrope rash on the eyelids, Gottron’s papules on the hands, ragged cuticles with prominent vessels on nail folds may be seen. Blood work may reveal elevated antinuclear antibodies (ANA), anti–Mi-2 and anti–Jo-1. Adult-onset Still disease is characterized by fever, arthritis, and salmon-colored patches.
Our patient’s dermatitis resolved spontaneously without treatment.
This case and photo were provided by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
Shiitake mushroom flagellate dermatitis
that resemble whiplash marks. The lesions may be extremely pruritic, and petechiae may be present in the streaks. The trunk is most commonly affected, although lesions can occur on the limbs. Mucosa is not affected. Sun exposure may exacerbate the condition. The dermatitis has been described in all ages and races, and males seem to be more affected than females.
Shiitake mushroom flagellate dermatitis typically occurs following the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). The mushrooms contain a polysaccharide called lentinan. Ingestion of lentinan activates interleukin-1 (IL-1), resulting in vasodilation and the subsequent dermatitis that can occur within a few hours and up to 5 days post ingestion. Associated gastrointestinal symptoms, fever, and localized swelling have been reported. The rash will resolve spontaneously over a few days to weeks.
Flagellate erythema has been described with bleomycin treatment. Other reported associations include peplomycin (a bleomycin derivative) and docetaxel. The rash may appear following administration of bleomycin by any route and has been shown to be dose independent. Onset occurs anywhere from 1 day to several months after exposure. Over time, the erythema will develop into postinflammatory hyperpigmentation.
Dermatomyositis may present with flagellate erythema. Other symptoms include muscle weakness and an inflammatory myopathy. A heliotrope rash on the eyelids, Gottron’s papules on the hands, ragged cuticles with prominent vessels on nail folds may be seen. Blood work may reveal elevated antinuclear antibodies (ANA), anti–Mi-2 and anti–Jo-1. Adult-onset Still disease is characterized by fever, arthritis, and salmon-colored patches.
Our patient’s dermatitis resolved spontaneously without treatment.
This case and photo were provided by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
Should physicians with OUDs return to practice after treatment?
New review points to importance of sustained recovery
A new article in the Journal of the Neurological Sciences provides an impressive review of research on the complex impairments produced by a wide range of drugs of abuse with a close look at physicians and other health care professionals.1
This review breaks new ground in outlining fitness for duty as an important outcome of the state physician health programs (PHPs). In addition, the review and case report by Alexandria G. Polles, MD, and colleagues are a response to the growing call for the state PHP system of care management to explicitly endorse the use of medication-assisted treatment, specifically the use of buprenorphine and methadone, in the treatment of physicians diagnosed with opioid use disorder (OUD). , because of the elevated rate of substance use disorders among physicians and the safety-sensitive nature of the practice of medicine.
Medication-assisted treatment (MAT)2 for opioid use disorders now dominates the field of treatment in terms of prescribing and also funding to address the opioid overdose crisis. MAT generally includes naltrexone and injectable naltrexone, though those antagonist medications have been used successfully for many decades by PHPs.3 However, to understand the controversy over the use of MAT in the care management of physicians first requires an understanding of state PHPs and how those programs oversee the care of physicians diagnosed with substance use disorders (SUDs), including OUDs.
A national blueprint study of PHPs showed that care begins with a formal diagnostic evaluation.4 Only when a diagnosis of an SUD is established is a physician referred to the attention of a state PHP, and a monitoring contract is signed. PHPs typically do not offer any direct treatment; instead, they manage the care of physician participants in programs in which the PHPs have confidence. Formal addiction treatment most often is 30 days of residential treatment, but many physicians receive intensive outpatient treatment.
After completing an episode of formal treatment, physicians are closely monitored, usually for 5 years, through random drug and alcohol tests, and work site monitors. They are required to engage in intensive recovery support, typically 12-step fellowships but also other alternative recovery support programs. Comorbid conditions, including mental health disorders, are also treated. Managing PHPs have no sanctions for noncompliance; however, importantly, they do offer a safe haven from state medical licensing boards for physicians who are compliant with their recommendations and who remain abstinent from any use of alcohol, marijuana, illicit drugs, or other nonmedical drug use.
The national blueprint study included 16 state PHPs and reviewed single episodes of PHP care for 908 physicians. Complete abstinence from any use of alcohol, marijuana, or other drugs was required of all physicians for monitoring periods of at least 5 years. During the extended period, 78% of the physicians did not have a single positive or missed test. Two-thirds of physicians who had one positive or missed test did not have a second. About a dozen publications have resulted from this national study, including an analysis of the roughly one-third of the physicians who were diagnosed with OUD.5
A sample of 702 PHP participants was grouped based on primary drug at intake: alcohol only, any opioid with or without alcohol, and nonopioid drugs. No significant differences were found among these groups in the percentage who completed PHP contracts, failed to complete their contract, or extended their contract and continued to be monitored. Only one physician received methadone to treat chronic pain. None received opioid agonists to treat their opioid use disorder. Opioid antagonist medication (naltrexone) was used for 40 physicians, or 5.7% of the total sample: 2 physicians (1%) from the alcohol-only group; 35 physicians (10.3%) from the any opioid group, and 3 physicians (1.9%) from nonopioid group.
The second fact that needs to be understood is that medical practice in relationship to SUDs is treated by state licensing boards as a safety-sensitive job, analogous to commercial airline pilots who have the Human Intervention Motivation Study (HIMS),6 which is their own care management program analogous to that of PHPs. A similar program exists for attorneys known as Commission on Lawyer Assistance Programs (CoLAP).7 Fitness for duty and prevention of harm are major concerns in occupations such as those of physicians, commercial truck drivers, and people working in the nuclear power industry, all of whom have similar safety protections requiring no drug use.
A third fact that deserves special attention is that the unique system of care management for physicians began in the early 1970s. It grew out of employee assistance programs, led then and often now by physicians who are themselves in recovery from SUDs. Many of the successful addiction treatment tools used today come from extensive research of their use in PHPs. Contingency management, 12 steps, caduceus recovery, cognitive-behavioral therapy, and treatment outcomes defined in years are examples in which PHP research helped change treatment and long-term management of SUDs in non-PHP populations.
Dr. Polles and colleagues provide an impressive and comprehensive summary of the issues involved in the new interest in providing the physicians with OUD under PHP care management the option of using buprenorphine or methadone. Such a model within an abstinence-based framework is now being pioneered by a variety of programs, from COAT8 at West Virginia University, Morgantown, to the Hazelden Betty Ford Foundation.9 In those programs, patients with OUD are offered the option of using buprenorphine, methadone, or naltrexone as well as the option of using none of those medications in an extended abstinence-based intensive treatment. The authors impressively and fairly summarize the evidence on whether there are cognitive or behavioral deficits associated with the therapeutic use of either buprenorphine or methadone, which might make them unacceptable for physicians. The strongest evidence that these medicines are not necessary in the treatment of OUDs in PHPs is the outstanding outcomes PHPs produce without use of these two medications. If skeptical of the use of medications for OUD treatment in PHP care management, Dr. Polles and colleagues are open to experiments to test the effects of this option just as Florida PHP programs pioneered contracts that included mandatory naltrexone.10 West Virginia University, the Hazelden Betty Ford Foundation, and other programs should be tested to evaluate just how safe, effective, and attractive such an option would be to physicians.
Many, if not most, SUD treatment programs that use MAT are not associated with the intensive psychological treatment or extended participation in recovery support, such as the 12-step fellowships. MAT is viewed as a harm reduction strategy rather than conceptualized as an abstinence-oriented treatment. For example, there is seldom a “sobriety date” among individuals in MAT, i.e., the last day the individual used any substance of abuse, including alcohol and marijuana. These are, however, central features of PHP care, and they are features of the Hazelden Betty Ford Foundation’s definition of recovery11 and use of MAT.
Dr. Polles and colleagues call attention to the unique care management of the PHP for all SUDs, not just for OUDs, because the PHPs set the standard for returning physicians to work who have the fitness and cognitive skills to first do no harm. They emphasize the importance of making sustained recovery the expected outcome of SUD treatment. There is a robust literature on the ways in which this distinctive system of care management shows the path forward for addiction treatment generally to regularly achieve 5-year recovery.12 The current controversy over the potential use of buprenorphine and buprenorphine plus naloxone in PHPs is a useful entry into this far larger issue of the potential for PHPs to show the path forward for the addiction treatment field.
Dr. DuPont, the first director of the National Institute on Drug Abuse (NIDA), is president of the Institute for Behavior and Health Inc., a nonprofit drug-policy research organization in Rockville, Md. He has no disclosures. Dr. Gold is professor of psychiatry (adjunct) at Washington University in St. Louis. He is also the 17th Distinguished Alumni Professor at the University of Florida Gainesville. He has no disclosures.
References
1. Polles AG et al. J Neurol Sci. 2020 Jan 30;411:116714.
2. Oesterle TS et al. Mayo Clin Proc. 2019 Oct;94(10):2072-86.
3. Srivastava AB and Gold MS. Cerebrum. 2018 Sep-Oct; cer-13-8.
4. DuPont RL et al. J Subst Abuse Treat. 2009 Mar 1;36(2):159-71.
5. Merlo LJ et al. J Subst Abuse Treat. 2016 May 1;64:47-54.
6. Human Intervention Motivation Study (HIMS): An Occupational Substance Abuse Treatment Program.
7. Commission on Lawyer Assistance Programs (CoLAP).
8. Lander LR et al. J Neurol Sci. 2020;411:116712-8.
9. Klein AA et al. J Subst Abuse Treat. 2019;104:51-63.
10. Merlo LJ et al. J Addict Med. 2012;5(4):279-83.
11. Betty Ford Consensus Panel. J Subst Abuse Treat. 2007 Oct;33(3):221-8.
12. Carr GD et al. “Physician health programs: The U.S. model.” In KJ Brower and MB Riba, (eds.) Physician Mental Health and Well-Being (pp. 265-94). Cham, Switzerland: Springer International Publishing, 2017.
New review points to importance of sustained recovery
New review points to importance of sustained recovery
A new article in the Journal of the Neurological Sciences provides an impressive review of research on the complex impairments produced by a wide range of drugs of abuse with a close look at physicians and other health care professionals.1
This review breaks new ground in outlining fitness for duty as an important outcome of the state physician health programs (PHPs). In addition, the review and case report by Alexandria G. Polles, MD, and colleagues are a response to the growing call for the state PHP system of care management to explicitly endorse the use of medication-assisted treatment, specifically the use of buprenorphine and methadone, in the treatment of physicians diagnosed with opioid use disorder (OUD). , because of the elevated rate of substance use disorders among physicians and the safety-sensitive nature of the practice of medicine.
Medication-assisted treatment (MAT)2 for opioid use disorders now dominates the field of treatment in terms of prescribing and also funding to address the opioid overdose crisis. MAT generally includes naltrexone and injectable naltrexone, though those antagonist medications have been used successfully for many decades by PHPs.3 However, to understand the controversy over the use of MAT in the care management of physicians first requires an understanding of state PHPs and how those programs oversee the care of physicians diagnosed with substance use disorders (SUDs), including OUDs.
A national blueprint study of PHPs showed that care begins with a formal diagnostic evaluation.4 Only when a diagnosis of an SUD is established is a physician referred to the attention of a state PHP, and a monitoring contract is signed. PHPs typically do not offer any direct treatment; instead, they manage the care of physician participants in programs in which the PHPs have confidence. Formal addiction treatment most often is 30 days of residential treatment, but many physicians receive intensive outpatient treatment.
After completing an episode of formal treatment, physicians are closely monitored, usually for 5 years, through random drug and alcohol tests, and work site monitors. They are required to engage in intensive recovery support, typically 12-step fellowships but also other alternative recovery support programs. Comorbid conditions, including mental health disorders, are also treated. Managing PHPs have no sanctions for noncompliance; however, importantly, they do offer a safe haven from state medical licensing boards for physicians who are compliant with their recommendations and who remain abstinent from any use of alcohol, marijuana, illicit drugs, or other nonmedical drug use.
The national blueprint study included 16 state PHPs and reviewed single episodes of PHP care for 908 physicians. Complete abstinence from any use of alcohol, marijuana, or other drugs was required of all physicians for monitoring periods of at least 5 years. During the extended period, 78% of the physicians did not have a single positive or missed test. Two-thirds of physicians who had one positive or missed test did not have a second. About a dozen publications have resulted from this national study, including an analysis of the roughly one-third of the physicians who were diagnosed with OUD.5
A sample of 702 PHP participants was grouped based on primary drug at intake: alcohol only, any opioid with or without alcohol, and nonopioid drugs. No significant differences were found among these groups in the percentage who completed PHP contracts, failed to complete their contract, or extended their contract and continued to be monitored. Only one physician received methadone to treat chronic pain. None received opioid agonists to treat their opioid use disorder. Opioid antagonist medication (naltrexone) was used for 40 physicians, or 5.7% of the total sample: 2 physicians (1%) from the alcohol-only group; 35 physicians (10.3%) from the any opioid group, and 3 physicians (1.9%) from nonopioid group.
The second fact that needs to be understood is that medical practice in relationship to SUDs is treated by state licensing boards as a safety-sensitive job, analogous to commercial airline pilots who have the Human Intervention Motivation Study (HIMS),6 which is their own care management program analogous to that of PHPs. A similar program exists for attorneys known as Commission on Lawyer Assistance Programs (CoLAP).7 Fitness for duty and prevention of harm are major concerns in occupations such as those of physicians, commercial truck drivers, and people working in the nuclear power industry, all of whom have similar safety protections requiring no drug use.
A third fact that deserves special attention is that the unique system of care management for physicians began in the early 1970s. It grew out of employee assistance programs, led then and often now by physicians who are themselves in recovery from SUDs. Many of the successful addiction treatment tools used today come from extensive research of their use in PHPs. Contingency management, 12 steps, caduceus recovery, cognitive-behavioral therapy, and treatment outcomes defined in years are examples in which PHP research helped change treatment and long-term management of SUDs in non-PHP populations.
Dr. Polles and colleagues provide an impressive and comprehensive summary of the issues involved in the new interest in providing the physicians with OUD under PHP care management the option of using buprenorphine or methadone. Such a model within an abstinence-based framework is now being pioneered by a variety of programs, from COAT8 at West Virginia University, Morgantown, to the Hazelden Betty Ford Foundation.9 In those programs, patients with OUD are offered the option of using buprenorphine, methadone, or naltrexone as well as the option of using none of those medications in an extended abstinence-based intensive treatment. The authors impressively and fairly summarize the evidence on whether there are cognitive or behavioral deficits associated with the therapeutic use of either buprenorphine or methadone, which might make them unacceptable for physicians. The strongest evidence that these medicines are not necessary in the treatment of OUDs in PHPs is the outstanding outcomes PHPs produce without use of these two medications. If skeptical of the use of medications for OUD treatment in PHP care management, Dr. Polles and colleagues are open to experiments to test the effects of this option just as Florida PHP programs pioneered contracts that included mandatory naltrexone.10 West Virginia University, the Hazelden Betty Ford Foundation, and other programs should be tested to evaluate just how safe, effective, and attractive such an option would be to physicians.
Many, if not most, SUD treatment programs that use MAT are not associated with the intensive psychological treatment or extended participation in recovery support, such as the 12-step fellowships. MAT is viewed as a harm reduction strategy rather than conceptualized as an abstinence-oriented treatment. For example, there is seldom a “sobriety date” among individuals in MAT, i.e., the last day the individual used any substance of abuse, including alcohol and marijuana. These are, however, central features of PHP care, and they are features of the Hazelden Betty Ford Foundation’s definition of recovery11 and use of MAT.
Dr. Polles and colleagues call attention to the unique care management of the PHP for all SUDs, not just for OUDs, because the PHPs set the standard for returning physicians to work who have the fitness and cognitive skills to first do no harm. They emphasize the importance of making sustained recovery the expected outcome of SUD treatment. There is a robust literature on the ways in which this distinctive system of care management shows the path forward for addiction treatment generally to regularly achieve 5-year recovery.12 The current controversy over the potential use of buprenorphine and buprenorphine plus naloxone in PHPs is a useful entry into this far larger issue of the potential for PHPs to show the path forward for the addiction treatment field.
Dr. DuPont, the first director of the National Institute on Drug Abuse (NIDA), is president of the Institute for Behavior and Health Inc., a nonprofit drug-policy research organization in Rockville, Md. He has no disclosures. Dr. Gold is professor of psychiatry (adjunct) at Washington University in St. Louis. He is also the 17th Distinguished Alumni Professor at the University of Florida Gainesville. He has no disclosures.
References
1. Polles AG et al. J Neurol Sci. 2020 Jan 30;411:116714.
2. Oesterle TS et al. Mayo Clin Proc. 2019 Oct;94(10):2072-86.
3. Srivastava AB and Gold MS. Cerebrum. 2018 Sep-Oct; cer-13-8.
4. DuPont RL et al. J Subst Abuse Treat. 2009 Mar 1;36(2):159-71.
5. Merlo LJ et al. J Subst Abuse Treat. 2016 May 1;64:47-54.
6. Human Intervention Motivation Study (HIMS): An Occupational Substance Abuse Treatment Program.
7. Commission on Lawyer Assistance Programs (CoLAP).
8. Lander LR et al. J Neurol Sci. 2020;411:116712-8.
9. Klein AA et al. J Subst Abuse Treat. 2019;104:51-63.
10. Merlo LJ et al. J Addict Med. 2012;5(4):279-83.
11. Betty Ford Consensus Panel. J Subst Abuse Treat. 2007 Oct;33(3):221-8.
12. Carr GD et al. “Physician health programs: The U.S. model.” In KJ Brower and MB Riba, (eds.) Physician Mental Health and Well-Being (pp. 265-94). Cham, Switzerland: Springer International Publishing, 2017.
A new article in the Journal of the Neurological Sciences provides an impressive review of research on the complex impairments produced by a wide range of drugs of abuse with a close look at physicians and other health care professionals.1
This review breaks new ground in outlining fitness for duty as an important outcome of the state physician health programs (PHPs). In addition, the review and case report by Alexandria G. Polles, MD, and colleagues are a response to the growing call for the state PHP system of care management to explicitly endorse the use of medication-assisted treatment, specifically the use of buprenorphine and methadone, in the treatment of physicians diagnosed with opioid use disorder (OUD). , because of the elevated rate of substance use disorders among physicians and the safety-sensitive nature of the practice of medicine.
Medication-assisted treatment (MAT)2 for opioid use disorders now dominates the field of treatment in terms of prescribing and also funding to address the opioid overdose crisis. MAT generally includes naltrexone and injectable naltrexone, though those antagonist medications have been used successfully for many decades by PHPs.3 However, to understand the controversy over the use of MAT in the care management of physicians first requires an understanding of state PHPs and how those programs oversee the care of physicians diagnosed with substance use disorders (SUDs), including OUDs.
A national blueprint study of PHPs showed that care begins with a formal diagnostic evaluation.4 Only when a diagnosis of an SUD is established is a physician referred to the attention of a state PHP, and a monitoring contract is signed. PHPs typically do not offer any direct treatment; instead, they manage the care of physician participants in programs in which the PHPs have confidence. Formal addiction treatment most often is 30 days of residential treatment, but many physicians receive intensive outpatient treatment.
After completing an episode of formal treatment, physicians are closely monitored, usually for 5 years, through random drug and alcohol tests, and work site monitors. They are required to engage in intensive recovery support, typically 12-step fellowships but also other alternative recovery support programs. Comorbid conditions, including mental health disorders, are also treated. Managing PHPs have no sanctions for noncompliance; however, importantly, they do offer a safe haven from state medical licensing boards for physicians who are compliant with their recommendations and who remain abstinent from any use of alcohol, marijuana, illicit drugs, or other nonmedical drug use.
The national blueprint study included 16 state PHPs and reviewed single episodes of PHP care for 908 physicians. Complete abstinence from any use of alcohol, marijuana, or other drugs was required of all physicians for monitoring periods of at least 5 years. During the extended period, 78% of the physicians did not have a single positive or missed test. Two-thirds of physicians who had one positive or missed test did not have a second. About a dozen publications have resulted from this national study, including an analysis of the roughly one-third of the physicians who were diagnosed with OUD.5
A sample of 702 PHP participants was grouped based on primary drug at intake: alcohol only, any opioid with or without alcohol, and nonopioid drugs. No significant differences were found among these groups in the percentage who completed PHP contracts, failed to complete their contract, or extended their contract and continued to be monitored. Only one physician received methadone to treat chronic pain. None received opioid agonists to treat their opioid use disorder. Opioid antagonist medication (naltrexone) was used for 40 physicians, or 5.7% of the total sample: 2 physicians (1%) from the alcohol-only group; 35 physicians (10.3%) from the any opioid group, and 3 physicians (1.9%) from nonopioid group.
The second fact that needs to be understood is that medical practice in relationship to SUDs is treated by state licensing boards as a safety-sensitive job, analogous to commercial airline pilots who have the Human Intervention Motivation Study (HIMS),6 which is their own care management program analogous to that of PHPs. A similar program exists for attorneys known as Commission on Lawyer Assistance Programs (CoLAP).7 Fitness for duty and prevention of harm are major concerns in occupations such as those of physicians, commercial truck drivers, and people working in the nuclear power industry, all of whom have similar safety protections requiring no drug use.
A third fact that deserves special attention is that the unique system of care management for physicians began in the early 1970s. It grew out of employee assistance programs, led then and often now by physicians who are themselves in recovery from SUDs. Many of the successful addiction treatment tools used today come from extensive research of their use in PHPs. Contingency management, 12 steps, caduceus recovery, cognitive-behavioral therapy, and treatment outcomes defined in years are examples in which PHP research helped change treatment and long-term management of SUDs in non-PHP populations.
Dr. Polles and colleagues provide an impressive and comprehensive summary of the issues involved in the new interest in providing the physicians with OUD under PHP care management the option of using buprenorphine or methadone. Such a model within an abstinence-based framework is now being pioneered by a variety of programs, from COAT8 at West Virginia University, Morgantown, to the Hazelden Betty Ford Foundation.9 In those programs, patients with OUD are offered the option of using buprenorphine, methadone, or naltrexone as well as the option of using none of those medications in an extended abstinence-based intensive treatment. The authors impressively and fairly summarize the evidence on whether there are cognitive or behavioral deficits associated with the therapeutic use of either buprenorphine or methadone, which might make them unacceptable for physicians. The strongest evidence that these medicines are not necessary in the treatment of OUDs in PHPs is the outstanding outcomes PHPs produce without use of these two medications. If skeptical of the use of medications for OUD treatment in PHP care management, Dr. Polles and colleagues are open to experiments to test the effects of this option just as Florida PHP programs pioneered contracts that included mandatory naltrexone.10 West Virginia University, the Hazelden Betty Ford Foundation, and other programs should be tested to evaluate just how safe, effective, and attractive such an option would be to physicians.
Many, if not most, SUD treatment programs that use MAT are not associated with the intensive psychological treatment or extended participation in recovery support, such as the 12-step fellowships. MAT is viewed as a harm reduction strategy rather than conceptualized as an abstinence-oriented treatment. For example, there is seldom a “sobriety date” among individuals in MAT, i.e., the last day the individual used any substance of abuse, including alcohol and marijuana. These are, however, central features of PHP care, and they are features of the Hazelden Betty Ford Foundation’s definition of recovery11 and use of MAT.
Dr. Polles and colleagues call attention to the unique care management of the PHP for all SUDs, not just for OUDs, because the PHPs set the standard for returning physicians to work who have the fitness and cognitive skills to first do no harm. They emphasize the importance of making sustained recovery the expected outcome of SUD treatment. There is a robust literature on the ways in which this distinctive system of care management shows the path forward for addiction treatment generally to regularly achieve 5-year recovery.12 The current controversy over the potential use of buprenorphine and buprenorphine plus naloxone in PHPs is a useful entry into this far larger issue of the potential for PHPs to show the path forward for the addiction treatment field.
Dr. DuPont, the first director of the National Institute on Drug Abuse (NIDA), is president of the Institute for Behavior and Health Inc., a nonprofit drug-policy research organization in Rockville, Md. He has no disclosures. Dr. Gold is professor of psychiatry (adjunct) at Washington University in St. Louis. He is also the 17th Distinguished Alumni Professor at the University of Florida Gainesville. He has no disclosures.
References
1. Polles AG et al. J Neurol Sci. 2020 Jan 30;411:116714.
2. Oesterle TS et al. Mayo Clin Proc. 2019 Oct;94(10):2072-86.
3. Srivastava AB and Gold MS. Cerebrum. 2018 Sep-Oct; cer-13-8.
4. DuPont RL et al. J Subst Abuse Treat. 2009 Mar 1;36(2):159-71.
5. Merlo LJ et al. J Subst Abuse Treat. 2016 May 1;64:47-54.
6. Human Intervention Motivation Study (HIMS): An Occupational Substance Abuse Treatment Program.
7. Commission on Lawyer Assistance Programs (CoLAP).
8. Lander LR et al. J Neurol Sci. 2020;411:116712-8.
9. Klein AA et al. J Subst Abuse Treat. 2019;104:51-63.
10. Merlo LJ et al. J Addict Med. 2012;5(4):279-83.
11. Betty Ford Consensus Panel. J Subst Abuse Treat. 2007 Oct;33(3):221-8.
12. Carr GD et al. “Physician health programs: The U.S. model.” In KJ Brower and MB Riba, (eds.) Physician Mental Health and Well-Being (pp. 265-94). Cham, Switzerland: Springer International Publishing, 2017.
COVID-19 guidance for children’s health care providers
We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.
Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
Offer clear, open, regular, and child-centered communication
If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).
Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.
It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”
Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.
School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.
Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
Be mindful of children’s vulnerabilities
Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.
Preserve routines and structure
Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.
Find opportunity in the disruption
Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.
Take care of the vulnerable and ease others’ hardships
Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com
We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.
Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
Offer clear, open, regular, and child-centered communication
If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).
Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.
It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”
Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.
School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.
Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
Be mindful of children’s vulnerabilities
Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.
Preserve routines and structure
Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.
Find opportunity in the disruption
Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.
Take care of the vulnerable and ease others’ hardships
Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com
We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.
Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
Offer clear, open, regular, and child-centered communication
If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).
Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.
It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”
Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.
School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.
Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
Be mindful of children’s vulnerabilities
Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.
Preserve routines and structure
Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.
Find opportunity in the disruption
Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.
Take care of the vulnerable and ease others’ hardships
Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com
Physicians and health systems can reduce fear around COVID-19
A message from a Chief Wellness Officer
We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.
Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.
It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.
First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.
Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.
So, what can physicians do?
- Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
- Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
- Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
- Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
- Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
- Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. which has a series of really excellent meditation and relaxation tools.
- Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
- Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
- Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.
Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.
This article first appeared on Medscape.com.
A message from a Chief Wellness Officer
We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.
Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.
It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.
First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.
Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.
So, what can physicians do?
- Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
- Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
- Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
- Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
- Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
- Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. which has a series of really excellent meditation and relaxation tools.
- Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
- Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
- Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.
Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.
This article first appeared on Medscape.com.
A message from a Chief Wellness Officer
We are at a time, unfortunately, of significant public uncertainty and fear of “the coronavirus.” Mixed and inaccurate messages from national leaders in the setting of delayed testing availability have heightened fears and impeded a uniformity in responses, medical and preventive.
Despite this, physicians, nurses, and other health professionals across the country, and in many other countries, have been addressing the medical realities of this pandemic in a way that should make every one of us health professionals proud – from the Chinese doctors and nurses to the Italian intensivists and primary care physicians throughout many countries who have treated patients suffering from, or fearful of, a novel disease with uncertain transmission characteristics and unpredictable clinical outcomes.
It is now time for physicians and other health providers in the United States to step up to the plate and model appropriate transmission-reducing behavior for the general public. This will help reduce the overall morbidity and mortality associated with this pandemic and let us return to a more normal lifestyle as soon as possible. Physicians need to be reassuring but realistic, and there are concrete steps that we can take to demonstrate to the general public that there is a way forward.
First the basic facts. The United States does not have enough intensive care beds or ventilators to handle a major pandemic. We will also have insufficient physicians and nurses if many are quarantined. The tragic experience in Italy, where patients are dying from lack of ventilators, intensive care facilities, and staff, must not be repeated here.
Many health systems are canceling or reducing outpatient appointments and increasingly using video and other telehealth technologies, especially for assessing and triaging people who believe that they may have become infected and are relatively asymptomatic. While all of the disruptions may seem unsettling, they are actually good news for those of us in healthcare. Efforts to “flatten the curve” will slow the infection spread and help us better manage patients who become critical.
So, what can physicians do?
- Make sure you are getting good information about the situation. Access reliable information and data that are widely available through the Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. Listen to professional news organizations, local and national. Pass this information to your patients and community.
- Obviously, when practicing clinically, follow all infection control protocols, which will inevitably change over time. Make it clear to your patients why you are following these protocols and procedures.
- Support and actively promote the public health responses to this pandemic. Systematic reviews of the evidence base have found that isolating ill persons, testing and tracing contacts, quarantining exposed persons, closing schools and workplaces, and avoiding crowding are more effective if implemented immediately, simultaneously (ie, school closures combined with teleworking for parents), and with high community compliance.
- Practice social distancing so that you remain as much in control as you can. This will make you feel psychologically better and safer, as well as reduce the risk for transmission. Take the essential precautionary measures that we are all being asked to take. Wash your hands. Do not shake hands. Clean shared items. Do not go to large public gatherings. Minimize large group travel as much as you can. Use video to see your patients or your own doctor.
- Connect and reconnect with people you trust and love. See your family, your partner, your children, your friends. Speak to them on the phone and nourish those relationships. See how they feel and care for each other. They will be worried about you. Reassure them. Be in the moment with them and use the importance of these relationships to give yourself a chance not to overthink any fears you might have.
- Look after yourself physically. Physical fitness is good for your mental health. While White House guidelines suggest avoiding gyms, you can still enjoy long walks and outdoor activities. Take the weekend off and don’t work excessively. Sleep well – at least 7-8 hours. which has a series of really excellent meditation and relaxation tools.
- Do not panic. Uncertainty surrounding the pandemic makes all of us anxious and afraid. It is normal to become hypervigilant, especially with our nonstop media. It is normal to be concerned when we feel out of control and when we are hearing about a possible future catastrophe, especially when fed with differing sets of information from multiple sources and countries.
- Be careful with any large decisions you are making that may affect the lives of yourself and your loved ones. Think about your decisions and try to take the long view; and run them by your spouse, partner, or friends. This is not a time to be making sudden big decisions that may be driven unconsciously, in part at least, by fear and anxiety.
- Realize that all of these societal disruptions are actually good for us in health care, and they help your family and friends understand the importance of slowing the disease’s spread. That’s good for health care and good for everyone.
Finally, remember that “this is what we do,” to quote Doug Kirk, MD, chief medical officer of UC Davis Health. We must look after our patients. But we also have to look after ourselves so that we can look after our patients. We should all be proud of our work and our caring. And we should model our personal behavior to our patients and to our families and friends so that they will model it to their community networks. That way, more people will keep well, and we will have more chance of “flattening the curve” and reducing the morbidity and mortality associated with COVID-19.
Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.
This article first appeared on Medscape.com.
CME in the time of COVID-19
As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.
The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.
On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.
The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.
On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.
As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.
If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.
For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.
For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.
Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.
As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.
If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.
As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.
The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.
On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.
The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.
On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.
As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.
If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.
For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.
For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.
Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.
As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.
If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.
As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.
The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.
On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.
The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.
On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.
As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.
If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.
For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.
For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.
Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.
As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.
If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.