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Commentary—Promising Results Should Prompt Further Study
During the past 20 years, mindfulness-based training has become an increasingly popular treatment for many conditions, including migraine. In the February online issue of the Journal of Headache and Pain, Dr. Grazzi addresses medication overuse chronic migraine (CM-MO) and provides initial evidence for the consideration of mindfulness training to help reduce headache symptoms.
However, the reader should take seriously the authors’ caution that “although our findings are encouraging and suggestive of the independent value of mindfulness for headache care, certain design limitations preclude us [from] making unequivocal claims.”
Since the goal of a noninferiority trial is to assess whether a new therapy is at least as beneficial as standard treatment, extra caution is necessary when interpreting findings from an underpowered feasibility study. In general, a useful approach to noninferiority is to determine whether the confidence intervals include effect sizes that one might consider clinically meaningful. Instead of focusing on whether the mindfulness-based training group performed the same as the comparison group, we should accept the valuable information that is presented. The take away message from this pilot study is threefold. Mindfulness-based training is potentially acceptable to patients with CM-MO. Patients with CM-MO might be amenable to participating in a fully powered randomized controlled trial of mindfulness-based training. Finally, it is possible that mindfulness-based training may show improvement similar in magnitude to pharmaceuticals. Overall, Grazzi et al have laid the groundwork for a fully powered, randomized version of their study.
—Alice R. Pressman, PhD
Director of Analytics and Evaluation
Sutter Health
Walnut Creek, California
During the past 20 years, mindfulness-based training has become an increasingly popular treatment for many conditions, including migraine. In the February online issue of the Journal of Headache and Pain, Dr. Grazzi addresses medication overuse chronic migraine (CM-MO) and provides initial evidence for the consideration of mindfulness training to help reduce headache symptoms.
However, the reader should take seriously the authors’ caution that “although our findings are encouraging and suggestive of the independent value of mindfulness for headache care, certain design limitations preclude us [from] making unequivocal claims.”
Since the goal of a noninferiority trial is to assess whether a new therapy is at least as beneficial as standard treatment, extra caution is necessary when interpreting findings from an underpowered feasibility study. In general, a useful approach to noninferiority is to determine whether the confidence intervals include effect sizes that one might consider clinically meaningful. Instead of focusing on whether the mindfulness-based training group performed the same as the comparison group, we should accept the valuable information that is presented. The take away message from this pilot study is threefold. Mindfulness-based training is potentially acceptable to patients with CM-MO. Patients with CM-MO might be amenable to participating in a fully powered randomized controlled trial of mindfulness-based training. Finally, it is possible that mindfulness-based training may show improvement similar in magnitude to pharmaceuticals. Overall, Grazzi et al have laid the groundwork for a fully powered, randomized version of their study.
—Alice R. Pressman, PhD
Director of Analytics and Evaluation
Sutter Health
Walnut Creek, California
During the past 20 years, mindfulness-based training has become an increasingly popular treatment for many conditions, including migraine. In the February online issue of the Journal of Headache and Pain, Dr. Grazzi addresses medication overuse chronic migraine (CM-MO) and provides initial evidence for the consideration of mindfulness training to help reduce headache symptoms.
However, the reader should take seriously the authors’ caution that “although our findings are encouraging and suggestive of the independent value of mindfulness for headache care, certain design limitations preclude us [from] making unequivocal claims.”
Since the goal of a noninferiority trial is to assess whether a new therapy is at least as beneficial as standard treatment, extra caution is necessary when interpreting findings from an underpowered feasibility study. In general, a useful approach to noninferiority is to determine whether the confidence intervals include effect sizes that one might consider clinically meaningful. Instead of focusing on whether the mindfulness-based training group performed the same as the comparison group, we should accept the valuable information that is presented. The take away message from this pilot study is threefold. Mindfulness-based training is potentially acceptable to patients with CM-MO. Patients with CM-MO might be amenable to participating in a fully powered randomized controlled trial of mindfulness-based training. Finally, it is possible that mindfulness-based training may show improvement similar in magnitude to pharmaceuticals. Overall, Grazzi et al have laid the groundwork for a fully powered, randomized version of their study.
—Alice R. Pressman, PhD
Director of Analytics and Evaluation
Sutter Health
Walnut Creek, California
The perils of the National Practitioner Data Bank
Question: With reference to the National Practitioner Data Bank (NPDB), which of the following statements is incorrect?
A. Both court judgments and out-of-court settlements are reportable to the NPDB.
B. Adverse actions by a hospital against a physician are reportable within 15 days.
C. In states with “Disclosure, Apology, and Offer” laws, a prompt settlement through mediation need not be reported.
D. Hospitals, state licensing boards, medical organizations, and the physician himself/herself can access the NPDB.
E. A plaintiff’s attorney cannot access the NPDB for information regarding a defendant.
Answer: C. Congress implemented the NPDB to collect information about an individual doctor’s malpractice and disciplinary histories, with the objective of restricting errant doctors from moving from one state to another.1
Federal law requires medical liability payments stemming from either a court judgment or an out-of-court settlement be reported to the NPDB. An institution’s disciplinary actions against a medical staff member must also be reported. In turn, the NPDB is obligated to make its information available to hospitals, state licensure boards, and legitimate medical organizations charged with granting privileges or membership. A physician also can ask to see his or her own records, but a plaintiff’s attorney cannot access the NPDB unless there is evidence that a hospital failed to query the NPDB as part of its credentialing process.
Some observers have claimed that the NPDB’s existence has hindered settlement negotiations, because many doctors fear being listed in the NPDB, thus significantly diminishing the likelihood of payments to satisfy a claim. It has been stated that within 6 years of NPDB’s inception, the probability that an injured patient’s claim would receive payment had fallen to 59% of the pre-NPDB level.
Many states have enacted so-called “apology laws” that promote full disclosure of medical errors and prompt out-of-court settlements, if warranted. However, the federal Department of Health and Human Services has ruled that all written demands for payment must be reported, even if the cases are resolved under state programs designed for early out-of-court resolution.
For example, a provision in the Oregon law asserts that a payment under the measure’s mediation mechanism “is not a payment resulting from a written claim or demand for payment.” The HHS has rejected this as “explicitly designed to avoid medical malpractice reporting to the NPDB for any claims that are part of the new process that do not proceed to litigation.”
Massachusetts’ 2012 apology law had proposed reporting only those cases where it was determined that a practitioner failed to meet the standard of care. The HHS responded by indicating that all cases had to be reported, regardless of whether care was determined to be up to standards, and that the state’s prelitigation notice to initiate the meditation process qualified as a reportable “written claim.”
Physicians can be impacted greatly by the NPDB. How much of an impact depends in large part on the underlying events and the wording of the report.
An NPDB account of a medical malpractice payment doesn’t necessarily affect a physician’s ability to practice, while those – especially when “severely-worded” – involving denial or restriction of privileges are taken more seriously by state licensing boards and employers. Physicians should therefore play an active role whenever a report to the NPDB appears likely.
The dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. To start out, consider making a request to the reporting entity to correct or vacate the report due to error. If the reporting entity declines, the physician may request a review by the HHS and file an accompanying statement seeking to explain the report.
Yet, out of more than 800,000 total reports for all practitioner types captured in the system, apparently only 44,273 included accompanying clarifying statements by the physician. Risk managers have urged vigilance.
For example, it may be that multiple reports involved a single incident, leading to a “piling on” effect. If an adverse decision at one hospital caused a physician’s clinical privileges to be terminated, this might lead the state medical board to restrict the physician’s license. It is necessary to explain that both of these NPDB-reportable events involved the same incident, and that the state board did not have any independent knowledge of anything that was wrong.
Others have advised that one should always clarify one’s involvement, e.g., “I was not the main doctor in the case.” And if dismissed in a malpractice lawsuit, be sure your name or identifying information isn’t included in the judgment or settlement agreement.
Hospital disciplinary actions being far more serious, physicians would do well to familiarize themselves with medical staff bylaws dealing with peer review and investigations. To avoid being reported to the NPDB, physicians must resist adverse actions that would be in effect for more than 30 days and fight attempts to place restrictions or sanctions on their licenses by the hospital or professional societies. Don’t withdraw applications for privileges during an investigation.
The 2015 NPDB Guidebook, the first update in more than 10 years, contains important changes pertaining to hospital adverse actions.2 The regulations now require any “surrender” of privileges while the physician is a subject of an investigation to be a reportable event. Previously, physicians sought to avoid being reported by simply giving up their privileges when an adverse decision appeared imminent.
Surrender includes not renewing one’s hospital privileges or the taking of a leave of absence, and “investigation” is widely defined to include any formal inquiry into a physician’s competence or conduct. And there need not be any “nexus,” i.e., connection, between what is being investigated and the privileges surrendered, in order to be reportable.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.
References
1. Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
2. 2015 NPDB e-Guidebook, available at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
Question: With reference to the National Practitioner Data Bank (NPDB), which of the following statements is incorrect?
A. Both court judgments and out-of-court settlements are reportable to the NPDB.
B. Adverse actions by a hospital against a physician are reportable within 15 days.
C. In states with “Disclosure, Apology, and Offer” laws, a prompt settlement through mediation need not be reported.
D. Hospitals, state licensing boards, medical organizations, and the physician himself/herself can access the NPDB.
E. A plaintiff’s attorney cannot access the NPDB for information regarding a defendant.
Answer: C. Congress implemented the NPDB to collect information about an individual doctor’s malpractice and disciplinary histories, with the objective of restricting errant doctors from moving from one state to another.1
Federal law requires medical liability payments stemming from either a court judgment or an out-of-court settlement be reported to the NPDB. An institution’s disciplinary actions against a medical staff member must also be reported. In turn, the NPDB is obligated to make its information available to hospitals, state licensure boards, and legitimate medical organizations charged with granting privileges or membership. A physician also can ask to see his or her own records, but a plaintiff’s attorney cannot access the NPDB unless there is evidence that a hospital failed to query the NPDB as part of its credentialing process.
Some observers have claimed that the NPDB’s existence has hindered settlement negotiations, because many doctors fear being listed in the NPDB, thus significantly diminishing the likelihood of payments to satisfy a claim. It has been stated that within 6 years of NPDB’s inception, the probability that an injured patient’s claim would receive payment had fallen to 59% of the pre-NPDB level.
Many states have enacted so-called “apology laws” that promote full disclosure of medical errors and prompt out-of-court settlements, if warranted. However, the federal Department of Health and Human Services has ruled that all written demands for payment must be reported, even if the cases are resolved under state programs designed for early out-of-court resolution.
For example, a provision in the Oregon law asserts that a payment under the measure’s mediation mechanism “is not a payment resulting from a written claim or demand for payment.” The HHS has rejected this as “explicitly designed to avoid medical malpractice reporting to the NPDB for any claims that are part of the new process that do not proceed to litigation.”
Massachusetts’ 2012 apology law had proposed reporting only those cases where it was determined that a practitioner failed to meet the standard of care. The HHS responded by indicating that all cases had to be reported, regardless of whether care was determined to be up to standards, and that the state’s prelitigation notice to initiate the meditation process qualified as a reportable “written claim.”
Physicians can be impacted greatly by the NPDB. How much of an impact depends in large part on the underlying events and the wording of the report.
An NPDB account of a medical malpractice payment doesn’t necessarily affect a physician’s ability to practice, while those – especially when “severely-worded” – involving denial or restriction of privileges are taken more seriously by state licensing boards and employers. Physicians should therefore play an active role whenever a report to the NPDB appears likely.
The dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. To start out, consider making a request to the reporting entity to correct or vacate the report due to error. If the reporting entity declines, the physician may request a review by the HHS and file an accompanying statement seeking to explain the report.
Yet, out of more than 800,000 total reports for all practitioner types captured in the system, apparently only 44,273 included accompanying clarifying statements by the physician. Risk managers have urged vigilance.
For example, it may be that multiple reports involved a single incident, leading to a “piling on” effect. If an adverse decision at one hospital caused a physician’s clinical privileges to be terminated, this might lead the state medical board to restrict the physician’s license. It is necessary to explain that both of these NPDB-reportable events involved the same incident, and that the state board did not have any independent knowledge of anything that was wrong.
Others have advised that one should always clarify one’s involvement, e.g., “I was not the main doctor in the case.” And if dismissed in a malpractice lawsuit, be sure your name or identifying information isn’t included in the judgment or settlement agreement.
Hospital disciplinary actions being far more serious, physicians would do well to familiarize themselves with medical staff bylaws dealing with peer review and investigations. To avoid being reported to the NPDB, physicians must resist adverse actions that would be in effect for more than 30 days and fight attempts to place restrictions or sanctions on their licenses by the hospital or professional societies. Don’t withdraw applications for privileges during an investigation.
The 2015 NPDB Guidebook, the first update in more than 10 years, contains important changes pertaining to hospital adverse actions.2 The regulations now require any “surrender” of privileges while the physician is a subject of an investigation to be a reportable event. Previously, physicians sought to avoid being reported by simply giving up their privileges when an adverse decision appeared imminent.
Surrender includes not renewing one’s hospital privileges or the taking of a leave of absence, and “investigation” is widely defined to include any formal inquiry into a physician’s competence or conduct. And there need not be any “nexus,” i.e., connection, between what is being investigated and the privileges surrendered, in order to be reportable.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.
References
1. Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
2. 2015 NPDB e-Guidebook, available at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
Question: With reference to the National Practitioner Data Bank (NPDB), which of the following statements is incorrect?
A. Both court judgments and out-of-court settlements are reportable to the NPDB.
B. Adverse actions by a hospital against a physician are reportable within 15 days.
C. In states with “Disclosure, Apology, and Offer” laws, a prompt settlement through mediation need not be reported.
D. Hospitals, state licensing boards, medical organizations, and the physician himself/herself can access the NPDB.
E. A plaintiff’s attorney cannot access the NPDB for information regarding a defendant.
Answer: C. Congress implemented the NPDB to collect information about an individual doctor’s malpractice and disciplinary histories, with the objective of restricting errant doctors from moving from one state to another.1
Federal law requires medical liability payments stemming from either a court judgment or an out-of-court settlement be reported to the NPDB. An institution’s disciplinary actions against a medical staff member must also be reported. In turn, the NPDB is obligated to make its information available to hospitals, state licensure boards, and legitimate medical organizations charged with granting privileges or membership. A physician also can ask to see his or her own records, but a plaintiff’s attorney cannot access the NPDB unless there is evidence that a hospital failed to query the NPDB as part of its credentialing process.
Some observers have claimed that the NPDB’s existence has hindered settlement negotiations, because many doctors fear being listed in the NPDB, thus significantly diminishing the likelihood of payments to satisfy a claim. It has been stated that within 6 years of NPDB’s inception, the probability that an injured patient’s claim would receive payment had fallen to 59% of the pre-NPDB level.
Many states have enacted so-called “apology laws” that promote full disclosure of medical errors and prompt out-of-court settlements, if warranted. However, the federal Department of Health and Human Services has ruled that all written demands for payment must be reported, even if the cases are resolved under state programs designed for early out-of-court resolution.
For example, a provision in the Oregon law asserts that a payment under the measure’s mediation mechanism “is not a payment resulting from a written claim or demand for payment.” The HHS has rejected this as “explicitly designed to avoid medical malpractice reporting to the NPDB for any claims that are part of the new process that do not proceed to litigation.”
Massachusetts’ 2012 apology law had proposed reporting only those cases where it was determined that a practitioner failed to meet the standard of care. The HHS responded by indicating that all cases had to be reported, regardless of whether care was determined to be up to standards, and that the state’s prelitigation notice to initiate the meditation process qualified as a reportable “written claim.”
Physicians can be impacted greatly by the NPDB. How much of an impact depends in large part on the underlying events and the wording of the report.
An NPDB account of a medical malpractice payment doesn’t necessarily affect a physician’s ability to practice, while those – especially when “severely-worded” – involving denial or restriction of privileges are taken more seriously by state licensing boards and employers. Physicians should therefore play an active role whenever a report to the NPDB appears likely.
The dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. To start out, consider making a request to the reporting entity to correct or vacate the report due to error. If the reporting entity declines, the physician may request a review by the HHS and file an accompanying statement seeking to explain the report.
Yet, out of more than 800,000 total reports for all practitioner types captured in the system, apparently only 44,273 included accompanying clarifying statements by the physician. Risk managers have urged vigilance.
For example, it may be that multiple reports involved a single incident, leading to a “piling on” effect. If an adverse decision at one hospital caused a physician’s clinical privileges to be terminated, this might lead the state medical board to restrict the physician’s license. It is necessary to explain that both of these NPDB-reportable events involved the same incident, and that the state board did not have any independent knowledge of anything that was wrong.
Others have advised that one should always clarify one’s involvement, e.g., “I was not the main doctor in the case.” And if dismissed in a malpractice lawsuit, be sure your name or identifying information isn’t included in the judgment or settlement agreement.
Hospital disciplinary actions being far more serious, physicians would do well to familiarize themselves with medical staff bylaws dealing with peer review and investigations. To avoid being reported to the NPDB, physicians must resist adverse actions that would be in effect for more than 30 days and fight attempts to place restrictions or sanctions on their licenses by the hospital or professional societies. Don’t withdraw applications for privileges during an investigation.
The 2015 NPDB Guidebook, the first update in more than 10 years, contains important changes pertaining to hospital adverse actions.2 The regulations now require any “surrender” of privileges while the physician is a subject of an investigation to be a reportable event. Previously, physicians sought to avoid being reported by simply giving up their privileges when an adverse decision appeared imminent.
Surrender includes not renewing one’s hospital privileges or the taking of a leave of absence, and “investigation” is widely defined to include any formal inquiry into a physician’s competence or conduct. And there need not be any “nexus,” i.e., connection, between what is being investigated and the privileges surrendered, in order to be reportable.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.
References
1. Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
2. 2015 NPDB e-Guidebook, available at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
See one, do one ...
It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673)? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
Risks of keeping controlled substances in office tilt away from benefits
I don’t stack narcotics in my office. Never have, never will.
Honestly, in this day and age, I don’t understand why anyone would.
I get the occasional patient with a bad migraine who wants to come in for “a shot.” Sorry, I don’t carry that. I suppose I could carry Ketorolac, but I try to run a simple, nonurgent practice. If you have an urgent situation, go to an emergency department or urgent care.
I couldn’t agree more. It’s better to avoid the problem altogether.
In 1998, on my very first day of work as an attending, the group I’d signed with put me in a satellite office normally used by their headache specialist. While familiarizing myself with what was where, I discovered a bottle of injectable meperidine. It wasn’t locked up, just sitting next to the zolmitriptan (Zomig) samples in an unsecured cabinet. I picked it up in shock to make sure I’d read the label correctly. I put it back down then (somewhat paranoid) picked it back up, wiped my fingerprints off, and put it down in the exact same spot it had been. Although it was obviously a serious infraction, I didn’t want to jeopardize my standing as a new hire. So, I just ignored it. But, I sure worried about what would happen if a DEA inspector showed up.
So, today, I just don’t deal with it. No controlled substances, less paperwork, fewer worries. Simplicity is bliss, and modern medicine has enough worries as it is.
This still gets me the occasional complaint of, “Well, my other neurologist did!” but, frankly, I don’t care. They can run their practice how they want, and I’ll run mine.
In a world of regulations, daily press stories on “pill mills” overusing narcotics, and my quarterly prescription tracking reports from the state board, I want to keep my involvement in them as minimal as possible. I may prescribe them, but I don’t want the potential nightmares of having them on site.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t stack narcotics in my office. Never have, never will.
Honestly, in this day and age, I don’t understand why anyone would.
I get the occasional patient with a bad migraine who wants to come in for “a shot.” Sorry, I don’t carry that. I suppose I could carry Ketorolac, but I try to run a simple, nonurgent practice. If you have an urgent situation, go to an emergency department or urgent care.
I couldn’t agree more. It’s better to avoid the problem altogether.
In 1998, on my very first day of work as an attending, the group I’d signed with put me in a satellite office normally used by their headache specialist. While familiarizing myself with what was where, I discovered a bottle of injectable meperidine. It wasn’t locked up, just sitting next to the zolmitriptan (Zomig) samples in an unsecured cabinet. I picked it up in shock to make sure I’d read the label correctly. I put it back down then (somewhat paranoid) picked it back up, wiped my fingerprints off, and put it down in the exact same spot it had been. Although it was obviously a serious infraction, I didn’t want to jeopardize my standing as a new hire. So, I just ignored it. But, I sure worried about what would happen if a DEA inspector showed up.
So, today, I just don’t deal with it. No controlled substances, less paperwork, fewer worries. Simplicity is bliss, and modern medicine has enough worries as it is.
This still gets me the occasional complaint of, “Well, my other neurologist did!” but, frankly, I don’t care. They can run their practice how they want, and I’ll run mine.
In a world of regulations, daily press stories on “pill mills” overusing narcotics, and my quarterly prescription tracking reports from the state board, I want to keep my involvement in them as minimal as possible. I may prescribe them, but I don’t want the potential nightmares of having them on site.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t stack narcotics in my office. Never have, never will.
Honestly, in this day and age, I don’t understand why anyone would.
I get the occasional patient with a bad migraine who wants to come in for “a shot.” Sorry, I don’t carry that. I suppose I could carry Ketorolac, but I try to run a simple, nonurgent practice. If you have an urgent situation, go to an emergency department or urgent care.
I couldn’t agree more. It’s better to avoid the problem altogether.
In 1998, on my very first day of work as an attending, the group I’d signed with put me in a satellite office normally used by their headache specialist. While familiarizing myself with what was where, I discovered a bottle of injectable meperidine. It wasn’t locked up, just sitting next to the zolmitriptan (Zomig) samples in an unsecured cabinet. I picked it up in shock to make sure I’d read the label correctly. I put it back down then (somewhat paranoid) picked it back up, wiped my fingerprints off, and put it down in the exact same spot it had been. Although it was obviously a serious infraction, I didn’t want to jeopardize my standing as a new hire. So, I just ignored it. But, I sure worried about what would happen if a DEA inspector showed up.
So, today, I just don’t deal with it. No controlled substances, less paperwork, fewer worries. Simplicity is bliss, and modern medicine has enough worries as it is.
This still gets me the occasional complaint of, “Well, my other neurologist did!” but, frankly, I don’t care. They can run their practice how they want, and I’ll run mine.
In a world of regulations, daily press stories on “pill mills” overusing narcotics, and my quarterly prescription tracking reports from the state board, I want to keep my involvement in them as minimal as possible. I may prescribe them, but I don’t want the potential nightmares of having them on site.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
‘How could he?’
The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?
However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.
I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.
This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.
We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?
However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.
I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.
This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.
We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
The headline in a Portland, Maine, newspaper read, “Standish man sentenced to serve 15 years in prison for death of his 3-month-old son” (Edward Murphy, May 23, 2017). I suspect that many of the folks who read the story under the headline feel that the sentence was too light. Others are asking themselves how a 21-year-old man could beat a fragile 5-pound infant to death. What kind of evil monster is this guy?
However, even with the snatches of information provided in the 500-word newspaper story, the unfortunate scenario makes sense, and the child’s death is a tragic culmination of a series of events that shouldn’t surprise any pediatrician. It turns out the infant was a twin who, with his sister, had been born at 30 weeks’ gestation. He had spent a month or more in the hospital, and his sister was still in neonatal ICU at the time of his death. While it is unclear from the newspaper article whether the twins’ parents were married, they were living in a house with eight other adults and some other children. The mother was out of the home working while the father was left to care for his son.
I am sure that the neonatologists and social workers at the hospital where the twins were born were aware of at least some of the red flags that waved over this unfortunate family. I also am confident that they did what they could to assure this infant a safe home environment when it was time for his discharge from the NICU. However, risks factors may have been missed that now seem obvious in retrospect. We should all realize by now from our experience with domestic terrorism that simply appearing on someone’s radar doesn’t mean that preemptive action can or will be taken. Short of keeping the parents of high-risk neonates under constant surveillance for a year or 2, there are few other workable options to prevent every tragedy like this one.
This case is another example of the erosive power of a baby’s cry. Most pediatricians have developed a filtering mechanism that allows us to function in a cacophonous environment dominated by a screaming infant. However, even adults without this young father’s deprived background crack under the stress when they are confined in a space with a crying child. The risk of decompensation is compounded when the adult also feels some responsibility for the child’s welfare. I don’t think we can condone what the father did in this tragic scenario, but we can certainly understand how the dominoes fell.
We are all potential child abusers. When faced with the right, or I guess the wrong, set of circumstances we might lash out to stop the crying. Luckily, most of us are several body lengths from the end of that rope.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
Not better late ...
You all know the statistics or at least have a sense of the scope of the problem. While 85% of mothers in this country intend to breastfeed their infants exclusively for at least 3 months, only slightly more than 30% achieve this goal. Among the dozens of reasons for this unfortunate shortfall is what some experts view as inadequate support by primary care physicians and their offices. In the May 2017 Pediatrics, two members of the American Academy of Pediatrics Section on Breastfeeding offer a clinical report that hopes to remedy this situation (“The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics. 2017 May. 139[5]:e20170647). It is a document that begins with an excellent review of the background and epidemiology of breastfeeding in the United States and a survey of the current initiatives targeted at improving our dismal performance. What follows is an extensive set of 19 evidence-based recommendations for the pediatric outpatient practice that hopes to “meet or exceed the AAP recommendations.”
A large part of the problem is the failure of the point person in the office, usually the receptionist, to realize that a tearful call from a new mother who is struggling with breastfeeding is an emergency, one that demands a response in minutes … not hours. Even when the call is eventually routed to someone with a compassionate voice who will call back with the right answers, if that process takes just an hour or two, that is enough time for a mother with a screaming and hungry newborn to reach for a bottle of formula.
I urge you to read this exhaustive clinical report in Pediatrics because it is very likely you will come across some things that you can include in your office practice to make it more breastfeeding friendly. However, Even if you and your staff have the right advice, this is not a situation of “better late than never.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
You all know the statistics or at least have a sense of the scope of the problem. While 85% of mothers in this country intend to breastfeed their infants exclusively for at least 3 months, only slightly more than 30% achieve this goal. Among the dozens of reasons for this unfortunate shortfall is what some experts view as inadequate support by primary care physicians and their offices. In the May 2017 Pediatrics, two members of the American Academy of Pediatrics Section on Breastfeeding offer a clinical report that hopes to remedy this situation (“The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics. 2017 May. 139[5]:e20170647). It is a document that begins with an excellent review of the background and epidemiology of breastfeeding in the United States and a survey of the current initiatives targeted at improving our dismal performance. What follows is an extensive set of 19 evidence-based recommendations for the pediatric outpatient practice that hopes to “meet or exceed the AAP recommendations.”
A large part of the problem is the failure of the point person in the office, usually the receptionist, to realize that a tearful call from a new mother who is struggling with breastfeeding is an emergency, one that demands a response in minutes … not hours. Even when the call is eventually routed to someone with a compassionate voice who will call back with the right answers, if that process takes just an hour or two, that is enough time for a mother with a screaming and hungry newborn to reach for a bottle of formula.
I urge you to read this exhaustive clinical report in Pediatrics because it is very likely you will come across some things that you can include in your office practice to make it more breastfeeding friendly. However, Even if you and your staff have the right advice, this is not a situation of “better late than never.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
You all know the statistics or at least have a sense of the scope of the problem. While 85% of mothers in this country intend to breastfeed their infants exclusively for at least 3 months, only slightly more than 30% achieve this goal. Among the dozens of reasons for this unfortunate shortfall is what some experts view as inadequate support by primary care physicians and their offices. In the May 2017 Pediatrics, two members of the American Academy of Pediatrics Section on Breastfeeding offer a clinical report that hopes to remedy this situation (“The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics. 2017 May. 139[5]:e20170647). It is a document that begins with an excellent review of the background and epidemiology of breastfeeding in the United States and a survey of the current initiatives targeted at improving our dismal performance. What follows is an extensive set of 19 evidence-based recommendations for the pediatric outpatient practice that hopes to “meet or exceed the AAP recommendations.”
A large part of the problem is the failure of the point person in the office, usually the receptionist, to realize that a tearful call from a new mother who is struggling with breastfeeding is an emergency, one that demands a response in minutes … not hours. Even when the call is eventually routed to someone with a compassionate voice who will call back with the right answers, if that process takes just an hour or two, that is enough time for a mother with a screaming and hungry newborn to reach for a bottle of formula.
I urge you to read this exhaustive clinical report in Pediatrics because it is very likely you will come across some things that you can include in your office practice to make it more breastfeeding friendly. However, Even if you and your staff have the right advice, this is not a situation of “better late than never.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Mitigating Burnout - Part 3
It is easy to look at the changes required to mitigate burnout and improve compassionate care and see the burden being placed mainly on the physician. Many of the proposed modifications seem to require the one commodity surgeons lack most, time. Any widespread effort to mitigate the burnout crisis must involve decreasing the barriers to patient care and reducing the physicians’ time constraints.
This may seem daunting, but broad changes in our healthcare system have been implemented in the name of quality, reducing errors, and alleviating trainee fatigue. Burnout can be a similar force for change. Much like the resident’s 80-hour workweek, however, in what manner this change is applied will be the ultimate determinant of the movement’s success.
This series of articles dealt with the adverse consequences of surgeon burnout on both clinicians and their patients, and then presented a conceptual framework to promote workforce well-being. Strategies that the SVS might adopt have been suggested. The central proposal is that helping physicians to deliver compassionate, collaborative care will not only mitigate burnout but also will enhance provider engagement, patient experience, and clinical outcomes, as well as improve the quality and safety of healthcare delivery. It seems reasonable to question if such broad strategic proposals are scalable to individual clinical settings.
The characteristics of compassionate care have been well described by patients, and, not surprisingly, only 53% reported that their last encounter with the health care system was compassionate. In 2014, a multidisciplinary consortium published recommendations for advancing compassionate person- and family-centered care. They detailed the attributes, values, and behaviors of such care, including focusing one’s attention, recognizing nonverbal clues, active listening, demonstrating nonjudgmental interest in the whole person, understanding the context of a person’s disease, and asking about the patient’s chief concerns in addition to their chief complaints. Most significantly, the authors outlined how these attributes could be integrated into existing competency documents such as those provided by the Association of American Medical Colleges (AAMC) Entrustable Professional Activities, or the milestones programs of the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM).
It is but a small step to enhance current criteria for certification, clinical appointment, and privileging by including these professional attributes. Bear in mind that these skills are teachable and easily incorporated into health professional education and clinical care. As for metrics, the Schwartz Compassionate Care Scale is a validated patient-rated questionnaire that reliably measures physicians’ compassion and overall patient satisfaction and is available in the public domain. It also provides a metric that is important to clinicians and, when placed on the hospital dashboard, highlights that compassion is an organizational priority. Such priorities become the fabric of the workforce when organizational leadership installs programs such as values-based recruitment, retention, and promotion as Vivian Lee describes at the University of Utah Health System. Mitigating burnout requires changing the culture in which clinicians work and with whom they work.
Vascular surgeons and their professional surgical societies have a leadership opportunity to design high performing teams. Most patient care models have been structured around traditional medical and surgical departments. This paradigm overlooks the fact that patients do not “get sick” within traditional teaching disciplines but do so across varied medical and surgical specialties. Changes in organizational hierarchy are needed so that team-based care is supported. In addition to physician and nurse clinicians, the new teams would do well to expand to all “caregivers,” i.e. everyone who touches the patient (technologists, interpreters, pharmacists, transport workers, support staff, and administrators).
On the front line
On April 15, 2013, at 2:49 pm, two homemade bombs detonated near the finish line of the Boston Marathon killing three people at the scene and injuring 264 others; the most severe sustaining mutilating lower extremity injuries. Much has been written about the preparedness, the emergency response, and the fact that all those who made it to the hospital survived. Jeffrey Kalish, MD, a vascular surgeon at Boston Medical Center and SVS member, was on the front line that day. We asked him to share his personal experience of caring for the victims through the lens of compassionate collaborative care.
“It has been over four years since I went from being a spectator near the Boston Marathon finish line to rushing directly to the operating rooms at Boston Medical Center to help our teams perform lifesaving procedures on critically ill patients, including amputations and complex vascular repairs. While I have learned a tremendous amount since that experience with regard to limb salvage and amputation, reconstructive techniques, and prosthetics, I will focus here on the care the patients and their families received, the lessons our hospital learned from the weeks and months that followed, and how we modeled this care going forward for all amputation patients at Boston Medical Center.
"Based on lessons from the Boston Marathon bombings, I aligned a multidisciplinary team of health care providers in order to formalize and standardize best practices to benefit our amputation patients. STRONG (Surgery To Rehab Ongoing Needs Group) continues to strive toward the ultimate goal of improving and coordinating care for amputation patients and their families as they transition from the hospital setting to rehabilitation. Some of our guiding principles, along with their positive impacts on patient care and physician well-being, are highlighted below:
1. Sustaining hope with a new mindset: Although surgeons have historically considered amputation as a treatment failure, a more appropriate mindset is that amputation can often be a reconstructive procedure in the surgical armamentarium designed to restore a patient back to full function.
2. Seeing the patient in context: Shared decision making can occur more readily once a surgeon and the care team seek to understand the whole person and their family, including what that person does for work and leisure.
3. Communication with colleagues, patients, and families: Patient and family fear and confusion can often be reduced after establishment of a multi-disciplinary team with daily care coordination and consistent messaging. Breaking down traditional hospital silos to allow for improved coordination of care benefits both the patients and the practitioners.
4. Managing emotional and physical suffering: Introducing social workers, mental health professionals, or pastoral care advocates into the care team as soon as a patient is ready can help manage the emotional and psychosocial needs of patients and their families.
5. Sustaining long term surgeon/patient relationships: As clinicians, we can feel rewarded after restoring functional performance in our patients and by meeting the needs of our patients and families. This can occur both in the short-term during the acute hospital stay and in the long-term as we follow our patients’ progress towards achievement of their ultimate goals.
6. Attend to one’s own well-being and foster resilience. There will never be a substitute in our profession for the human connection between our patients and ourselves as their caregivers, and this connection should be one of the most treasured aspects of our work life. We should seek daily reminders of these positive interactions to nurture our ability to cope with a grueling and challenging field, where the outcomes are not always as ideal as we hope.
For me, STRONG is now a consistent and powerful reminder of why I originally became a doctor in the first place, and I strive to propagate this model of compassionate care to benefit future patients as we move forward together.”
We are at an inflexion point in health care. No amount of individual resilience can withstand a toxic or nonsupportive environment. It is unreasonable to think that simply by taking better care of ourselves we are going to resolve the issue of burnout. We need to rethink our current systems of care and focus our energy on developing those that support our ability to deliver the kind of care we know our patients need and deserve. We have an opportunity to alleviate the suffering many providers are experiencing as they strive to heal their patients. We have an opportunity to improve both physician and patient engagement, develop care delivery systems we know our patients deserve, and restore the deep sense of satisfaction that comes from practicing medicine and surgery. There is abundant expertise within our professional medical and surgical societies. The SVS has the courage and the duty to lead.
Drs. Colman, Kalish, and Sheahan extend their thanks and appreciation for the guidance, resources and support of Michael Goldberg, M.D., Scholar in Residence, Schwartz Center for Compassionate Care, Boston, Mass., and Clinical Professor of Orthopedics at Seattle Children’s Hospital.
Bibliography
1. Acad Med (2016) 91:338-344
2. Health Aff (2011) 30:1772-1778
3. Patient Educ Couns (2015) 98:1005-10
4. Acad Med (2016) 91:310-316
5. http://www.theschwartzcenter.org/media/Triple-C-Conference-Framework-Tables_FINAL.pdf
6. http://www.theschwartzcenter.org/media/Triple-C-Conference-Recommendations-Report_FINAL1.pdf
7. JAMA (2017) 317: 901-2
8. Clin Orthop Relat Res. (2017) 475:1309-14.
It is easy to look at the changes required to mitigate burnout and improve compassionate care and see the burden being placed mainly on the physician. Many of the proposed modifications seem to require the one commodity surgeons lack most, time. Any widespread effort to mitigate the burnout crisis must involve decreasing the barriers to patient care and reducing the physicians’ time constraints.
This may seem daunting, but broad changes in our healthcare system have been implemented in the name of quality, reducing errors, and alleviating trainee fatigue. Burnout can be a similar force for change. Much like the resident’s 80-hour workweek, however, in what manner this change is applied will be the ultimate determinant of the movement’s success.
This series of articles dealt with the adverse consequences of surgeon burnout on both clinicians and their patients, and then presented a conceptual framework to promote workforce well-being. Strategies that the SVS might adopt have been suggested. The central proposal is that helping physicians to deliver compassionate, collaborative care will not only mitigate burnout but also will enhance provider engagement, patient experience, and clinical outcomes, as well as improve the quality and safety of healthcare delivery. It seems reasonable to question if such broad strategic proposals are scalable to individual clinical settings.
The characteristics of compassionate care have been well described by patients, and, not surprisingly, only 53% reported that their last encounter with the health care system was compassionate. In 2014, a multidisciplinary consortium published recommendations for advancing compassionate person- and family-centered care. They detailed the attributes, values, and behaviors of such care, including focusing one’s attention, recognizing nonverbal clues, active listening, demonstrating nonjudgmental interest in the whole person, understanding the context of a person’s disease, and asking about the patient’s chief concerns in addition to their chief complaints. Most significantly, the authors outlined how these attributes could be integrated into existing competency documents such as those provided by the Association of American Medical Colleges (AAMC) Entrustable Professional Activities, or the milestones programs of the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM).
It is but a small step to enhance current criteria for certification, clinical appointment, and privileging by including these professional attributes. Bear in mind that these skills are teachable and easily incorporated into health professional education and clinical care. As for metrics, the Schwartz Compassionate Care Scale is a validated patient-rated questionnaire that reliably measures physicians’ compassion and overall patient satisfaction and is available in the public domain. It also provides a metric that is important to clinicians and, when placed on the hospital dashboard, highlights that compassion is an organizational priority. Such priorities become the fabric of the workforce when organizational leadership installs programs such as values-based recruitment, retention, and promotion as Vivian Lee describes at the University of Utah Health System. Mitigating burnout requires changing the culture in which clinicians work and with whom they work.
Vascular surgeons and their professional surgical societies have a leadership opportunity to design high performing teams. Most patient care models have been structured around traditional medical and surgical departments. This paradigm overlooks the fact that patients do not “get sick” within traditional teaching disciplines but do so across varied medical and surgical specialties. Changes in organizational hierarchy are needed so that team-based care is supported. In addition to physician and nurse clinicians, the new teams would do well to expand to all “caregivers,” i.e. everyone who touches the patient (technologists, interpreters, pharmacists, transport workers, support staff, and administrators).
On the front line
On April 15, 2013, at 2:49 pm, two homemade bombs detonated near the finish line of the Boston Marathon killing three people at the scene and injuring 264 others; the most severe sustaining mutilating lower extremity injuries. Much has been written about the preparedness, the emergency response, and the fact that all those who made it to the hospital survived. Jeffrey Kalish, MD, a vascular surgeon at Boston Medical Center and SVS member, was on the front line that day. We asked him to share his personal experience of caring for the victims through the lens of compassionate collaborative care.
“It has been over four years since I went from being a spectator near the Boston Marathon finish line to rushing directly to the operating rooms at Boston Medical Center to help our teams perform lifesaving procedures on critically ill patients, including amputations and complex vascular repairs. While I have learned a tremendous amount since that experience with regard to limb salvage and amputation, reconstructive techniques, and prosthetics, I will focus here on the care the patients and their families received, the lessons our hospital learned from the weeks and months that followed, and how we modeled this care going forward for all amputation patients at Boston Medical Center.
"Based on lessons from the Boston Marathon bombings, I aligned a multidisciplinary team of health care providers in order to formalize and standardize best practices to benefit our amputation patients. STRONG (Surgery To Rehab Ongoing Needs Group) continues to strive toward the ultimate goal of improving and coordinating care for amputation patients and their families as they transition from the hospital setting to rehabilitation. Some of our guiding principles, along with their positive impacts on patient care and physician well-being, are highlighted below:
1. Sustaining hope with a new mindset: Although surgeons have historically considered amputation as a treatment failure, a more appropriate mindset is that amputation can often be a reconstructive procedure in the surgical armamentarium designed to restore a patient back to full function.
2. Seeing the patient in context: Shared decision making can occur more readily once a surgeon and the care team seek to understand the whole person and their family, including what that person does for work and leisure.
3. Communication with colleagues, patients, and families: Patient and family fear and confusion can often be reduced after establishment of a multi-disciplinary team with daily care coordination and consistent messaging. Breaking down traditional hospital silos to allow for improved coordination of care benefits both the patients and the practitioners.
4. Managing emotional and physical suffering: Introducing social workers, mental health professionals, or pastoral care advocates into the care team as soon as a patient is ready can help manage the emotional and psychosocial needs of patients and their families.
5. Sustaining long term surgeon/patient relationships: As clinicians, we can feel rewarded after restoring functional performance in our patients and by meeting the needs of our patients and families. This can occur both in the short-term during the acute hospital stay and in the long-term as we follow our patients’ progress towards achievement of their ultimate goals.
6. Attend to one’s own well-being and foster resilience. There will never be a substitute in our profession for the human connection between our patients and ourselves as their caregivers, and this connection should be one of the most treasured aspects of our work life. We should seek daily reminders of these positive interactions to nurture our ability to cope with a grueling and challenging field, where the outcomes are not always as ideal as we hope.
For me, STRONG is now a consistent and powerful reminder of why I originally became a doctor in the first place, and I strive to propagate this model of compassionate care to benefit future patients as we move forward together.”
We are at an inflexion point in health care. No amount of individual resilience can withstand a toxic or nonsupportive environment. It is unreasonable to think that simply by taking better care of ourselves we are going to resolve the issue of burnout. We need to rethink our current systems of care and focus our energy on developing those that support our ability to deliver the kind of care we know our patients need and deserve. We have an opportunity to alleviate the suffering many providers are experiencing as they strive to heal their patients. We have an opportunity to improve both physician and patient engagement, develop care delivery systems we know our patients deserve, and restore the deep sense of satisfaction that comes from practicing medicine and surgery. There is abundant expertise within our professional medical and surgical societies. The SVS has the courage and the duty to lead.
Drs. Colman, Kalish, and Sheahan extend their thanks and appreciation for the guidance, resources and support of Michael Goldberg, M.D., Scholar in Residence, Schwartz Center for Compassionate Care, Boston, Mass., and Clinical Professor of Orthopedics at Seattle Children’s Hospital.
Bibliography
1. Acad Med (2016) 91:338-344
2. Health Aff (2011) 30:1772-1778
3. Patient Educ Couns (2015) 98:1005-10
4. Acad Med (2016) 91:310-316
5. http://www.theschwartzcenter.org/media/Triple-C-Conference-Framework-Tables_FINAL.pdf
6. http://www.theschwartzcenter.org/media/Triple-C-Conference-Recommendations-Report_FINAL1.pdf
7. JAMA (2017) 317: 901-2
8. Clin Orthop Relat Res. (2017) 475:1309-14.
It is easy to look at the changes required to mitigate burnout and improve compassionate care and see the burden being placed mainly on the physician. Many of the proposed modifications seem to require the one commodity surgeons lack most, time. Any widespread effort to mitigate the burnout crisis must involve decreasing the barriers to patient care and reducing the physicians’ time constraints.
This may seem daunting, but broad changes in our healthcare system have been implemented in the name of quality, reducing errors, and alleviating trainee fatigue. Burnout can be a similar force for change. Much like the resident’s 80-hour workweek, however, in what manner this change is applied will be the ultimate determinant of the movement’s success.
This series of articles dealt with the adverse consequences of surgeon burnout on both clinicians and their patients, and then presented a conceptual framework to promote workforce well-being. Strategies that the SVS might adopt have been suggested. The central proposal is that helping physicians to deliver compassionate, collaborative care will not only mitigate burnout but also will enhance provider engagement, patient experience, and clinical outcomes, as well as improve the quality and safety of healthcare delivery. It seems reasonable to question if such broad strategic proposals are scalable to individual clinical settings.
The characteristics of compassionate care have been well described by patients, and, not surprisingly, only 53% reported that their last encounter with the health care system was compassionate. In 2014, a multidisciplinary consortium published recommendations for advancing compassionate person- and family-centered care. They detailed the attributes, values, and behaviors of such care, including focusing one’s attention, recognizing nonverbal clues, active listening, demonstrating nonjudgmental interest in the whole person, understanding the context of a person’s disease, and asking about the patient’s chief concerns in addition to their chief complaints. Most significantly, the authors outlined how these attributes could be integrated into existing competency documents such as those provided by the Association of American Medical Colleges (AAMC) Entrustable Professional Activities, or the milestones programs of the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM).
It is but a small step to enhance current criteria for certification, clinical appointment, and privileging by including these professional attributes. Bear in mind that these skills are teachable and easily incorporated into health professional education and clinical care. As for metrics, the Schwartz Compassionate Care Scale is a validated patient-rated questionnaire that reliably measures physicians’ compassion and overall patient satisfaction and is available in the public domain. It also provides a metric that is important to clinicians and, when placed on the hospital dashboard, highlights that compassion is an organizational priority. Such priorities become the fabric of the workforce when organizational leadership installs programs such as values-based recruitment, retention, and promotion as Vivian Lee describes at the University of Utah Health System. Mitigating burnout requires changing the culture in which clinicians work and with whom they work.
Vascular surgeons and their professional surgical societies have a leadership opportunity to design high performing teams. Most patient care models have been structured around traditional medical and surgical departments. This paradigm overlooks the fact that patients do not “get sick” within traditional teaching disciplines but do so across varied medical and surgical specialties. Changes in organizational hierarchy are needed so that team-based care is supported. In addition to physician and nurse clinicians, the new teams would do well to expand to all “caregivers,” i.e. everyone who touches the patient (technologists, interpreters, pharmacists, transport workers, support staff, and administrators).
On the front line
On April 15, 2013, at 2:49 pm, two homemade bombs detonated near the finish line of the Boston Marathon killing three people at the scene and injuring 264 others; the most severe sustaining mutilating lower extremity injuries. Much has been written about the preparedness, the emergency response, and the fact that all those who made it to the hospital survived. Jeffrey Kalish, MD, a vascular surgeon at Boston Medical Center and SVS member, was on the front line that day. We asked him to share his personal experience of caring for the victims through the lens of compassionate collaborative care.
“It has been over four years since I went from being a spectator near the Boston Marathon finish line to rushing directly to the operating rooms at Boston Medical Center to help our teams perform lifesaving procedures on critically ill patients, including amputations and complex vascular repairs. While I have learned a tremendous amount since that experience with regard to limb salvage and amputation, reconstructive techniques, and prosthetics, I will focus here on the care the patients and their families received, the lessons our hospital learned from the weeks and months that followed, and how we modeled this care going forward for all amputation patients at Boston Medical Center.
"Based on lessons from the Boston Marathon bombings, I aligned a multidisciplinary team of health care providers in order to formalize and standardize best practices to benefit our amputation patients. STRONG (Surgery To Rehab Ongoing Needs Group) continues to strive toward the ultimate goal of improving and coordinating care for amputation patients and their families as they transition from the hospital setting to rehabilitation. Some of our guiding principles, along with their positive impacts on patient care and physician well-being, are highlighted below:
1. Sustaining hope with a new mindset: Although surgeons have historically considered amputation as a treatment failure, a more appropriate mindset is that amputation can often be a reconstructive procedure in the surgical armamentarium designed to restore a patient back to full function.
2. Seeing the patient in context: Shared decision making can occur more readily once a surgeon and the care team seek to understand the whole person and their family, including what that person does for work and leisure.
3. Communication with colleagues, patients, and families: Patient and family fear and confusion can often be reduced after establishment of a multi-disciplinary team with daily care coordination and consistent messaging. Breaking down traditional hospital silos to allow for improved coordination of care benefits both the patients and the practitioners.
4. Managing emotional and physical suffering: Introducing social workers, mental health professionals, or pastoral care advocates into the care team as soon as a patient is ready can help manage the emotional and psychosocial needs of patients and their families.
5. Sustaining long term surgeon/patient relationships: As clinicians, we can feel rewarded after restoring functional performance in our patients and by meeting the needs of our patients and families. This can occur both in the short-term during the acute hospital stay and in the long-term as we follow our patients’ progress towards achievement of their ultimate goals.
6. Attend to one’s own well-being and foster resilience. There will never be a substitute in our profession for the human connection between our patients and ourselves as their caregivers, and this connection should be one of the most treasured aspects of our work life. We should seek daily reminders of these positive interactions to nurture our ability to cope with a grueling and challenging field, where the outcomes are not always as ideal as we hope.
For me, STRONG is now a consistent and powerful reminder of why I originally became a doctor in the first place, and I strive to propagate this model of compassionate care to benefit future patients as we move forward together.”
We are at an inflexion point in health care. No amount of individual resilience can withstand a toxic or nonsupportive environment. It is unreasonable to think that simply by taking better care of ourselves we are going to resolve the issue of burnout. We need to rethink our current systems of care and focus our energy on developing those that support our ability to deliver the kind of care we know our patients need and deserve. We have an opportunity to alleviate the suffering many providers are experiencing as they strive to heal their patients. We have an opportunity to improve both physician and patient engagement, develop care delivery systems we know our patients deserve, and restore the deep sense of satisfaction that comes from practicing medicine and surgery. There is abundant expertise within our professional medical and surgical societies. The SVS has the courage and the duty to lead.
Drs. Colman, Kalish, and Sheahan extend their thanks and appreciation for the guidance, resources and support of Michael Goldberg, M.D., Scholar in Residence, Schwartz Center for Compassionate Care, Boston, Mass., and Clinical Professor of Orthopedics at Seattle Children’s Hospital.
Bibliography
1. Acad Med (2016) 91:338-344
2. Health Aff (2011) 30:1772-1778
3. Patient Educ Couns (2015) 98:1005-10
4. Acad Med (2016) 91:310-316
5. http://www.theschwartzcenter.org/media/Triple-C-Conference-Framework-Tables_FINAL.pdf
6. http://www.theschwartzcenter.org/media/Triple-C-Conference-Recommendations-Report_FINAL1.pdf
7. JAMA (2017) 317: 901-2
8. Clin Orthop Relat Res. (2017) 475:1309-14.
The Professional Doctorate: What Are We Waiting for?
The increasingly complex health care system in the United States relies heavily on quality improvement, interprofessional collaboration, patient outcomes, health policy legislation, and advocacy. While important, most of these factors are outside the scope of the traditional master’s-level education program—necessitating the development of methods to help advanced practice providers, including NPs and PAs, obtain additional skills. The solution of choice, for many professions, has been the introduction of the “professional doctorate” as a complementary alternative to the typical research-focused doctoral program, such as the PhD.
Traditional PhD curricula prepare individuals to perform research that is typically specialized and confined to their field of study.1 While this research does produce new knowledge, it usually remains in the realm of academia and often does not address any specific “real-world” problem.2 But to be recognized, compensated, and identified as a full professional in modern societ
Analysis by Taylor and Maxwell and by Lee, Green, and Brennan has shown that, rather than theory, the workplace demands the application of knowledge geared toward daily professional duties.3,4 They envisioned a doctorate-prepared practitioner who had less skill in pure research but who would be able to apply theory to everyday problems in the workplace.4,5 Rather than devalue the contributions of classical PhD training, this model proposed the creation of a hybrid curriculum that would prepare individuals to use “applied research.”3 As the professional doctorate gained acceptance, it matured from the “first-generation” concept (which was quite similar to the PhD in structure) to “second-generation,” which is more focused on discipline and workplace realities.3,5 In general, these professional doctorates can be earned in less time than a PhD and do not require original research.
Over the past two decades, more than 500 unique professional practice doctorate programs have emerged across the US, in fields ranging from nursing to bioethics. One of the most prominent is the Doctor of Nursing Practice (DNP), designed for RNs seeking a post-professional degree in nursing. In 2004, following three years of research by a task force, the American Association of Colleges of Nursing (AACN) endorsed the DNP, with the goal that it would become the minimum educational standard for advanced practice nurses by 2015.6 According to the AACN, there are 289 DNP programs in the US, with an additional 128 in development.6
The PA profession has lagged behind not only our NP colleagues, but also many other health professions, in the adoption of a discipline-specific, doctoral-level degree. Our counterparts in audiology, physical therapy, occupational therapy, and athletic training have been part of the exponential growth in second-generation health care doctorates.7 While these programs may differ in concept, they share several similarities: They do not require original research; they include a clinical component; and they promote knowledge in the context of the workplace.5-8
In the past five years, PAs have started considering (or debating, depending on your perspective) a professional/clinical doctorate as the next step in our post-professional journey. It’s about time, when you consider that 16.8% of newly certified PAs intend to pursue additional education or clinical training, according to a recent report from the National Commission on Certification of Physician Assistants.9
There are already a few doctoral programs for PAs. Among the earliest clinically focused doctorate programs was the US Army/Air Force-Baylor DScPAS-EM program, designed to educate military PAs at the doctoral level upon completion of an 18-month emergency medicine residency.10 Lincoln Memorial University has a Doctor of Medical Science (DMS) program, comprised of one year of online advanced clinical medicine coursework and one year of online coursework focused on primary care, hospital medicine, emergency medicine, or education.11 And Lynchburg College in Virginia has just launched a post-professional doctoral program for PAs; this DMS program includes a clinical fellowship, as well as coursework in leadership training, health care management and law, organizational behavior, disaster medicine, and global health.12
While not strictly created for PAs, the Doctor of Health Science programs at Nova Southeastern University and A.T. Still University have been educating PAs at the doctoral level for more than 10 years.13,14 Later this year, A.T. Still University plans to introduce a post-professional Doctor of Physician Assistant Studies that will provide a pathway for PAs wishing to become leaders and scholar-practitioners, develop core leadership abilities, and/or enter PA education without the location-specific requirement of a clinical or academic residency.
When the push for professional practice doctorates started, pundits claimed they were just an attempt at a “cash grab” by universities looking to bolster their rosters (and their coffers). But advocates have long argued that these degrees provide practitioners with the knowledge and training required to offer advanced services in increasingly complex social and technologic environments.7 No less than The Institute of Medicine, The Joint Commission, and the Robert Wood Johnson Foundation have called for the reinvention of education programs to equip today’s health professionals
Why? First and foremost, to ensure quality patient outcomes. Beyond that, better prepared clinicians can help to address provider shortages. Those with doctorates can also serve as faculty, educating the next generation of health care providers. And practically speaking, for those seeking advanced education, holding a doctorate will create opportunities for increased decision-making and upward mobility in the workplace.
There is no question that our current health care environment is driven by the regulations and costs of the Affordable Care Act, as well as quality management systems and strategies. NPs and PAs are in a unique position to cost-effectively direct the care of, and advocate for, diverse patient populations. NPs and PAs who recognize this opportunity to serve need doctoral-level training tailored to this milieu.
Do you agree? Share your thoughts on professional doctorates with me at PAEditor@frontlinemedcom.com.
1. Carnegie Project on the Education Doctorate. Founding literature. www.cpedinitiative.org/?. Accessed May 8, 2017.
2. Costley C, Lester S. Work-based doctorates: professional extension at the highest levels. Studies in Higher Education. 2012;37(3):257-269.
3. Taylor N, Maxwell T. Enhancing the relevance of a professional doctorate: the case of the doctor of education degree at the University of New England. Asia-Pacific J Coop Edu. 2004;5(1):60-69.
4. Lee A, Green B, Brennan M. Organisational knowledge, professional practice and the professional doctorate at work. In: Garrick J, Rhodes C (eds). Research and Knowledge at Work. Perspectives, Case-studies and Innovative Strategies. London: Routledge; 2000.
5. Maxwell T. From first to second generation professional doctorate. Studies in Higher Education. 2003;28(3):279-291.
6. American Association of Colleges of Nursing. DNP fact sheet. www.aacn.nche.edu/media-relations/fact-sheets/dnp. Accessed May 8, 2017.
7. Zusman A. Degrees of change: how new kinds of professional doctorates are changing higher education institutions. Research and Occasional Paper Series. 2013;8(13):1-20.
8. Kumar S, Dawson K. Exploring the impact of a professional practice education doctorate in educational environments. Studies in Continuing Education. 2013;35(2):165-178.
9. National Commission on Certification of Physician Assistants. 2014 statistical profile of recently certified physician assistants: an annual report of the NCCPA. www.nccpa.net/Uploads/docs/RecentlyCertifiedReport2014.pdf. Accessed May 8, 2017.
10. Baylor University. Army-Baylor emergency medicine physician assistant (EMPA) program. www.baylor.edu/graduate/pa/index.php?id=936090. Accessed May 8, 2017.
11. Lincoln Memorial University. Doctor of medical science announcement. www.lmunet.edu/academics/schools/debusk-college-of-osteopathic-medicine/dms. Accessed May 8, 2017.
12. Lynchburg College. Doctor of medical science. www.lynchburg.edu/graduate/physician-assistant-medicine/doctor-of-medical-science/. Accessed May 8, 2017.
13. Nova Southeastern University. Doctor of health science program. http://healthsciences.nova.edu/healthsciences/dhs/. Accessed May 8, 2017.
14. A.T. Still University. About the college of graduate health studies – online. www.atsu.edu/college-of-graduate-health-studies. Accessed May 8, 2017.
The increasingly complex health care system in the United States relies heavily on quality improvement, interprofessional collaboration, patient outcomes, health policy legislation, and advocacy. While important, most of these factors are outside the scope of the traditional master’s-level education program—necessitating the development of methods to help advanced practice providers, including NPs and PAs, obtain additional skills. The solution of choice, for many professions, has been the introduction of the “professional doctorate” as a complementary alternative to the typical research-focused doctoral program, such as the PhD.
Traditional PhD curricula prepare individuals to perform research that is typically specialized and confined to their field of study.1 While this research does produce new knowledge, it usually remains in the realm of academia and often does not address any specific “real-world” problem.2 But to be recognized, compensated, and identified as a full professional in modern societ
Analysis by Taylor and Maxwell and by Lee, Green, and Brennan has shown that, rather than theory, the workplace demands the application of knowledge geared toward daily professional duties.3,4 They envisioned a doctorate-prepared practitioner who had less skill in pure research but who would be able to apply theory to everyday problems in the workplace.4,5 Rather than devalue the contributions of classical PhD training, this model proposed the creation of a hybrid curriculum that would prepare individuals to use “applied research.”3 As the professional doctorate gained acceptance, it matured from the “first-generation” concept (which was quite similar to the PhD in structure) to “second-generation,” which is more focused on discipline and workplace realities.3,5 In general, these professional doctorates can be earned in less time than a PhD and do not require original research.
Over the past two decades, more than 500 unique professional practice doctorate programs have emerged across the US, in fields ranging from nursing to bioethics. One of the most prominent is the Doctor of Nursing Practice (DNP), designed for RNs seeking a post-professional degree in nursing. In 2004, following three years of research by a task force, the American Association of Colleges of Nursing (AACN) endorsed the DNP, with the goal that it would become the minimum educational standard for advanced practice nurses by 2015.6 According to the AACN, there are 289 DNP programs in the US, with an additional 128 in development.6
The PA profession has lagged behind not only our NP colleagues, but also many other health professions, in the adoption of a discipline-specific, doctoral-level degree. Our counterparts in audiology, physical therapy, occupational therapy, and athletic training have been part of the exponential growth in second-generation health care doctorates.7 While these programs may differ in concept, they share several similarities: They do not require original research; they include a clinical component; and they promote knowledge in the context of the workplace.5-8
In the past five years, PAs have started considering (or debating, depending on your perspective) a professional/clinical doctorate as the next step in our post-professional journey. It’s about time, when you consider that 16.8% of newly certified PAs intend to pursue additional education or clinical training, according to a recent report from the National Commission on Certification of Physician Assistants.9
There are already a few doctoral programs for PAs. Among the earliest clinically focused doctorate programs was the US Army/Air Force-Baylor DScPAS-EM program, designed to educate military PAs at the doctoral level upon completion of an 18-month emergency medicine residency.10 Lincoln Memorial University has a Doctor of Medical Science (DMS) program, comprised of one year of online advanced clinical medicine coursework and one year of online coursework focused on primary care, hospital medicine, emergency medicine, or education.11 And Lynchburg College in Virginia has just launched a post-professional doctoral program for PAs; this DMS program includes a clinical fellowship, as well as coursework in leadership training, health care management and law, organizational behavior, disaster medicine, and global health.12
While not strictly created for PAs, the Doctor of Health Science programs at Nova Southeastern University and A.T. Still University have been educating PAs at the doctoral level for more than 10 years.13,14 Later this year, A.T. Still University plans to introduce a post-professional Doctor of Physician Assistant Studies that will provide a pathway for PAs wishing to become leaders and scholar-practitioners, develop core leadership abilities, and/or enter PA education without the location-specific requirement of a clinical or academic residency.
When the push for professional practice doctorates started, pundits claimed they were just an attempt at a “cash grab” by universities looking to bolster their rosters (and their coffers). But advocates have long argued that these degrees provide practitioners with the knowledge and training required to offer advanced services in increasingly complex social and technologic environments.7 No less than The Institute of Medicine, The Joint Commission, and the Robert Wood Johnson Foundation have called for the reinvention of education programs to equip today’s health professionals
Why? First and foremost, to ensure quality patient outcomes. Beyond that, better prepared clinicians can help to address provider shortages. Those with doctorates can also serve as faculty, educating the next generation of health care providers. And practically speaking, for those seeking advanced education, holding a doctorate will create opportunities for increased decision-making and upward mobility in the workplace.
There is no question that our current health care environment is driven by the regulations and costs of the Affordable Care Act, as well as quality management systems and strategies. NPs and PAs are in a unique position to cost-effectively direct the care of, and advocate for, diverse patient populations. NPs and PAs who recognize this opportunity to serve need doctoral-level training tailored to this milieu.
Do you agree? Share your thoughts on professional doctorates with me at PAEditor@frontlinemedcom.com.
The increasingly complex health care system in the United States relies heavily on quality improvement, interprofessional collaboration, patient outcomes, health policy legislation, and advocacy. While important, most of these factors are outside the scope of the traditional master’s-level education program—necessitating the development of methods to help advanced practice providers, including NPs and PAs, obtain additional skills. The solution of choice, for many professions, has been the introduction of the “professional doctorate” as a complementary alternative to the typical research-focused doctoral program, such as the PhD.
Traditional PhD curricula prepare individuals to perform research that is typically specialized and confined to their field of study.1 While this research does produce new knowledge, it usually remains in the realm of academia and often does not address any specific “real-world” problem.2 But to be recognized, compensated, and identified as a full professional in modern societ
Analysis by Taylor and Maxwell and by Lee, Green, and Brennan has shown that, rather than theory, the workplace demands the application of knowledge geared toward daily professional duties.3,4 They envisioned a doctorate-prepared practitioner who had less skill in pure research but who would be able to apply theory to everyday problems in the workplace.4,5 Rather than devalue the contributions of classical PhD training, this model proposed the creation of a hybrid curriculum that would prepare individuals to use “applied research.”3 As the professional doctorate gained acceptance, it matured from the “first-generation” concept (which was quite similar to the PhD in structure) to “second-generation,” which is more focused on discipline and workplace realities.3,5 In general, these professional doctorates can be earned in less time than a PhD and do not require original research.
Over the past two decades, more than 500 unique professional practice doctorate programs have emerged across the US, in fields ranging from nursing to bioethics. One of the most prominent is the Doctor of Nursing Practice (DNP), designed for RNs seeking a post-professional degree in nursing. In 2004, following three years of research by a task force, the American Association of Colleges of Nursing (AACN) endorsed the DNP, with the goal that it would become the minimum educational standard for advanced practice nurses by 2015.6 According to the AACN, there are 289 DNP programs in the US, with an additional 128 in development.6
The PA profession has lagged behind not only our NP colleagues, but also many other health professions, in the adoption of a discipline-specific, doctoral-level degree. Our counterparts in audiology, physical therapy, occupational therapy, and athletic training have been part of the exponential growth in second-generation health care doctorates.7 While these programs may differ in concept, they share several similarities: They do not require original research; they include a clinical component; and they promote knowledge in the context of the workplace.5-8
In the past five years, PAs have started considering (or debating, depending on your perspective) a professional/clinical doctorate as the next step in our post-professional journey. It’s about time, when you consider that 16.8% of newly certified PAs intend to pursue additional education or clinical training, according to a recent report from the National Commission on Certification of Physician Assistants.9
There are already a few doctoral programs for PAs. Among the earliest clinically focused doctorate programs was the US Army/Air Force-Baylor DScPAS-EM program, designed to educate military PAs at the doctoral level upon completion of an 18-month emergency medicine residency.10 Lincoln Memorial University has a Doctor of Medical Science (DMS) program, comprised of one year of online advanced clinical medicine coursework and one year of online coursework focused on primary care, hospital medicine, emergency medicine, or education.11 And Lynchburg College in Virginia has just launched a post-professional doctoral program for PAs; this DMS program includes a clinical fellowship, as well as coursework in leadership training, health care management and law, organizational behavior, disaster medicine, and global health.12
While not strictly created for PAs, the Doctor of Health Science programs at Nova Southeastern University and A.T. Still University have been educating PAs at the doctoral level for more than 10 years.13,14 Later this year, A.T. Still University plans to introduce a post-professional Doctor of Physician Assistant Studies that will provide a pathway for PAs wishing to become leaders and scholar-practitioners, develop core leadership abilities, and/or enter PA education without the location-specific requirement of a clinical or academic residency.
When the push for professional practice doctorates started, pundits claimed they were just an attempt at a “cash grab” by universities looking to bolster their rosters (and their coffers). But advocates have long argued that these degrees provide practitioners with the knowledge and training required to offer advanced services in increasingly complex social and technologic environments.7 No less than The Institute of Medicine, The Joint Commission, and the Robert Wood Johnson Foundation have called for the reinvention of education programs to equip today’s health professionals
Why? First and foremost, to ensure quality patient outcomes. Beyond that, better prepared clinicians can help to address provider shortages. Those with doctorates can also serve as faculty, educating the next generation of health care providers. And practically speaking, for those seeking advanced education, holding a doctorate will create opportunities for increased decision-making and upward mobility in the workplace.
There is no question that our current health care environment is driven by the regulations and costs of the Affordable Care Act, as well as quality management systems and strategies. NPs and PAs are in a unique position to cost-effectively direct the care of, and advocate for, diverse patient populations. NPs and PAs who recognize this opportunity to serve need doctoral-level training tailored to this milieu.
Do you agree? Share your thoughts on professional doctorates with me at PAEditor@frontlinemedcom.com.
1. Carnegie Project on the Education Doctorate. Founding literature. www.cpedinitiative.org/?. Accessed May 8, 2017.
2. Costley C, Lester S. Work-based doctorates: professional extension at the highest levels. Studies in Higher Education. 2012;37(3):257-269.
3. Taylor N, Maxwell T. Enhancing the relevance of a professional doctorate: the case of the doctor of education degree at the University of New England. Asia-Pacific J Coop Edu. 2004;5(1):60-69.
4. Lee A, Green B, Brennan M. Organisational knowledge, professional practice and the professional doctorate at work. In: Garrick J, Rhodes C (eds). Research and Knowledge at Work. Perspectives, Case-studies and Innovative Strategies. London: Routledge; 2000.
5. Maxwell T. From first to second generation professional doctorate. Studies in Higher Education. 2003;28(3):279-291.
6. American Association of Colleges of Nursing. DNP fact sheet. www.aacn.nche.edu/media-relations/fact-sheets/dnp. Accessed May 8, 2017.
7. Zusman A. Degrees of change: how new kinds of professional doctorates are changing higher education institutions. Research and Occasional Paper Series. 2013;8(13):1-20.
8. Kumar S, Dawson K. Exploring the impact of a professional practice education doctorate in educational environments. Studies in Continuing Education. 2013;35(2):165-178.
9. National Commission on Certification of Physician Assistants. 2014 statistical profile of recently certified physician assistants: an annual report of the NCCPA. www.nccpa.net/Uploads/docs/RecentlyCertifiedReport2014.pdf. Accessed May 8, 2017.
10. Baylor University. Army-Baylor emergency medicine physician assistant (EMPA) program. www.baylor.edu/graduate/pa/index.php?id=936090. Accessed May 8, 2017.
11. Lincoln Memorial University. Doctor of medical science announcement. www.lmunet.edu/academics/schools/debusk-college-of-osteopathic-medicine/dms. Accessed May 8, 2017.
12. Lynchburg College. Doctor of medical science. www.lynchburg.edu/graduate/physician-assistant-medicine/doctor-of-medical-science/. Accessed May 8, 2017.
13. Nova Southeastern University. Doctor of health science program. http://healthsciences.nova.edu/healthsciences/dhs/. Accessed May 8, 2017.
14. A.T. Still University. About the college of graduate health studies – online. www.atsu.edu/college-of-graduate-health-studies. Accessed May 8, 2017.
1. Carnegie Project on the Education Doctorate. Founding literature. www.cpedinitiative.org/?. Accessed May 8, 2017.
2. Costley C, Lester S. Work-based doctorates: professional extension at the highest levels. Studies in Higher Education. 2012;37(3):257-269.
3. Taylor N, Maxwell T. Enhancing the relevance of a professional doctorate: the case of the doctor of education degree at the University of New England. Asia-Pacific J Coop Edu. 2004;5(1):60-69.
4. Lee A, Green B, Brennan M. Organisational knowledge, professional practice and the professional doctorate at work. In: Garrick J, Rhodes C (eds). Research and Knowledge at Work. Perspectives, Case-studies and Innovative Strategies. London: Routledge; 2000.
5. Maxwell T. From first to second generation professional doctorate. Studies in Higher Education. 2003;28(3):279-291.
6. American Association of Colleges of Nursing. DNP fact sheet. www.aacn.nche.edu/media-relations/fact-sheets/dnp. Accessed May 8, 2017.
7. Zusman A. Degrees of change: how new kinds of professional doctorates are changing higher education institutions. Research and Occasional Paper Series. 2013;8(13):1-20.
8. Kumar S, Dawson K. Exploring the impact of a professional practice education doctorate in educational environments. Studies in Continuing Education. 2013;35(2):165-178.
9. National Commission on Certification of Physician Assistants. 2014 statistical profile of recently certified physician assistants: an annual report of the NCCPA. www.nccpa.net/Uploads/docs/RecentlyCertifiedReport2014.pdf. Accessed May 8, 2017.
10. Baylor University. Army-Baylor emergency medicine physician assistant (EMPA) program. www.baylor.edu/graduate/pa/index.php?id=936090. Accessed May 8, 2017.
11. Lincoln Memorial University. Doctor of medical science announcement. www.lmunet.edu/academics/schools/debusk-college-of-osteopathic-medicine/dms. Accessed May 8, 2017.
12. Lynchburg College. Doctor of medical science. www.lynchburg.edu/graduate/physician-assistant-medicine/doctor-of-medical-science/. Accessed May 8, 2017.
13. Nova Southeastern University. Doctor of health science program. http://healthsciences.nova.edu/healthsciences/dhs/. Accessed May 8, 2017.
14. A.T. Still University. About the college of graduate health studies – online. www.atsu.edu/college-of-graduate-health-studies. Accessed May 8, 2017.
Access to ‘the little blue book’ just got a lot more expensive
“The little blue book” has been an office standard as long as I’ve been in practice. Every practice has a dog-eared copy in a drawer somewhere that’s constantly being pulled out to look up hospitals, other doctors, and pharmacies.
As small as it is, it’s pretty useful in the daily flow of my office routine.
Until now.
Sadly, 2016 was apparently the year I ordered my last copies. The publisher’s marketing people inform me that the paper version has been discontinued, and I can now get the digital version for only ... $500 per year.
Thanks, but no thanks.
I have nothing against digital editions. In fact, if it was the same price as the paper one, I’d get it. If I were a big practice that needed, say, 50 copies for the staff, the $500 per practice fee is a deal, compared with the $998 I’d pay for 50 paper copies.
But for my dinky little two-person practice? The difference between $39.90 and $500 just isn’t worth all the advantages a digital version may offer. For that kind of money, I’ll use Google.
This is another part of a gradual, and disturbing, trend in medicine: ignoring small practices. Large corporate practices are worth a lot more in sales than little one-to-three doctor groups, so companies, such as “the little blue book,” have no incentive to tailor their products to us. We have become medical persona non grata.
I understand this is a business decision. It’s not specifically directed at me.
Yet ...
I’ve been in practice for almost 20 years now, and buying two copies of the LBB is something I’ve done annually, in good and bad economic years. I’ve supported the publisher because it was a good product at a fair price. Sadly, they no longer find my little practice to be worth the effort or profit margin.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“The little blue book” has been an office standard as long as I’ve been in practice. Every practice has a dog-eared copy in a drawer somewhere that’s constantly being pulled out to look up hospitals, other doctors, and pharmacies.
As small as it is, it’s pretty useful in the daily flow of my office routine.
Until now.
Sadly, 2016 was apparently the year I ordered my last copies. The publisher’s marketing people inform me that the paper version has been discontinued, and I can now get the digital version for only ... $500 per year.
Thanks, but no thanks.
I have nothing against digital editions. In fact, if it was the same price as the paper one, I’d get it. If I were a big practice that needed, say, 50 copies for the staff, the $500 per practice fee is a deal, compared with the $998 I’d pay for 50 paper copies.
But for my dinky little two-person practice? The difference between $39.90 and $500 just isn’t worth all the advantages a digital version may offer. For that kind of money, I’ll use Google.
This is another part of a gradual, and disturbing, trend in medicine: ignoring small practices. Large corporate practices are worth a lot more in sales than little one-to-three doctor groups, so companies, such as “the little blue book,” have no incentive to tailor their products to us. We have become medical persona non grata.
I understand this is a business decision. It’s not specifically directed at me.
Yet ...
I’ve been in practice for almost 20 years now, and buying two copies of the LBB is something I’ve done annually, in good and bad economic years. I’ve supported the publisher because it was a good product at a fair price. Sadly, they no longer find my little practice to be worth the effort or profit margin.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“The little blue book” has been an office standard as long as I’ve been in practice. Every practice has a dog-eared copy in a drawer somewhere that’s constantly being pulled out to look up hospitals, other doctors, and pharmacies.
As small as it is, it’s pretty useful in the daily flow of my office routine.
Until now.
Sadly, 2016 was apparently the year I ordered my last copies. The publisher’s marketing people inform me that the paper version has been discontinued, and I can now get the digital version for only ... $500 per year.
Thanks, but no thanks.
I have nothing against digital editions. In fact, if it was the same price as the paper one, I’d get it. If I were a big practice that needed, say, 50 copies for the staff, the $500 per practice fee is a deal, compared with the $998 I’d pay for 50 paper copies.
But for my dinky little two-person practice? The difference between $39.90 and $500 just isn’t worth all the advantages a digital version may offer. For that kind of money, I’ll use Google.
This is another part of a gradual, and disturbing, trend in medicine: ignoring small practices. Large corporate practices are worth a lot more in sales than little one-to-three doctor groups, so companies, such as “the little blue book,” have no incentive to tailor their products to us. We have become medical persona non grata.
I understand this is a business decision. It’s not specifically directed at me.
Yet ...
I’ve been in practice for almost 20 years now, and buying two copies of the LBB is something I’ve done annually, in good and bad economic years. I’ve supported the publisher because it was a good product at a fair price. Sadly, they no longer find my little practice to be worth the effort or profit margin.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Adenomyosis increasingly is a concern
“WHY ARE THERE DELAYS IN THE DIAGNOSIS OF ENDOMETRIOSIS?”
ROBERT L. BARBIERI, MD (EDITORIAL; MARCH 2017)
Adenomyosis increasingly is a concern
Dr. Barbieri’s article on delay in diagnosis of endometriosis is timely and important. I agree that family history is very important, but often the mother had a hysterectomy at a relatively young age for heavy bleeding that was blamed on fibroids.
Adenomyosis seems to be increasing in prevalence and may be suggested by cystic changes in the endometrium on 3D ultrasonography. The patient often reports dark brown spotting before or after periods. The second day of the period is very heavy, and cramping may precede the period. Sometimes you can note punctate lesions on the cervix that cause a very friable cervix that is likely to bleed after the patient has coitus or a Pap smear. Adenomyosis may cause much of the troublesome bleeding seen after medroxyprogesterone acetate injection, insertion of a levonorgestrel-containing intrauterine device, etonogestrel implant placement, and even birth control pills, and it is often dismissed as dysfunctional uterine bleeding. The dark brown blood may represent blood exiting the crypts of the endometrium.
It is concerning that patients who are treated aggressively for adenomyosis in order to get pregnant seem to be at increased risk for retained placenta and decreased uterine tone in the third stage of labor. Certainly this makes intuitive sense if one surmises that the endometrium is abnormally deep into the myometrium, allowing for microscopic placental invasion and myometrial dysfunction.
Most troubling is the warning from the public health community regarding endocrine disruptors. Could BPA (bisphenol A) be contaminating our plastic water bottles and be causing an epidemic of younger-onset adenomyosis? It is certainly something worth studying.
John Lewis, MD
Waterbury, Connecticut
Endometriosis patients receive delayed diagnosis, ineffective treatments
Several points came to mind reading Dr. Barbieri’s article. First, with the surge in deep infiltrating endometriosis as reported in the literature, one has to ask about treating mild disease with hormones initially. Disease can and does progress with hormonal suppression, I assume because endometriosis makes its own estrogen. Yet when the surge is noticed, the recommendation, at least in Europe, is that we should look at pollution.
Second, I have to wonder why it is not reported that older women have endometriosis. I manage a 20,000-member education board for endometriosis patients and many of those seeking help are older and often already castrated. When I can find them access to advanced surgical skill, they are found to have active endometriosis.
The patients seeking more information (gaining 300 a week) have failed all that gynecology has to offer except expert surgical excision of their disease. In my view, gynecology in general has failed this patient population. I have worked with endometriosis patients for 32 years, and 75% of them have been dismissed as neurotic, with average time to diagnosis 9 years after symptoms appear.
It seems that the symptom profile found in endometriosis patients is not well known, and once the disease is diagnosed, the treatment options are ineffective.
Nancy Petersen, RN
Portland, Oregon
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
“WHY ARE THERE DELAYS IN THE DIAGNOSIS OF ENDOMETRIOSIS?”
ROBERT L. BARBIERI, MD (EDITORIAL; MARCH 2017)
Adenomyosis increasingly is a concern
Dr. Barbieri’s article on delay in diagnosis of endometriosis is timely and important. I agree that family history is very important, but often the mother had a hysterectomy at a relatively young age for heavy bleeding that was blamed on fibroids.
Adenomyosis seems to be increasing in prevalence and may be suggested by cystic changes in the endometrium on 3D ultrasonography. The patient often reports dark brown spotting before or after periods. The second day of the period is very heavy, and cramping may precede the period. Sometimes you can note punctate lesions on the cervix that cause a very friable cervix that is likely to bleed after the patient has coitus or a Pap smear. Adenomyosis may cause much of the troublesome bleeding seen after medroxyprogesterone acetate injection, insertion of a levonorgestrel-containing intrauterine device, etonogestrel implant placement, and even birth control pills, and it is often dismissed as dysfunctional uterine bleeding. The dark brown blood may represent blood exiting the crypts of the endometrium.
It is concerning that patients who are treated aggressively for adenomyosis in order to get pregnant seem to be at increased risk for retained placenta and decreased uterine tone in the third stage of labor. Certainly this makes intuitive sense if one surmises that the endometrium is abnormally deep into the myometrium, allowing for microscopic placental invasion and myometrial dysfunction.
Most troubling is the warning from the public health community regarding endocrine disruptors. Could BPA (bisphenol A) be contaminating our plastic water bottles and be causing an epidemic of younger-onset adenomyosis? It is certainly something worth studying.
John Lewis, MD
Waterbury, Connecticut
Endometriosis patients receive delayed diagnosis, ineffective treatments
Several points came to mind reading Dr. Barbieri’s article. First, with the surge in deep infiltrating endometriosis as reported in the literature, one has to ask about treating mild disease with hormones initially. Disease can and does progress with hormonal suppression, I assume because endometriosis makes its own estrogen. Yet when the surge is noticed, the recommendation, at least in Europe, is that we should look at pollution.
Second, I have to wonder why it is not reported that older women have endometriosis. I manage a 20,000-member education board for endometriosis patients and many of those seeking help are older and often already castrated. When I can find them access to advanced surgical skill, they are found to have active endometriosis.
The patients seeking more information (gaining 300 a week) have failed all that gynecology has to offer except expert surgical excision of their disease. In my view, gynecology in general has failed this patient population. I have worked with endometriosis patients for 32 years, and 75% of them have been dismissed as neurotic, with average time to diagnosis 9 years after symptoms appear.
It seems that the symptom profile found in endometriosis patients is not well known, and once the disease is diagnosed, the treatment options are ineffective.
Nancy Petersen, RN
Portland, Oregon
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
“WHY ARE THERE DELAYS IN THE DIAGNOSIS OF ENDOMETRIOSIS?”
ROBERT L. BARBIERI, MD (EDITORIAL; MARCH 2017)
Adenomyosis increasingly is a concern
Dr. Barbieri’s article on delay in diagnosis of endometriosis is timely and important. I agree that family history is very important, but often the mother had a hysterectomy at a relatively young age for heavy bleeding that was blamed on fibroids.
Adenomyosis seems to be increasing in prevalence and may be suggested by cystic changes in the endometrium on 3D ultrasonography. The patient often reports dark brown spotting before or after periods. The second day of the period is very heavy, and cramping may precede the period. Sometimes you can note punctate lesions on the cervix that cause a very friable cervix that is likely to bleed after the patient has coitus or a Pap smear. Adenomyosis may cause much of the troublesome bleeding seen after medroxyprogesterone acetate injection, insertion of a levonorgestrel-containing intrauterine device, etonogestrel implant placement, and even birth control pills, and it is often dismissed as dysfunctional uterine bleeding. The dark brown blood may represent blood exiting the crypts of the endometrium.
It is concerning that patients who are treated aggressively for adenomyosis in order to get pregnant seem to be at increased risk for retained placenta and decreased uterine tone in the third stage of labor. Certainly this makes intuitive sense if one surmises that the endometrium is abnormally deep into the myometrium, allowing for microscopic placental invasion and myometrial dysfunction.
Most troubling is the warning from the public health community regarding endocrine disruptors. Could BPA (bisphenol A) be contaminating our plastic water bottles and be causing an epidemic of younger-onset adenomyosis? It is certainly something worth studying.
John Lewis, MD
Waterbury, Connecticut
Endometriosis patients receive delayed diagnosis, ineffective treatments
Several points came to mind reading Dr. Barbieri’s article. First, with the surge in deep infiltrating endometriosis as reported in the literature, one has to ask about treating mild disease with hormones initially. Disease can and does progress with hormonal suppression, I assume because endometriosis makes its own estrogen. Yet when the surge is noticed, the recommendation, at least in Europe, is that we should look at pollution.
Second, I have to wonder why it is not reported that older women have endometriosis. I manage a 20,000-member education board for endometriosis patients and many of those seeking help are older and often already castrated. When I can find them access to advanced surgical skill, they are found to have active endometriosis.
The patients seeking more information (gaining 300 a week) have failed all that gynecology has to offer except expert surgical excision of their disease. In my view, gynecology in general has failed this patient population. I have worked with endometriosis patients for 32 years, and 75% of them have been dismissed as neurotic, with average time to diagnosis 9 years after symptoms appear.
It seems that the symptom profile found in endometriosis patients is not well known, and once the disease is diagnosed, the treatment options are ineffective.
Nancy Petersen, RN
Portland, Oregon
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
