Commentary

Myth: Docusate is a stool softener and helps with constipation.

A 60-year-old man is injured in a fall and breaks four ribs. He is in severe pain and is prescribed oxycodone and naproxen for pain. What treatment would you prescribe to help decrease problems with constipation?

A. Docusate.

B. Docusate and polyethylene glycol.

C. Psyllium.

D. Polyethylene glycol.

Constipation is extremely common, occurring in up to 20%-25% of the elderly population and 90% of patients treated with opioids. The formal definition of constipation is fewer than three bowel movements per week. Patients are concerned with other symptoms as well, including hard stool consistency and the feeling of incomplete evacuation.

An extremely commonly prescribed medication for patients with symptoms of constipation/hard stool passage is docusate (Colace). This medication is often a part of bowel programs for institutionalized/hospitalized patients, as well as being frequently prescribed when patients are treated with opiates.

Does it work?

Docusate is frequently prescribed as a “stool softener,” but does it increase water content in stool? In a randomized, controlled trial of docusate vs. psyllium, 170 adult patients with chronic constipation received either 5.1 g twice a day of psyllium or 100 mg twice a day of docusate (Aliment Pharmacol Ther. 1998 May;12[5]:491-7).

Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33%, vs .01% for docusate (P =. 007), and stool weight was increased in the group treated with psyllium, compared with docusate-treated patients (359.9 g/week vs. 271.9 g/week, respectively; P = .005). Docusate does not appear to have any effect on stool water content or amount of stool.

In a study of constipation treatment in patients receiving opioids, Dr. Yoko Tarumi and her colleagues studied 74 patients admitted to hospice units (J Pain Symptom Manage. 2013 Jan;45[1]:2-13). A total of 74 patients were randomized to receive docusate 100 mg twice a day plus senna, or placebo plus senna. Once the study was started, inclusion criteria were broadened to include hospice patients with nonmalignant disease and patients who were not on opioids.

Almost all patients in the study did receive opioids (94% of the docusate patients and 100% of placebo-treated patients). There were no significant between the groups in stool volume, frequency, consistency, or in perceived completeness of evacuation.

In a randomized, controlled study of elderly patients on a medicine ward, 34 patients were randomized to docusate or control (no laxatives)(J Chronic Dis. 1976 Jan;29[1]:59-63). There was no difference in frequency or quality of stools between groups.

A systematic review of the usefulness of docusate in chronically ill patients concluded that the widespread use of docusate for the treatment of constipation in palliative-care patients is based on inadequate experimental evidence (J Pain Symptom Manage. 2000 Feb;19[2]:130-6).

The Canadian Agency for Drugs and Technologies in Health concluded “the available evidence suggests that docusate is no more effective than placebo in the prevention or management of constipation” (Dioctyl sulfosuccinate or docusate [calcium or sodium] for the prevention or management of constipation: a review of the clinical effectiveness. Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26).

Dr. Davendra Ramkumar and his colleagues published a systematic review of drug trials for the treatment of constipation in 2005 (Am J Gastroenterol. 2005 Apr;100[4]:936-71). Only polyethylene glycol and tegaserod received grade A evidence for published trials. Psyllium and lactulose received grade B evidence. Docusate received a level 3, grade C for evidence (poor quality evidence, poor evidence to support a recommendation for or against the use of the modality).

I have been surprised at how docusate has been the most commonly prescribed laxative agent. Polyethylene glycol or psyllium are better evidence-based options. Docusate is often prescribed as a stool softener, and it has even less evidence that it softens stool than its poor evidence as a laxative.

Acknowledgments

My thanks to the late Dr. David Saunders for teaching me 30 years ago that docusate was not a helpful option for the management of constipation, and to Sarah Steinkruger for doing much of the research that was used in this column.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

Myth: Docusate is a stool softener and helps with constipation.

A 60-year-old man is injured in a fall and breaks four ribs. He is in severe pain and is prescribed oxycodone and naproxen for pain. What treatment would you prescribe to help decrease problems with constipation?

A. Docusate.

B. Docusate and polyethylene glycol.

C. Psyllium.

D. Polyethylene glycol.

Constipation is extremely common, occurring in up to 20%-25% of the elderly population and 90% of patients treated with opioids. The formal definition of constipation is fewer than three bowel movements per week. Patients are concerned with other symptoms as well, including hard stool consistency and the feeling of incomplete evacuation.

An extremely commonly prescribed medication for patients with symptoms of constipation/hard stool passage is docusate (Colace). This medication is often a part of bowel programs for institutionalized/hospitalized patients, as well as being frequently prescribed when patients are treated with opiates.

Does it work?

Docusate is frequently prescribed as a “stool softener,” but does it increase water content in stool? In a randomized, controlled trial of docusate vs. psyllium, 170 adult patients with chronic constipation received either 5.1 g twice a day of psyllium or 100 mg twice a day of docusate (Aliment Pharmacol Ther. 1998 May;12[5]:491-7).

Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33%, vs .01% for docusate (P =. 007), and stool weight was increased in the group treated with psyllium, compared with docusate-treated patients (359.9 g/week vs. 271.9 g/week, respectively; P = .005). Docusate does not appear to have any effect on stool water content or amount of stool.

In a study of constipation treatment in patients receiving opioids, Dr. Yoko Tarumi and her colleagues studied 74 patients admitted to hospice units (J Pain Symptom Manage. 2013 Jan;45[1]:2-13). A total of 74 patients were randomized to receive docusate 100 mg twice a day plus senna, or placebo plus senna. Once the study was started, inclusion criteria were broadened to include hospice patients with nonmalignant disease and patients who were not on opioids.

Almost all patients in the study did receive opioids (94% of the docusate patients and 100% of placebo-treated patients). There were no significant between the groups in stool volume, frequency, consistency, or in perceived completeness of evacuation.

In a randomized, controlled study of elderly patients on a medicine ward, 34 patients were randomized to docusate or control (no laxatives)(J Chronic Dis. 1976 Jan;29[1]:59-63). There was no difference in frequency or quality of stools between groups.

A systematic review of the usefulness of docusate in chronically ill patients concluded that the widespread use of docusate for the treatment of constipation in palliative-care patients is based on inadequate experimental evidence (J Pain Symptom Manage. 2000 Feb;19[2]:130-6).

The Canadian Agency for Drugs and Technologies in Health concluded “the available evidence suggests that docusate is no more effective than placebo in the prevention or management of constipation” (Dioctyl sulfosuccinate or docusate [calcium or sodium] for the prevention or management of constipation: a review of the clinical effectiveness. Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26).

Dr. Davendra Ramkumar and his colleagues published a systematic review of drug trials for the treatment of constipation in 2005 (Am J Gastroenterol. 2005 Apr;100[4]:936-71). Only polyethylene glycol and tegaserod received grade A evidence for published trials. Psyllium and lactulose received grade B evidence. Docusate received a level 3, grade C for evidence (poor quality evidence, poor evidence to support a recommendation for or against the use of the modality).

I have been surprised at how docusate has been the most commonly prescribed laxative agent. Polyethylene glycol or psyllium are better evidence-based options. Docusate is often prescribed as a stool softener, and it has even less evidence that it softens stool than its poor evidence as a laxative.

Acknowledgments

My thanks to the late Dr. David Saunders for teaching me 30 years ago that docusate was not a helpful option for the management of constipation, and to Sarah Steinkruger for doing much of the research that was used in this column.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

Myth: Docusate is a stool softener and helps with constipation.

A 60-year-old man is injured in a fall and breaks four ribs. He is in severe pain and is prescribed oxycodone and naproxen for pain. What treatment would you prescribe to help decrease problems with constipation?

A. Docusate.

B. Docusate and polyethylene glycol.

C. Psyllium.

D. Polyethylene glycol.

Constipation is extremely common, occurring in up to 20%-25% of the elderly population and 90% of patients treated with opioids. The formal definition of constipation is fewer than three bowel movements per week. Patients are concerned with other symptoms as well, including hard stool consistency and the feeling of incomplete evacuation.

An extremely commonly prescribed medication for patients with symptoms of constipation/hard stool passage is docusate (Colace). This medication is often a part of bowel programs for institutionalized/hospitalized patients, as well as being frequently prescribed when patients are treated with opiates.

Does it work?

Docusate is frequently prescribed as a “stool softener,” but does it increase water content in stool? In a randomized, controlled trial of docusate vs. psyllium, 170 adult patients with chronic constipation received either 5.1 g twice a day of psyllium or 100 mg twice a day of docusate (Aliment Pharmacol Ther. 1998 May;12[5]:491-7).

Psyllium was superior in its effect on stool frequency, stool water content, total stool output, and the combination of several objective measures of constipation. Compared with baseline, psyllium increased stool water content by 2.33%, vs .01% for docusate (P =. 007), and stool weight was increased in the group treated with psyllium, compared with docusate-treated patients (359.9 g/week vs. 271.9 g/week, respectively; P = .005). Docusate does not appear to have any effect on stool water content or amount of stool.

In a study of constipation treatment in patients receiving opioids, Dr. Yoko Tarumi and her colleagues studied 74 patients admitted to hospice units (J Pain Symptom Manage. 2013 Jan;45[1]:2-13). A total of 74 patients were randomized to receive docusate 100 mg twice a day plus senna, or placebo plus senna. Once the study was started, inclusion criteria were broadened to include hospice patients with nonmalignant disease and patients who were not on opioids.

Almost all patients in the study did receive opioids (94% of the docusate patients and 100% of placebo-treated patients). There were no significant between the groups in stool volume, frequency, consistency, or in perceived completeness of evacuation.

In a randomized, controlled study of elderly patients on a medicine ward, 34 patients were randomized to docusate or control (no laxatives)(J Chronic Dis. 1976 Jan;29[1]:59-63). There was no difference in frequency or quality of stools between groups.

A systematic review of the usefulness of docusate in chronically ill patients concluded that the widespread use of docusate for the treatment of constipation in palliative-care patients is based on inadequate experimental evidence (J Pain Symptom Manage. 2000 Feb;19[2]:130-6).

The Canadian Agency for Drugs and Technologies in Health concluded “the available evidence suggests that docusate is no more effective than placebo in the prevention or management of constipation” (Dioctyl sulfosuccinate or docusate [calcium or sodium] for the prevention or management of constipation: a review of the clinical effectiveness. Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26).

Dr. Davendra Ramkumar and his colleagues published a systematic review of drug trials for the treatment of constipation in 2005 (Am J Gastroenterol. 2005 Apr;100[4]:936-71). Only polyethylene glycol and tegaserod received grade A evidence for published trials. Psyllium and lactulose received grade B evidence. Docusate received a level 3, grade C for evidence (poor quality evidence, poor evidence to support a recommendation for or against the use of the modality).

I have been surprised at how docusate has been the most commonly prescribed laxative agent. Polyethylene glycol or psyllium are better evidence-based options. Docusate is often prescribed as a stool softener, and it has even less evidence that it softens stool than its poor evidence as a laxative.

Acknowledgments

My thanks to the late Dr. David Saunders for teaching me 30 years ago that docusate was not a helpful option for the management of constipation, and to Sarah Steinkruger for doing much of the research that was used in this column.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

Question: A doctor may owe a duty of care in the setting of:

A. A cyber relationship.

B. A special relationship.

C. Both A and B.

D. Neither A nor B.

Answer: C. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries.

Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

Duty in the context of medical negligence is not usually in dispute, as it is plainly owed by a doctor to his or her patient. It arises out of the doctor-patient relationship. Whether a relationship has been formed in the first place is a threshold inquiry. Where a doctor accepts a patient who is seeking his or her services, the relationship is readily evident. Duty is also established when the doctor begins the evaluation process in a typical encounter.

However, a phone inquiry by a potential patient, without more, may be insufficient to create this relationship, although this may depend on the nature of the phone conversation and the doctor’s response.

Likewise, a “curbside” consultation sought by a colleague does not normally translate into a duty for the doctor offering the opinion. Presumably casual advice given freely and understood as such at social gatherings does not add up to a doctor-patient relationship, and courts will look to reasonableness as the touchstone in deciding whether such a relationship was ever formed.

Still, there are some medical situations where a legitimate question of duty can be raised. With the growth of electronic medical records and communication, medical encounters in cyberspace will emerge as an increasing source of litigation.

Internet liability can be far reaching. In addition to risks governing negligence, informed consent, and privacy/confidentiality, there are additional issues of product liability, cross-border jurisdictional conflicts, and others.

The threshold question when assessing cyberspace liability arising, for example, from the use of doctor-operated medical websites concerns duty, because its existence or denial will determine whether the case can go forward in the first place. Although not the typical office or hospital patient, a plaintiff may argue successfully that a doctor-patient relationship had nonetheless been formed in cyberspace.

It is possible that such a relationship will be found in some circumstances, relevant factors being knowledge of names of subscribers, frequency of interactions, specificity of queries, and so on. In particular, a subscription fee is likely to be construed as evidence of soliciting and accepting a more committed interaction, so it places the operator of the website at greater legal risk. A specific disclaimer is a standard precaution but may not be enough to definitively protect against a lawsuit.

Courts have ruled in favor of plaintiffs despite the absence of face-to-face interaction with a physician. In one case, a doctor speaking to a patient from the emergency department was deemed to have formed a doctor-patient relationship (O’Neill v. Montefiore Hospital, 11 A.D.2d 132 (N.Y.A.D. 1 Dept. 1960). In another, an on-call neurologist’s telephone advice to the treating doctor likewise raised the issue of legal duty (Lection v. Dyll, 65 S.W.3d 696 (Tex. App. Dallas 2001).

The state of Hawaii now permits telehealth services to be reimbursable, notwithstanding the absence of face-to-face contact (HI Rev Stat § 431:10A-116.3[a]). With this law, an online encounter will likely translate into a professional relationship – with corresponding legal duty of due care.

In the case of a Good Samaritan physician – i.e., one who offers gratuitous aid to a stranger in need of medical assistance – courts are unlikely to find a professional relationship, because there is no common law duty to help a stranger.

However, once treatment has begun, there is a duty not to make matters worse. So, all 50 states have enacted Good Samaritan statutes, which protect against liability arising out of negligent rescue. Note that statutory protection is generally excluded for Good Samaritan acts performed within a hospital setting, under the theory that doctors have an ongoing relationship with the hospital and are already obligated to provide emergency care within its walls.

Another category of legal duty concerns nonpatient third parties. The complaint may relate to a failure to warn family members of a patient’s contagious disease, or the transmissible condition may have been missed and an innocent third party was injured as a result.

Another situation where duty to a third party might arise is the learning of a credible threat of harm directed at a named individual. This is famously known as the Tarasoff doctrine, after a California case in which the court imposed a duty on a college psychologist to directly warn an intended victim of harm by his patient – even though that meant breaching confidentiality of a professional relationship, and the victim was a nonpatient third party (Tarasoff v. Regents of University of California, 551 P.2d 334 [Cal. 1976]).

A doctor may also incur liability for automobile injuries sustained by one other than his or her own patient. In a Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old bystander. The driver alleged that the prescription medication prazosin caused him to lose control of the car.

In ruling that the health care provider was liable to the injured bystander, the Hawaii Supreme Court held that physicians have a duty to warn their patients of potential adverse medication effects, and this responsibility should extend to third parties (McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 [Haw. 2002]).

A foreseeable and unreasonable risk of harm is an important factor, but not the only decisive factor, in construing the existence of a legal duty. Under some circumstances, the term “special relationship” has been employed based on a consideration of “existing social values, customs, and considerations of policy.”

In a Massachusetts case, a family practitioner had failed to warn his patient of the risk of diabetic drugs when operating a vehicle. Just 45 minutes after the patient’s discharge from the hospital, he developed hypoglycemia, losing consciousness and injuring a motorcyclist who then sued the doctor. The court used the “special relationship” rationale in ruling that the doctor owed a duty to the motorcyclist (Arsenault v. McConarty, 21 Mass. L. Rptr. 500 [2006]).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.

Question: A doctor may owe a duty of care in the setting of:

A. A cyber relationship.

B. A special relationship.

C. Both A and B.

D. Neither A nor B.

Answer: C. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries.

Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

Duty in the context of medical negligence is not usually in dispute, as it is plainly owed by a doctor to his or her patient. It arises out of the doctor-patient relationship. Whether a relationship has been formed in the first place is a threshold inquiry. Where a doctor accepts a patient who is seeking his or her services, the relationship is readily evident. Duty is also established when the doctor begins the evaluation process in a typical encounter.

However, a phone inquiry by a potential patient, without more, may be insufficient to create this relationship, although this may depend on the nature of the phone conversation and the doctor’s response.

Likewise, a “curbside” consultation sought by a colleague does not normally translate into a duty for the doctor offering the opinion. Presumably casual advice given freely and understood as such at social gatherings does not add up to a doctor-patient relationship, and courts will look to reasonableness as the touchstone in deciding whether such a relationship was ever formed.

Still, there are some medical situations where a legitimate question of duty can be raised. With the growth of electronic medical records and communication, medical encounters in cyberspace will emerge as an increasing source of litigation.

Internet liability can be far reaching. In addition to risks governing negligence, informed consent, and privacy/confidentiality, there are additional issues of product liability, cross-border jurisdictional conflicts, and others.

The threshold question when assessing cyberspace liability arising, for example, from the use of doctor-operated medical websites concerns duty, because its existence or denial will determine whether the case can go forward in the first place. Although not the typical office or hospital patient, a plaintiff may argue successfully that a doctor-patient relationship had nonetheless been formed in cyberspace.

It is possible that such a relationship will be found in some circumstances, relevant factors being knowledge of names of subscribers, frequency of interactions, specificity of queries, and so on. In particular, a subscription fee is likely to be construed as evidence of soliciting and accepting a more committed interaction, so it places the operator of the website at greater legal risk. A specific disclaimer is a standard precaution but may not be enough to definitively protect against a lawsuit.

Courts have ruled in favor of plaintiffs despite the absence of face-to-face interaction with a physician. In one case, a doctor speaking to a patient from the emergency department was deemed to have formed a doctor-patient relationship (O’Neill v. Montefiore Hospital, 11 A.D.2d 132 (N.Y.A.D. 1 Dept. 1960). In another, an on-call neurologist’s telephone advice to the treating doctor likewise raised the issue of legal duty (Lection v. Dyll, 65 S.W.3d 696 (Tex. App. Dallas 2001).

The state of Hawaii now permits telehealth services to be reimbursable, notwithstanding the absence of face-to-face contact (HI Rev Stat § 431:10A-116.3[a]). With this law, an online encounter will likely translate into a professional relationship – with corresponding legal duty of due care.

In the case of a Good Samaritan physician – i.e., one who offers gratuitous aid to a stranger in need of medical assistance – courts are unlikely to find a professional relationship, because there is no common law duty to help a stranger.

However, once treatment has begun, there is a duty not to make matters worse. So, all 50 states have enacted Good Samaritan statutes, which protect against liability arising out of negligent rescue. Note that statutory protection is generally excluded for Good Samaritan acts performed within a hospital setting, under the theory that doctors have an ongoing relationship with the hospital and are already obligated to provide emergency care within its walls.

Another category of legal duty concerns nonpatient third parties. The complaint may relate to a failure to warn family members of a patient’s contagious disease, or the transmissible condition may have been missed and an innocent third party was injured as a result.

Another situation where duty to a third party might arise is the learning of a credible threat of harm directed at a named individual. This is famously known as the Tarasoff doctrine, after a California case in which the court imposed a duty on a college psychologist to directly warn an intended victim of harm by his patient – even though that meant breaching confidentiality of a professional relationship, and the victim was a nonpatient third party (Tarasoff v. Regents of University of California, 551 P.2d 334 [Cal. 1976]).

A doctor may also incur liability for automobile injuries sustained by one other than his or her own patient. In a Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old bystander. The driver alleged that the prescription medication prazosin caused him to lose control of the car.

In ruling that the health care provider was liable to the injured bystander, the Hawaii Supreme Court held that physicians have a duty to warn their patients of potential adverse medication effects, and this responsibility should extend to third parties (McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 [Haw. 2002]).

A foreseeable and unreasonable risk of harm is an important factor, but not the only decisive factor, in construing the existence of a legal duty. Under some circumstances, the term “special relationship” has been employed based on a consideration of “existing social values, customs, and considerations of policy.”

In a Massachusetts case, a family practitioner had failed to warn his patient of the risk of diabetic drugs when operating a vehicle. Just 45 minutes after the patient’s discharge from the hospital, he developed hypoglycemia, losing consciousness and injuring a motorcyclist who then sued the doctor. The court used the “special relationship” rationale in ruling that the doctor owed a duty to the motorcyclist (Arsenault v. McConarty, 21 Mass. L. Rptr. 500 [2006]).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.

Question: A doctor may owe a duty of care in the setting of:

A. A cyber relationship.

B. A special relationship.

C. Both A and B.

D. Neither A nor B.

Answer: C. Ascertaining whether a defendant owes a duty to a claimant is the first inquiry in the tort of negligence. To say there is no duty owed is to deny liability altogether, however obvious the breach or horrendous the foreseeable injuries.

Thus, duty is used as a filter mechanism to reduce frivolous suits or otherwise control the tide of litigation, to prevent “liability in an indeterminate amount for an indeterminate time to an indeterminate class.”

Duty in the context of medical negligence is not usually in dispute, as it is plainly owed by a doctor to his or her patient. It arises out of the doctor-patient relationship. Whether a relationship has been formed in the first place is a threshold inquiry. Where a doctor accepts a patient who is seeking his or her services, the relationship is readily evident. Duty is also established when the doctor begins the evaluation process in a typical encounter.

However, a phone inquiry by a potential patient, without more, may be insufficient to create this relationship, although this may depend on the nature of the phone conversation and the doctor’s response.

Likewise, a “curbside” consultation sought by a colleague does not normally translate into a duty for the doctor offering the opinion. Presumably casual advice given freely and understood as such at social gatherings does not add up to a doctor-patient relationship, and courts will look to reasonableness as the touchstone in deciding whether such a relationship was ever formed.

Still, there are some medical situations where a legitimate question of duty can be raised. With the growth of electronic medical records and communication, medical encounters in cyberspace will emerge as an increasing source of litigation.

Internet liability can be far reaching. In addition to risks governing negligence, informed consent, and privacy/confidentiality, there are additional issues of product liability, cross-border jurisdictional conflicts, and others.

The threshold question when assessing cyberspace liability arising, for example, from the use of doctor-operated medical websites concerns duty, because its existence or denial will determine whether the case can go forward in the first place. Although not the typical office or hospital patient, a plaintiff may argue successfully that a doctor-patient relationship had nonetheless been formed in cyberspace.

It is possible that such a relationship will be found in some circumstances, relevant factors being knowledge of names of subscribers, frequency of interactions, specificity of queries, and so on. In particular, a subscription fee is likely to be construed as evidence of soliciting and accepting a more committed interaction, so it places the operator of the website at greater legal risk. A specific disclaimer is a standard precaution but may not be enough to definitively protect against a lawsuit.

Courts have ruled in favor of plaintiffs despite the absence of face-to-face interaction with a physician. In one case, a doctor speaking to a patient from the emergency department was deemed to have formed a doctor-patient relationship (O’Neill v. Montefiore Hospital, 11 A.D.2d 132 (N.Y.A.D. 1 Dept. 1960). In another, an on-call neurologist’s telephone advice to the treating doctor likewise raised the issue of legal duty (Lection v. Dyll, 65 S.W.3d 696 (Tex. App. Dallas 2001).

The state of Hawaii now permits telehealth services to be reimbursable, notwithstanding the absence of face-to-face contact (HI Rev Stat § 431:10A-116.3[a]). With this law, an online encounter will likely translate into a professional relationship – with corresponding legal duty of due care.

In the case of a Good Samaritan physician – i.e., one who offers gratuitous aid to a stranger in need of medical assistance – courts are unlikely to find a professional relationship, because there is no common law duty to help a stranger.

However, once treatment has begun, there is a duty not to make matters worse. So, all 50 states have enacted Good Samaritan statutes, which protect against liability arising out of negligent rescue. Note that statutory protection is generally excluded for Good Samaritan acts performed within a hospital setting, under the theory that doctors have an ongoing relationship with the hospital and are already obligated to provide emergency care within its walls.

Another category of legal duty concerns nonpatient third parties. The complaint may relate to a failure to warn family members of a patient’s contagious disease, or the transmissible condition may have been missed and an innocent third party was injured as a result.

Another situation where duty to a third party might arise is the learning of a credible threat of harm directed at a named individual. This is famously known as the Tarasoff doctrine, after a California case in which the court imposed a duty on a college psychologist to directly warn an intended victim of harm by his patient – even though that meant breaching confidentiality of a professional relationship, and the victim was a nonpatient third party (Tarasoff v. Regents of University of California, 551 P.2d 334 [Cal. 1976]).

A doctor may also incur liability for automobile injuries sustained by one other than his or her own patient. In a Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old bystander. The driver alleged that the prescription medication prazosin caused him to lose control of the car.

In ruling that the health care provider was liable to the injured bystander, the Hawaii Supreme Court held that physicians have a duty to warn their patients of potential adverse medication effects, and this responsibility should extend to third parties (McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 [Haw. 2002]).

A foreseeable and unreasonable risk of harm is an important factor, but not the only decisive factor, in construing the existence of a legal duty. Under some circumstances, the term “special relationship” has been employed based on a consideration of “existing social values, customs, and considerations of policy.”

In a Massachusetts case, a family practitioner had failed to warn his patient of the risk of diabetic drugs when operating a vehicle. Just 45 minutes after the patient’s discharge from the hospital, he developed hypoglycemia, losing consciousness and injuring a motorcyclist who then sued the doctor. The court used the “special relationship” rationale in ruling that the doctor owed a duty to the motorcyclist (Arsenault v. McConarty, 21 Mass. L. Rptr. 500 [2006]).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.

Is it just me? I don’t think that I have visited with a single patient this week who’s not struggling with sleep. Our heavily caffeinated, media-obsessed, melatonin-killing, computer-screen-staring, tragic work-life imbalances explain away a lot of it. Knowing that, though, patients in front of me seek immediate relief.

A prescription takes substantially less effort than does training patients on sleep hygiene or sleep restriction. The problem with “z” drugs is, of course, that tolerance can develop within 4 weeks with daily use. These drugs have been associated with mood and cognitive changes and increased mortality. Many of my patients cannot use them sparingly, because relief of insomnia is something of which they cannot get enough. Then we are either back to square one or playing the dose-escalation game.

I have always wondered how much of this is the “placebo effect” and how we could use this to our clinical advantage. This is certainly what I hear from my cynical colleagues when I recommend melatonin – which, by the way, I personally believe is an extremely effective and underutilized intervention. We should remind ourselves to be cognizant of the “if I can’t prescribe it, it can’t work that well” mentality.

Alexander Winkler and Winfried Rief of the University of Marburg, Germany, conducted a brilliant systematic review examining the effect of placebo conditions in randomized trials including polysomnography addressing primary insomnia (Sleep. 2015 Jun 1;38[6]:925-31).

The investigators identified 32 studies with almost 4,000 patients in 82 treatment conditions: The studies were published between 1992 and 2012. Of those 82 treatment conditions, 17 included hypnotic drugs.

Results suggest that 64% of drug response to medications for primary insomnia is achieved in the placebo group.

So what does this mean clinically? I think the first thing it means is that we should consider (re)launching frank discourse about the ethics surrounding the use of placebo in clinical medicine. Are we all too horrified to think that patients may get better despite us rather than because of us to dig too deeply here?

The second thing it means is that patients should be instructed to use the medications only when needed. If a minority of the drug effect for insomnia is from the drug itself, we should minimize the buildup of tolerance by using it sparingly. Studies that have alternated a hypnotic with a placebo show that this works just as well as using a hypnotic every night.

Patients should be encouraged to alternate therapy, such as trying melatonin first and resorting to a “z” drug only if sleep remains elusive. Alternating drug therapy may also enhance the efficacy of the medication.

Always try to combine pharmacotherapy with good sleep hygiene to maximize benefits.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Is it just me? I don’t think that I have visited with a single patient this week who’s not struggling with sleep. Our heavily caffeinated, media-obsessed, melatonin-killing, computer-screen-staring, tragic work-life imbalances explain away a lot of it. Knowing that, though, patients in front of me seek immediate relief.

A prescription takes substantially less effort than does training patients on sleep hygiene or sleep restriction. The problem with “z” drugs is, of course, that tolerance can develop within 4 weeks with daily use. These drugs have been associated with mood and cognitive changes and increased mortality. Many of my patients cannot use them sparingly, because relief of insomnia is something of which they cannot get enough. Then we are either back to square one or playing the dose-escalation game.

I have always wondered how much of this is the “placebo effect” and how we could use this to our clinical advantage. This is certainly what I hear from my cynical colleagues when I recommend melatonin – which, by the way, I personally believe is an extremely effective and underutilized intervention. We should remind ourselves to be cognizant of the “if I can’t prescribe it, it can’t work that well” mentality.

Alexander Winkler and Winfried Rief of the University of Marburg, Germany, conducted a brilliant systematic review examining the effect of placebo conditions in randomized trials including polysomnography addressing primary insomnia (Sleep. 2015 Jun 1;38[6]:925-31).

The investigators identified 32 studies with almost 4,000 patients in 82 treatment conditions: The studies were published between 1992 and 2012. Of those 82 treatment conditions, 17 included hypnotic drugs.

Results suggest that 64% of drug response to medications for primary insomnia is achieved in the placebo group.

So what does this mean clinically? I think the first thing it means is that we should consider (re)launching frank discourse about the ethics surrounding the use of placebo in clinical medicine. Are we all too horrified to think that patients may get better despite us rather than because of us to dig too deeply here?

The second thing it means is that patients should be instructed to use the medications only when needed. If a minority of the drug effect for insomnia is from the drug itself, we should minimize the buildup of tolerance by using it sparingly. Studies that have alternated a hypnotic with a placebo show that this works just as well as using a hypnotic every night.

Patients should be encouraged to alternate therapy, such as trying melatonin first and resorting to a “z” drug only if sleep remains elusive. Alternating drug therapy may also enhance the efficacy of the medication.

Always try to combine pharmacotherapy with good sleep hygiene to maximize benefits.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Is it just me? I don’t think that I have visited with a single patient this week who’s not struggling with sleep. Our heavily caffeinated, media-obsessed, melatonin-killing, computer-screen-staring, tragic work-life imbalances explain away a lot of it. Knowing that, though, patients in front of me seek immediate relief.

A prescription takes substantially less effort than does training patients on sleep hygiene or sleep restriction. The problem with “z” drugs is, of course, that tolerance can develop within 4 weeks with daily use. These drugs have been associated with mood and cognitive changes and increased mortality. Many of my patients cannot use them sparingly, because relief of insomnia is something of which they cannot get enough. Then we are either back to square one or playing the dose-escalation game.

I have always wondered how much of this is the “placebo effect” and how we could use this to our clinical advantage. This is certainly what I hear from my cynical colleagues when I recommend melatonin – which, by the way, I personally believe is an extremely effective and underutilized intervention. We should remind ourselves to be cognizant of the “if I can’t prescribe it, it can’t work that well” mentality.

Alexander Winkler and Winfried Rief of the University of Marburg, Germany, conducted a brilliant systematic review examining the effect of placebo conditions in randomized trials including polysomnography addressing primary insomnia (Sleep. 2015 Jun 1;38[6]:925-31).

The investigators identified 32 studies with almost 4,000 patients in 82 treatment conditions: The studies were published between 1992 and 2012. Of those 82 treatment conditions, 17 included hypnotic drugs.

Results suggest that 64% of drug response to medications for primary insomnia is achieved in the placebo group.

So what does this mean clinically? I think the first thing it means is that we should consider (re)launching frank discourse about the ethics surrounding the use of placebo in clinical medicine. Are we all too horrified to think that patients may get better despite us rather than because of us to dig too deeply here?

The second thing it means is that patients should be instructed to use the medications only when needed. If a minority of the drug effect for insomnia is from the drug itself, we should minimize the buildup of tolerance by using it sparingly. Studies that have alternated a hypnotic with a placebo show that this works just as well as using a hypnotic every night.

Patients should be encouraged to alternate therapy, such as trying melatonin first and resorting to a “z” drug only if sleep remains elusive. Alternating drug therapy may also enhance the efficacy of the medication.

Always try to combine pharmacotherapy with good sleep hygiene to maximize benefits.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

September, October, and November are well known as the “coughing months” in any general pediatrician’s office. We all can relate to the frustration we feel when that handful of patients returns for the unrelenting cough after steroids and albuterol have failed. Codeine has been known to be a good cough suppressant, and when coupled with promethazine (antihistamine), you have a very effective cough syrup that been used as such for decades.

Unfortunately, over the last few decades, this cough syrup has gained notoriety for use other than cough, and now is under great scrutiny. This common syrup is now the main ingredient of a poplar drink among teens known as “Sizzurp” or the “Purple Drank.” Well known artists tweet about it, post pictures of it on Instagram, sing about it in their songs, and glamorize it in their videos.

The mixture is simple; promethazine with codeine, lemon-lime sodas, and hard candies has all the makings of a party drink. It is fizzy, colorful, and sweet, with no horrible aftertaste, so gulping is easy. Most teens don’t limit their drinking to just the purple drink, so now we have a mixture of codeine with alcohol and or marijuana. All of which result in respiratory depression and potentially death.

The abuse of this cough syrup has become so great that Actavis was reported to pull it from production. Already the pint-size bottle sells on the street for $800, and limited access will only skyrocket its value.

As clinicians, we must be aware of the misuse and abuse of common prescription medications because teens prey on busy practices with false or exaggerated symptoms to try to obtain a prescription. Despite the American Academy of Pediatrics’ warning against codeine’s use as an antitussive in children (Pediatrics. 1997 Jun;99[6]:918-20.), there has not been a significant decline in its use (Pediatrics 2014 May;133[5]:e1139-47). Pediatricians need to use extreme caution, and be vigilant to identify frequent flyers or teens known to be at risk for drug abuse. Prescribe nonnarcotic-containing products first, and only prescribe small amounts promethazine/codeine products to prevent leftovers from being kept around the house for unsupervised use.

Most importantly, educate parents and families about the danger of overdose with these products so they can monitor its use.

Dr. Pearce is a pediatrician in Frankfort, Ill.

September, October, and November are well known as the “coughing months” in any general pediatrician’s office. We all can relate to the frustration we feel when that handful of patients returns for the unrelenting cough after steroids and albuterol have failed. Codeine has been known to be a good cough suppressant, and when coupled with promethazine (antihistamine), you have a very effective cough syrup that been used as such for decades.

Unfortunately, over the last few decades, this cough syrup has gained notoriety for use other than cough, and now is under great scrutiny. This common syrup is now the main ingredient of a poplar drink among teens known as “Sizzurp” or the “Purple Drank.” Well known artists tweet about it, post pictures of it on Instagram, sing about it in their songs, and glamorize it in their videos.

The mixture is simple; promethazine with codeine, lemon-lime sodas, and hard candies has all the makings of a party drink. It is fizzy, colorful, and sweet, with no horrible aftertaste, so gulping is easy. Most teens don’t limit their drinking to just the purple drink, so now we have a mixture of codeine with alcohol and or marijuana. All of which result in respiratory depression and potentially death.

The abuse of this cough syrup has become so great that Actavis was reported to pull it from production. Already the pint-size bottle sells on the street for $800, and limited access will only skyrocket its value.

As clinicians, we must be aware of the misuse and abuse of common prescription medications because teens prey on busy practices with false or exaggerated symptoms to try to obtain a prescription. Despite the American Academy of Pediatrics’ warning against codeine’s use as an antitussive in children (Pediatrics. 1997 Jun;99[6]:918-20.), there has not been a significant decline in its use (Pediatrics 2014 May;133[5]:e1139-47). Pediatricians need to use extreme caution, and be vigilant to identify frequent flyers or teens known to be at risk for drug abuse. Prescribe nonnarcotic-containing products first, and only prescribe small amounts promethazine/codeine products to prevent leftovers from being kept around the house for unsupervised use.

Most importantly, educate parents and families about the danger of overdose with these products so they can monitor its use.

Dr. Pearce is a pediatrician in Frankfort, Ill.

September, October, and November are well known as the “coughing months” in any general pediatrician’s office. We all can relate to the frustration we feel when that handful of patients returns for the unrelenting cough after steroids and albuterol have failed. Codeine has been known to be a good cough suppressant, and when coupled with promethazine (antihistamine), you have a very effective cough syrup that been used as such for decades.

Unfortunately, over the last few decades, this cough syrup has gained notoriety for use other than cough, and now is under great scrutiny. This common syrup is now the main ingredient of a poplar drink among teens known as “Sizzurp” or the “Purple Drank.” Well known artists tweet about it, post pictures of it on Instagram, sing about it in their songs, and glamorize it in their videos.

The mixture is simple; promethazine with codeine, lemon-lime sodas, and hard candies has all the makings of a party drink. It is fizzy, colorful, and sweet, with no horrible aftertaste, so gulping is easy. Most teens don’t limit their drinking to just the purple drink, so now we have a mixture of codeine with alcohol and or marijuana. All of which result in respiratory depression and potentially death.

The abuse of this cough syrup has become so great that Actavis was reported to pull it from production. Already the pint-size bottle sells on the street for $800, and limited access will only skyrocket its value.

As clinicians, we must be aware of the misuse and abuse of common prescription medications because teens prey on busy practices with false or exaggerated symptoms to try to obtain a prescription. Despite the American Academy of Pediatrics’ warning against codeine’s use as an antitussive in children (Pediatrics. 1997 Jun;99[6]:918-20.), there has not been a significant decline in its use (Pediatrics 2014 May;133[5]:e1139-47). Pediatricians need to use extreme caution, and be vigilant to identify frequent flyers or teens known to be at risk for drug abuse. Prescribe nonnarcotic-containing products first, and only prescribe small amounts promethazine/codeine products to prevent leftovers from being kept around the house for unsupervised use.

Most importantly, educate parents and families about the danger of overdose with these products so they can monitor its use.

Dr. Pearce is a pediatrician in Frankfort, Ill.

Primary care clinicians have come to realize that a large percentage of patients use alternative or complementary approaches to many types of health problems, including emotional-behavioral ones.

Families often are reluctant to bring up these interventions in primary care appointments for fear that their doctor will criticize them for using unproven and sometimes risky treatments. When it comes to dietary supplements, the evidence for many is rather weak, while others have been studied in controlled trials and now may deserve a closer look. Omega-3 fatty acid supplementation for various types of psychiatric disorders and problems may be leading the pack as an alternative treatment that has earned the right to be on the radar screen of all pediatricians. This article briefly summarizes what scientific evidence exists about the efficacy of omega-3s in pediatric emotional-behavioral problems and where significant gaps in our knowledge remain.

Case summary

Samantha is an 11-year-old girl who was adopted into a loving and supportive family at the age of 4 years after having suffered a tumultuous early childhood that included domestic violence as well as physical and emotional abuse. Despite a much improved home environment, she has continued to struggle for many years with difficulties including inattention, emotional dysregulation, and aggression toward others. Samantha and her family have worked with a mental health counselor, and her pediatrician also has started her on pharmacotherapy with a stimulant medication and an alpha-agonist. Despite some gains, significant difficulties remain. At a follow-up visit, Samantha’s mother states that she has done some research on the Internet and has heard positive things about omega-3 fatty acid supplements. She wonders if this might be appropriate for Samantha and if so, how specifically the treatment would be administered.

Discussion

The possible benefits of omega-3s in the treatment of behavioral problems has been discussed for decades, and good evidence from rigorous trials has slowly been accumulating. In October 2015 at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers in a clinical trial called Omega-3 and Therapy Studies (OATS) presented some preliminary results to see if omega-3s could augment response in children aged 7-14 years with depression and bipolar spectrum disorders who also were receiving evidence-based psychotherapy. The daily dose was 2,000 mg, consisting of 1,400 mg of eicosapentaenoic acid (EPA), 200 mg of docosahexaenoic acid (DHA), and 400 mg of other omega-3s. Significant improvement of small to medium effect was found for omega-3s, particularly for depressive symptoms, and side effects were minimal.

Another relatively recent study from 2014 used a randomized double-blind design in 200 youth between the ages of 6 and 18 years from the island nation of Mauritius, near Madagascar (J Child Psychol Psychiatry. 2015 May;56[5]:509-20). The active treatment here was 1,000 mg of omega-3s (300 mg DHA, 200 mg EPA, 500 mg of others). After subjects were followed for a year, significant and fairly large improvements were found for omega-3s, relative to placebo, across a wide range of problems including aggression in addition to anxiety and depressive symptoms. One very interesting side note of this study was that the improvement in child behavior seemed to be partially mediated by improvements in the parents’ behavior, even though parents did not receive the supplements.

In attention-deficit/hyperactivity disorder, a meta-analysis of 10 clinical trials also was positive (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50[10]:991-1000). The effect size was small, but there seemed to be a dose effect with more positive trials related to higher daily doses of EPA. Side effects again were few.

The mechanism for improvement remains to be fully understood, although evidence points to changes in cell membrane fluidity and possible anti-inflammatory properties. The biggest question mark that remains from a practical standpoint is dose, both in absolute numbers and with regard to ratios of EPA to DHA. Given the vast number of suppliers of omega-3 supplementation and the wide range of quality with regard to accurate dosing and impurities, it also is important to help families identify a specific product that can be trusted.

Case follow-up

Somewhat to the surprise of Samantha’s mother, the pediatrician supports a trial of omega-3 supplementation, given the increasing evidence of efficacy and the favorable side effect profile. They discuss reasonable expectations, dosing, and ways that the family can obtain a high-quality supplement. Six months later, the family reports noticeable further improvements in Samantha’s behavior to the point that more aggressive psychopharmacologic treatment is not indicated currently.

In sum, it is reasonable to conclude at this point that evidence supporting omega-3 use for a variety of emotional-behavioral problems now equals or exceeds that for many off-label prescription medications that are now used in similar situations. This increasing evidence, combined with the low risk for most patients, would seem to warrant pediatricians considering omega-3 supplementation as a more mainstream and evidence-based intervention that deserves a place in one’s treatment algorithm for several emotional-behavioral concerns.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He will also be course director of the 10th annual Child Psychiatry in Primary Care conference on May 13, 2016, in Burlington. Follow him on Twitter @pedipsych.

Primary care clinicians have come to realize that a large percentage of patients use alternative or complementary approaches to many types of health problems, including emotional-behavioral ones.

Families often are reluctant to bring up these interventions in primary care appointments for fear that their doctor will criticize them for using unproven and sometimes risky treatments. When it comes to dietary supplements, the evidence for many is rather weak, while others have been studied in controlled trials and now may deserve a closer look. Omega-3 fatty acid supplementation for various types of psychiatric disorders and problems may be leading the pack as an alternative treatment that has earned the right to be on the radar screen of all pediatricians. This article briefly summarizes what scientific evidence exists about the efficacy of omega-3s in pediatric emotional-behavioral problems and where significant gaps in our knowledge remain.

Case summary

Samantha is an 11-year-old girl who was adopted into a loving and supportive family at the age of 4 years after having suffered a tumultuous early childhood that included domestic violence as well as physical and emotional abuse. Despite a much improved home environment, she has continued to struggle for many years with difficulties including inattention, emotional dysregulation, and aggression toward others. Samantha and her family have worked with a mental health counselor, and her pediatrician also has started her on pharmacotherapy with a stimulant medication and an alpha-agonist. Despite some gains, significant difficulties remain. At a follow-up visit, Samantha’s mother states that she has done some research on the Internet and has heard positive things about omega-3 fatty acid supplements. She wonders if this might be appropriate for Samantha and if so, how specifically the treatment would be administered.

Discussion

The possible benefits of omega-3s in the treatment of behavioral problems has been discussed for decades, and good evidence from rigorous trials has slowly been accumulating. In October 2015 at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers in a clinical trial called Omega-3 and Therapy Studies (OATS) presented some preliminary results to see if omega-3s could augment response in children aged 7-14 years with depression and bipolar spectrum disorders who also were receiving evidence-based psychotherapy. The daily dose was 2,000 mg, consisting of 1,400 mg of eicosapentaenoic acid (EPA), 200 mg of docosahexaenoic acid (DHA), and 400 mg of other omega-3s. Significant improvement of small to medium effect was found for omega-3s, particularly for depressive symptoms, and side effects were minimal.

Another relatively recent study from 2014 used a randomized double-blind design in 200 youth between the ages of 6 and 18 years from the island nation of Mauritius, near Madagascar (J Child Psychol Psychiatry. 2015 May;56[5]:509-20). The active treatment here was 1,000 mg of omega-3s (300 mg DHA, 200 mg EPA, 500 mg of others). After subjects were followed for a year, significant and fairly large improvements were found for omega-3s, relative to placebo, across a wide range of problems including aggression in addition to anxiety and depressive symptoms. One very interesting side note of this study was that the improvement in child behavior seemed to be partially mediated by improvements in the parents’ behavior, even though parents did not receive the supplements.

In attention-deficit/hyperactivity disorder, a meta-analysis of 10 clinical trials also was positive (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50[10]:991-1000). The effect size was small, but there seemed to be a dose effect with more positive trials related to higher daily doses of EPA. Side effects again were few.

The mechanism for improvement remains to be fully understood, although evidence points to changes in cell membrane fluidity and possible anti-inflammatory properties. The biggest question mark that remains from a practical standpoint is dose, both in absolute numbers and with regard to ratios of EPA to DHA. Given the vast number of suppliers of omega-3 supplementation and the wide range of quality with regard to accurate dosing and impurities, it also is important to help families identify a specific product that can be trusted.

Case follow-up

Somewhat to the surprise of Samantha’s mother, the pediatrician supports a trial of omega-3 supplementation, given the increasing evidence of efficacy and the favorable side effect profile. They discuss reasonable expectations, dosing, and ways that the family can obtain a high-quality supplement. Six months later, the family reports noticeable further improvements in Samantha’s behavior to the point that more aggressive psychopharmacologic treatment is not indicated currently.

In sum, it is reasonable to conclude at this point that evidence supporting omega-3 use for a variety of emotional-behavioral problems now equals or exceeds that for many off-label prescription medications that are now used in similar situations. This increasing evidence, combined with the low risk for most patients, would seem to warrant pediatricians considering omega-3 supplementation as a more mainstream and evidence-based intervention that deserves a place in one’s treatment algorithm for several emotional-behavioral concerns.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He will also be course director of the 10th annual Child Psychiatry in Primary Care conference on May 13, 2016, in Burlington. Follow him on Twitter @pedipsych.

Primary care clinicians have come to realize that a large percentage of patients use alternative or complementary approaches to many types of health problems, including emotional-behavioral ones.

Families often are reluctant to bring up these interventions in primary care appointments for fear that their doctor will criticize them for using unproven and sometimes risky treatments. When it comes to dietary supplements, the evidence for many is rather weak, while others have been studied in controlled trials and now may deserve a closer look. Omega-3 fatty acid supplementation for various types of psychiatric disorders and problems may be leading the pack as an alternative treatment that has earned the right to be on the radar screen of all pediatricians. This article briefly summarizes what scientific evidence exists about the efficacy of omega-3s in pediatric emotional-behavioral problems and where significant gaps in our knowledge remain.

Case summary

Samantha is an 11-year-old girl who was adopted into a loving and supportive family at the age of 4 years after having suffered a tumultuous early childhood that included domestic violence as well as physical and emotional abuse. Despite a much improved home environment, she has continued to struggle for many years with difficulties including inattention, emotional dysregulation, and aggression toward others. Samantha and her family have worked with a mental health counselor, and her pediatrician also has started her on pharmacotherapy with a stimulant medication and an alpha-agonist. Despite some gains, significant difficulties remain. At a follow-up visit, Samantha’s mother states that she has done some research on the Internet and has heard positive things about omega-3 fatty acid supplements. She wonders if this might be appropriate for Samantha and if so, how specifically the treatment would be administered.

Discussion

The possible benefits of omega-3s in the treatment of behavioral problems has been discussed for decades, and good evidence from rigorous trials has slowly been accumulating. In October 2015 at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers in a clinical trial called Omega-3 and Therapy Studies (OATS) presented some preliminary results to see if omega-3s could augment response in children aged 7-14 years with depression and bipolar spectrum disorders who also were receiving evidence-based psychotherapy. The daily dose was 2,000 mg, consisting of 1,400 mg of eicosapentaenoic acid (EPA), 200 mg of docosahexaenoic acid (DHA), and 400 mg of other omega-3s. Significant improvement of small to medium effect was found for omega-3s, particularly for depressive symptoms, and side effects were minimal.

Another relatively recent study from 2014 used a randomized double-blind design in 200 youth between the ages of 6 and 18 years from the island nation of Mauritius, near Madagascar (J Child Psychol Psychiatry. 2015 May;56[5]:509-20). The active treatment here was 1,000 mg of omega-3s (300 mg DHA, 200 mg EPA, 500 mg of others). After subjects were followed for a year, significant and fairly large improvements were found for omega-3s, relative to placebo, across a wide range of problems including aggression in addition to anxiety and depressive symptoms. One very interesting side note of this study was that the improvement in child behavior seemed to be partially mediated by improvements in the parents’ behavior, even though parents did not receive the supplements.

In attention-deficit/hyperactivity disorder, a meta-analysis of 10 clinical trials also was positive (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50[10]:991-1000). The effect size was small, but there seemed to be a dose effect with more positive trials related to higher daily doses of EPA. Side effects again were few.

The mechanism for improvement remains to be fully understood, although evidence points to changes in cell membrane fluidity and possible anti-inflammatory properties. The biggest question mark that remains from a practical standpoint is dose, both in absolute numbers and with regard to ratios of EPA to DHA. Given the vast number of suppliers of omega-3 supplementation and the wide range of quality with regard to accurate dosing and impurities, it also is important to help families identify a specific product that can be trusted.

Case follow-up

Somewhat to the surprise of Samantha’s mother, the pediatrician supports a trial of omega-3 supplementation, given the increasing evidence of efficacy and the favorable side effect profile. They discuss reasonable expectations, dosing, and ways that the family can obtain a high-quality supplement. Six months later, the family reports noticeable further improvements in Samantha’s behavior to the point that more aggressive psychopharmacologic treatment is not indicated currently.

In sum, it is reasonable to conclude at this point that evidence supporting omega-3 use for a variety of emotional-behavioral problems now equals or exceeds that for many off-label prescription medications that are now used in similar situations. This increasing evidence, combined with the low risk for most patients, would seem to warrant pediatricians considering omega-3 supplementation as a more mainstream and evidence-based intervention that deserves a place in one’s treatment algorithm for several emotional-behavioral concerns.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He will also be course director of the 10th annual Child Psychiatry in Primary Care conference on May 13, 2016, in Burlington. Follow him on Twitter @pedipsych.

I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.

Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.

There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.

Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.

Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.

These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.

In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.

Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.

There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.

Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.

Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.

These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.

In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.

Dr. Chan practices rheumatology in Pawtucket, R.I.

I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.

Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.

There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.

Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.

Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.

These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.

In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.

Dr. Chan practices rheumatology in Pawtucket, R.I.

The ongoing sea change in medicine has led to a substantial erosion of physician autonomy and to ever-increasing administrative burdens that hit small practices the hardest. Does this mean that the independent private physician practice model is doomed, as some predict? Absolutely not; but it will force many solo practitioners and small groups to join forces to protect themselves.

Those practices that offer unique services, or fill an unmet niche, may be able to remain small; but most smaller practices will need to consider a larger alternative. In my last column, I outlined the basics of arriving at a fair market value for a private practice; once that has been accomplished, you will be in a position to consider the various merger options that are available.

One attractive and relatively straightforward strategy is the formation of a cooperative group. In most areas, there are very likely several small practices in similar predicaments that might be receptive to discussing a collaboration on billing and purchasing. This allows each participant to maintain independence as a private practice, while pooling resources to ease the administrative burdens of all. Once that arrangement is in place, the group can consider more ambitious projects, such as the joint purchase of an integrated electronic health records (EHR) network, sharing personnel to lower staffing costs, and an integrated scheduling system. The latter will be particularly attractive to participants in later stages of their careers who are considering an intermediate option, somewhere between full-time work and complete retirement.

After a time, when the structure is stabilized and everyone agrees that his or her individual and shared interests and goals are being met, an outright merger can be contemplated. Obviously, projects of this scope require careful planning and implementation, and should not be undertaken without the help of competent legal counsel and an experienced business consultant.

A more complex but increasingly popular option is to join other small practices and providers in an independent practice association. An IPA is a legal entity, organized and directed by physicians for the purpose of negotiating contracts with insurance companies on their behalf. Because of its structure, an IPA is better positioned to enter into such financial arrangements and to counterbalance the leverage of insurers; but there are legal issues to consider. Many IPAs are vulnerable to antitrust charges because they include competing health care providers. You should check with legal counsel before signing on to an IPA, to make sure that it abides by antitrust and price fixing laws. IPAs have also been known to fail, particularly in states where they are not adequately regulated.

One proposed successor to the IPA is the accountable care organization (ACO), an entity born as a component of the Affordable Care Act. While the official definition remains nebulous, an ACO is basically a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated and efficient care to patients. The goal of ACO participators is to limit unnecessary spending, both individually and collectively, according to criteria established by the Centers for Medicare & Medicaid Services (CMS), without compromising quality of care in the process. More than 600 ACOs had been approved by the CMS as of the beginning of 2014.

As the name implies, ACOs make providers jointly accountable for the health of their patients; they offer financial incentives to cooperate and to save money by avoiding unnecessary tests and procedures. A key component is the sharing of information. Providers that save money while also meeting quality targets are theoretically entitled to a portion of the savings.

As with IPAs, ACO ventures involve a measure of risk. ACOs that fail to meet the CMS performance and savings benchmarks can be stuck with the bill for investments made to improve care, such as equipment and computer purchases, and the hiring of mid-level providers and managers, and may be assessed monetary penalties as well. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help finance infrastructure investments – a concession the Obama administration made after receiving complaints from rural hospitals. It is important to remember that the ACO model remains very much a work in progress.

Clearly, the price of remaining autonomous will be significant, and many private practitioners will be unwilling to pay it: Only 36% of physicians remained in independent practice at the end of the 2013, according to data from the American Medical Association – down from 57% in 2000; but those of us who remain committed to independence will find ways to preserve it, by mergers or other methods. In medicine, as in life, those most responsive to change will survive and flourish.

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

The ongoing sea change in medicine has led to a substantial erosion of physician autonomy and to ever-increasing administrative burdens that hit small practices the hardest. Does this mean that the independent private physician practice model is doomed, as some predict? Absolutely not; but it will force many solo practitioners and small groups to join forces to protect themselves.

Those practices that offer unique services, or fill an unmet niche, may be able to remain small; but most smaller practices will need to consider a larger alternative. In my last column, I outlined the basics of arriving at a fair market value for a private practice; once that has been accomplished, you will be in a position to consider the various merger options that are available.

One attractive and relatively straightforward strategy is the formation of a cooperative group. In most areas, there are very likely several small practices in similar predicaments that might be receptive to discussing a collaboration on billing and purchasing. This allows each participant to maintain independence as a private practice, while pooling resources to ease the administrative burdens of all. Once that arrangement is in place, the group can consider more ambitious projects, such as the joint purchase of an integrated electronic health records (EHR) network, sharing personnel to lower staffing costs, and an integrated scheduling system. The latter will be particularly attractive to participants in later stages of their careers who are considering an intermediate option, somewhere between full-time work and complete retirement.

After a time, when the structure is stabilized and everyone agrees that his or her individual and shared interests and goals are being met, an outright merger can be contemplated. Obviously, projects of this scope require careful planning and implementation, and should not be undertaken without the help of competent legal counsel and an experienced business consultant.

A more complex but increasingly popular option is to join other small practices and providers in an independent practice association. An IPA is a legal entity, organized and directed by physicians for the purpose of negotiating contracts with insurance companies on their behalf. Because of its structure, an IPA is better positioned to enter into such financial arrangements and to counterbalance the leverage of insurers; but there are legal issues to consider. Many IPAs are vulnerable to antitrust charges because they include competing health care providers. You should check with legal counsel before signing on to an IPA, to make sure that it abides by antitrust and price fixing laws. IPAs have also been known to fail, particularly in states where they are not adequately regulated.

One proposed successor to the IPA is the accountable care organization (ACO), an entity born as a component of the Affordable Care Act. While the official definition remains nebulous, an ACO is basically a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated and efficient care to patients. The goal of ACO participators is to limit unnecessary spending, both individually and collectively, according to criteria established by the Centers for Medicare & Medicaid Services (CMS), without compromising quality of care in the process. More than 600 ACOs had been approved by the CMS as of the beginning of 2014.

As the name implies, ACOs make providers jointly accountable for the health of their patients; they offer financial incentives to cooperate and to save money by avoiding unnecessary tests and procedures. A key component is the sharing of information. Providers that save money while also meeting quality targets are theoretically entitled to a portion of the savings.

As with IPAs, ACO ventures involve a measure of risk. ACOs that fail to meet the CMS performance and savings benchmarks can be stuck with the bill for investments made to improve care, such as equipment and computer purchases, and the hiring of mid-level providers and managers, and may be assessed monetary penalties as well. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help finance infrastructure investments – a concession the Obama administration made after receiving complaints from rural hospitals. It is important to remember that the ACO model remains very much a work in progress.

Clearly, the price of remaining autonomous will be significant, and many private practitioners will be unwilling to pay it: Only 36% of physicians remained in independent practice at the end of the 2013, according to data from the American Medical Association – down from 57% in 2000; but those of us who remain committed to independence will find ways to preserve it, by mergers or other methods. In medicine, as in life, those most responsive to change will survive and flourish.

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

The ongoing sea change in medicine has led to a substantial erosion of physician autonomy and to ever-increasing administrative burdens that hit small practices the hardest. Does this mean that the independent private physician practice model is doomed, as some predict? Absolutely not; but it will force many solo practitioners and small groups to join forces to protect themselves.

Those practices that offer unique services, or fill an unmet niche, may be able to remain small; but most smaller practices will need to consider a larger alternative. In my last column, I outlined the basics of arriving at a fair market value for a private practice; once that has been accomplished, you will be in a position to consider the various merger options that are available.

One attractive and relatively straightforward strategy is the formation of a cooperative group. In most areas, there are very likely several small practices in similar predicaments that might be receptive to discussing a collaboration on billing and purchasing. This allows each participant to maintain independence as a private practice, while pooling resources to ease the administrative burdens of all. Once that arrangement is in place, the group can consider more ambitious projects, such as the joint purchase of an integrated electronic health records (EHR) network, sharing personnel to lower staffing costs, and an integrated scheduling system. The latter will be particularly attractive to participants in later stages of their careers who are considering an intermediate option, somewhere between full-time work and complete retirement.

After a time, when the structure is stabilized and everyone agrees that his or her individual and shared interests and goals are being met, an outright merger can be contemplated. Obviously, projects of this scope require careful planning and implementation, and should not be undertaken without the help of competent legal counsel and an experienced business consultant.

A more complex but increasingly popular option is to join other small practices and providers in an independent practice association. An IPA is a legal entity, organized and directed by physicians for the purpose of negotiating contracts with insurance companies on their behalf. Because of its structure, an IPA is better positioned to enter into such financial arrangements and to counterbalance the leverage of insurers; but there are legal issues to consider. Many IPAs are vulnerable to antitrust charges because they include competing health care providers. You should check with legal counsel before signing on to an IPA, to make sure that it abides by antitrust and price fixing laws. IPAs have also been known to fail, particularly in states where they are not adequately regulated.

One proposed successor to the IPA is the accountable care organization (ACO), an entity born as a component of the Affordable Care Act. While the official definition remains nebulous, an ACO is basically a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated and efficient care to patients. The goal of ACO participators is to limit unnecessary spending, both individually and collectively, according to criteria established by the Centers for Medicare & Medicaid Services (CMS), without compromising quality of care in the process. More than 600 ACOs had been approved by the CMS as of the beginning of 2014.

As the name implies, ACOs make providers jointly accountable for the health of their patients; they offer financial incentives to cooperate and to save money by avoiding unnecessary tests and procedures. A key component is the sharing of information. Providers that save money while also meeting quality targets are theoretically entitled to a portion of the savings.

As with IPAs, ACO ventures involve a measure of risk. ACOs that fail to meet the CMS performance and savings benchmarks can be stuck with the bill for investments made to improve care, such as equipment and computer purchases, and the hiring of mid-level providers and managers, and may be assessed monetary penalties as well. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help finance infrastructure investments – a concession the Obama administration made after receiving complaints from rural hospitals. It is important to remember that the ACO model remains very much a work in progress.

Clearly, the price of remaining autonomous will be significant, and many private practitioners will be unwilling to pay it: Only 36% of physicians remained in independent practice at the end of the 2013, according to data from the American Medical Association – down from 57% in 2000; but those of us who remain committed to independence will find ways to preserve it, by mergers or other methods. In medicine, as in life, those most responsive to change will survive and flourish.

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

Busy day at the office. Five different people asked when I plan to retire.

Dennis was first. I last saw him a year ago, as I’d been doing annually for 25 years. A few months later, he asked to have his records sent to his home. There was no obvious reason. Now he was back.

“I had an eventful year, medically,” he said. “You know, that biopsy you did on my nose was precancerous.”

I did know that. I had called him with the results. It was an actinic keratosis. I’d asked him to come back in a few months for me to recheck the area.

“I went to see another doctor,” he said. “He gave me a cream that made my skin turn red. I think it worked.”

It must have. After all, the keratosis had already been removed.

“But I didn’t like his office,” said Dennis, “so I decided to come back to you.”

Touching, I thought. “Nice to see you,” I said.

“I wanted a younger doctor,” said Dennis. “Someone who would be around for a while.”

“Well, I’m not planning to retire just yet.”

“Everyone retires eventually,” said Dennis.

“Yes,” I agreed. “I guess they do. See you next year.” Perhaps.

Well, that felt pretty good. Then I went in to see Phil.

“Good morning,” he said. “Are you thinking about retiring?”

“Not really,” I said.

“How old are you?” asked Phil.

“68,” I said.

Phil took a long look at me. “You look good,” he decided.

You don’t have to sound so surprised, I thought.

An hour later I saw Emma.

“I see you haven’t retired yet,” she said.

“No,” I replied. “It seems I haven’t. Would you like me to?”

“Oh, no!” said Emma. “I was just wondering. A lot of my doctors have been retiring.”

There it was. Fear of abandonment. Who will be there for me? I wanted to hold Emma’s hand and assure her that when the time came, someone would indeed be there for her when I wasn’t. But I didn’t. Like grown children, patients have to find out things like that for themselves.

A little later Mabel came by. Her rash was worrying her. “I saw a couple of doctors about it, but they didn’t seem to know what it was,” she said.

“It’s eczema,” I told her. “This is what I suggest you do.” I made some suggestions.

“I was here once before,” she said, “in the 80s. Then, when I couldn’t figure out what this rash I have was, I remembered your name. ‘No,’ I thought to myself. ‘He couldn’t possibly still be practicing.’ And then I found out that you were!”

Well, there you go.

This kind of thing can give you a complex. If so many people are surprised that you’re around, maybe you shouldn’t be. But the best was yet to come.

The last patient of the day was Jenna.

I introduced myself. “How did you get my name?” I asked. Nowadays, the most common answer I get goes something like, “I Googled you. I recognized your address and you got decent reviews.”

But Jenna answered, “My sister came here 10 years ago. She used to be a patient of Dr. Alvin Sherwin.”

“I took over Dr. Sherwin’s practice when he moved to Florida,” I told her. “That was in 1981, so it’s closer to 35 years ago, not 10.”

“My goodness,” she said. “That explains what my sister said.”

“What did your sister say?”

“Well, my mother found your name on a piece of paper. My mother likes to hold onto things.”

“I’ll say she does,” I said.

“My mother said, ‘Why don’t you call this guy Rockoff? He took care of your sister. He’s very good.’ So I looked you up and found your office.

“Anyway,” Jenna went on, “when I told my sister that I found you, she said, ‘Yes, I remember seeing him. You mean he’s still around? After all these years, I figured he was probably dead.’ ”

“Nope,” I said. “Not yet.”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Busy day at the office. Five different people asked when I plan to retire.

Dennis was first. I last saw him a year ago, as I’d been doing annually for 25 years. A few months later, he asked to have his records sent to his home. There was no obvious reason. Now he was back.

“I had an eventful year, medically,” he said. “You know, that biopsy you did on my nose was precancerous.”

I did know that. I had called him with the results. It was an actinic keratosis. I’d asked him to come back in a few months for me to recheck the area.

“I went to see another doctor,” he said. “He gave me a cream that made my skin turn red. I think it worked.”

It must have. After all, the keratosis had already been removed.

“But I didn’t like his office,” said Dennis, “so I decided to come back to you.”

Touching, I thought. “Nice to see you,” I said.

“I wanted a younger doctor,” said Dennis. “Someone who would be around for a while.”

“Well, I’m not planning to retire just yet.”

“Everyone retires eventually,” said Dennis.

“Yes,” I agreed. “I guess they do. See you next year.” Perhaps.

Well, that felt pretty good. Then I went in to see Phil.

“Good morning,” he said. “Are you thinking about retiring?”

“Not really,” I said.

“How old are you?” asked Phil.

“68,” I said.

Phil took a long look at me. “You look good,” he decided.

You don’t have to sound so surprised, I thought.

An hour later I saw Emma.

“I see you haven’t retired yet,” she said.

“No,” I replied. “It seems I haven’t. Would you like me to?”

“Oh, no!” said Emma. “I was just wondering. A lot of my doctors have been retiring.”

There it was. Fear of abandonment. Who will be there for me? I wanted to hold Emma’s hand and assure her that when the time came, someone would indeed be there for her when I wasn’t. But I didn’t. Like grown children, patients have to find out things like that for themselves.

A little later Mabel came by. Her rash was worrying her. “I saw a couple of doctors about it, but they didn’t seem to know what it was,” she said.

“It’s eczema,” I told her. “This is what I suggest you do.” I made some suggestions.

“I was here once before,” she said, “in the 80s. Then, when I couldn’t figure out what this rash I have was, I remembered your name. ‘No,’ I thought to myself. ‘He couldn’t possibly still be practicing.’ And then I found out that you were!”

Well, there you go.

This kind of thing can give you a complex. If so many people are surprised that you’re around, maybe you shouldn’t be. But the best was yet to come.

The last patient of the day was Jenna.

I introduced myself. “How did you get my name?” I asked. Nowadays, the most common answer I get goes something like, “I Googled you. I recognized your address and you got decent reviews.”

But Jenna answered, “My sister came here 10 years ago. She used to be a patient of Dr. Alvin Sherwin.”

“I took over Dr. Sherwin’s practice when he moved to Florida,” I told her. “That was in 1981, so it’s closer to 35 years ago, not 10.”

“My goodness,” she said. “That explains what my sister said.”

“What did your sister say?”

“Well, my mother found your name on a piece of paper. My mother likes to hold onto things.”

“I’ll say she does,” I said.

“My mother said, ‘Why don’t you call this guy Rockoff? He took care of your sister. He’s very good.’ So I looked you up and found your office.

“Anyway,” Jenna went on, “when I told my sister that I found you, she said, ‘Yes, I remember seeing him. You mean he’s still around? After all these years, I figured he was probably dead.’ ”

“Nope,” I said. “Not yet.”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Busy day at the office. Five different people asked when I plan to retire.

Dennis was first. I last saw him a year ago, as I’d been doing annually for 25 years. A few months later, he asked to have his records sent to his home. There was no obvious reason. Now he was back.

“I had an eventful year, medically,” he said. “You know, that biopsy you did on my nose was precancerous.”

I did know that. I had called him with the results. It was an actinic keratosis. I’d asked him to come back in a few months for me to recheck the area.

“I went to see another doctor,” he said. “He gave me a cream that made my skin turn red. I think it worked.”

It must have. After all, the keratosis had already been removed.

“But I didn’t like his office,” said Dennis, “so I decided to come back to you.”

Touching, I thought. “Nice to see you,” I said.

“I wanted a younger doctor,” said Dennis. “Someone who would be around for a while.”

“Well, I’m not planning to retire just yet.”

“Everyone retires eventually,” said Dennis.

“Yes,” I agreed. “I guess they do. See you next year.” Perhaps.

Well, that felt pretty good. Then I went in to see Phil.

“Good morning,” he said. “Are you thinking about retiring?”

“Not really,” I said.

“How old are you?” asked Phil.

“68,” I said.

Phil took a long look at me. “You look good,” he decided.

You don’t have to sound so surprised, I thought.

An hour later I saw Emma.

“I see you haven’t retired yet,” she said.

“No,” I replied. “It seems I haven’t. Would you like me to?”

“Oh, no!” said Emma. “I was just wondering. A lot of my doctors have been retiring.”

There it was. Fear of abandonment. Who will be there for me? I wanted to hold Emma’s hand and assure her that when the time came, someone would indeed be there for her when I wasn’t. But I didn’t. Like grown children, patients have to find out things like that for themselves.

A little later Mabel came by. Her rash was worrying her. “I saw a couple of doctors about it, but they didn’t seem to know what it was,” she said.

“It’s eczema,” I told her. “This is what I suggest you do.” I made some suggestions.

“I was here once before,” she said, “in the 80s. Then, when I couldn’t figure out what this rash I have was, I remembered your name. ‘No,’ I thought to myself. ‘He couldn’t possibly still be practicing.’ And then I found out that you were!”

Well, there you go.

This kind of thing can give you a complex. If so many people are surprised that you’re around, maybe you shouldn’t be. But the best was yet to come.

The last patient of the day was Jenna.

I introduced myself. “How did you get my name?” I asked. Nowadays, the most common answer I get goes something like, “I Googled you. I recognized your address and you got decent reviews.”

But Jenna answered, “My sister came here 10 years ago. She used to be a patient of Dr. Alvin Sherwin.”

“I took over Dr. Sherwin’s practice when he moved to Florida,” I told her. “That was in 1981, so it’s closer to 35 years ago, not 10.”

“My goodness,” she said. “That explains what my sister said.”

“What did your sister say?”

“Well, my mother found your name on a piece of paper. My mother likes to hold onto things.”

“I’ll say she does,” I said.

“My mother said, ‘Why don’t you call this guy Rockoff? He took care of your sister. He’s very good.’ So I looked you up and found your office.

“Anyway,” Jenna went on, “when I told my sister that I found you, she said, ‘Yes, I remember seeing him. You mean he’s still around? After all these years, I figured he was probably dead.’ ”

“Nope,” I said. “Not yet.”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).

In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.

The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.

Tobacco use by sexual identity

Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15[11]:1822-31).

This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.

However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.

©pmphoto/ iStockphoto.com

Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.

Practical next steps for your practice

One approach to addressing tobacco use with your patients is to implement the “5 A’s”:

1.  Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.

2.  Advise. In clear, strong, personalized language, urge the tobacco user to quit.

3.  Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.

4.  Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.

5.  Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.

The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134[3]:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.

Dr. Tierney is a Washington-based pediatrician who is a member of the Institute for Public Health Innovation and the D.C. Primary Care Association Medicaid Financing Task Force on Medicaid payment for community health workers. She also works with Howard University Hospital’s Cancer Center on tobacco use avoidance and/or cessation by African American youth. She is on the board of Whitman-Walker Health to advise on Medicaid payment and sits on the quality assurance committee.

Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).

In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.

The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.

Tobacco use by sexual identity

Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15[11]:1822-31).

This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.

However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.

©pmphoto/ iStockphoto.com

Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.

Practical next steps for your practice

One approach to addressing tobacco use with your patients is to implement the “5 A’s”:

1.  Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.

2.  Advise. In clear, strong, personalized language, urge the tobacco user to quit.

3.  Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.

4.  Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.

5.  Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.

The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134[3]:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.

Dr. Tierney is a Washington-based pediatrician who is a member of the Institute for Public Health Innovation and the D.C. Primary Care Association Medicaid Financing Task Force on Medicaid payment for community health workers. She also works with Howard University Hospital’s Cancer Center on tobacco use avoidance and/or cessation by African American youth. She is on the board of Whitman-Walker Health to advise on Medicaid payment and sits on the quality assurance committee.

Tobacco addiction and smoke exposure are among the leading causes of preventable and premature death and disability in the United States and elsewhere in the world. The landmark 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, stated, “The vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.” All youth are at risk for experimenting and using “standard” tobacco products, as well as relatively new merchandise such as e-cigarettes, hookas, bidis (small, hand-rolled cigarettes), and little cigars (Pediatrics. 2013 Aug 5;132:e578-86). In a 2015 article, data show more than twice as many youth use two or more types of tobacco products than use cigarettes alone (Pediatrics. 2015 March;135:409-15).

In a 2015 American Academy of Pediatrics policy statement, the academy stated that all children, adolescents, and young adults must be safeguarded from using all of the various tobacco products (Pediatrics. 2015 Oct 26. doi: 10.1542/peds.2015-3108). Therefore, a working knowledge of the various types of products is essential when speaking with youth on this subject.

The AAP recommended that all children and youth, without exception, must be considered to be at risk for using tobacco products. Therefore, all youth should be counseled, as the AAP made no exceptions with regard to race, national origin, ethnic group, socioeconomic status, or membership in the LGBT community.

Tobacco use by sexual identity

Much more needs to be known with regard to tobacco use for all children, youth, and young adults. National surveillance data are needed for the LGBT community, whose members have unique health care needs. A 2013 article demonstrated disparities in the use of tobacco products in young adults in the LGBT community (Nicotine Tob Res. 2013;15[11]:1822-31).

This study used data from the American Legacy Foundation’s Young Adult Study. The survey compared the use of tobacco by the LGBT community versus the heterosexual community during the previous 30-day period. The prevalence of use of tobacco products for young adults who self-identified as sexual minorities was statistically higher than for their heterosexual counterparts. For example, current use of tobacco products was 22% in heterosexual young adults, compared with 35% in young adults who identified as homosexual and 31% in young adults who identified as bisexual.

However, this same publication stated that there are very few studies on this subject, including why there are these disparities. This information is important to know so better approaches can be developed to address these issues. In addition, health care providers must address the issue of tobacco use by youth and young adults, and develop specific approaches that can specifically target at-risk populations that are culturally competent. The authors concluded that it remains unclear why the tobacco use rate among the LGBT community is significantly higher than in their peers who are heterosexual. Risk factors that have been posited include social stigma, the role of bars in this community, and alcohol and drug use. Also, social acceptance issues, inclusion issues, alienation and depression, and marketing by tobacco manufacturers may be risk factors.

©pmphoto/ iStockphoto.com

Much work remains to be done to address these risk factors and, therefore, the use of tobacco and similar drugs. The 2012 surgeon general’s report emphasized that health care providers of young people must address these issues directly and consistently with their patients.

Practical next steps for your practice

One approach to addressing tobacco use with your patients is to implement the “5 A’s”:

1.  Anticipate/Ask. Ask young people if they or their friends are interested in tobacco products and/or if they use tobacco products of any type. Do this at every visit.

2.  Advise. In clear, strong, personalized language, urge the tobacco user to quit.

3.  Assess. Assess the willingness of the tobacco user to quit, and urge the youth to quit smoking.

4.  Assist. For the youth willing to quit, use counseling yourself and/or refer for counseling to individuals with expertise in tobacco cessation or support groups, and consider pharmacotherapy if necessary.

5.  Arrange. Schedule a follow-up contact in person within the first week and then on a regularly scheduled basis.

The 5 A’s have been recognized by the Agency for Healthcare Research and Quality as an evidence-based practice for both adult and pediatric patients. In a 2014 article, Dr. Jonathan Klein reported on a study of youth who had seen a clinician for a preventive visit within the past year. However, the youth also reported that the rate of their receiving counseling on tobacco use was relatively low (Pediatrics. 2014 Sep;134[3]:600-1) Most recently, Howard University completed a project funded by the District of Columbia Department of Health to develop and teach a curriculum for medical and nursing students, residents, and physician and nursing staff on this important issue. The youth whom we interviewed in developing the curriculum reported that they had never received counseling by health professionals during their preventive health care visits. This important issue needs to be addressed because it truly is a key to future health for our children and youth.

Dr. Tierney is a Washington-based pediatrician who is a member of the Institute for Public Health Innovation and the D.C. Primary Care Association Medicaid Financing Task Force on Medicaid payment for community health workers. She also works with Howard University Hospital’s Cancer Center on tobacco use avoidance and/or cessation by African American youth. She is on the board of Whitman-Walker Health to advise on Medicaid payment and sits on the quality assurance committee.