Commentary

Recently I received a lengthy e-mail from a very worried woman. She claimed to be an established patient in my office, which I had no way of confirming because she did not sign her message. She asked many questions about sexually transmitted diseases and how they might affect her and a new boyfriend.

I was undecided on how to reply – or even whether to reply at all – so I queried several dozen dermatology colleagues around the country, as well as a few physician friends and acquaintances in other specialties.

Responses varied all over the map – from “I never answer patient e-mails,” to “What harm could it do, she’s better off getting correct answers from you than incorrect answers from some ‘advocacy’ web site” – and everything in between.

Clearly, this is a controversial issue which will only get more controversial in the future, so I decided to look at what has been published on the subject.

It turns out that as early as 1998, a group of investigators asked this same question and designed a study to address it. (Eysenbach and Diepgen: “Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA. 1998;280[15]:1333-5). Posing as a fictitious patient, they sent e-mails to random dermatologists describing an acute dermatological problem, tallied the responses they received, and followed up with a questionnaire to responders and nonresponders alike.

As with my informal survey, the authors found what they termed “a striking lack of consensus” on how to deal with this situation: Fifty percent responded to the fictitious patient’s e-mail. Of those, 31% refused to give advice without seeing the patient, but 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to the questionnaire, 28% said that they tended not to answer any patient e-mails, 24% said they usually replied with a standard message, and 24% said they answer each request individually. The authors concluded that “standards for physician response to unsolicited patient e-mail are needed.”

Indeed; but my own survey suggests that, 17 years later, there is still nothing resembling a consensus on this issue. In the interim, several groups, including the American Medical Informatics Association, Medem, and the AMA have proposed guidelines; but none have been generally accepted.

Until such time as that happens, it seems advisable for each individual practice to take the time to adopt its own guidelines. For ideas, take a look at the examples I’ve listed, plus any others you can find. When you’re done, consider running your list past your lawyer to make sure you haven’t forgotten anything, and that there are no peculiar requirements in your state.

Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. But all guidelines should cover such issues of authentication of patient correspondents, informed consent of those patients, licensing jurisdiction (if you receive e-mails from states in which you are not licensed), and above all, confidentiality.

Contrary to popular belief, the Health Insurance Portability and Accountability Act (HIPAA) does not prohibit such communication, nor require that it be encrypted. The HIPAA website says, “Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”

Still, if the lack of encryption and other privacy safeguards makes you (or your patients) uncomfortable, encryption software can be added to your practice’s e-mail system. Enli (www.enli.net), Sigaba (www.sigaba.com), Tumbleweed (www.axway.com), Zix (www.zixcorp.com), and many other vendors sell encryption packages. (As always, I have no financial interest in any product or enterprise mentioned in this column.)

But rather than simply encrypting your e-mail, consider adopting web-based messaging. Patients enter your web site and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can be accessed only by the patient. Besides enhancing privacy and security, you can state your guidelines in plain English to preclude any misunderstanding of what you will and will not address online.

Web-based messaging services can be freestanding or incorporated into existing secure websites. Medfusion (www.medfusion.net), and RelayHealth (www.relayhealth.com) are among the leading vendors of secure messaging services.

As for the e-mail query which triggered all this: I responded, but I told the patient I could not provide specific answers to such personal questions over the Internet, particularly when they were asked anonymously; but I would be happy to address her concerns in person, in my office.

And now, I’m writing my guidelines.

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.

Recently I received a lengthy e-mail from a very worried woman. She claimed to be an established patient in my office, which I had no way of confirming because she did not sign her message. She asked many questions about sexually transmitted diseases and how they might affect her and a new boyfriend.

I was undecided on how to reply – or even whether to reply at all – so I queried several dozen dermatology colleagues around the country, as well as a few physician friends and acquaintances in other specialties.

Responses varied all over the map – from “I never answer patient e-mails,” to “What harm could it do, she’s better off getting correct answers from you than incorrect answers from some ‘advocacy’ web site” – and everything in between.

Clearly, this is a controversial issue which will only get more controversial in the future, so I decided to look at what has been published on the subject.

It turns out that as early as 1998, a group of investigators asked this same question and designed a study to address it. (Eysenbach and Diepgen: “Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA. 1998;280[15]:1333-5). Posing as a fictitious patient, they sent e-mails to random dermatologists describing an acute dermatological problem, tallied the responses they received, and followed up with a questionnaire to responders and nonresponders alike.

As with my informal survey, the authors found what they termed “a striking lack of consensus” on how to deal with this situation: Fifty percent responded to the fictitious patient’s e-mail. Of those, 31% refused to give advice without seeing the patient, but 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to the questionnaire, 28% said that they tended not to answer any patient e-mails, 24% said they usually replied with a standard message, and 24% said they answer each request individually. The authors concluded that “standards for physician response to unsolicited patient e-mail are needed.”

Indeed; but my own survey suggests that, 17 years later, there is still nothing resembling a consensus on this issue. In the interim, several groups, including the American Medical Informatics Association, Medem, and the AMA have proposed guidelines; but none have been generally accepted.

Until such time as that happens, it seems advisable for each individual practice to take the time to adopt its own guidelines. For ideas, take a look at the examples I’ve listed, plus any others you can find. When you’re done, consider running your list past your lawyer to make sure you haven’t forgotten anything, and that there are no peculiar requirements in your state.

Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. But all guidelines should cover such issues of authentication of patient correspondents, informed consent of those patients, licensing jurisdiction (if you receive e-mails from states in which you are not licensed), and above all, confidentiality.

Contrary to popular belief, the Health Insurance Portability and Accountability Act (HIPAA) does not prohibit such communication, nor require that it be encrypted. The HIPAA website says, “Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”

Still, if the lack of encryption and other privacy safeguards makes you (or your patients) uncomfortable, encryption software can be added to your practice’s e-mail system. Enli (www.enli.net), Sigaba (www.sigaba.com), Tumbleweed (www.axway.com), Zix (www.zixcorp.com), and many other vendors sell encryption packages. (As always, I have no financial interest in any product or enterprise mentioned in this column.)

But rather than simply encrypting your e-mail, consider adopting web-based messaging. Patients enter your web site and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can be accessed only by the patient. Besides enhancing privacy and security, you can state your guidelines in plain English to preclude any misunderstanding of what you will and will not address online.

Web-based messaging services can be freestanding or incorporated into existing secure websites. Medfusion (www.medfusion.net), and RelayHealth (www.relayhealth.com) are among the leading vendors of secure messaging services.

As for the e-mail query which triggered all this: I responded, but I told the patient I could not provide specific answers to such personal questions over the Internet, particularly when they were asked anonymously; but I would be happy to address her concerns in person, in my office.

And now, I’m writing my guidelines.

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.

Recently I received a lengthy e-mail from a very worried woman. She claimed to be an established patient in my office, which I had no way of confirming because she did not sign her message. She asked many questions about sexually transmitted diseases and how they might affect her and a new boyfriend.

I was undecided on how to reply – or even whether to reply at all – so I queried several dozen dermatology colleagues around the country, as well as a few physician friends and acquaintances in other specialties.

Responses varied all over the map – from “I never answer patient e-mails,” to “What harm could it do, she’s better off getting correct answers from you than incorrect answers from some ‘advocacy’ web site” – and everything in between.

Clearly, this is a controversial issue which will only get more controversial in the future, so I decided to look at what has been published on the subject.

It turns out that as early as 1998, a group of investigators asked this same question and designed a study to address it. (Eysenbach and Diepgen: “Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA. 1998;280[15]:1333-5). Posing as a fictitious patient, they sent e-mails to random dermatologists describing an acute dermatological problem, tallied the responses they received, and followed up with a questionnaire to responders and nonresponders alike.

As with my informal survey, the authors found what they termed “a striking lack of consensus” on how to deal with this situation: Fifty percent responded to the fictitious patient’s e-mail. Of those, 31% refused to give advice without seeing the patient, but 59% offered a diagnosis, and a third of that group went on to provide specific advice about therapy. In response to the questionnaire, 28% said that they tended not to answer any patient e-mails, 24% said they usually replied with a standard message, and 24% said they answer each request individually. The authors concluded that “standards for physician response to unsolicited patient e-mail are needed.”

Indeed; but my own survey suggests that, 17 years later, there is still nothing resembling a consensus on this issue. In the interim, several groups, including the American Medical Informatics Association, Medem, and the AMA have proposed guidelines; but none have been generally accepted.

Until such time as that happens, it seems advisable for each individual practice to take the time to adopt its own guidelines. For ideas, take a look at the examples I’ve listed, plus any others you can find. When you’re done, consider running your list past your lawyer to make sure you haven’t forgotten anything, and that there are no peculiar requirements in your state.

Your guidelines may be very simple (if you decide never to answer any queries) or very complex, depending on your situation and personal philosophy. But all guidelines should cover such issues of authentication of patient correspondents, informed consent of those patients, licensing jurisdiction (if you receive e-mails from states in which you are not licensed), and above all, confidentiality.

Contrary to popular belief, the Health Insurance Portability and Accountability Act (HIPAA) does not prohibit such communication, nor require that it be encrypted. The HIPAA website says, “Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual.”

Still, if the lack of encryption and other privacy safeguards makes you (or your patients) uncomfortable, encryption software can be added to your practice’s e-mail system. Enli (www.enli.net), Sigaba (www.sigaba.com), Tumbleweed (www.axway.com), Zix (www.zixcorp.com), and many other vendors sell encryption packages. (As always, I have no financial interest in any product or enterprise mentioned in this column.)

But rather than simply encrypting your e-mail, consider adopting web-based messaging. Patients enter your web site and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can be accessed only by the patient. Besides enhancing privacy and security, you can state your guidelines in plain English to preclude any misunderstanding of what you will and will not address online.

Web-based messaging services can be freestanding or incorporated into existing secure websites. Medfusion (www.medfusion.net), and RelayHealth (www.relayhealth.com) are among the leading vendors of secure messaging services.

As for the e-mail query which triggered all this: I responded, but I told the patient I could not provide specific answers to such personal questions over the Internet, particularly when they were asked anonymously; but I would be happy to address her concerns in person, in my office.

And now, I’m writing my guidelines.

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.

Recently, I was amazed to see a small walk-in booth with a webcam, a monitor, and a curtain, offering telemedicine consults from the comfort of a service station on I-95. Pandora’s Box, I thought.

The robots are coming! Take a dip into popular science fiction if you don’t believe me. From Asimov to “Star Wars,” there are innumerable examples of aseptic, polite automatons providing prompt, unbiased, unfatigued medical care. People have always been enamored by such visions of the future. And booths like this are the gateway to that vision. As excited as I am about this tremendous advance and the potential it holds, I can’t help but feel that when this new frontier of medicine reaches fruition, we will have lost something, too.

Medical education is exacting, exciting, and at times, excruciating. But above all, the privileged experience of learning about the inner workings of the body is an innately human process. Looking back, it’s not syndromes, numbers, or dosages I remember, but the colorful spectrum of characters I encountered along the way. We’ve all met them – the funny, the quirky, the warm, the gentle, the stern, the phlegmatic, the intermittently explosive, the socially inept, the obliviously savant, and occasionally, the frankly sociopathic. They are the ones who teach us how the science of medicine connects with the art of healing. Our bedside manners and critical thinking processes are molded by the intercourse between the different types of personalities we encounter in our education.

Until the first Medibot 3000 is rolled out, doctors will be flawed, biased, and stressed humans. We deal with the same roller coaster journey through life as do our patients, but we accept a responsibility to be the caretakers of their health. Perhaps we do so not in spite of our faults, but all the better because of them. The human experience provides us with empathy. It ingrains within us unique insights and perspectives. It allows us to read between the lines of a patient’s statements. It pushes us to go beyond protocols when we need to, and it helps us create the trust that is the heart of the doctor-patient relationship.

Kintsugi is the Japanese art of fixing cracks along broken pottery with rare metals, thus creating unique and beautiful patterns which accentuate the character of the pot. It is part of a philosophy called wabi-sabi, which is all about embracing imperfection. I think they’re on to something there.

Patients are not vignettes. There is no peer-reviewed algorithm for being a good doctor. Not to say that these things are not important. They are crucial tools in our endeavor to improve our medical skills and knowledge – the bedrock upon which a career in medicine must be founded. But I hope that in our quest to improve outcomes, to remove suffering, and move toward the beckoning future, we still will have a place in medicine for human characteristics that define the act of healing, and for the philosophy of wabi-sabi. Bring the robots on, I say.

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, New Hampshire, when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at pdnews@frontlinemedcom.com.

Recently, I was amazed to see a small walk-in booth with a webcam, a monitor, and a curtain, offering telemedicine consults from the comfort of a service station on I-95. Pandora’s Box, I thought.

The robots are coming! Take a dip into popular science fiction if you don’t believe me. From Asimov to “Star Wars,” there are innumerable examples of aseptic, polite automatons providing prompt, unbiased, unfatigued medical care. People have always been enamored by such visions of the future. And booths like this are the gateway to that vision. As excited as I am about this tremendous advance and the potential it holds, I can’t help but feel that when this new frontier of medicine reaches fruition, we will have lost something, too.

Medical education is exacting, exciting, and at times, excruciating. But above all, the privileged experience of learning about the inner workings of the body is an innately human process. Looking back, it’s not syndromes, numbers, or dosages I remember, but the colorful spectrum of characters I encountered along the way. We’ve all met them – the funny, the quirky, the warm, the gentle, the stern, the phlegmatic, the intermittently explosive, the socially inept, the obliviously savant, and occasionally, the frankly sociopathic. They are the ones who teach us how the science of medicine connects with the art of healing. Our bedside manners and critical thinking processes are molded by the intercourse between the different types of personalities we encounter in our education.

Until the first Medibot 3000 is rolled out, doctors will be flawed, biased, and stressed humans. We deal with the same roller coaster journey through life as do our patients, but we accept a responsibility to be the caretakers of their health. Perhaps we do so not in spite of our faults, but all the better because of them. The human experience provides us with empathy. It ingrains within us unique insights and perspectives. It allows us to read between the lines of a patient’s statements. It pushes us to go beyond protocols when we need to, and it helps us create the trust that is the heart of the doctor-patient relationship.

Kintsugi is the Japanese art of fixing cracks along broken pottery with rare metals, thus creating unique and beautiful patterns which accentuate the character of the pot. It is part of a philosophy called wabi-sabi, which is all about embracing imperfection. I think they’re on to something there.

Patients are not vignettes. There is no peer-reviewed algorithm for being a good doctor. Not to say that these things are not important. They are crucial tools in our endeavor to improve our medical skills and knowledge – the bedrock upon which a career in medicine must be founded. But I hope that in our quest to improve outcomes, to remove suffering, and move toward the beckoning future, we still will have a place in medicine for human characteristics that define the act of healing, and for the philosophy of wabi-sabi. Bring the robots on, I say.

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, New Hampshire, when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at pdnews@frontlinemedcom.com.

Recently, I was amazed to see a small walk-in booth with a webcam, a monitor, and a curtain, offering telemedicine consults from the comfort of a service station on I-95. Pandora’s Box, I thought.

The robots are coming! Take a dip into popular science fiction if you don’t believe me. From Asimov to “Star Wars,” there are innumerable examples of aseptic, polite automatons providing prompt, unbiased, unfatigued medical care. People have always been enamored by such visions of the future. And booths like this are the gateway to that vision. As excited as I am about this tremendous advance and the potential it holds, I can’t help but feel that when this new frontier of medicine reaches fruition, we will have lost something, too.

Medical education is exacting, exciting, and at times, excruciating. But above all, the privileged experience of learning about the inner workings of the body is an innately human process. Looking back, it’s not syndromes, numbers, or dosages I remember, but the colorful spectrum of characters I encountered along the way. We’ve all met them – the funny, the quirky, the warm, the gentle, the stern, the phlegmatic, the intermittently explosive, the socially inept, the obliviously savant, and occasionally, the frankly sociopathic. They are the ones who teach us how the science of medicine connects with the art of healing. Our bedside manners and critical thinking processes are molded by the intercourse between the different types of personalities we encounter in our education.

Until the first Medibot 3000 is rolled out, doctors will be flawed, biased, and stressed humans. We deal with the same roller coaster journey through life as do our patients, but we accept a responsibility to be the caretakers of their health. Perhaps we do so not in spite of our faults, but all the better because of them. The human experience provides us with empathy. It ingrains within us unique insights and perspectives. It allows us to read between the lines of a patient’s statements. It pushes us to go beyond protocols when we need to, and it helps us create the trust that is the heart of the doctor-patient relationship.

Kintsugi is the Japanese art of fixing cracks along broken pottery with rare metals, thus creating unique and beautiful patterns which accentuate the character of the pot. It is part of a philosophy called wabi-sabi, which is all about embracing imperfection. I think they’re on to something there.

Patients are not vignettes. There is no peer-reviewed algorithm for being a good doctor. Not to say that these things are not important. They are crucial tools in our endeavor to improve our medical skills and knowledge – the bedrock upon which a career in medicine must be founded. But I hope that in our quest to improve outcomes, to remove suffering, and move toward the beckoning future, we still will have a place in medicine for human characteristics that define the act of healing, and for the philosophy of wabi-sabi. Bring the robots on, I say.

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, New Hampshire, when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at pdnews@frontlinemedcom.com.

A 32-year-old man develops diarrhea after receiving amoxicillin/clavulanate to treat an infection following a dog bite. He is diagnosed with Clostridium difficile and prescribed a 10-day course of metronidazole. He has no other medical problems. He will be the best man at his brother’s wedding tomorrow. What advice should you give him about alcohol use at the reception?

A. Do not take metronidazole the day of the wedding if you will be drinking alcohol.

B. Take metronidazole, do not drink alcohol.

C. It’s okay to drink alcohol.

For years, we have advised patients to not use alcohol if they are taking metronidazole because of concern for a disulfiram-like reaction between alcohol and metronidazole. This has been a standard warning given by physicians and appears as a contraindication in the prescribing information. It has been well accepted as a true, proven reaction.

Is it true?

As early as the 1960s, case reports and an uncontrolled study suggested that combining metronidazole with alcohol produced a disulfiram-like reaction, with case reports of severe reactions, including death.^{1, 2, 3} This was initially considered an area that might be therapeutic in the treatment of alcoholism, but several studies showed no benefit.^{4, 5}

Caroline S. Williams and Dr. Kevin R. Woodcock reviewed the case reports for evidence of proof of a true interaction between metronidazole and ethanol.⁶ The case reports referenced textbooks to substantiate the interaction, but they did not present clear evidence of an interaction as the cause of elevated acetaldehyde levels.

Researchers have shown in a rat model that metronidazole can increase intracolonic, but not blood, acetaldehyde levels in rats that have received a combination of ethanol and metronidazole.⁷ Metronidazole did not have any inhibitory effect on hepatic or colonic alcohol dehydrogenase or aldehyde dehydrogenase. What was found was that rats treated with metronidazole had increased growth of Enterobacteriaceae, an alcohol dehydrogenase–containing aerobe, which could be the cause of the higher intracolonic acetaldehyde levels.

Jukka-Pekka Visapää and his colleagues studied the effect of coadministration of metronidazole and ethanol in young, healthy male volunteers.⁸ The study was a placebo-controlled, randomized trial. The study was small, with 12 participants. One-half of the study participants received metronidazole three times a day for 5 days; the other half received placebo. All participants then received ethanol 0.4g/kg, with blood testing being done every 20 minutes for the next 4 hours. Blood was tested for ethanol concentrations and for acetaldehyde levels. The study participants also had blood pressure, pulse, skin temperature, and symptoms monitored during the study.

There was no difference in blood acetaldehyde levels, vital signs, or symptoms between patients who received metronidazole or placebo. None of the subjects in the study had any measurable symptoms.

Metronidazole has many side effects, including nausea, vomiting, headache, dizziness, and seizures. These symptoms have a great deal of overlap with the symptoms of alcohol-disulfiram interaction. It has been assumed in early case reports that metronidazole caused a similar interaction with alcohol and raised acetaldehyde levels by interfering with aldehyde dehydrogenase.

Animal models and the human study do not show this to be the case. It is possible that metronidazole side effects alone were the cause of the symptoms in case reports. The one human study done was on healthy male volunteers, so projecting the results to a population with liver disease or other serious illness is a bit of a stretch. I think that if a problem exists with alcohol and metronidazole, it is uncommon and unlikely to occur in healthy individuals.

So, what would I advise the patient in the case about whether he can drink alcohol? I think that the risk would be minimal and that it would be safe for him to drink alcohol.

References

1. Br J Clin Pract. 1985 Jul;39(7):292-3.

2. Psychiatr Neurol. 1966;152:395-401.

3. Am J Forensic Med Pathol. 1996 Dec;17(4):343-6.

4. Q J Stud Alcohol. 1972 Sep;33: 734-40.

5. Q J Stud Ethanol. 1969 Mar;30: 140-51.

6. Ann Pharmacother. 2000 Feb;34(2):255-7.

7. Alcohol Clin Exp Res. 2000 Apr;24(4):570-5.

8. Ann Pharmacother. 2002 Jun;36(6):971-4.

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.

A 32-year-old man develops diarrhea after receiving amoxicillin/clavulanate to treat an infection following a dog bite. He is diagnosed with Clostridium difficile and prescribed a 10-day course of metronidazole. He has no other medical problems. He will be the best man at his brother’s wedding tomorrow. What advice should you give him about alcohol use at the reception?

A. Do not take metronidazole the day of the wedding if you will be drinking alcohol.

B. Take metronidazole, do not drink alcohol.

C. It’s okay to drink alcohol.

For years, we have advised patients to not use alcohol if they are taking metronidazole because of concern for a disulfiram-like reaction between alcohol and metronidazole. This has been a standard warning given by physicians and appears as a contraindication in the prescribing information. It has been well accepted as a true, proven reaction.

Is it true?

As early as the 1960s, case reports and an uncontrolled study suggested that combining metronidazole with alcohol produced a disulfiram-like reaction, with case reports of severe reactions, including death.^{1, 2, 3} This was initially considered an area that might be therapeutic in the treatment of alcoholism, but several studies showed no benefit.^{4, 5}

Caroline S. Williams and Dr. Kevin R. Woodcock reviewed the case reports for evidence of proof of a true interaction between metronidazole and ethanol.⁶ The case reports referenced textbooks to substantiate the interaction, but they did not present clear evidence of an interaction as the cause of elevated acetaldehyde levels.

Researchers have shown in a rat model that metronidazole can increase intracolonic, but not blood, acetaldehyde levels in rats that have received a combination of ethanol and metronidazole.⁷ Metronidazole did not have any inhibitory effect on hepatic or colonic alcohol dehydrogenase or aldehyde dehydrogenase. What was found was that rats treated with metronidazole had increased growth of Enterobacteriaceae, an alcohol dehydrogenase–containing aerobe, which could be the cause of the higher intracolonic acetaldehyde levels.

Jukka-Pekka Visapää and his colleagues studied the effect of coadministration of metronidazole and ethanol in young, healthy male volunteers.⁸ The study was a placebo-controlled, randomized trial. The study was small, with 12 participants. One-half of the study participants received metronidazole three times a day for 5 days; the other half received placebo. All participants then received ethanol 0.4g/kg, with blood testing being done every 20 minutes for the next 4 hours. Blood was tested for ethanol concentrations and for acetaldehyde levels. The study participants also had blood pressure, pulse, skin temperature, and symptoms monitored during the study.

There was no difference in blood acetaldehyde levels, vital signs, or symptoms between patients who received metronidazole or placebo. None of the subjects in the study had any measurable symptoms.

Metronidazole has many side effects, including nausea, vomiting, headache, dizziness, and seizures. These symptoms have a great deal of overlap with the symptoms of alcohol-disulfiram interaction. It has been assumed in early case reports that metronidazole caused a similar interaction with alcohol and raised acetaldehyde levels by interfering with aldehyde dehydrogenase.

Animal models and the human study do not show this to be the case. It is possible that metronidazole side effects alone were the cause of the symptoms in case reports. The one human study done was on healthy male volunteers, so projecting the results to a population with liver disease or other serious illness is a bit of a stretch. I think that if a problem exists with alcohol and metronidazole, it is uncommon and unlikely to occur in healthy individuals.

So, what would I advise the patient in the case about whether he can drink alcohol? I think that the risk would be minimal and that it would be safe for him to drink alcohol.

References

1. Br J Clin Pract. 1985 Jul;39(7):292-3.

2. Psychiatr Neurol. 1966;152:395-401.

3. Am J Forensic Med Pathol. 1996 Dec;17(4):343-6.

4. Q J Stud Alcohol. 1972 Sep;33: 734-40.

5. Q J Stud Ethanol. 1969 Mar;30: 140-51.

6. Ann Pharmacother. 2000 Feb;34(2):255-7.

7. Alcohol Clin Exp Res. 2000 Apr;24(4):570-5.

8. Ann Pharmacother. 2002 Jun;36(6):971-4.

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.

A 32-year-old man develops diarrhea after receiving amoxicillin/clavulanate to treat an infection following a dog bite. He is diagnosed with Clostridium difficile and prescribed a 10-day course of metronidazole. He has no other medical problems. He will be the best man at his brother’s wedding tomorrow. What advice should you give him about alcohol use at the reception?

A. Do not take metronidazole the day of the wedding if you will be drinking alcohol.

B. Take metronidazole, do not drink alcohol.

C. It’s okay to drink alcohol.

For years, we have advised patients to not use alcohol if they are taking metronidazole because of concern for a disulfiram-like reaction between alcohol and metronidazole. This has been a standard warning given by physicians and appears as a contraindication in the prescribing information. It has been well accepted as a true, proven reaction.

Is it true?

As early as the 1960s, case reports and an uncontrolled study suggested that combining metronidazole with alcohol produced a disulfiram-like reaction, with case reports of severe reactions, including death.^{1, 2, 3} This was initially considered an area that might be therapeutic in the treatment of alcoholism, but several studies showed no benefit.^{4, 5}

Caroline S. Williams and Dr. Kevin R. Woodcock reviewed the case reports for evidence of proof of a true interaction between metronidazole and ethanol.⁶ The case reports referenced textbooks to substantiate the interaction, but they did not present clear evidence of an interaction as the cause of elevated acetaldehyde levels.

Researchers have shown in a rat model that metronidazole can increase intracolonic, but not blood, acetaldehyde levels in rats that have received a combination of ethanol and metronidazole.⁷ Metronidazole did not have any inhibitory effect on hepatic or colonic alcohol dehydrogenase or aldehyde dehydrogenase. What was found was that rats treated with metronidazole had increased growth of Enterobacteriaceae, an alcohol dehydrogenase–containing aerobe, which could be the cause of the higher intracolonic acetaldehyde levels.

Jukka-Pekka Visapää and his colleagues studied the effect of coadministration of metronidazole and ethanol in young, healthy male volunteers.⁸ The study was a placebo-controlled, randomized trial. The study was small, with 12 participants. One-half of the study participants received metronidazole three times a day for 5 days; the other half received placebo. All participants then received ethanol 0.4g/kg, with blood testing being done every 20 minutes for the next 4 hours. Blood was tested for ethanol concentrations and for acetaldehyde levels. The study participants also had blood pressure, pulse, skin temperature, and symptoms monitored during the study.

There was no difference in blood acetaldehyde levels, vital signs, or symptoms between patients who received metronidazole or placebo. None of the subjects in the study had any measurable symptoms.

Metronidazole has many side effects, including nausea, vomiting, headache, dizziness, and seizures. These symptoms have a great deal of overlap with the symptoms of alcohol-disulfiram interaction. It has been assumed in early case reports that metronidazole caused a similar interaction with alcohol and raised acetaldehyde levels by interfering with aldehyde dehydrogenase.

Animal models and the human study do not show this to be the case. It is possible that metronidazole side effects alone were the cause of the symptoms in case reports. The one human study done was on healthy male volunteers, so projecting the results to a population with liver disease or other serious illness is a bit of a stretch. I think that if a problem exists with alcohol and metronidazole, it is uncommon and unlikely to occur in healthy individuals.

So, what would I advise the patient in the case about whether he can drink alcohol? I think that the risk would be minimal and that it would be safe for him to drink alcohol.

References

1. Br J Clin Pract. 1985 Jul;39(7):292-3.

2. Psychiatr Neurol. 1966;152:395-401.

3. Am J Forensic Med Pathol. 1996 Dec;17(4):343-6.

4. Q J Stud Alcohol. 1972 Sep;33: 734-40.

5. Q J Stud Ethanol. 1969 Mar;30: 140-51.

6. Ann Pharmacother. 2000 Feb;34(2):255-7.

7. Alcohol Clin Exp Res. 2000 Apr;24(4):570-5.

8. Ann Pharmacother. 2002 Jun;36(6):971-4.

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.

The introduction of high-density radiation electronic brachytherapy (eBX) for the treatment of nonmelanoma skin cancers has induced great angst within the dermatology community.¹ The Current Procedural Terminology (CPT) code 0182T (high dose rate eBX) reimburses at an extraordinarily high rate, which has drawn a substantial amount of attention. Some critics see it as another case of overutilization, of sucking more money out of a bleeding Medicare system. The financial opportunity afforded by eBX has even led some entrepreneurs to purchase dermatology clinics so that skin cancer patients can be treated via this modality instead of more traditional and less costly techniques (personal communication, 2014).

Among radiation oncologists, high-density radiation eBX is considered to be an important treatment option for select patients who have skin cancers staged as T1 or T2 tumors that are 4 cm or smaller in diameter and 5 mm or less in depth.² Additionally, ideal candidates for nonsurgical treatment options such as eBX include patients with lesions in cosmetically challenging areas (eg, ears, nose), those who may experience problematic wound healing due to tumor location (eg, lower extremities) or medical conditions (eg, diabetes mellitus, peripheral vascular disease), those with medical comorbidities that may preclude them from surgery, those currently taking anticoagulants, and those who are not interested in undergoing surgery.

A common criticism of eBX is that there is little data on long-term treatment outcomes, which will soon be addressed by a 5-year multicenter, prospective, randomized study of 720 patients with basal cell carcinoma and squamous cell carcinoma led by the University of California, Irvine, and the University of California, San Diego (study protocol currently with institutional review board). Another criticism is that some manufacturers of eBX devices gained the less rigorous US Food and Drug Administration Premarket Notification 510(k) certification; however, this certification is quite commonplace in the United States, and an examination of the data actually shows a lower recall rate with this method when compared to the longer premarket approval application process.³ A more important criticism of eBX might be that radiation therapy is associated with a substantial increase in skin cancers that may occur decades later in irradiated areas; however, there remains a paucity of studies examining the safety data on eBX during the posttreatment period when such effects would be expected.

In practice, the forces for good and evil are not only limited to those who utilize eBX. It is widely known that CPT codes for Mohs micrographic surgery also have been abused—that is, the procedure has been used in circumstances where it was not absolutely necessary⁴—which led to an effort by dermatologic surgery organizations to agree on appropriate use criteria for Mohs surgery.⁵ These criteria are not perfect but should help curb the misuse of a valuable technique, which is one that is recognized as being optimal for the treatment of complex skin cancers. One might suggest forming similar appropriate use criteria for eBX and limiting this treatment to patients who either are older than 65 years, have serious medical issues, are currently taking anticoagulants, are immobile, or simply cannot handle further dermatologic surgeries.

The American Medical Association has developed new Category III CPT codes for treatment of the skin with eBX that will become effective January 2016.⁶ These codes take into consideration the need for a radiation oncologist and a physicist to be present for planning, dosimetry, simulation, and selection of parameters for the appropriate depth. Although I do not know the reimbursement rates for these new codes yet, they will likely be substantially less than the current payment for treatment with eBX. That said, the gravy train has left the station, and those who have invested in the devices for eBX will either see the benefit of continued treatment for their patients or divest themselves of eBX now that the reimbursement will be more modest.

Some of my dermatology colleagues, who also are some of my very good friends, have a visceral and absolute objection to the use of any form of radiation therapy, and I respect their opinions. However, eBX does play a role in treating cutaneous malignancies, and our radiation oncology colleagues—many who treat patients with extensive, aggressive, and recurrent skin cancers—also have a place at the table.

Speaking as a fellowship-trained dermatologic surgeon and a department chair, I am very aware that the teaching we provide today for our dermatology residents and fellows is likely to be their modus operandi for the future, a future in which the Patient Protection and Affordable Care Act will force physicians to carefully choose quality of care over personal gain and where financial rewards will be based on appropriate utilization and measurable outcomes. Electronic brachytherapy is one tool amongst many. I have a plethora of patients in their 70s and 80s who have given up on surgery for skin cancer and who would prefer painless treatment with eBX, which allows for the appropriate use of such a controversial therapy.

Acknowledgments—I would like to thank Janellen Smith, MD (Irvine, California), Joshua Spanogle, MD (Saint Augustine, Florida), and Jordan 
V. Wang, MBE (Philadelphia, Pennsylvania), for their constructive comments.

The introduction of high-density radiation electronic brachytherapy (eBX) for the treatment of nonmelanoma skin cancers has induced great angst within the dermatology community.¹ The Current Procedural Terminology (CPT) code 0182T (high dose rate eBX) reimburses at an extraordinarily high rate, which has drawn a substantial amount of attention. Some critics see it as another case of overutilization, of sucking more money out of a bleeding Medicare system. The financial opportunity afforded by eBX has even led some entrepreneurs to purchase dermatology clinics so that skin cancer patients can be treated via this modality instead of more traditional and less costly techniques (personal communication, 2014).

Among radiation oncologists, high-density radiation eBX is considered to be an important treatment option for select patients who have skin cancers staged as T1 or T2 tumors that are 4 cm or smaller in diameter and 5 mm or less in depth.² Additionally, ideal candidates for nonsurgical treatment options such as eBX include patients with lesions in cosmetically challenging areas (eg, ears, nose), those who may experience problematic wound healing due to tumor location (eg, lower extremities) or medical conditions (eg, diabetes mellitus, peripheral vascular disease), those with medical comorbidities that may preclude them from surgery, those currently taking anticoagulants, and those who are not interested in undergoing surgery.

A common criticism of eBX is that there is little data on long-term treatment outcomes, which will soon be addressed by a 5-year multicenter, prospective, randomized study of 720 patients with basal cell carcinoma and squamous cell carcinoma led by the University of California, Irvine, and the University of California, San Diego (study protocol currently with institutional review board). Another criticism is that some manufacturers of eBX devices gained the less rigorous US Food and Drug Administration Premarket Notification 510(k) certification; however, this certification is quite commonplace in the United States, and an examination of the data actually shows a lower recall rate with this method when compared to the longer premarket approval application process.³ A more important criticism of eBX might be that radiation therapy is associated with a substantial increase in skin cancers that may occur decades later in irradiated areas; however, there remains a paucity of studies examining the safety data on eBX during the posttreatment period when such effects would be expected.

In practice, the forces for good and evil are not only limited to those who utilize eBX. It is widely known that CPT codes for Mohs micrographic surgery also have been abused—that is, the procedure has been used in circumstances where it was not absolutely necessary⁴—which led to an effort by dermatologic surgery organizations to agree on appropriate use criteria for Mohs surgery.⁵ These criteria are not perfect but should help curb the misuse of a valuable technique, which is one that is recognized as being optimal for the treatment of complex skin cancers. One might suggest forming similar appropriate use criteria for eBX and limiting this treatment to patients who either are older than 65 years, have serious medical issues, are currently taking anticoagulants, are immobile, or simply cannot handle further dermatologic surgeries.

The American Medical Association has developed new Category III CPT codes for treatment of the skin with eBX that will become effective January 2016.⁶ These codes take into consideration the need for a radiation oncologist and a physicist to be present for planning, dosimetry, simulation, and selection of parameters for the appropriate depth. Although I do not know the reimbursement rates for these new codes yet, they will likely be substantially less than the current payment for treatment with eBX. That said, the gravy train has left the station, and those who have invested in the devices for eBX will either see the benefit of continued treatment for their patients or divest themselves of eBX now that the reimbursement will be more modest.

Some of my dermatology colleagues, who also are some of my very good friends, have a visceral and absolute objection to the use of any form of radiation therapy, and I respect their opinions. However, eBX does play a role in treating cutaneous malignancies, and our radiation oncology colleagues—many who treat patients with extensive, aggressive, and recurrent skin cancers—also have a place at the table.

Speaking as a fellowship-trained dermatologic surgeon and a department chair, I am very aware that the teaching we provide today for our dermatology residents and fellows is likely to be their modus operandi for the future, a future in which the Patient Protection and Affordable Care Act will force physicians to carefully choose quality of care over personal gain and where financial rewards will be based on appropriate utilization and measurable outcomes. Electronic brachytherapy is one tool amongst many. I have a plethora of patients in their 70s and 80s who have given up on surgery for skin cancer and who would prefer painless treatment with eBX, which allows for the appropriate use of such a controversial therapy.

Acknowledgments—I would like to thank Janellen Smith, MD (Irvine, California), Joshua Spanogle, MD (Saint Augustine, Florida), and Jordan 
V. Wang, MBE (Philadelphia, Pennsylvania), for their constructive comments.

The introduction of high-density radiation electronic brachytherapy (eBX) for the treatment of nonmelanoma skin cancers has induced great angst within the dermatology community.¹ The Current Procedural Terminology (CPT) code 0182T (high dose rate eBX) reimburses at an extraordinarily high rate, which has drawn a substantial amount of attention. Some critics see it as another case of overutilization, of sucking more money out of a bleeding Medicare system. The financial opportunity afforded by eBX has even led some entrepreneurs to purchase dermatology clinics so that skin cancer patients can be treated via this modality instead of more traditional and less costly techniques (personal communication, 2014).

Among radiation oncologists, high-density radiation eBX is considered to be an important treatment option for select patients who have skin cancers staged as T1 or T2 tumors that are 4 cm or smaller in diameter and 5 mm or less in depth.² Additionally, ideal candidates for nonsurgical treatment options such as eBX include patients with lesions in cosmetically challenging areas (eg, ears, nose), those who may experience problematic wound healing due to tumor location (eg, lower extremities) or medical conditions (eg, diabetes mellitus, peripheral vascular disease), those with medical comorbidities that may preclude them from surgery, those currently taking anticoagulants, and those who are not interested in undergoing surgery.

A common criticism of eBX is that there is little data on long-term treatment outcomes, which will soon be addressed by a 5-year multicenter, prospective, randomized study of 720 patients with basal cell carcinoma and squamous cell carcinoma led by the University of California, Irvine, and the University of California, San Diego (study protocol currently with institutional review board). Another criticism is that some manufacturers of eBX devices gained the less rigorous US Food and Drug Administration Premarket Notification 510(k) certification; however, this certification is quite commonplace in the United States, and an examination of the data actually shows a lower recall rate with this method when compared to the longer premarket approval application process.³ A more important criticism of eBX might be that radiation therapy is associated with a substantial increase in skin cancers that may occur decades later in irradiated areas; however, there remains a paucity of studies examining the safety data on eBX during the posttreatment period when such effects would be expected.

In practice, the forces for good and evil are not only limited to those who utilize eBX. It is widely known that CPT codes for Mohs micrographic surgery also have been abused—that is, the procedure has been used in circumstances where it was not absolutely necessary⁴—which led to an effort by dermatologic surgery organizations to agree on appropriate use criteria for Mohs surgery.⁵ These criteria are not perfect but should help curb the misuse of a valuable technique, which is one that is recognized as being optimal for the treatment of complex skin cancers. One might suggest forming similar appropriate use criteria for eBX and limiting this treatment to patients who either are older than 65 years, have serious medical issues, are currently taking anticoagulants, are immobile, or simply cannot handle further dermatologic surgeries.

The American Medical Association has developed new Category III CPT codes for treatment of the skin with eBX that will become effective January 2016.⁶ These codes take into consideration the need for a radiation oncologist and a physicist to be present for planning, dosimetry, simulation, and selection of parameters for the appropriate depth. Although I do not know the reimbursement rates for these new codes yet, they will likely be substantially less than the current payment for treatment with eBX. That said, the gravy train has left the station, and those who have invested in the devices for eBX will either see the benefit of continued treatment for their patients or divest themselves of eBX now that the reimbursement will be more modest.

Some of my dermatology colleagues, who also are some of my very good friends, have a visceral and absolute objection to the use of any form of radiation therapy, and I respect their opinions. However, eBX does play a role in treating cutaneous malignancies, and our radiation oncology colleagues—many who treat patients with extensive, aggressive, and recurrent skin cancers—also have a place at the table.

Speaking as a fellowship-trained dermatologic surgeon and a department chair, I am very aware that the teaching we provide today for our dermatology residents and fellows is likely to be their modus operandi for the future, a future in which the Patient Protection and Affordable Care Act will force physicians to carefully choose quality of care over personal gain and where financial rewards will be based on appropriate utilization and measurable outcomes. Electronic brachytherapy is one tool amongst many. I have a plethora of patients in their 70s and 80s who have given up on surgery for skin cancer and who would prefer painless treatment with eBX, which allows for the appropriate use of such a controversial therapy.

Acknowledgments—I would like to thank Janellen Smith, MD (Irvine, California), Joshua Spanogle, MD (Saint Augustine, Florida), and Jordan 
V. Wang, MBE (Philadelphia, Pennsylvania), for their constructive comments.

Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.

Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.

No, it is not fine, because there are no validated quality measures for dermatologists.

Well great, you say, then dermatologists can’t be ranked.

No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.

Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.

Yes, some dermatologists get credit and a star for something that has nothing to do with them.

The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.

This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.

Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.

Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”

Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.

The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.

Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at dermnews@frontlinemedcom.com

Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.

Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.

No, it is not fine, because there are no validated quality measures for dermatologists.

Well great, you say, then dermatologists can’t be ranked.

No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.

Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.

Yes, some dermatologists get credit and a star for something that has nothing to do with them.

The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.

This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.

Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.

Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”

Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.

The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.

Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at dermnews@frontlinemedcom.com

Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.

Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.

No, it is not fine, because there are no validated quality measures for dermatologists.

Well great, you say, then dermatologists can’t be ranked.

No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.

Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.

Yes, some dermatologists get credit and a star for something that has nothing to do with them.

The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.

This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.

Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.

Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”

Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.

The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.

Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at dermnews@frontlinemedcom.com

A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.

Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?

While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?

Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?

In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”

First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.

Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.

What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.

I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.

I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”

A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.

Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?

While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?

Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?

In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”

First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.

Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.

What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.

I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.

I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”

A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.

Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?

While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?

Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?

In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”

First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.

Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.

What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.

I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.

I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”

Analyzing the Guidelines: It Can't All Be Level I

The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.

The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.

An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.

We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.

Analyzing the Guidelines: It Can't All Be Level I

The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.

The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.

An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.

We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.

Analyzing the Guidelines: It Can't All Be Level I

The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.

The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.

An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.

We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.

I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.

“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.

I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.

The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.

As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.

We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.

I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.

Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.

We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.

Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.

“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.

I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.

The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.

As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.

We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.

I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.

Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.

We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.

Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.

“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.

I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.

The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.

As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.

We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.

I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.

Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.

We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.

Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.