Commentary

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

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.” E-mail him at pdnews@frontlinemedcom.com. Scan this QR code to read similar articles or go to pediatricnews.com.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

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.” E-mail him at pdnews@frontlinemedcom.com. Scan this QR code to read similar articles or go to pediatricnews.com.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

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.” E-mail him at pdnews@frontlinemedcom.com. Scan this QR code to read similar articles or go to pediatricnews.com.

Portulaca oleracea, also known as purslane, has long been used in various traditional medicine systems to relieve pain and edema.¹Portulaca oleracea is a warm-climate annual plant originally found in the Middle East, North Africa, and the Indian subcontinent and now cultivated in the Arabian peninsula; Japan, where it is an abundant garden plant from spring to fall;^2,3 and throughout the world.

The use of P. oleracea, a member of the Portulacaceae family, as a vegetable as well as herbal medicine dates back several centuries.⁴ In modern times, purslane has been found to be rich in antioxidants, particularly omega-3 fatty acids, vitamins C and E, beta-carotene, melatonin, and glutathione, as well as several minerals.^5,6,7 Currently, it is considered one of the top ten most common plants in the world, and one of the most-used medical plants according to the World Health Organization.⁶ It is considered a weed in the United States, but is eaten in many parts of the world.

Antioxidant activity

Using two different assays, Uddin et al. determined in 2012 that P. oleracea cultivars exhibited significant antioxidant activity through various growth stages. In addition, the researchers suggested that purslane could provide multiple minerals as well as antioxidants in the context of nutraceutical products and functional food.⁷ Early this year, Silva et al. studied the antioxidant activity of P. oleracea leaves, flowers, and stems from two different locations in Portugal, with assays revealing significantly greater antioxidant activity in the stems of both samples compared to the leaves and flowers. However, the phenolic extracts of all three plant sections from both samples were found to protect DNA against hydroxyl radicals. The investigators concluded that their findings, particularly related to high antioxidant activity, support the potential benefits of purslane consumption to human health.⁸

A 2014 analysis of 13 collected purslane accessions revealed significant mineral content (particularly potassium, followed by nitrogen, sodium, calcium, magnesium, phosphorus, iron, zinc, and manganese) and showed that antioxidant activity was more strongly associated with ornamental as opposed to common purslane, the latter of which was richer in mineral content.⁶

Anti-inflammatory activity

In 2000, Chan et al. found that a 10% ethanolic extract of the dried leaves and stem of a P. oleracea cultivar displayed significant anti-inflammatory and analgesic properties after topical and intraperitoneal, but not oral, administration in comparison to diclofenac sodium, a synthetic drug used as active control. They added that these activities corresponded to the reputed effects of the traditional uses of the wild species.⁹

Wound healing activity

Rashed et al. reported in 2003 that a crude extract of P. oleracea accelerates wound healing. They used Mus musculus JVI-1 to show that fresh homogenized crude aerial parts of the plant topically applied on excision wound surfaces reduced wound surface areas and increased tensile strength. The best documented contraction was associated with a single dose of 50 mg, followed by two doses of 25 mg each.¹⁰

Oral lichen planus treatment

In 2010, Agha-Hosseini et al. conducted a randomized double-blind placebo-controlled 3-month study to assess the effectiveness of purslane in the treatment of oral lichen planus. Thirty-seven symptomatic patients (confirmed by biopsy) were divided into a purslane treatment group (n = 20) and a placebo group (n = 17). The investigators reported that partial to complete clinical improvement was observed in 83% of the treatment group, with no response in the remaining 17%, whereas partial improvement was seen in 17% of the placebo group, 73% had no response, and the condition was aggravated in 10% of the placebo group. No adverse side effects were reported in either group, and the researchers concluded that purslane was clinically effective in treating oral lichen planus and warrants consideration as a treatment option for the disorder.⁵

Other activities

In 2001, Radhakrishnan et al. identified several neuropharmacological actions, particularly anti-nociceptive and muscle-relaxing activity, with a range of effects on the central and peripheral nervous system observed in animal studies.¹ The betacyanins found in P. oleracea have subsequently been found to confer a protective effect against neurotoxicity, specifically, ameliorating the D-galactose-induced cognitive deficits in senescent mice.¹¹P. oleracea also has been shown to efficiently eliminate the endocrine-disrupting chemical bisphenol A from a hydroponic solution.¹²

In 2012, Yan et al. showed that three newly isolated homoisoflavonoids, known as portulacanones, and the compound 2,2’-dihydroxy-4’,6’-dimethoxychalcone selectively exhibited in vitro cytotoxic activities against four human cancer cell lines.²

Conclusions

This antioxidant-rich plant is found throughout the world and has long been associated with traditional health care. Modern research into its potential dermatologic uses is ongoing, but the evidence is relatively scarce. There are indications that the antioxidant, anti-inflammatory, and wound healing activity reportedly exhibited by purslane may be harnessed for various cutaneous applications. However, much more research is necessary to determine how extensive a role purslane may play in skin care.

References

1.J. Ethnopharmacol. 2001;76:171-6

2.Phytochemistry 2012;80:37-41

3.J. Biosci. Bioeng. 2007;103:420-6

4.J. Ethnopharmacol. 2000;73:445-51

5.Phytother. Res. 2010;24:240-4

6.Biomed. Res. Int. 2014;2014:296063

7.Int. J. Mol. Sci. 2012;13:10257-67

8.Nat Prod. Commun. 2014;9:45-50

9. J. Ethnopharmacol. 2000;73:445-51

10. J. Ethnopharmacol. 2003;88:131-6

11. Phytomedicine. 2010 Jun;17:527-32

12. Biosci. Biotechnol. Biochem. 2012;76:1015-7

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Portulaca oleracea, also known as purslane, has long been used in various traditional medicine systems to relieve pain and edema.¹Portulaca oleracea is a warm-climate annual plant originally found in the Middle East, North Africa, and the Indian subcontinent and now cultivated in the Arabian peninsula; Japan, where it is an abundant garden plant from spring to fall;^2,3 and throughout the world.

The use of P. oleracea, a member of the Portulacaceae family, as a vegetable as well as herbal medicine dates back several centuries.⁴ In modern times, purslane has been found to be rich in antioxidants, particularly omega-3 fatty acids, vitamins C and E, beta-carotene, melatonin, and glutathione, as well as several minerals.^5,6,7 Currently, it is considered one of the top ten most common plants in the world, and one of the most-used medical plants according to the World Health Organization.⁶ It is considered a weed in the United States, but is eaten in many parts of the world.

Antioxidant activity

Using two different assays, Uddin et al. determined in 2012 that P. oleracea cultivars exhibited significant antioxidant activity through various growth stages. In addition, the researchers suggested that purslane could provide multiple minerals as well as antioxidants in the context of nutraceutical products and functional food.⁷ Early this year, Silva et al. studied the antioxidant activity of P. oleracea leaves, flowers, and stems from two different locations in Portugal, with assays revealing significantly greater antioxidant activity in the stems of both samples compared to the leaves and flowers. However, the phenolic extracts of all three plant sections from both samples were found to protect DNA against hydroxyl radicals. The investigators concluded that their findings, particularly related to high antioxidant activity, support the potential benefits of purslane consumption to human health.⁸

A 2014 analysis of 13 collected purslane accessions revealed significant mineral content (particularly potassium, followed by nitrogen, sodium, calcium, magnesium, phosphorus, iron, zinc, and manganese) and showed that antioxidant activity was more strongly associated with ornamental as opposed to common purslane, the latter of which was richer in mineral content.⁶

Anti-inflammatory activity

In 2000, Chan et al. found that a 10% ethanolic extract of the dried leaves and stem of a P. oleracea cultivar displayed significant anti-inflammatory and analgesic properties after topical and intraperitoneal, but not oral, administration in comparison to diclofenac sodium, a synthetic drug used as active control. They added that these activities corresponded to the reputed effects of the traditional uses of the wild species.⁹

Wound healing activity

Rashed et al. reported in 2003 that a crude extract of P. oleracea accelerates wound healing. They used Mus musculus JVI-1 to show that fresh homogenized crude aerial parts of the plant topically applied on excision wound surfaces reduced wound surface areas and increased tensile strength. The best documented contraction was associated with a single dose of 50 mg, followed by two doses of 25 mg each.¹⁰

Oral lichen planus treatment

In 2010, Agha-Hosseini et al. conducted a randomized double-blind placebo-controlled 3-month study to assess the effectiveness of purslane in the treatment of oral lichen planus. Thirty-seven symptomatic patients (confirmed by biopsy) were divided into a purslane treatment group (n = 20) and a placebo group (n = 17). The investigators reported that partial to complete clinical improvement was observed in 83% of the treatment group, with no response in the remaining 17%, whereas partial improvement was seen in 17% of the placebo group, 73% had no response, and the condition was aggravated in 10% of the placebo group. No adverse side effects were reported in either group, and the researchers concluded that purslane was clinically effective in treating oral lichen planus and warrants consideration as a treatment option for the disorder.⁵

Other activities

In 2001, Radhakrishnan et al. identified several neuropharmacological actions, particularly anti-nociceptive and muscle-relaxing activity, with a range of effects on the central and peripheral nervous system observed in animal studies.¹ The betacyanins found in P. oleracea have subsequently been found to confer a protective effect against neurotoxicity, specifically, ameliorating the D-galactose-induced cognitive deficits in senescent mice.¹¹P. oleracea also has been shown to efficiently eliminate the endocrine-disrupting chemical bisphenol A from a hydroponic solution.¹²

In 2012, Yan et al. showed that three newly isolated homoisoflavonoids, known as portulacanones, and the compound 2,2’-dihydroxy-4’,6’-dimethoxychalcone selectively exhibited in vitro cytotoxic activities against four human cancer cell lines.²

Conclusions

This antioxidant-rich plant is found throughout the world and has long been associated with traditional health care. Modern research into its potential dermatologic uses is ongoing, but the evidence is relatively scarce. There are indications that the antioxidant, anti-inflammatory, and wound healing activity reportedly exhibited by purslane may be harnessed for various cutaneous applications. However, much more research is necessary to determine how extensive a role purslane may play in skin care.

References

1.J. Ethnopharmacol. 2001;76:171-6

2.Phytochemistry 2012;80:37-41

3.J. Biosci. Bioeng. 2007;103:420-6

4.J. Ethnopharmacol. 2000;73:445-51

5.Phytother. Res. 2010;24:240-4

6.Biomed. Res. Int. 2014;2014:296063

7.Int. J. Mol. Sci. 2012;13:10257-67

8.Nat Prod. Commun. 2014;9:45-50

9. J. Ethnopharmacol. 2000;73:445-51

10. J. Ethnopharmacol. 2003;88:131-6

11. Phytomedicine. 2010 Jun;17:527-32

12. Biosci. Biotechnol. Biochem. 2012;76:1015-7

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Portulaca oleracea, also known as purslane, has long been used in various traditional medicine systems to relieve pain and edema.¹Portulaca oleracea is a warm-climate annual plant originally found in the Middle East, North Africa, and the Indian subcontinent and now cultivated in the Arabian peninsula; Japan, where it is an abundant garden plant from spring to fall;^2,3 and throughout the world.

The use of P. oleracea, a member of the Portulacaceae family, as a vegetable as well as herbal medicine dates back several centuries.⁴ In modern times, purslane has been found to be rich in antioxidants, particularly omega-3 fatty acids, vitamins C and E, beta-carotene, melatonin, and glutathione, as well as several minerals.^5,6,7 Currently, it is considered one of the top ten most common plants in the world, and one of the most-used medical plants according to the World Health Organization.⁶ It is considered a weed in the United States, but is eaten in many parts of the world.

Antioxidant activity

Using two different assays, Uddin et al. determined in 2012 that P. oleracea cultivars exhibited significant antioxidant activity through various growth stages. In addition, the researchers suggested that purslane could provide multiple minerals as well as antioxidants in the context of nutraceutical products and functional food.⁷ Early this year, Silva et al. studied the antioxidant activity of P. oleracea leaves, flowers, and stems from two different locations in Portugal, with assays revealing significantly greater antioxidant activity in the stems of both samples compared to the leaves and flowers. However, the phenolic extracts of all three plant sections from both samples were found to protect DNA against hydroxyl radicals. The investigators concluded that their findings, particularly related to high antioxidant activity, support the potential benefits of purslane consumption to human health.⁸

A 2014 analysis of 13 collected purslane accessions revealed significant mineral content (particularly potassium, followed by nitrogen, sodium, calcium, magnesium, phosphorus, iron, zinc, and manganese) and showed that antioxidant activity was more strongly associated with ornamental as opposed to common purslane, the latter of which was richer in mineral content.⁶

Anti-inflammatory activity

In 2000, Chan et al. found that a 10% ethanolic extract of the dried leaves and stem of a P. oleracea cultivar displayed significant anti-inflammatory and analgesic properties after topical and intraperitoneal, but not oral, administration in comparison to diclofenac sodium, a synthetic drug used as active control. They added that these activities corresponded to the reputed effects of the traditional uses of the wild species.⁹

Wound healing activity

Rashed et al. reported in 2003 that a crude extract of P. oleracea accelerates wound healing. They used Mus musculus JVI-1 to show that fresh homogenized crude aerial parts of the plant topically applied on excision wound surfaces reduced wound surface areas and increased tensile strength. The best documented contraction was associated with a single dose of 50 mg, followed by two doses of 25 mg each.¹⁰

Oral lichen planus treatment

In 2010, Agha-Hosseini et al. conducted a randomized double-blind placebo-controlled 3-month study to assess the effectiveness of purslane in the treatment of oral lichen planus. Thirty-seven symptomatic patients (confirmed by biopsy) were divided into a purslane treatment group (n = 20) and a placebo group (n = 17). The investigators reported that partial to complete clinical improvement was observed in 83% of the treatment group, with no response in the remaining 17%, whereas partial improvement was seen in 17% of the placebo group, 73% had no response, and the condition was aggravated in 10% of the placebo group. No adverse side effects were reported in either group, and the researchers concluded that purslane was clinically effective in treating oral lichen planus and warrants consideration as a treatment option for the disorder.⁵

Other activities

In 2001, Radhakrishnan et al. identified several neuropharmacological actions, particularly anti-nociceptive and muscle-relaxing activity, with a range of effects on the central and peripheral nervous system observed in animal studies.¹ The betacyanins found in P. oleracea have subsequently been found to confer a protective effect against neurotoxicity, specifically, ameliorating the D-galactose-induced cognitive deficits in senescent mice.¹¹P. oleracea also has been shown to efficiently eliminate the endocrine-disrupting chemical bisphenol A from a hydroponic solution.¹²

In 2012, Yan et al. showed that three newly isolated homoisoflavonoids, known as portulacanones, and the compound 2,2’-dihydroxy-4’,6’-dimethoxychalcone selectively exhibited in vitro cytotoxic activities against four human cancer cell lines.²

Conclusions

This antioxidant-rich plant is found throughout the world and has long been associated with traditional health care. Modern research into its potential dermatologic uses is ongoing, but the evidence is relatively scarce. There are indications that the antioxidant, anti-inflammatory, and wound healing activity reportedly exhibited by purslane may be harnessed for various cutaneous applications. However, much more research is necessary to determine how extensive a role purslane may play in skin care.

References

1.J. Ethnopharmacol. 2001;76:171-6

2.Phytochemistry 2012;80:37-41

3.J. Biosci. Bioeng. 2007;103:420-6

4.J. Ethnopharmacol. 2000;73:445-51

5.Phytother. Res. 2010;24:240-4

6.Biomed. Res. Int. 2014;2014:296063

7.Int. J. Mol. Sci. 2012;13:10257-67

8.Nat Prod. Commun. 2014;9:45-50

9. J. Ethnopharmacol. 2000;73:445-51

10. J. Ethnopharmacol. 2003;88:131-6

11. Phytomedicine. 2010 Jun;17:527-32

12. Biosci. Biotechnol. Biochem. 2012;76:1015-7

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

In a previous column, I warned about the high cost of generic desonide. This month, I alert you to the many potential dangers of this drug. By the time I’m done, you may not want to go near the stuff.

To approve e-scribe refills, we all need to acknowledge warnings and dangers and click “Benefit outweighs risk” or “Previously tolerated” or some other option. But some of these warnings make me wonder who on earth writes them.

Desonide comes with more warnings than almost any other medicine I prescribe electronically. I counted 21 such warnings. Here are some examples:

1. Desonide External Cream 0.05% should be used cautiously in Bacterial Infection, especially in Systemic Bacterial Infection. Since Folliculitis is a specific form of Bacterial Infection, the same precaution may apply.

I confess that I never thought of prescribing desonide for Bacterial Infection, Systemic or otherwise. Have you? (By the way, what’s with the excess use of capital letters?)

The second warning is even more dramatic.

2. Desonide External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection.

What makes this even more curious is the Viral Infections the warnings go on to enumerate.

2a. Since Actinic Keratosis is a specific form of Viral Infection, the same precaution may apply.

Actinic Keratosis is a Viral Infection? I didn’t know that.

3. Since Actinic Keratosis of the Hands and Arms is a specific form of Viral Infection, the same precaution may apply.

Now we learn of different subgroups of Actinic Keratoses that are Viral Infections. Did they teach you these in Dermatology School? (Please see Warnings 6-10, below.)

4. This warning refers to a specific Bacterial Infection called Folliculitis Nares Perforans. I don’t know what that is, but it sounds bad. Glad they warned me.

5. Since Pseudofolliculitis Barbae is a specific form of Bacterial Infection, the same precaution may apply.

I never used much desonide for pseudofolliculitis, cautiously or otherwise.

Warnings 6-10 describe more specific forms of Viral Infection: (6) Non-Hyperkeratotic Actinic Keratosis, (7) Actinic Keratosis of Face and Anterior Scalp, (8) Non-Hyperkeratotic Non-Pigmented Actinic Keratosis, (9) Non-Hyperkeratotic Face and Scalp Actinic Keratosis, (10) Pigmented Actinic Keratosis.

This is most disturbing. What Systemic Viral Infections did they leave me to use desonide on? Hyperkeratotic Non-Pigmented Actinic Keratoses of the Posterior Scalp?

Warning 11 is another specific Bacterial Infection: Local Folliculitis. What is the opposite of Local Folliculitis? Express Folliculitis?

Warning 12 is Perioral Dermatitis. Steroids on rosacea? Really? Maybe a cheaper one.

I will now skip to warning 16: Hirsutism has been associated with Desonide External Cream 0.05%. Since Hair Disease is a more general form of Hirsutism, it may also be considered a drug-related medical condition.

Did you know that desonide causes unwanted hair growth? Or realize that Hair Disease is a more general form of Hirsutism? I myself have male-pattern baldness. (Sorry, Male-Pattern BALDNESS.) Since Baldness is a Hair Disease, is it also a more general form of Hirsutism? Instead of having too little hair, do I now have too much?

The same is true for warning 17, which is identical to 16, except that it substitutes “Hypertrichosis” for “Hirsutism.”

Okay, colleagues, it’s time for a personal reckoning. You trained, practiced, took CME, but you didn’t know about any of these risks, did you? You’ve just been just heedlessly, incautiously, throwing around desonide, producing hairy patients with Systemic Bacterial and Viral Infections. And on “Non-Hyperkeratotic Non-Pigmented Actinic Keratosis,” no less. Aren’t you disappointed in yourselves?

When I first read warnings like these, I wrote my EMR provider to ask who puts together this stuff, and which consultants vet it. They never answered. It is very hard to believe that a dermatologist was involved at any stage of developing these warnings, with their irrelevant caveats and absurd classification schemes.

Who would develop electronic prescribing guidelines without at least consulting the physicians who do the prescribing? Why would they want to?

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

In a previous column, I warned about the high cost of generic desonide. This month, I alert you to the many potential dangers of this drug. By the time I’m done, you may not want to go near the stuff.

To approve e-scribe refills, we all need to acknowledge warnings and dangers and click “Benefit outweighs risk” or “Previously tolerated” or some other option. But some of these warnings make me wonder who on earth writes them.

Desonide comes with more warnings than almost any other medicine I prescribe electronically. I counted 21 such warnings. Here are some examples:

1. Desonide External Cream 0.05% should be used cautiously in Bacterial Infection, especially in Systemic Bacterial Infection. Since Folliculitis is a specific form of Bacterial Infection, the same precaution may apply.

I confess that I never thought of prescribing desonide for Bacterial Infection, Systemic or otherwise. Have you? (By the way, what’s with the excess use of capital letters?)

The second warning is even more dramatic.

2. Desonide External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection.

What makes this even more curious is the Viral Infections the warnings go on to enumerate.

2a. Since Actinic Keratosis is a specific form of Viral Infection, the same precaution may apply.

Actinic Keratosis is a Viral Infection? I didn’t know that.

3. Since Actinic Keratosis of the Hands and Arms is a specific form of Viral Infection, the same precaution may apply.

Now we learn of different subgroups of Actinic Keratoses that are Viral Infections. Did they teach you these in Dermatology School? (Please see Warnings 6-10, below.)

4. This warning refers to a specific Bacterial Infection called Folliculitis Nares Perforans. I don’t know what that is, but it sounds bad. Glad they warned me.

5. Since Pseudofolliculitis Barbae is a specific form of Bacterial Infection, the same precaution may apply.

I never used much desonide for pseudofolliculitis, cautiously or otherwise.

Warnings 6-10 describe more specific forms of Viral Infection: (6) Non-Hyperkeratotic Actinic Keratosis, (7) Actinic Keratosis of Face and Anterior Scalp, (8) Non-Hyperkeratotic Non-Pigmented Actinic Keratosis, (9) Non-Hyperkeratotic Face and Scalp Actinic Keratosis, (10) Pigmented Actinic Keratosis.

This is most disturbing. What Systemic Viral Infections did they leave me to use desonide on? Hyperkeratotic Non-Pigmented Actinic Keratoses of the Posterior Scalp?

Warning 11 is another specific Bacterial Infection: Local Folliculitis. What is the opposite of Local Folliculitis? Express Folliculitis?

Warning 12 is Perioral Dermatitis. Steroids on rosacea? Really? Maybe a cheaper one.

I will now skip to warning 16: Hirsutism has been associated with Desonide External Cream 0.05%. Since Hair Disease is a more general form of Hirsutism, it may also be considered a drug-related medical condition.

Did you know that desonide causes unwanted hair growth? Or realize that Hair Disease is a more general form of Hirsutism? I myself have male-pattern baldness. (Sorry, Male-Pattern BALDNESS.) Since Baldness is a Hair Disease, is it also a more general form of Hirsutism? Instead of having too little hair, do I now have too much?

The same is true for warning 17, which is identical to 16, except that it substitutes “Hypertrichosis” for “Hirsutism.”

Okay, colleagues, it’s time for a personal reckoning. You trained, practiced, took CME, but you didn’t know about any of these risks, did you? You’ve just been just heedlessly, incautiously, throwing around desonide, producing hairy patients with Systemic Bacterial and Viral Infections. And on “Non-Hyperkeratotic Non-Pigmented Actinic Keratosis,” no less. Aren’t you disappointed in yourselves?

When I first read warnings like these, I wrote my EMR provider to ask who puts together this stuff, and which consultants vet it. They never answered. It is very hard to believe that a dermatologist was involved at any stage of developing these warnings, with their irrelevant caveats and absurd classification schemes.

Who would develop electronic prescribing guidelines without at least consulting the physicians who do the prescribing? Why would they want to?

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

In a previous column, I warned about the high cost of generic desonide. This month, I alert you to the many potential dangers of this drug. By the time I’m done, you may not want to go near the stuff.

To approve e-scribe refills, we all need to acknowledge warnings and dangers and click “Benefit outweighs risk” or “Previously tolerated” or some other option. But some of these warnings make me wonder who on earth writes them.

Desonide comes with more warnings than almost any other medicine I prescribe electronically. I counted 21 such warnings. Here are some examples:

1. Desonide External Cream 0.05% should be used cautiously in Bacterial Infection, especially in Systemic Bacterial Infection. Since Folliculitis is a specific form of Bacterial Infection, the same precaution may apply.

I confess that I never thought of prescribing desonide for Bacterial Infection, Systemic or otherwise. Have you? (By the way, what’s with the excess use of capital letters?)

The second warning is even more dramatic.

2. Desonide External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection.

What makes this even more curious is the Viral Infections the warnings go on to enumerate.

2a. Since Actinic Keratosis is a specific form of Viral Infection, the same precaution may apply.

Actinic Keratosis is a Viral Infection? I didn’t know that.

3. Since Actinic Keratosis of the Hands and Arms is a specific form of Viral Infection, the same precaution may apply.

Now we learn of different subgroups of Actinic Keratoses that are Viral Infections. Did they teach you these in Dermatology School? (Please see Warnings 6-10, below.)

4. This warning refers to a specific Bacterial Infection called Folliculitis Nares Perforans. I don’t know what that is, but it sounds bad. Glad they warned me.

5. Since Pseudofolliculitis Barbae is a specific form of Bacterial Infection, the same precaution may apply.

I never used much desonide for pseudofolliculitis, cautiously or otherwise.

Warnings 6-10 describe more specific forms of Viral Infection: (6) Non-Hyperkeratotic Actinic Keratosis, (7) Actinic Keratosis of Face and Anterior Scalp, (8) Non-Hyperkeratotic Non-Pigmented Actinic Keratosis, (9) Non-Hyperkeratotic Face and Scalp Actinic Keratosis, (10) Pigmented Actinic Keratosis.

This is most disturbing. What Systemic Viral Infections did they leave me to use desonide on? Hyperkeratotic Non-Pigmented Actinic Keratoses of the Posterior Scalp?

Warning 11 is another specific Bacterial Infection: Local Folliculitis. What is the opposite of Local Folliculitis? Express Folliculitis?

Warning 12 is Perioral Dermatitis. Steroids on rosacea? Really? Maybe a cheaper one.

I will now skip to warning 16: Hirsutism has been associated with Desonide External Cream 0.05%. Since Hair Disease is a more general form of Hirsutism, it may also be considered a drug-related medical condition.

Did you know that desonide causes unwanted hair growth? Or realize that Hair Disease is a more general form of Hirsutism? I myself have male-pattern baldness. (Sorry, Male-Pattern BALDNESS.) Since Baldness is a Hair Disease, is it also a more general form of Hirsutism? Instead of having too little hair, do I now have too much?

The same is true for warning 17, which is identical to 16, except that it substitutes “Hypertrichosis” for “Hirsutism.”

Okay, colleagues, it’s time for a personal reckoning. You trained, practiced, took CME, but you didn’t know about any of these risks, did you? You’ve just been just heedlessly, incautiously, throwing around desonide, producing hairy patients with Systemic Bacterial and Viral Infections. And on “Non-Hyperkeratotic Non-Pigmented Actinic Keratosis,” no less. Aren’t you disappointed in yourselves?

When I first read warnings like these, I wrote my EMR provider to ask who puts together this stuff, and which consultants vet it. They never answered. It is very hard to believe that a dermatologist was involved at any stage of developing these warnings, with their irrelevant caveats and absurd classification schemes.

Who would develop electronic prescribing guidelines without at least consulting the physicians who do the prescribing? Why would they want to?

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

Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. 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 over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. 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 over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. 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 over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Question: Grandma finally checked into a skilled nursing facility (SNF), a member of a national chain of for-profit SNFs, after her progressive dementia prevented her from performing the basic activities of daily living. Unfortunately, the staffing was inadequate, and there were lapses in attention toward her nutrition, medications, and body hygiene. She even fell from her bed on a couple of occasions. Other residents have registered similar complaints. Which of the following legal recourses is available?

A. A lawsuit against the SNF, alleging neglect and abuse.
B. A class action suit against the SNF and its corporate owners.
C. A lawsuit against the attending physician and/or the medical director.
D. A, B, and C.
E. Only A and B.

Answer: D. According to the Wall Street Journal, more than 1.4 million people live in U.S. nursing homes, 69% of which are run by for-profit entities.¹ In contrast to a malpractice complaint, lawsuits against nursing homes and SNFs typically involve allegations of a pattern of neglect and abuse rather than any single incident of negligence. The terms nursing home and SNF are often used interchangeably, but do differ somewhat in that the former deals with non-Medicare regulated custodial care, whereas Medicare regulates and certifies all SNFs, which provide both custodial and medical care. Federal and state statutes, e.g., 42 CFR §483 and Centers for Medicare and Medicaid Services guidelines in the State Operations Manual, prescribe the requisite standards. Collectively referred to as the OBRA standards, their violations are frequently at the heart of a plaintiff’s allegations. These may include short staffing, inattention to body hygiene, skin infections, pressure ulcers, improper use of restraints, poor nutrition and hydration, and failure to monitor or supervise, including failure to administer prescription medications and prevention of falls and violent acts from other residents.

In the past 2 decades, nursing homes and SNFs have experienced soaring numbers of lawsuits, with Texas and Florida being especially vulnerable.² Runaway jury verdicts can result even where the elderly victim has incurred little or no economic loss. Noneconomic losses such as pain and suffering as well as punitive damages explain these huge awards. A recent widely publicized case is illustrative: On Sept. 4, 2009, 87-year-old Dorothy Douglas, an Alzheimer’s patient, was admitted to Heartland Nursing Home in Charleston, W.Va. Still cognitive, she was able to ambulate with an assistive device and was well nourished. However, within 19 days of admission, she became barely responsive, dehydrated, and bedridden, and had fallen numerous times, injuring her head. She died shortly thereafter. Her son sued the owner of Heartland and those responsible for its operations, claiming, among other things, medical and corporate negligence. A jury found in his favor, awarding $11.5 million in compensatory damages and $80 million in punitive damages. On appeal, the West Virginia Supreme Court affirmed in part the trial court’s order, although it reduced the punitive damages from $80 million to $32 million (termed a remittitur).³

There are other sizable verdicts, such as a $29 million lawsuit against a Rocklin, Calif., facility in 2010. Another, possibly the largest on record, was a 2013 Florida jury award of $110 million in compensatory damages and $1.0 billion in punitive damages against Auburndale Oaks Healthcare Center. However, this may not have been the final negotiated amount. Increasingly popular is the use of class action lawsuits, where representative plaintiffs assert claims on behalf of a large class of similarly injured members. Typically, they allege grossly substandard care and understaffing in violation of Medicare and/or other statutory rules. New York’s first nursing home class action suit,⁴ which dragged on for some 9 years, ended up with a settlement sum of only $950,000 for its 22 class members. The suit alleged, among other things, inedible food, inadequate heat, and squalid conditions. A more recent example: In 2010, a Humboldt County, Calif., jury returned a $677 million verdict (Lavender v. Skilled Healthcare Group Inc.) against one of the nation’s largest nursing home chains for violating California’s Health and Safety Code in its 22 statewide facilities. The case later settled for $62.8 million on behalf of the 32,000 residents.

What about physician liability? Many doctors attend to SNF patients and a number act as medical directors. Liability exists in both roles. The first is governed by the usual tort action of malpractice. The latter is infinitely trickier. Medicare mandates all SNFs to have a medical director, and federal law [42 CFR 483.75 (i)] requires the medical director to be responsible for implementation of resident care policies and the coordination of medical care in the facility. Although their duties are administrative in nature, medical directors are not infrequently named as codefendants in SNF lawsuits. Allegations against the medical director may include negligent supervision of staff, and/or the failure to set standards, policies, and procedures, especially if they have been made aware of citations by auditing agencies. Because a doctor’s professional liability policy typically excludes coverage for such work, it behooves all medical directors to insist on being a named insured in the institution’s general liability policy (to include tail coverage), and to be informed in a timely fashion should there be a relevant change or cancellation of coverage. Their contract should stipulate that the facility would indemnify them for all lawsuits arising out of their work. More and more nursing homes are dropping their insurance to bypass legal exposure, leaving the attending physician and/or medical director at increased risk. To avoid a serious gap in coverage, medical directors should consider purchasing a specific medical director policy.⁵ Medical directors should also be aware of potential Stark Law violations, such as treating private patients without paying fair rent or receiving compensation in exchange for referrals.

Importantly, elder abuse judgments, as opposed to malpractice awards, may negate restrictions on attorney fees and noneconomic damages such as California’s $250,000 cap. The jury may also levy punitive damages, which are not covered by professional insurance. The plaintiff will need to prove, by clear and convincing evidence, something more than simple or gross negligence such as malice, fraud, oppression, or recklessness.⁶ Under California’s elder abuse and dependent Adult Civil Protection Act, an appellate court has held that a plaintiff may mount an elder abuse claim directed at physicians and not just facilities with “custodial” duties.⁷This important issue is currently under appeal before the California Supreme Court.

References

1. The Wall Street Journal, Oct. 3, 2014.

2. Stevenson, DG and DM Studdert, The Rise Of Nursing Home Litigation: Findings From A National Survey Of Attorneys. Health Affairs 2003; 22:219-29.

3. Manor Care Inc. v. Douglas, 763 N.E.2d 73 (W. Va. 2014).

4. Fleming v. Barnwell Nursing Hone and Health Facilities Inc., 309 A.D.2d 1132 (N.Y. App. Div. 2003).

5. See the American Medical Directors Association’s (AMDA) offering at http://locktonmedicalliabilityinsurance.com/amda/.

6. Delaney v. Baker, 20 Cal. 4th 23 (1999).

7. Winn v. Pioneer Medical Group Inc., 216 Cal. App. 4th 875 (2013).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. He currently directs The St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

Question: Grandma finally checked into a skilled nursing facility (SNF), a member of a national chain of for-profit SNFs, after her progressive dementia prevented her from performing the basic activities of daily living. Unfortunately, the staffing was inadequate, and there were lapses in attention toward her nutrition, medications, and body hygiene. She even fell from her bed on a couple of occasions. Other residents have registered similar complaints. Which of the following legal recourses is available?

A. A lawsuit against the SNF, alleging neglect and abuse.
B. A class action suit against the SNF and its corporate owners.
C. A lawsuit against the attending physician and/or the medical director.
D. A, B, and C.
E. Only A and B.

Answer: D. According to the Wall Street Journal, more than 1.4 million people live in U.S. nursing homes, 69% of which are run by for-profit entities.¹ In contrast to a malpractice complaint, lawsuits against nursing homes and SNFs typically involve allegations of a pattern of neglect and abuse rather than any single incident of negligence. The terms nursing home and SNF are often used interchangeably, but do differ somewhat in that the former deals with non-Medicare regulated custodial care, whereas Medicare regulates and certifies all SNFs, which provide both custodial and medical care. Federal and state statutes, e.g., 42 CFR §483 and Centers for Medicare and Medicaid Services guidelines in the State Operations Manual, prescribe the requisite standards. Collectively referred to as the OBRA standards, their violations are frequently at the heart of a plaintiff’s allegations. These may include short staffing, inattention to body hygiene, skin infections, pressure ulcers, improper use of restraints, poor nutrition and hydration, and failure to monitor or supervise, including failure to administer prescription medications and prevention of falls and violent acts from other residents.

In the past 2 decades, nursing homes and SNFs have experienced soaring numbers of lawsuits, with Texas and Florida being especially vulnerable.² Runaway jury verdicts can result even where the elderly victim has incurred little or no economic loss. Noneconomic losses such as pain and suffering as well as punitive damages explain these huge awards. A recent widely publicized case is illustrative: On Sept. 4, 2009, 87-year-old Dorothy Douglas, an Alzheimer’s patient, was admitted to Heartland Nursing Home in Charleston, W.Va. Still cognitive, she was able to ambulate with an assistive device and was well nourished. However, within 19 days of admission, she became barely responsive, dehydrated, and bedridden, and had fallen numerous times, injuring her head. She died shortly thereafter. Her son sued the owner of Heartland and those responsible for its operations, claiming, among other things, medical and corporate negligence. A jury found in his favor, awarding $11.5 million in compensatory damages and $80 million in punitive damages. On appeal, the West Virginia Supreme Court affirmed in part the trial court’s order, although it reduced the punitive damages from $80 million to $32 million (termed a remittitur).³

There are other sizable verdicts, such as a $29 million lawsuit against a Rocklin, Calif., facility in 2010. Another, possibly the largest on record, was a 2013 Florida jury award of $110 million in compensatory damages and $1.0 billion in punitive damages against Auburndale Oaks Healthcare Center. However, this may not have been the final negotiated amount. Increasingly popular is the use of class action lawsuits, where representative plaintiffs assert claims on behalf of a large class of similarly injured members. Typically, they allege grossly substandard care and understaffing in violation of Medicare and/or other statutory rules. New York’s first nursing home class action suit,⁴ which dragged on for some 9 years, ended up with a settlement sum of only $950,000 for its 22 class members. The suit alleged, among other things, inedible food, inadequate heat, and squalid conditions. A more recent example: In 2010, a Humboldt County, Calif., jury returned a $677 million verdict (Lavender v. Skilled Healthcare Group Inc.) against one of the nation’s largest nursing home chains for violating California’s Health and Safety Code in its 22 statewide facilities. The case later settled for $62.8 million on behalf of the 32,000 residents.

What about physician liability? Many doctors attend to SNF patients and a number act as medical directors. Liability exists in both roles. The first is governed by the usual tort action of malpractice. The latter is infinitely trickier. Medicare mandates all SNFs to have a medical director, and federal law [42 CFR 483.75 (i)] requires the medical director to be responsible for implementation of resident care policies and the coordination of medical care in the facility. Although their duties are administrative in nature, medical directors are not infrequently named as codefendants in SNF lawsuits. Allegations against the medical director may include negligent supervision of staff, and/or the failure to set standards, policies, and procedures, especially if they have been made aware of citations by auditing agencies. Because a doctor’s professional liability policy typically excludes coverage for such work, it behooves all medical directors to insist on being a named insured in the institution’s general liability policy (to include tail coverage), and to be informed in a timely fashion should there be a relevant change or cancellation of coverage. Their contract should stipulate that the facility would indemnify them for all lawsuits arising out of their work. More and more nursing homes are dropping their insurance to bypass legal exposure, leaving the attending physician and/or medical director at increased risk. To avoid a serious gap in coverage, medical directors should consider purchasing a specific medical director policy.⁵ Medical directors should also be aware of potential Stark Law violations, such as treating private patients without paying fair rent or receiving compensation in exchange for referrals.

Importantly, elder abuse judgments, as opposed to malpractice awards, may negate restrictions on attorney fees and noneconomic damages such as California’s $250,000 cap. The jury may also levy punitive damages, which are not covered by professional insurance. The plaintiff will need to prove, by clear and convincing evidence, something more than simple or gross negligence such as malice, fraud, oppression, or recklessness.⁶ Under California’s elder abuse and dependent Adult Civil Protection Act, an appellate court has held that a plaintiff may mount an elder abuse claim directed at physicians and not just facilities with “custodial” duties.⁷This important issue is currently under appeal before the California Supreme Court.

References

1. The Wall Street Journal, Oct. 3, 2014.

2. Stevenson, DG and DM Studdert, The Rise Of Nursing Home Litigation: Findings From A National Survey Of Attorneys. Health Affairs 2003; 22:219-29.

3. Manor Care Inc. v. Douglas, 763 N.E.2d 73 (W. Va. 2014).

4. Fleming v. Barnwell Nursing Hone and Health Facilities Inc., 309 A.D.2d 1132 (N.Y. App. Div. 2003).

5. See the American Medical Directors Association’s (AMDA) offering at http://locktonmedicalliabilityinsurance.com/amda/.

6. Delaney v. Baker, 20 Cal. 4th 23 (1999).

7. Winn v. Pioneer Medical Group Inc., 216 Cal. App. 4th 875 (2013).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. He currently directs The St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

Question: Grandma finally checked into a skilled nursing facility (SNF), a member of a national chain of for-profit SNFs, after her progressive dementia prevented her from performing the basic activities of daily living. Unfortunately, the staffing was inadequate, and there were lapses in attention toward her nutrition, medications, and body hygiene. She even fell from her bed on a couple of occasions. Other residents have registered similar complaints. Which of the following legal recourses is available?

A. A lawsuit against the SNF, alleging neglect and abuse.
B. A class action suit against the SNF and its corporate owners.
C. A lawsuit against the attending physician and/or the medical director.
D. A, B, and C.
E. Only A and B.

Answer: D. According to the Wall Street Journal, more than 1.4 million people live in U.S. nursing homes, 69% of which are run by for-profit entities.¹ In contrast to a malpractice complaint, lawsuits against nursing homes and SNFs typically involve allegations of a pattern of neglect and abuse rather than any single incident of negligence. The terms nursing home and SNF are often used interchangeably, but do differ somewhat in that the former deals with non-Medicare regulated custodial care, whereas Medicare regulates and certifies all SNFs, which provide both custodial and medical care. Federal and state statutes, e.g., 42 CFR §483 and Centers for Medicare and Medicaid Services guidelines in the State Operations Manual, prescribe the requisite standards. Collectively referred to as the OBRA standards, their violations are frequently at the heart of a plaintiff’s allegations. These may include short staffing, inattention to body hygiene, skin infections, pressure ulcers, improper use of restraints, poor nutrition and hydration, and failure to monitor or supervise, including failure to administer prescription medications and prevention of falls and violent acts from other residents.

In the past 2 decades, nursing homes and SNFs have experienced soaring numbers of lawsuits, with Texas and Florida being especially vulnerable.² Runaway jury verdicts can result even where the elderly victim has incurred little or no economic loss. Noneconomic losses such as pain and suffering as well as punitive damages explain these huge awards. A recent widely publicized case is illustrative: On Sept. 4, 2009, 87-year-old Dorothy Douglas, an Alzheimer’s patient, was admitted to Heartland Nursing Home in Charleston, W.Va. Still cognitive, she was able to ambulate with an assistive device and was well nourished. However, within 19 days of admission, she became barely responsive, dehydrated, and bedridden, and had fallen numerous times, injuring her head. She died shortly thereafter. Her son sued the owner of Heartland and those responsible for its operations, claiming, among other things, medical and corporate negligence. A jury found in his favor, awarding $11.5 million in compensatory damages and $80 million in punitive damages. On appeal, the West Virginia Supreme Court affirmed in part the trial court’s order, although it reduced the punitive damages from $80 million to $32 million (termed a remittitur).³

There are other sizable verdicts, such as a $29 million lawsuit against a Rocklin, Calif., facility in 2010. Another, possibly the largest on record, was a 2013 Florida jury award of $110 million in compensatory damages and $1.0 billion in punitive damages against Auburndale Oaks Healthcare Center. However, this may not have been the final negotiated amount. Increasingly popular is the use of class action lawsuits, where representative plaintiffs assert claims on behalf of a large class of similarly injured members. Typically, they allege grossly substandard care and understaffing in violation of Medicare and/or other statutory rules. New York’s first nursing home class action suit,⁴ which dragged on for some 9 years, ended up with a settlement sum of only $950,000 for its 22 class members. The suit alleged, among other things, inedible food, inadequate heat, and squalid conditions. A more recent example: In 2010, a Humboldt County, Calif., jury returned a $677 million verdict (Lavender v. Skilled Healthcare Group Inc.) against one of the nation’s largest nursing home chains for violating California’s Health and Safety Code in its 22 statewide facilities. The case later settled for $62.8 million on behalf of the 32,000 residents.

What about physician liability? Many doctors attend to SNF patients and a number act as medical directors. Liability exists in both roles. The first is governed by the usual tort action of malpractice. The latter is infinitely trickier. Medicare mandates all SNFs to have a medical director, and federal law [42 CFR 483.75 (i)] requires the medical director to be responsible for implementation of resident care policies and the coordination of medical care in the facility. Although their duties are administrative in nature, medical directors are not infrequently named as codefendants in SNF lawsuits. Allegations against the medical director may include negligent supervision of staff, and/or the failure to set standards, policies, and procedures, especially if they have been made aware of citations by auditing agencies. Because a doctor’s professional liability policy typically excludes coverage for such work, it behooves all medical directors to insist on being a named insured in the institution’s general liability policy (to include tail coverage), and to be informed in a timely fashion should there be a relevant change or cancellation of coverage. Their contract should stipulate that the facility would indemnify them for all lawsuits arising out of their work. More and more nursing homes are dropping their insurance to bypass legal exposure, leaving the attending physician and/or medical director at increased risk. To avoid a serious gap in coverage, medical directors should consider purchasing a specific medical director policy.⁵ Medical directors should also be aware of potential Stark Law violations, such as treating private patients without paying fair rent or receiving compensation in exchange for referrals.

Importantly, elder abuse judgments, as opposed to malpractice awards, may negate restrictions on attorney fees and noneconomic damages such as California’s $250,000 cap. The jury may also levy punitive damages, which are not covered by professional insurance. The plaintiff will need to prove, by clear and convincing evidence, something more than simple or gross negligence such as malice, fraud, oppression, or recklessness.⁶ Under California’s elder abuse and dependent Adult Civil Protection Act, an appellate court has held that a plaintiff may mount an elder abuse claim directed at physicians and not just facilities with “custodial” duties.⁷This important issue is currently under appeal before the California Supreme Court.

References

1. The Wall Street Journal, Oct. 3, 2014.

2. Stevenson, DG and DM Studdert, The Rise Of Nursing Home Litigation: Findings From A National Survey Of Attorneys. Health Affairs 2003; 22:219-29.

3. Manor Care Inc. v. Douglas, 763 N.E.2d 73 (W. Va. 2014).

4. Fleming v. Barnwell Nursing Hone and Health Facilities Inc., 309 A.D.2d 1132 (N.Y. App. Div. 2003).

5. See the American Medical Directors Association’s (AMDA) offering at http://locktonmedicalliabilityinsurance.com/amda/.

6. Delaney v. Baker, 20 Cal. 4th 23 (1999).

7. Winn v. Pioneer Medical Group Inc., 216 Cal. App. 4th 875 (2013).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. He currently directs The St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.

With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:

• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.

• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.

• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.

It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.

• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.

• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.

In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.

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

I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.

With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:

• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.

• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.

• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.

It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.

• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.

• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.

In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.

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

I heard somewhere that doctors are judged by patients as soon as we walk in the door. We are held to high standards of behavior and knowledge – and rightly so. After all, we are given this incredible responsibility of keeping people healthy. But our ability to do our job is limited by regulations that make up the business of medicine: time constraints, insurance hurdles, meaningful use requirements, and coding issues. Few of us would count those as part of the good doctor’s toolbox, but these are the hidden forces that shape how we conduct our jobs.

With that in mind, here is a wish list of sorts for how patients might do their part in making the interaction pleasant and productive:

• I wish patients arrived on time. I often hear the counter argument that we doctors do not run on time, but that’s not the same. When we run late it is often for reasons that are beyond our control. On the other hand, patients coming on time indicates a respect for the doctor’s time and a commitment to their own health and well-being.

• It would be helpful if patients brought a medication list and, along with that, a list of their medical conditions. A list of their doctors is helpful as well. Not infrequently, when I ask a patient how they came to need a rheumatologist, the answer is “It should be in my records.” This is problematic, in part because what counts for records these days is actually an auto-filled document containing pages upon pages of repetitive information that is not germane to the problem at hand.

• If your practice is anything like mine, patients often bring up another problem or two at the end of the visit. Twenty minutes into the visit, as they are stepping off the exam table, they throw in “one last question” or an “oh, by the way.” This can run the gamut from chest pain or weight loss to disability paperwork or medical marijuana. Our patients may not be aware that we can only afford to spend 15-20 minutes with them.

It is also difficult for patients to identify which problems are related to their rheumatologic condition and which are not, leading them to expect us to weigh in on issues that are perhaps better discussed with their primary care physicians. And because we are physicians and want to do what we can for them, we also feel obligated to address all of their concerns. It would be helpful if patients came to the visit prepared with the issues they want to discuss in order of priority. Otherwise, we will never be able to satisfactorily address all of their concerns and still run an efficient practice.

• I have seen many patients who were unhappy with their previous rheumatologist. I have also had unhappy patients fire me and seek care elsewhere. I completely support this system as it leads to a self-selection of sorts. This works out for everyone involved, particularly for the patients. Some patients, though, feel the need to denigrate their other doctors to me in a conspiratorial manner, as if waiting for me to confirm their opinions. This makes me very uncomfortable. I discourage this behavior by reminding patients that symptoms evolve and that the previous doctor, in all likelihood, already did some of the preliminary work that allows the next doctor to seem brilliant in comparison.

• My assistant is fantastic. She can almost read my mind. My mentor at the University of Massachusetts, Dr. Kathy Upchurch, used to say that she saw her assistant more than she saw her husband. This is probably true for most of us who work full time. Our staffs have the unenviable job of keeping both patients and doctors happy, and they are largely responsible for the seamless operations that we run. It is very important to me that my patients treat our staff with respect.

In the end it comes down to this: In this age of managed care, the business of medicine has gotten in the way of the art of medicine. But, as with any human interaction, courtesy and respect make the whole enterprise much more rewarding.

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

We hear a lot about the pros and cons of cash-pay medicine. I’ve written about it in the past. So far, I haven’t made the leap of faith it would require in my own practice.

But recently I developed a gradually worsening toothache. For a while I ignored it, hoping it would go away. Like most doctors, my first thought was “I don’t have time for this.” But, as it progressed, I knew I didn’t have a choice.

I didn’t have a dentist, either, and have never had dental insurance. Now what?

So I called a family friend who’s a dentist. His actual charge for the visit was around $200, but he kindly charged me only $50. I sent him a $100 gift card to thank him for his help, and I’m well aware most folks don’t have the benefit of knowing a dentist on nonprofessional terms.

Unfortunately, he found he couldn’t help me. I had an upper molar that was busily reabsorbing itself, and needed to come out.

So I went to an oral surgeon. The first visit (“limited exam and counseling”) was $95. Two days later, I went back to get the tooth yanked for good. That was $275. I paid both in full by credit card.

Do I think any of these charges were unreasonable? Absolutely not. The transaction is done; the tooth is out. His office doesn’t have to bill my insurance, hope to collect part of it, and then bill me for the rest. I don’t have to worry about being billed for something my insurance didn’t pay, or spend an hour (or more) on hold to ask questions of an insurance representative as to why my claim was denied. And I get to put the $520 down on my 2015 taxes as a medical deduction.

It’s pretty simple, isn’t it? The guy pulls my tooth, and I pay a fair amount for his service. This is the same business relationship I have with a grocery store, car mechanic, or office landlord.

So why doesn’t this catch on for most of medicine? It would be nice if it were that simple.

I’m fortunate to be able to afford the total of $520 I’ve spent on the tooth. Many people don’t have that luxury, and have to rely on insurance coverage; $520 is also a pittance, compared with what other things may run. Multiple MRIs? An electromyogram/nerve conduction velocity test? Multiple sclerosis drugs? Chemotherapy? Neurosurgery? A hospital stay? In that group, you’re talking about things that can range from $1,000 to $100,000 (or more) – a far cry from what I spent on my tooth, but still medically necessary for many.

Some will argue these medical costs should all be cash pay, too. If patients can’t afford multiple sclerosis drugs out of pocket ($50,000/year and up for some), then the market will force the drug companies to lower their prices to where people will buy them. That may be, but the price an average person can likely afford isn’t going to support what the company spent to bring the drug to market or pay for trials of the next generation of treatments. So in the long run, it hurts people more than it helps.

Now if I apply this to my practice, I’m sure there are many who could afford my cash rates if I dropped their plan, but since there are other neurologists taking insurance in the area, people will generally go to whoever is best for their wallet. And a copay is going to trump my cash price for most – not to mention the costs of tests that may be needed.

For an office visit, cash pay would likely work for most. It’s simple, quick, and straightforward. But it’s the high costs of modern medicine – advanced tests, hospital stays, and upper-line pharmaceuticals (some patients don’t have other options) – that make it an unworkable proposition for many.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

We hear a lot about the pros and cons of cash-pay medicine. I’ve written about it in the past. So far, I haven’t made the leap of faith it would require in my own practice.

But recently I developed a gradually worsening toothache. For a while I ignored it, hoping it would go away. Like most doctors, my first thought was “I don’t have time for this.” But, as it progressed, I knew I didn’t have a choice.

I didn’t have a dentist, either, and have never had dental insurance. Now what?

So I called a family friend who’s a dentist. His actual charge for the visit was around $200, but he kindly charged me only $50. I sent him a $100 gift card to thank him for his help, and I’m well aware most folks don’t have the benefit of knowing a dentist on nonprofessional terms.

Unfortunately, he found he couldn’t help me. I had an upper molar that was busily reabsorbing itself, and needed to come out.

So I went to an oral surgeon. The first visit (“limited exam and counseling”) was $95. Two days later, I went back to get the tooth yanked for good. That was $275. I paid both in full by credit card.

Do I think any of these charges were unreasonable? Absolutely not. The transaction is done; the tooth is out. His office doesn’t have to bill my insurance, hope to collect part of it, and then bill me for the rest. I don’t have to worry about being billed for something my insurance didn’t pay, or spend an hour (or more) on hold to ask questions of an insurance representative as to why my claim was denied. And I get to put the $520 down on my 2015 taxes as a medical deduction.

It’s pretty simple, isn’t it? The guy pulls my tooth, and I pay a fair amount for his service. This is the same business relationship I have with a grocery store, car mechanic, or office landlord.

So why doesn’t this catch on for most of medicine? It would be nice if it were that simple.

I’m fortunate to be able to afford the total of $520 I’ve spent on the tooth. Many people don’t have that luxury, and have to rely on insurance coverage; $520 is also a pittance, compared with what other things may run. Multiple MRIs? An electromyogram/nerve conduction velocity test? Multiple sclerosis drugs? Chemotherapy? Neurosurgery? A hospital stay? In that group, you’re talking about things that can range from $1,000 to $100,000 (or more) – a far cry from what I spent on my tooth, but still medically necessary for many.

Some will argue these medical costs should all be cash pay, too. If patients can’t afford multiple sclerosis drugs out of pocket ($50,000/year and up for some), then the market will force the drug companies to lower their prices to where people will buy them. That may be, but the price an average person can likely afford isn’t going to support what the company spent to bring the drug to market or pay for trials of the next generation of treatments. So in the long run, it hurts people more than it helps.

Now if I apply this to my practice, I’m sure there are many who could afford my cash rates if I dropped their plan, but since there are other neurologists taking insurance in the area, people will generally go to whoever is best for their wallet. And a copay is going to trump my cash price for most – not to mention the costs of tests that may be needed.

For an office visit, cash pay would likely work for most. It’s simple, quick, and straightforward. But it’s the high costs of modern medicine – advanced tests, hospital stays, and upper-line pharmaceuticals (some patients don’t have other options) – that make it an unworkable proposition for many.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

We hear a lot about the pros and cons of cash-pay medicine. I’ve written about it in the past. So far, I haven’t made the leap of faith it would require in my own practice.

But recently I developed a gradually worsening toothache. For a while I ignored it, hoping it would go away. Like most doctors, my first thought was “I don’t have time for this.” But, as it progressed, I knew I didn’t have a choice.

I didn’t have a dentist, either, and have never had dental insurance. Now what?

So I called a family friend who’s a dentist. His actual charge for the visit was around $200, but he kindly charged me only $50. I sent him a $100 gift card to thank him for his help, and I’m well aware most folks don’t have the benefit of knowing a dentist on nonprofessional terms.

Unfortunately, he found he couldn’t help me. I had an upper molar that was busily reabsorbing itself, and needed to come out.

So I went to an oral surgeon. The first visit (“limited exam and counseling”) was $95. Two days later, I went back to get the tooth yanked for good. That was $275. I paid both in full by credit card.

Do I think any of these charges were unreasonable? Absolutely not. The transaction is done; the tooth is out. His office doesn’t have to bill my insurance, hope to collect part of it, and then bill me for the rest. I don’t have to worry about being billed for something my insurance didn’t pay, or spend an hour (or more) on hold to ask questions of an insurance representative as to why my claim was denied. And I get to put the $520 down on my 2015 taxes as a medical deduction.

It’s pretty simple, isn’t it? The guy pulls my tooth, and I pay a fair amount for his service. This is the same business relationship I have with a grocery store, car mechanic, or office landlord.

So why doesn’t this catch on for most of medicine? It would be nice if it were that simple.

I’m fortunate to be able to afford the total of $520 I’ve spent on the tooth. Many people don’t have that luxury, and have to rely on insurance coverage; $520 is also a pittance, compared with what other things may run. Multiple MRIs? An electromyogram/nerve conduction velocity test? Multiple sclerosis drugs? Chemotherapy? Neurosurgery? A hospital stay? In that group, you’re talking about things that can range from $1,000 to $100,000 (or more) – a far cry from what I spent on my tooth, but still medically necessary for many.

Some will argue these medical costs should all be cash pay, too. If patients can’t afford multiple sclerosis drugs out of pocket ($50,000/year and up for some), then the market will force the drug companies to lower their prices to where people will buy them. That may be, but the price an average person can likely afford isn’t going to support what the company spent to bring the drug to market or pay for trials of the next generation of treatments. So in the long run, it hurts people more than it helps.

Now if I apply this to my practice, I’m sure there are many who could afford my cash rates if I dropped their plan, but since there are other neurologists taking insurance in the area, people will generally go to whoever is best for their wallet. And a copay is going to trump my cash price for most – not to mention the costs of tests that may be needed.

For an office visit, cash pay would likely work for most. It’s simple, quick, and straightforward. But it’s the high costs of modern medicine – advanced tests, hospital stays, and upper-line pharmaceuticals (some patients don’t have other options) – that make it an unworkable proposition for many.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Whenever I meet families who oppose vaccination, my first response is to flood them with more evidence, reciting the pro-vaccine fact sheet that every doctor knows by heart. I can’t help myself. The evidence is so self-explanatory that it should put any question to rest.

But this approach may just exacerbate the problem. In fact, studies suggest that attacking parents’ beliefs can backfire, and that “attempts to increase concerns about communicable diseases or correct false claims about vaccines may be … counterproductive.” We can inform parents that vaccines prevent thousands of deaths and millions of cases of disease while saving billions in health care costs, but this will not change the mind of someone who does not trust the data.

One major problem is that doctors and parents sometimes speak different languages. As trainees, we are raised on nomograms, algorithms, and clinical trials. When a problem presents itself, we instinctively seek out a rational, data-driven response. This is how doctors are built, but studies suggest that vaccine-hesitant parents may be built differently, driven more by fears and negative emotions than by data. Their decisions seem to be based not on a misunderstanding of the facts, but rather a mistrust of the facts.

As pediatric trainees, this is the world we are inheriting. The more successful vaccines become at preventing disease, the harder it will become to convince parents of the serious risks of nonvaccination. It is a perpetual uphill battle.

To make the future better for our patients (and to contribute to our future sanity), we need to work past frustrations and focus on developing pragmatic solutions. There is surely no easy or perfect answer, and different parents may require different approaches, but the status quo is not working. To find the solutions, we need to develop a robust evidence base to guide our good intentions. Perhaps the answer will come from tailoring communication strategies, refocusing public outreach efforts, creating legal mandates, or maybe something completely different.

And if we are successful, maybe we can close the communications gap between vaccine-resisting parents and doctors.

Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at pdnews@frontlinemedcom.com.

Whenever I meet families who oppose vaccination, my first response is to flood them with more evidence, reciting the pro-vaccine fact sheet that every doctor knows by heart. I can’t help myself. The evidence is so self-explanatory that it should put any question to rest.

But this approach may just exacerbate the problem. In fact, studies suggest that attacking parents’ beliefs can backfire, and that “attempts to increase concerns about communicable diseases or correct false claims about vaccines may be … counterproductive.” We can inform parents that vaccines prevent thousands of deaths and millions of cases of disease while saving billions in health care costs, but this will not change the mind of someone who does not trust the data.

One major problem is that doctors and parents sometimes speak different languages. As trainees, we are raised on nomograms, algorithms, and clinical trials. When a problem presents itself, we instinctively seek out a rational, data-driven response. This is how doctors are built, but studies suggest that vaccine-hesitant parents may be built differently, driven more by fears and negative emotions than by data. Their decisions seem to be based not on a misunderstanding of the facts, but rather a mistrust of the facts.

As pediatric trainees, this is the world we are inheriting. The more successful vaccines become at preventing disease, the harder it will become to convince parents of the serious risks of nonvaccination. It is a perpetual uphill battle.

To make the future better for our patients (and to contribute to our future sanity), we need to work past frustrations and focus on developing pragmatic solutions. There is surely no easy or perfect answer, and different parents may require different approaches, but the status quo is not working. To find the solutions, we need to develop a robust evidence base to guide our good intentions. Perhaps the answer will come from tailoring communication strategies, refocusing public outreach efforts, creating legal mandates, or maybe something completely different.

And if we are successful, maybe we can close the communications gap between vaccine-resisting parents and doctors.

Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at pdnews@frontlinemedcom.com.

Whenever I meet families who oppose vaccination, my first response is to flood them with more evidence, reciting the pro-vaccine fact sheet that every doctor knows by heart. I can’t help myself. The evidence is so self-explanatory that it should put any question to rest.

But this approach may just exacerbate the problem. In fact, studies suggest that attacking parents’ beliefs can backfire, and that “attempts to increase concerns about communicable diseases or correct false claims about vaccines may be … counterproductive.” We can inform parents that vaccines prevent thousands of deaths and millions of cases of disease while saving billions in health care costs, but this will not change the mind of someone who does not trust the data.

One major problem is that doctors and parents sometimes speak different languages. As trainees, we are raised on nomograms, algorithms, and clinical trials. When a problem presents itself, we instinctively seek out a rational, data-driven response. This is how doctors are built, but studies suggest that vaccine-hesitant parents may be built differently, driven more by fears and negative emotions than by data. Their decisions seem to be based not on a misunderstanding of the facts, but rather a mistrust of the facts.

As pediatric trainees, this is the world we are inheriting. The more successful vaccines become at preventing disease, the harder it will become to convince parents of the serious risks of nonvaccination. It is a perpetual uphill battle.

To make the future better for our patients (and to contribute to our future sanity), we need to work past frustrations and focus on developing pragmatic solutions. There is surely no easy or perfect answer, and different parents may require different approaches, but the status quo is not working. To find the solutions, we need to develop a robust evidence base to guide our good intentions. Perhaps the answer will come from tailoring communication strategies, refocusing public outreach efforts, creating legal mandates, or maybe something completely different.

And if we are successful, maybe we can close the communications gap between vaccine-resisting parents and doctors.

Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at pdnews@frontlinemedcom.com.

While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.

I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.

However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.

I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.

As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.

So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.

While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.

The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?

How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?

I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.

While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.

I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.

However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.

I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.

As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.

So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.

While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.

The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?

How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?

I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.

While folks my age are sometimes referred to as “elderly” victims in newspaper stories about phone and Internet scams, I resist and object to the implication that I am less than sharp and worrisomely vulnerable to being duped.

I hang up when a stranger calls to warn me that I am about to be audited by the Internal Revenue Service and asks for my Social Security number. I double-delete e-mails purported to come from my Internet provider that ask for my e-mail address and password. I’m no pushover.

However, I fear that over the last 20 years of my practice career, I was duped by several of my adolescent patients on more than one occasion. I hope that I had a reputation in town as one of the physicians least likely to leap to the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and even less likely to pull out my pad and prescribe stimulants.

I was particularly hesitant to make the diagnosis of ADHD in an adolescent whose academic career and behavior in grade school had been unremarkable. But from time to time I was presented with a case that included a combination of apparently reliable teachers’ reports, parental pleas, and patient complaints that was hard to ignore. Having ruled out anxiety, depression, learning disabilities, and severe sleep deprivation (all my teenage patients were sleep deprived to some degree) I would reluctantly agree to a trial of stimulant medication.

As you can imagine, assessing success or failure took time because we were usually looking for improvement in academic performance. For adolescents, this often means waiting to the end of the semester or grading period. If the academic improvement was less than dramatic as it was in the usual scenario, I was left relying on the patient’s report of his subjective observations and waiting another 6 months for more information from the school. Occasionally, the patient would report that the medication made him feel weird and that he wanted to stop it. More often, the patient would report that he was able to pay attention in class more easily, even though he had difficulty pointing to a documented improvement in his performance.

So what does one do? Sometimes I could convince the patient and his family that the trial had failed and that we should stop the medication and work harder to find a better match between his learning style, study habits, and the demands of the school. In other cases, I would adjust dosages and switch medications. The results were seldom dramatic. However, if the patient continued to claim a benefit, I would continue to prescribe the stimulant. I would make phone assessments with every refill, and face-to-face visits at least once a year.

While it may be that a few of those adolescents without clearly demonstrable benefit were indeed being helped by the stimulants, I am now convinced that I was being duped more often than I cared to admit then. I know there were stimulants available on the streets and in the school hallways and parking lots because some of my patients told me that they were easy to find and had tried them. I have to believe that some of those pills on the street were ones I had prescribed. I worry when I consider how many.

The national statistics are staggering and embarrassing. In 2013, the federal Substance Abuse and Mental Health Services Administration reported that ED visits associated with the nonmedical use of prescribed stimulants among adults aged 18-34 years had tripled from 2005 to 2011. (“Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs,” by Alan Schwarz, New York Times, April 18, 2015). How many of the pills associated with those visits were originally prescribed for adolescent who didn’t have ADHD?

How many of my patients were just trying to be good friends by sharing their pills and how many were selling them? How many of the pills I prescribed were fueling all-night parties, and how many were being used as performance-enhancing drugs by students who needed to finish a term paper on time?

I don’t know. But I do know that although I miss practicing pediatrics, I am glad I no longer have to face the dilemma of the adolescent with ADHD-like complaints, because I hate being duped.