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Shared decision making? Part two
In a previous editorial I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.
This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.
Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.
Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.
For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?
Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?
On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.
Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?
So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.
Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.
In a previous editorial I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.
This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.
Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.
Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.
For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?
Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?
On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.
Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?
So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.
Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.
In a previous editorial I outlined the problem with performance measures that demand that we incorporate the patient into our decision-making process. From the responses received I have found that most vascular surgeons do indeed attempt to explain their choice of procedure and outline the various risks, consequences, and alternatives. However, it is apparent that both patients and physicians may no longer have control over their decisions. As a group, physicians and surgeons are increasingly being marginalized by entities that are deciding, without our input, what we can do, to whom, and with what.
This is especially so when it involves the technologies that we employ daily – or would like to employ. Thus, if we are not given the opportunity to use a technology we believe most appropriate for our patient, then the patient is also removed from the decision-making process.
Following trips overseas and with meeting vascular surgeons at the World Federation of Vascular Associations, I am now aware that our marginalization has become a universal problem. Because it is not only hospital administrators but insurance carriers, industry, and government agencies that are involved in restricting our freedom of choice. Although cost is usually the limiting factor, sometimes perverse incentives are in effect, and these may differ depending not only in which hospital a surgeon practices but also in which state or country the surgeon resides.
Unfortunately, most surgeons are now accustomed to having hospital chief financial officers (CFOs) refuse to purchase devices that these administrators consider too expensive despite evidence demonstrating clinical superiority. In the U.S. hospitals are compensated for a procedure irrespective of whether it was performed because of a failed prior surgery or endovascular intervention.
For example, if a patient has a prosthetic infra-inguinal bypass that fails within a few months, insurance companies and Medicare will still pay for the subsequent revascularization. Strangely, it would actually be in the hospital’s financial interest that the original procedure require a revision! Accordingly, there is no incentive for a hospital to purchase grafts or endovascular devices with superior short- or long-term results, especially if they are more costly. Is it any wonder then that health care expenses in this country are spiraling out of control?
Surely vascular surgeons would not be equally motivated to use an inferior product simply to be able to bill for a repeat procedure at a later date? But are some of our colleagues or those in other specialties paying attention to the paucity of data supporting long-term outcomes of some of the new endovascular procedures such as atherectomy? Do they really care that these devices may not offer anything more than a few months of palliation necessitating that the patient make a return trip to a lucrative outpatient facility?
On the other hand a health maintenance organization (HMO) or government that pays for all health- related issues of its populace would be inclined to pay for a device that offers long-term efficacy provided that it proves to be cost effective. For example an expensive drug-eluting stent that resists restenosis may still be worth funding if it prevents the need for re-intervention. However, if the result is that every covered patient will henceforth be treated with these costly stents, the overall cost may prove uneconomical and the use of these stents will be disallowed.Moreover, I am sure most surgeons also would be amazed to learn that the availability of a technology may be limited by restrictions on foreign trade and import/export regulations. Some countries insist that devices, and even their packaging, be made in part or totally in that country. Many countries now require that their own equivalent of the FDA analyze the safety or benefit of new medical devices rather than relying on the CE mark in Europe or the U.S. FDA. These regulations may make it economically unfeasible for companies to do business in that country. Thus vascular surgeons in those countries may be denied access to devices produced by market-leading U.S .companies.
Industry also controls availability. A certain recent device was quite effective in the few patients in whom I used it. But apparently it proved to be commercially nonviable and was discontinued. The question is – how many other potentially useful devices have never made it into production?
So how do we fight back against these restrictions? Perhaps the following stratagems may work. If you practice in a city with at least two hospitals, use only the hospital that provides you with all the tools you need. Understand that vascular surgical procedures are profitable for most hospitals. As a result the second hospital will soon notice your absence and may be willing to negotiate. If you are meeting resistance from an ACO, make sure when you present the reasons for requesting a new device that you can also provide valid long-term cost-effective data.
Insurance carriers and government institutions will be more difficult to convince. Accordingly, utilize the collective power of a state or national vascular Society. When dealing with trade embargoes perhaps the European Society for Vascular Surgery, the Society for Vascular Surgery, or the World Federation of Vascular Societies may be able to assist. Appealing to the public through newspaper articles may also be beneficial. It’s time for physicians and surgeons to protest our continued marginalization. After all who knows better which device, drug, or treatment to use? The doctor or the recently graduated MBA? On behalf of our patients we need to take a stand.
Helping parents manage rules across two homes
A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.
Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.
When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.
Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.
As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”
Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.
You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.
Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.
Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.
When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.
Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.
As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”
Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.
You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.
Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.
Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.
When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.
Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.
As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”
Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.
You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.
Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
Technology misuse hinders development in very young
We often hear parents express concern that misuse of technology may be harming their children’s communication health. Despite this concern, significant numbers of parents are handing off smart phones to children as young as age 2 years and are allowing considerable use of technology at the dinner table, sacrificing what should be a prime time to provide the human interaction so vital to their children’s development of strong communication skills.
These are some of the leading findings from a national survey of parents of children aged 0-8 years that the American Speech-Language-Hearing Association (ASHA) commissioned for release during Better Hearing and Speech Month May 2015.
Is technology bad? Are smart phones, tablets, MP3 players, and other devices overtaking and quite possibly harming young children? Not exactly. The devices themselves aren’t the problem, the problem is how they are used. Our survey showed that very young children are using devices such as tablets and smart phones – and that, unfortunately, parents are often not heeding pediatrician screen time recommendations. According to survey respondents, a majority of 2-year-olds use a tablet. The survey also suggests that as children grow older, they prefer to spend more time with technology, where they are free to stare at screens or blast music into ear buds as they wish – potentially damaging their hearing and losing out on important human interaction.
While children are developing their vocabulary and communication skills, it is vital that they not be preoccupied by activities involving use of tablets, smart phones, and other personal technology. This is especially the case for young children, who experience the vast majority of their brain development in their first few years of life. We know that early verbal communication is a strong predictor of a child’s future reading ability and overall academic success. It is critical that we make parents aware of the convincing benefits of reducing screen time and increasing time spent talking, reading, and interacting verbally with children.
We applaud you addressing this subject via the American Academy of Pediatrics’ literacy toolkit and other avenues for reducing screen time (Pediatrics 2013;132:958-61).Unfortunately, according to our poll, well-meaning parents haven’t completely gotten the message – and many rely on technology for a variety of purposes. About half of them say they use technology to keep kids aged 0-3 years entertained, and many report using it to prevent behavior problems and tantrums.
Let’s join forces in raising awareness about the importance of communication health and how parents can foster it through simple, free steps like regularly engaging their kids in conversation, talking to them about the importance of keeping volume levels down, and modeling safe listening behavior themselves.
The need for action is great. A study in Pediatrics reported significant increases between 2001-2002 and 2010-2011 in disabilities associated with speech and hearing among U.S. children (Pediatrics 2014;134:530-8).
Unlike most other conditions, many communication disorders are reversible or even preventable with early treatment. Parents may delay an assessment by a speech-language pathologist or audiologist in hopes that a child will “outgrow” a problem, or they may not recognize potentially problematic signs. We want to see kids before age 3 years if the early signs are there, when it is more likely they will qualify for early intervention services. Early intervention often results in a shorter, more effective, and less expensive course of treatment for these disorders. Ideally, early intervention will assure that any issue will be resolved or significantly improved by the time a child enters school.
ASHA has a current campaign, Identify the Signs (IdentifytheSigns.org), which offers resources about identifying communication disorders for parents and professionals alike. We invite you and your patients to use these materials to help assure that children receive early intervention for communication disorders. We look forward to working together for the communication health of children.
Dr. Page is director of the division of communication sciences and disorders at the University of Kentucky, Lexington, and 2015 ASHA President. E-mail her at pdnews@frontlinemedcom.com.
We often hear parents express concern that misuse of technology may be harming their children’s communication health. Despite this concern, significant numbers of parents are handing off smart phones to children as young as age 2 years and are allowing considerable use of technology at the dinner table, sacrificing what should be a prime time to provide the human interaction so vital to their children’s development of strong communication skills.
These are some of the leading findings from a national survey of parents of children aged 0-8 years that the American Speech-Language-Hearing Association (ASHA) commissioned for release during Better Hearing and Speech Month May 2015.
Is technology bad? Are smart phones, tablets, MP3 players, and other devices overtaking and quite possibly harming young children? Not exactly. The devices themselves aren’t the problem, the problem is how they are used. Our survey showed that very young children are using devices such as tablets and smart phones – and that, unfortunately, parents are often not heeding pediatrician screen time recommendations. According to survey respondents, a majority of 2-year-olds use a tablet. The survey also suggests that as children grow older, they prefer to spend more time with technology, where they are free to stare at screens or blast music into ear buds as they wish – potentially damaging their hearing and losing out on important human interaction.
While children are developing their vocabulary and communication skills, it is vital that they not be preoccupied by activities involving use of tablets, smart phones, and other personal technology. This is especially the case for young children, who experience the vast majority of their brain development in their first few years of life. We know that early verbal communication is a strong predictor of a child’s future reading ability and overall academic success. It is critical that we make parents aware of the convincing benefits of reducing screen time and increasing time spent talking, reading, and interacting verbally with children.
We applaud you addressing this subject via the American Academy of Pediatrics’ literacy toolkit and other avenues for reducing screen time (Pediatrics 2013;132:958-61).Unfortunately, according to our poll, well-meaning parents haven’t completely gotten the message – and many rely on technology for a variety of purposes. About half of them say they use technology to keep kids aged 0-3 years entertained, and many report using it to prevent behavior problems and tantrums.
Let’s join forces in raising awareness about the importance of communication health and how parents can foster it through simple, free steps like regularly engaging their kids in conversation, talking to them about the importance of keeping volume levels down, and modeling safe listening behavior themselves.
The need for action is great. A study in Pediatrics reported significant increases between 2001-2002 and 2010-2011 in disabilities associated with speech and hearing among U.S. children (Pediatrics 2014;134:530-8).
Unlike most other conditions, many communication disorders are reversible or even preventable with early treatment. Parents may delay an assessment by a speech-language pathologist or audiologist in hopes that a child will “outgrow” a problem, or they may not recognize potentially problematic signs. We want to see kids before age 3 years if the early signs are there, when it is more likely they will qualify for early intervention services. Early intervention often results in a shorter, more effective, and less expensive course of treatment for these disorders. Ideally, early intervention will assure that any issue will be resolved or significantly improved by the time a child enters school.
ASHA has a current campaign, Identify the Signs (IdentifytheSigns.org), which offers resources about identifying communication disorders for parents and professionals alike. We invite you and your patients to use these materials to help assure that children receive early intervention for communication disorders. We look forward to working together for the communication health of children.
Dr. Page is director of the division of communication sciences and disorders at the University of Kentucky, Lexington, and 2015 ASHA President. E-mail her at pdnews@frontlinemedcom.com.
We often hear parents express concern that misuse of technology may be harming their children’s communication health. Despite this concern, significant numbers of parents are handing off smart phones to children as young as age 2 years and are allowing considerable use of technology at the dinner table, sacrificing what should be a prime time to provide the human interaction so vital to their children’s development of strong communication skills.
These are some of the leading findings from a national survey of parents of children aged 0-8 years that the American Speech-Language-Hearing Association (ASHA) commissioned for release during Better Hearing and Speech Month May 2015.
Is technology bad? Are smart phones, tablets, MP3 players, and other devices overtaking and quite possibly harming young children? Not exactly. The devices themselves aren’t the problem, the problem is how they are used. Our survey showed that very young children are using devices such as tablets and smart phones – and that, unfortunately, parents are often not heeding pediatrician screen time recommendations. According to survey respondents, a majority of 2-year-olds use a tablet. The survey also suggests that as children grow older, they prefer to spend more time with technology, where they are free to stare at screens or blast music into ear buds as they wish – potentially damaging their hearing and losing out on important human interaction.
While children are developing their vocabulary and communication skills, it is vital that they not be preoccupied by activities involving use of tablets, smart phones, and other personal technology. This is especially the case for young children, who experience the vast majority of their brain development in their first few years of life. We know that early verbal communication is a strong predictor of a child’s future reading ability and overall academic success. It is critical that we make parents aware of the convincing benefits of reducing screen time and increasing time spent talking, reading, and interacting verbally with children.
We applaud you addressing this subject via the American Academy of Pediatrics’ literacy toolkit and other avenues for reducing screen time (Pediatrics 2013;132:958-61).Unfortunately, according to our poll, well-meaning parents haven’t completely gotten the message – and many rely on technology for a variety of purposes. About half of them say they use technology to keep kids aged 0-3 years entertained, and many report using it to prevent behavior problems and tantrums.
Let’s join forces in raising awareness about the importance of communication health and how parents can foster it through simple, free steps like regularly engaging their kids in conversation, talking to them about the importance of keeping volume levels down, and modeling safe listening behavior themselves.
The need for action is great. A study in Pediatrics reported significant increases between 2001-2002 and 2010-2011 in disabilities associated with speech and hearing among U.S. children (Pediatrics 2014;134:530-8).
Unlike most other conditions, many communication disorders are reversible or even preventable with early treatment. Parents may delay an assessment by a speech-language pathologist or audiologist in hopes that a child will “outgrow” a problem, or they may not recognize potentially problematic signs. We want to see kids before age 3 years if the early signs are there, when it is more likely they will qualify for early intervention services. Early intervention often results in a shorter, more effective, and less expensive course of treatment for these disorders. Ideally, early intervention will assure that any issue will be resolved or significantly improved by the time a child enters school.
ASHA has a current campaign, Identify the Signs (IdentifytheSigns.org), which offers resources about identifying communication disorders for parents and professionals alike. We invite you and your patients to use these materials to help assure that children receive early intervention for communication disorders. We look forward to working together for the communication health of children.
Dr. Page is director of the division of communication sciences and disorders at the University of Kentucky, Lexington, and 2015 ASHA President. E-mail her at pdnews@frontlinemedcom.com.
Is the wedding still on?
“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”
“Yes!” she said.
I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.
Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.
Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.
“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.
“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.
“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.
Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.
“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.
“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.
“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.
“Your job is to know the options, watch their eyes, and negotiate,” I said.
My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.
Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”
These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:
• Are there pimples, pustules, whiteheads, blackheads, cysts?
• How many of each?
• Where they are – face, chest, back?
This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.
Here is what electronic medical records do not have you click off:
• Is the patient getting married soon?
• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?
• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?
They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.
So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.
More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.
As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.
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.
“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”
“Yes!” she said.
I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.
Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.
Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.
“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.
“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.
“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.
Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.
“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.
“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.
“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.
“Your job is to know the options, watch their eyes, and negotiate,” I said.
My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.
Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”
These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:
• Are there pimples, pustules, whiteheads, blackheads, cysts?
• How many of each?
• Where they are – face, chest, back?
This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.
Here is what electronic medical records do not have you click off:
• Is the patient getting married soon?
• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?
• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?
They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.
So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.
More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.
As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.
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.
“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”
“Yes!” she said.
I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.
Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.
Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.
“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.
“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.
“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.
Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.
“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.
“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.
“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.
“Your job is to know the options, watch their eyes, and negotiate,” I said.
My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.
Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”
These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:
• Are there pimples, pustules, whiteheads, blackheads, cysts?
• How many of each?
• Where they are – face, chest, back?
This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.
Here is what electronic medical records do not have you click off:
• Is the patient getting married soon?
• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?
• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?
They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.
So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.
More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.
As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.
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.
Plantago major
For centuries, the leaves of Plantago major have been used in most regions of the world in traditional medical treatment of wounds and various diseases, including cutaneous conditions (J. Ethnopharmacol. 2000;71:1-21). P. major, also known as broadleaf plantain or greater plantain, is a member of the Plantaginaceae family, which is now widely dispersed throughout the world, though native to much of Europe as well as northern and central Asia. The Norwegian and Swedish name for the plant, groblad, means “healing leaves” (J. Ethnopharmacol. 2000;71:1-21). It was brought to the Americas by Europeans during the colonial period. Native Americans referred to it as the “white man’s footprint,” which inspired the genus name Plantago from the Latin planta (foot) (J. Ethnopharmacol. 2000;71:1-21).
Among the biologically active constituents of P. major are polysaccharides, lipids, caffeic acid derivatives, flavonoids (apigenin, luteolin, scutellarin, baicalein, nepetin, hispidulin, plantagoside), iridoid glycosides (aucubin, catalpol), terpenoids, and alkaloids (J. Ethnopharmacol. 2000;71:1-21; Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press). In an ethnopharmacologic and folk medicine survey study of 1,225 residents of the Atlantic coast of Colombia completed in 2011, Gómez-Estrada et al. found that P. major was one of the plants traditionally used to treat inflammation; it also was used to treat kidney pain and eye injuries (J. Ethnobiol. Ethnomed. 2011;7:27). P. major also is traditionally used as a mucilage and bulk laxative (Principles and Practice of Phytotherapy: Modern Herbal Medicine, 2013, Churchill Livingstone).
Extracts of the plant have been associated with myriad biologic activities, including wound healing, anti-inflammatory, antimicrobial, analgesic, antioxidant, immunomodulating, and antiulcerogenic action, which Samuelsen suggested may account for the use of the botanical in traditional medicine (J. Ethnopharmacol. 2000;71:1-21; Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press). In fact, the range of biologic properties attributed to P. major also includes astringent, anesthetic, antihelminthic, analeptic, antihistaminic, antirheumatic, antiviral, antitumor, antiulcer, diuretic, hypotensive, and expectorant activity (Exp. Biol. Med. [Maywood] 2012;237:1379-86). Though not the most popular botanical for this indication, P. major is among the plants used in the treatment of cutaneous leishmanial ulcers in Bahia, Brazil, where Leishmania brazilenesis is endemic (Rev. Soc. Bras. Med. Trop. 1996;29:229-32). Other dermatologic uses in traditional medicine include eczema, cuts, hemorrhoids, ulcerations, and wounds (Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press).
Wound healing
The use of P. major for wound healing dates back to the first century, as described by the Greek physician Dioscorides in “De Materia Medica” (J. Ethnopharmacol. 2000;71:1-21).
In 2011, Krasnov et al. developed an experimental model for characterizing proteins and showed that a newly discovered group of tissue-specific biogregulating proteins found previously in animal tissues was also present in P. major and responsible for the wound-healing activity associated with the plant (Prikl Biokhim. Mikrobiol. 2011;47:146-53).
The next year, Thomé et al. investigated and compared the wound-healing effects of P. major and Siparuna guianensis with a commercial product used in Brazil. Mice with cervical dorsal area wounds were treated with the botanical ingredients and the commercial product. Decreases in the wound area occurred earliest in mice treated with P. major, with complete closure (by day 15) seen only in this group. The investigators concluded that their findings support the traditional application of P. major, which shows potential as a viable wound-healing agent (Exp. Biol. Med. [Maywood] 2012;237:1379-86).
Conclusion
The numerous biologic properties of P. major are well established. In addition, use of the plant in traditional medicine for some cutaneous indications warrants consideration for modern therapeutic usage. Much more research is necessary, however, to elucidate the potential incorporation of this botanical into standard topical preparations for any of various skin conditions.
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.
For centuries, the leaves of Plantago major have been used in most regions of the world in traditional medical treatment of wounds and various diseases, including cutaneous conditions (J. Ethnopharmacol. 2000;71:1-21). P. major, also known as broadleaf plantain or greater plantain, is a member of the Plantaginaceae family, which is now widely dispersed throughout the world, though native to much of Europe as well as northern and central Asia. The Norwegian and Swedish name for the plant, groblad, means “healing leaves” (J. Ethnopharmacol. 2000;71:1-21). It was brought to the Americas by Europeans during the colonial period. Native Americans referred to it as the “white man’s footprint,” which inspired the genus name Plantago from the Latin planta (foot) (J. Ethnopharmacol. 2000;71:1-21).
Among the biologically active constituents of P. major are polysaccharides, lipids, caffeic acid derivatives, flavonoids (apigenin, luteolin, scutellarin, baicalein, nepetin, hispidulin, plantagoside), iridoid glycosides (aucubin, catalpol), terpenoids, and alkaloids (J. Ethnopharmacol. 2000;71:1-21; Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press). In an ethnopharmacologic and folk medicine survey study of 1,225 residents of the Atlantic coast of Colombia completed in 2011, Gómez-Estrada et al. found that P. major was one of the plants traditionally used to treat inflammation; it also was used to treat kidney pain and eye injuries (J. Ethnobiol. Ethnomed. 2011;7:27). P. major also is traditionally used as a mucilage and bulk laxative (Principles and Practice of Phytotherapy: Modern Herbal Medicine, 2013, Churchill Livingstone).
Extracts of the plant have been associated with myriad biologic activities, including wound healing, anti-inflammatory, antimicrobial, analgesic, antioxidant, immunomodulating, and antiulcerogenic action, which Samuelsen suggested may account for the use of the botanical in traditional medicine (J. Ethnopharmacol. 2000;71:1-21; Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press). In fact, the range of biologic properties attributed to P. major also includes astringent, anesthetic, antihelminthic, analeptic, antihistaminic, antirheumatic, antiviral, antitumor, antiulcer, diuretic, hypotensive, and expectorant activity (Exp. Biol. Med. [Maywood] 2012;237:1379-86). Though not the most popular botanical for this indication, P. major is among the plants used in the treatment of cutaneous leishmanial ulcers in Bahia, Brazil, where Leishmania brazilenesis is endemic (Rev. Soc. Bras. Med. Trop. 1996;29:229-32). Other dermatologic uses in traditional medicine include eczema, cuts, hemorrhoids, ulcerations, and wounds (Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press).
Wound healing
The use of P. major for wound healing dates back to the first century, as described by the Greek physician Dioscorides in “De Materia Medica” (J. Ethnopharmacol. 2000;71:1-21).
In 2011, Krasnov et al. developed an experimental model for characterizing proteins and showed that a newly discovered group of tissue-specific biogregulating proteins found previously in animal tissues was also present in P. major and responsible for the wound-healing activity associated with the plant (Prikl Biokhim. Mikrobiol. 2011;47:146-53).
The next year, Thomé et al. investigated and compared the wound-healing effects of P. major and Siparuna guianensis with a commercial product used in Brazil. Mice with cervical dorsal area wounds were treated with the botanical ingredients and the commercial product. Decreases in the wound area occurred earliest in mice treated with P. major, with complete closure (by day 15) seen only in this group. The investigators concluded that their findings support the traditional application of P. major, which shows potential as a viable wound-healing agent (Exp. Biol. Med. [Maywood] 2012;237:1379-86).
Conclusion
The numerous biologic properties of P. major are well established. In addition, use of the plant in traditional medicine for some cutaneous indications warrants consideration for modern therapeutic usage. Much more research is necessary, however, to elucidate the potential incorporation of this botanical into standard topical preparations for any of various skin conditions.
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.
For centuries, the leaves of Plantago major have been used in most regions of the world in traditional medical treatment of wounds and various diseases, including cutaneous conditions (J. Ethnopharmacol. 2000;71:1-21). P. major, also known as broadleaf plantain or greater plantain, is a member of the Plantaginaceae family, which is now widely dispersed throughout the world, though native to much of Europe as well as northern and central Asia. The Norwegian and Swedish name for the plant, groblad, means “healing leaves” (J. Ethnopharmacol. 2000;71:1-21). It was brought to the Americas by Europeans during the colonial period. Native Americans referred to it as the “white man’s footprint,” which inspired the genus name Plantago from the Latin planta (foot) (J. Ethnopharmacol. 2000;71:1-21).
Among the biologically active constituents of P. major are polysaccharides, lipids, caffeic acid derivatives, flavonoids (apigenin, luteolin, scutellarin, baicalein, nepetin, hispidulin, plantagoside), iridoid glycosides (aucubin, catalpol), terpenoids, and alkaloids (J. Ethnopharmacol. 2000;71:1-21; Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press). In an ethnopharmacologic and folk medicine survey study of 1,225 residents of the Atlantic coast of Colombia completed in 2011, Gómez-Estrada et al. found that P. major was one of the plants traditionally used to treat inflammation; it also was used to treat kidney pain and eye injuries (J. Ethnobiol. Ethnomed. 2011;7:27). P. major also is traditionally used as a mucilage and bulk laxative (Principles and Practice of Phytotherapy: Modern Herbal Medicine, 2013, Churchill Livingstone).
Extracts of the plant have been associated with myriad biologic activities, including wound healing, anti-inflammatory, antimicrobial, analgesic, antioxidant, immunomodulating, and antiulcerogenic action, which Samuelsen suggested may account for the use of the botanical in traditional medicine (J. Ethnopharmacol. 2000;71:1-21; Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press). In fact, the range of biologic properties attributed to P. major also includes astringent, anesthetic, antihelminthic, analeptic, antihistaminic, antirheumatic, antiviral, antitumor, antiulcer, diuretic, hypotensive, and expectorant activity (Exp. Biol. Med. [Maywood] 2012;237:1379-86). Though not the most popular botanical for this indication, P. major is among the plants used in the treatment of cutaneous leishmanial ulcers in Bahia, Brazil, where Leishmania brazilenesis is endemic (Rev. Soc. Bras. Med. Trop. 1996;29:229-32). Other dermatologic uses in traditional medicine include eczema, cuts, hemorrhoids, ulcerations, and wounds (Medical Herbalism: The Science and Practice of Herbal Medicine, 2003, Healing Arts Press).
Wound healing
The use of P. major for wound healing dates back to the first century, as described by the Greek physician Dioscorides in “De Materia Medica” (J. Ethnopharmacol. 2000;71:1-21).
In 2011, Krasnov et al. developed an experimental model for characterizing proteins and showed that a newly discovered group of tissue-specific biogregulating proteins found previously in animal tissues was also present in P. major and responsible for the wound-healing activity associated with the plant (Prikl Biokhim. Mikrobiol. 2011;47:146-53).
The next year, Thomé et al. investigated and compared the wound-healing effects of P. major and Siparuna guianensis with a commercial product used in Brazil. Mice with cervical dorsal area wounds were treated with the botanical ingredients and the commercial product. Decreases in the wound area occurred earliest in mice treated with P. major, with complete closure (by day 15) seen only in this group. The investigators concluded that their findings support the traditional application of P. major, which shows potential as a viable wound-healing agent (Exp. Biol. Med. [Maywood] 2012;237:1379-86).
Conclusion
The numerous biologic properties of P. major are well established. In addition, use of the plant in traditional medicine for some cutaneous indications warrants consideration for modern therapeutic usage. Much more research is necessary, however, to elucidate the potential incorporation of this botanical into standard topical preparations for any of various skin conditions.
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.
Sound advice
“It’s best to let her cry it out.” Easy advice to give, but not always easy to follow. The simplest recommendations from pediatricians can pose great challenges, at least initially, for parents. As trainees in pediatrics, we learn the script, but we do not always understand the reality of implementing our advice. Before becoming a parent, “crying it out” seemed the obvious and easy choice. Now, as a parent, I have felt the desperate necessity of getting a child to fall asleep. Although I would never condone unsafe sleeping practices, I understand what drives parents to such extremes.
When the dreaded 2-month-visit came around, I also felt the angst of intentionally putting your child through pain. Sweat dripped down my forehead and my vision blurred when I first saw the nurse immunize my son. Before this, I had ordered countless vaccinations for other patients, and I heard their screaming every day in the halls of clinic as background noise. Yet, seeing my own son being held down and jabbed with a needle was hard to bear. His high-pitched scream seemed perfectly calibrated to pound me with guilt. Of course, I knew the science and I had no fear of adverse events, but seeing your own child in pain does strange things to you. It strikes the same evolutionary chord that sends parents running into traffic to save their babies.
As trainees, many of us have put off having children until later in life. There is nothing wrong with this choice; however, it means that many of us lack the firsthand experience of parenting. We may not know that something as simple as getting a toddler to sit at the dinner table to eat anything can be a night-long struggle. To better prepare new parents and to better understand seasoned parents, we ought to solicit their experiences during office visits. By simply listening for 2 minutes, we can give parents a chance to vent (often well needed and deserved), and we can store their experiences in our memory for future use. Just as we stow away the image of the lacy rash of Fifth disease, we also should stockpile parenting tidbits. The only way to empathize with people going through something foreign to us is to acquire surrogate experiences. Parents in our clinics carry expansive libraries of these experiences, and we should not waste this opportunity.
By better understanding the realities of parenting, we can learn to frame our recommendations in terms that resonate with parents. We can preface our advice with challenges the parents can expect. We can remind them that parenting is hard, but their struggles are normal. When we better understand parents, they can better understand us.
Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at pdnews@frontlinemedcom.com.
“It’s best to let her cry it out.” Easy advice to give, but not always easy to follow. The simplest recommendations from pediatricians can pose great challenges, at least initially, for parents. As trainees in pediatrics, we learn the script, but we do not always understand the reality of implementing our advice. Before becoming a parent, “crying it out” seemed the obvious and easy choice. Now, as a parent, I have felt the desperate necessity of getting a child to fall asleep. Although I would never condone unsafe sleeping practices, I understand what drives parents to such extremes.
When the dreaded 2-month-visit came around, I also felt the angst of intentionally putting your child through pain. Sweat dripped down my forehead and my vision blurred when I first saw the nurse immunize my son. Before this, I had ordered countless vaccinations for other patients, and I heard their screaming every day in the halls of clinic as background noise. Yet, seeing my own son being held down and jabbed with a needle was hard to bear. His high-pitched scream seemed perfectly calibrated to pound me with guilt. Of course, I knew the science and I had no fear of adverse events, but seeing your own child in pain does strange things to you. It strikes the same evolutionary chord that sends parents running into traffic to save their babies.
As trainees, many of us have put off having children until later in life. There is nothing wrong with this choice; however, it means that many of us lack the firsthand experience of parenting. We may not know that something as simple as getting a toddler to sit at the dinner table to eat anything can be a night-long struggle. To better prepare new parents and to better understand seasoned parents, we ought to solicit their experiences during office visits. By simply listening for 2 minutes, we can give parents a chance to vent (often well needed and deserved), and we can store their experiences in our memory for future use. Just as we stow away the image of the lacy rash of Fifth disease, we also should stockpile parenting tidbits. The only way to empathize with people going through something foreign to us is to acquire surrogate experiences. Parents in our clinics carry expansive libraries of these experiences, and we should not waste this opportunity.
By better understanding the realities of parenting, we can learn to frame our recommendations in terms that resonate with parents. We can preface our advice with challenges the parents can expect. We can remind them that parenting is hard, but their struggles are normal. When we better understand parents, they can better understand us.
Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at pdnews@frontlinemedcom.com.
“It’s best to let her cry it out.” Easy advice to give, but not always easy to follow. The simplest recommendations from pediatricians can pose great challenges, at least initially, for parents. As trainees in pediatrics, we learn the script, but we do not always understand the reality of implementing our advice. Before becoming a parent, “crying it out” seemed the obvious and easy choice. Now, as a parent, I have felt the desperate necessity of getting a child to fall asleep. Although I would never condone unsafe sleeping practices, I understand what drives parents to such extremes.
When the dreaded 2-month-visit came around, I also felt the angst of intentionally putting your child through pain. Sweat dripped down my forehead and my vision blurred when I first saw the nurse immunize my son. Before this, I had ordered countless vaccinations for other patients, and I heard their screaming every day in the halls of clinic as background noise. Yet, seeing my own son being held down and jabbed with a needle was hard to bear. His high-pitched scream seemed perfectly calibrated to pound me with guilt. Of course, I knew the science and I had no fear of adverse events, but seeing your own child in pain does strange things to you. It strikes the same evolutionary chord that sends parents running into traffic to save their babies.
As trainees, many of us have put off having children until later in life. There is nothing wrong with this choice; however, it means that many of us lack the firsthand experience of parenting. We may not know that something as simple as getting a toddler to sit at the dinner table to eat anything can be a night-long struggle. To better prepare new parents and to better understand seasoned parents, we ought to solicit their experiences during office visits. By simply listening for 2 minutes, we can give parents a chance to vent (often well needed and deserved), and we can store their experiences in our memory for future use. Just as we stow away the image of the lacy rash of Fifth disease, we also should stockpile parenting tidbits. The only way to empathize with people going through something foreign to us is to acquire surrogate experiences. Parents in our clinics carry expansive libraries of these experiences, and we should not waste this opportunity.
By better understanding the realities of parenting, we can learn to frame our recommendations in terms that resonate with parents. We can preface our advice with challenges the parents can expect. We can remind them that parenting is hard, but their struggles are normal. When we better understand parents, they can better understand us.
Dr. Sisk is a pediatrics resident at St. Louis Children’s Hospital. E-mail him at pdnews@frontlinemedcom.com.
Telehealth Q&A
Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.
Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.
Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.
Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?
Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.
Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.
The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.
Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.
Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.
Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.
Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?
Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.
What type of liability do dermatologists face when using telehealth?
Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.
How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?
Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.
What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?
Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.
What advice do you have for dermatologists who are considering implementing teledermatology in their practice?
Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.
What are your predictions for the future of teledermatology?
Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.
For more information and contacts, please visit DirectDermatology.com.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.
Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.
Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.
Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?
Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.
Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.
The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.
Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.
Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.
Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.
Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?
Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.
What type of liability do dermatologists face when using telehealth?
Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.
How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?
Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.
What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?
Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.
What advice do you have for dermatologists who are considering implementing teledermatology in their practice?
Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.
What are your predictions for the future of teledermatology?
Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.
For more information and contacts, please visit DirectDermatology.com.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.
Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.
Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.
Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?
Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.
Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.
The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.
Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.
Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.
Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.
Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?
Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.
What type of liability do dermatologists face when using telehealth?
Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.
How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?
Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.
What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?
Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.
What advice do you have for dermatologists who are considering implementing teledermatology in their practice?
Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.
What are your predictions for the future of teledermatology?
Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.
For more information and contacts, please visit DirectDermatology.com.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
ICD-10 update
When I last wrote about the International Classification of Diseases, 10th Revision (ICD-10) – last year, at about this time – the switchover was scheduled to take place on Oct. 1. Shortly thereafter, of course, Congress decided to delay the inevitable for 1 year. While the House Energy and Commerce Committee has hinted at the possibility of further postponements, we must all assume, until we hear otherwise, that the day of reckoning will arrive as scheduled. You will need to be ready if you expect to be paid come October.
Remember, on Sept. 30 you will be using ICD-9 codes, and the next day you will have to begin using ICD-10. There is no transition period; all ICD-9–coded claims will be rejected from Oct. 1 forward, and no ICD-10 codes can be used before that date. Failure to prepare will be an unmitigated disaster for your practice’s cash flow.
First, decide which parts of your coding and billing systems – and EHR, if you have one – need to be upgraded, how you will do it, and what it will cost. Then, you must get familiar with the new system.
Coders and billers will need the most training on the new methodology, but physicians and other providers must also learn how the new codes are different from the old ones. In general, most differences are in specificity and level of documentation (left/right, acute/chronic, etc.), but there are new codes as well.
I suggest you start by identifying your most-used 20 or 30 diagnosis codes, and then study in detail the differences between the ICD-9 and ICD-10 versions of them. Once you have mastered those, you can go on to other, less-used codes. Take as much time as you need to do this: Remember, everything changes abruptly on Oct. 1, and you will have to get it right the first time.
Be sure to cross-train your coders and other staff members. If a crucial employee quits in the middle of September, you don’t want to have to start from square one. Also, ask your employees to plan their vacations well in advance – and not during the last 3 months of the year. That goes for you, too. This will not be a good time for you to be away, or for the office to run short-staffed.
Next, I suggest you contact all of your third-party payers, billing services, and clearinghouses. Be aggressive; ask them how, exactly, they are preparing for the changeover, and stay in continuous contact with them. Unfortunately, many of these organizations are as behind as most medical practices in their preparations.
Many payers and clearinghouses (including the Centers for Medicare & Medicaid Services) are staging test runs during which you can submit practice claims using the new system. Payers will determine whether your ICD-10 code is in the right place and in the right format; whether the code you used is appropriate; and whether the claim would have been accepted, rejected, or held pending additional information. You will need to do this for each payer, because each will have different coding policies. Many of those policies have not yet been released, and, in some cases, have not even been developed.
You can register for CMS testing sessions through your local Medicare Administrative Contractor (MAC) website. Use the sessions to test your internal system as well, to ensure that everything works smoothly from the time you code a claim until payment is received. Select commonly used ICD-9 claims and practice coding them in ICD-10. The American Academy of Dermatology offers an assortment of training aids at its website, aad.org.
Even the best-laid plans can go awry, however, so it would be prudent to put aside a cash reserve or secure a line of credit to cover expenses during the first few months of the transition, in case the payment machinery falters and large numbers of claims go unpaid. For the same reason, consider postponing major capital investments until early 2016.
You may have heard that ICD-10 is only a transition system; that ICD-11 will be following closely on its heels. I doubt it. In all probability, we will be using ICD-10 a lot longer than CMS originally planned. Besides, ICD-11 is essentially a refinement of ICD-10, not the significant departure that the 10th revision is over the 9th.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
When I last wrote about the International Classification of Diseases, 10th Revision (ICD-10) – last year, at about this time – the switchover was scheduled to take place on Oct. 1. Shortly thereafter, of course, Congress decided to delay the inevitable for 1 year. While the House Energy and Commerce Committee has hinted at the possibility of further postponements, we must all assume, until we hear otherwise, that the day of reckoning will arrive as scheduled. You will need to be ready if you expect to be paid come October.
Remember, on Sept. 30 you will be using ICD-9 codes, and the next day you will have to begin using ICD-10. There is no transition period; all ICD-9–coded claims will be rejected from Oct. 1 forward, and no ICD-10 codes can be used before that date. Failure to prepare will be an unmitigated disaster for your practice’s cash flow.
First, decide which parts of your coding and billing systems – and EHR, if you have one – need to be upgraded, how you will do it, and what it will cost. Then, you must get familiar with the new system.
Coders and billers will need the most training on the new methodology, but physicians and other providers must also learn how the new codes are different from the old ones. In general, most differences are in specificity and level of documentation (left/right, acute/chronic, etc.), but there are new codes as well.
I suggest you start by identifying your most-used 20 or 30 diagnosis codes, and then study in detail the differences between the ICD-9 and ICD-10 versions of them. Once you have mastered those, you can go on to other, less-used codes. Take as much time as you need to do this: Remember, everything changes abruptly on Oct. 1, and you will have to get it right the first time.
Be sure to cross-train your coders and other staff members. If a crucial employee quits in the middle of September, you don’t want to have to start from square one. Also, ask your employees to plan their vacations well in advance – and not during the last 3 months of the year. That goes for you, too. This will not be a good time for you to be away, or for the office to run short-staffed.
Next, I suggest you contact all of your third-party payers, billing services, and clearinghouses. Be aggressive; ask them how, exactly, they are preparing for the changeover, and stay in continuous contact with them. Unfortunately, many of these organizations are as behind as most medical practices in their preparations.
Many payers and clearinghouses (including the Centers for Medicare & Medicaid Services) are staging test runs during which you can submit practice claims using the new system. Payers will determine whether your ICD-10 code is in the right place and in the right format; whether the code you used is appropriate; and whether the claim would have been accepted, rejected, or held pending additional information. You will need to do this for each payer, because each will have different coding policies. Many of those policies have not yet been released, and, in some cases, have not even been developed.
You can register for CMS testing sessions through your local Medicare Administrative Contractor (MAC) website. Use the sessions to test your internal system as well, to ensure that everything works smoothly from the time you code a claim until payment is received. Select commonly used ICD-9 claims and practice coding them in ICD-10. The American Academy of Dermatology offers an assortment of training aids at its website, aad.org.
Even the best-laid plans can go awry, however, so it would be prudent to put aside a cash reserve or secure a line of credit to cover expenses during the first few months of the transition, in case the payment machinery falters and large numbers of claims go unpaid. For the same reason, consider postponing major capital investments until early 2016.
You may have heard that ICD-10 is only a transition system; that ICD-11 will be following closely on its heels. I doubt it. In all probability, we will be using ICD-10 a lot longer than CMS originally planned. Besides, ICD-11 is essentially a refinement of ICD-10, not the significant departure that the 10th revision is over the 9th.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
When I last wrote about the International Classification of Diseases, 10th Revision (ICD-10) – last year, at about this time – the switchover was scheduled to take place on Oct. 1. Shortly thereafter, of course, Congress decided to delay the inevitable for 1 year. While the House Energy and Commerce Committee has hinted at the possibility of further postponements, we must all assume, until we hear otherwise, that the day of reckoning will arrive as scheduled. You will need to be ready if you expect to be paid come October.
Remember, on Sept. 30 you will be using ICD-9 codes, and the next day you will have to begin using ICD-10. There is no transition period; all ICD-9–coded claims will be rejected from Oct. 1 forward, and no ICD-10 codes can be used before that date. Failure to prepare will be an unmitigated disaster for your practice’s cash flow.
First, decide which parts of your coding and billing systems – and EHR, if you have one – need to be upgraded, how you will do it, and what it will cost. Then, you must get familiar with the new system.
Coders and billers will need the most training on the new methodology, but physicians and other providers must also learn how the new codes are different from the old ones. In general, most differences are in specificity and level of documentation (left/right, acute/chronic, etc.), but there are new codes as well.
I suggest you start by identifying your most-used 20 or 30 diagnosis codes, and then study in detail the differences between the ICD-9 and ICD-10 versions of them. Once you have mastered those, you can go on to other, less-used codes. Take as much time as you need to do this: Remember, everything changes abruptly on Oct. 1, and you will have to get it right the first time.
Be sure to cross-train your coders and other staff members. If a crucial employee quits in the middle of September, you don’t want to have to start from square one. Also, ask your employees to plan their vacations well in advance – and not during the last 3 months of the year. That goes for you, too. This will not be a good time for you to be away, or for the office to run short-staffed.
Next, I suggest you contact all of your third-party payers, billing services, and clearinghouses. Be aggressive; ask them how, exactly, they are preparing for the changeover, and stay in continuous contact with them. Unfortunately, many of these organizations are as behind as most medical practices in their preparations.
Many payers and clearinghouses (including the Centers for Medicare & Medicaid Services) are staging test runs during which you can submit practice claims using the new system. Payers will determine whether your ICD-10 code is in the right place and in the right format; whether the code you used is appropriate; and whether the claim would have been accepted, rejected, or held pending additional information. You will need to do this for each payer, because each will have different coding policies. Many of those policies have not yet been released, and, in some cases, have not even been developed.
You can register for CMS testing sessions through your local Medicare Administrative Contractor (MAC) website. Use the sessions to test your internal system as well, to ensure that everything works smoothly from the time you code a claim until payment is received. Select commonly used ICD-9 claims and practice coding them in ICD-10. The American Academy of Dermatology offers an assortment of training aids at its website, aad.org.
Even the best-laid plans can go awry, however, so it would be prudent to put aside a cash reserve or secure a line of credit to cover expenses during the first few months of the transition, in case the payment machinery falters and large numbers of claims go unpaid. For the same reason, consider postponing major capital investments until early 2016.
You may have heard that ICD-10 is only a transition system; that ICD-11 will be following closely on its heels. I doubt it. In all probability, we will be using ICD-10 a lot longer than CMS originally planned. Besides, ICD-11 is essentially a refinement of ICD-10, not the significant departure that the 10th revision is over the 9th.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
Did Niacin Get a Bum Rap?
I had thought that my long-standing romance with niacin was finally over. Although it was a very early love of mine, reluctantly I had gone along with the mainstream consensus. It seemed that niacin had been sent into near-permanent pharmaceutical exile by the devastating one-two punches of the AIM HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) and the HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events) studies. I had even stopped taking my own self- prescribed niacin 2,500 mg twice a day, which I had been religiously consuming for over 2 decades. But before long, I found that I had real difficulty divorcing myself completely from the charms of this lipid-lowering Lorelei. Now, after agonizing over the issue for some time, I’m here to tell you that niacin almost certainly did get a bum rap and should be restored as an important tool in your therapeutic armamentarium.
Related: Niacin: Not Dead Yet, but on Life Support
A recent report that niacin seems to function partially as an inhibitor of the PCSK-9 enzyme accelerated my reconsideration. The inhibition of PCSK-9, an enzyme that removes low-density lipoprotein cholesterol (LDL-C) receptors from hepatocytes, is the hot new way of dropping LDL-C levels. And I mean really dropping LDL-C levels. Studies conducted with investigational compounds developed by Amgen and Pfizer have shown truly dramatic drops in LDL-C levels by as much as 80%—often down to ridiculously low levels (around 25 mg/dL).
Of course, we are still waiting for outcome trials, which will answer the critical question: Are these dramatic falls in LDL-C levels actually associated with meaningful reductions in the occurrence rates for cardiovascular events such as myocardial infarction and stroke? For now, inhibiting PCSK-9 seems to be a good way to change the lipid profile dramatically. Even if niacin is not nearly as potent an inhibitor of the PCSK-9 enzymes as some newer compounds, the fact that it has measurable inhibiting activity seems enough to earn it a second look.
The concerns over niacin derive almost entirely from the results of the AIM HIGH study and the HPS2-THRIVE trials. Thus, any effort to rehabilitate niacin will require a reckoning with each of these major trials.
Related: The Niacin Debate Continues: Higher Doses, Please
I was one of the original AIM HIGH investigators, but our study site at the Phoenix VA eventually was removed from the trial because of poor enrollment. Nonetheless, I had a front-row seat to observe the conduct of the trial, and it seemed less than optimal. The relatively infrequent monitor visits for this study probably contributed to the finding that the lipid differences between the 2 study groups were considerably smaller than they could have been. It was my impression that study sites did not have their feet held to the fire when niacin compliance became problematic for subjects randomized to the larger dose of niacin.
The study design also contributed to blunting the difference between the 2 study groups. Subjects in the control group actually received 200 mg of immediate-release niacin to help blind the study by ensuring that all subjects experienced a niacin flush. The statin dose wound up being higher in the control group, and the use of the add-on lipid-lowering agent ezetimibe was also greater (22% vs 10%) in the control group. All these factors would tend to blunt the differences between the 2 groups, and indeed lipid levels did improve significantly in both groups.
To add insult to injury, the trial was stopped after just 3 years. A number of other lipid trials that were ultimately positive had not yet reached a statistically significant separation between the control and the experimental groups after that relatively brief study interval. Although these study flaws are hardly fatal, when taken together, they suggest the need to maintain an open mind. If niacin is like Brylcreem and “a little dab’ll do ya,” then the small dusting received by the control subjects might have been cardioprotective enough to blunt any differences in event rates between the 2 groups, especially over the truncated period of the actual trial.
What about the much larger HPS2-THRIVE study; surely there can’t be similar flaws in that study as well? Well, a critical review identifies a number of significant shortcomings. Although conducted by British academics through the Medical Research Council, the trial was funded and largely designed by Merck, which had hoped it would demonstrate the clinical utility of its new combination of extended-release niacin and an antiflushing agent called laropiprant, a prostaglandin-inhibiting compound. One has only to remember the fiasco with the cyclo-oxygenase-2 inhibitor celecoxib to recognize the potential increase in cardiovascular events of any agent that blocks prostaglandins. Any failure of the niacin/laropiprant arm to show a reduced cardiovascular event rate on top of baseline statin therapy might have been because the laropiprant was increasing events enough to cancel any reductions the niacin might have produced.
Related: You'll Have a Dickens of a Time
A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
I had thought that my long-standing romance with niacin was finally over. Although it was a very early love of mine, reluctantly I had gone along with the mainstream consensus. It seemed that niacin had been sent into near-permanent pharmaceutical exile by the devastating one-two punches of the AIM HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) and the HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events) studies. I had even stopped taking my own self- prescribed niacin 2,500 mg twice a day, which I had been religiously consuming for over 2 decades. But before long, I found that I had real difficulty divorcing myself completely from the charms of this lipid-lowering Lorelei. Now, after agonizing over the issue for some time, I’m here to tell you that niacin almost certainly did get a bum rap and should be restored as an important tool in your therapeutic armamentarium.
Related: Niacin: Not Dead Yet, but on Life Support
A recent report that niacin seems to function partially as an inhibitor of the PCSK-9 enzyme accelerated my reconsideration. The inhibition of PCSK-9, an enzyme that removes low-density lipoprotein cholesterol (LDL-C) receptors from hepatocytes, is the hot new way of dropping LDL-C levels. And I mean really dropping LDL-C levels. Studies conducted with investigational compounds developed by Amgen and Pfizer have shown truly dramatic drops in LDL-C levels by as much as 80%—often down to ridiculously low levels (around 25 mg/dL).
Of course, we are still waiting for outcome trials, which will answer the critical question: Are these dramatic falls in LDL-C levels actually associated with meaningful reductions in the occurrence rates for cardiovascular events such as myocardial infarction and stroke? For now, inhibiting PCSK-9 seems to be a good way to change the lipid profile dramatically. Even if niacin is not nearly as potent an inhibitor of the PCSK-9 enzymes as some newer compounds, the fact that it has measurable inhibiting activity seems enough to earn it a second look.
The concerns over niacin derive almost entirely from the results of the AIM HIGH study and the HPS2-THRIVE trials. Thus, any effort to rehabilitate niacin will require a reckoning with each of these major trials.
Related: The Niacin Debate Continues: Higher Doses, Please
I was one of the original AIM HIGH investigators, but our study site at the Phoenix VA eventually was removed from the trial because of poor enrollment. Nonetheless, I had a front-row seat to observe the conduct of the trial, and it seemed less than optimal. The relatively infrequent monitor visits for this study probably contributed to the finding that the lipid differences between the 2 study groups were considerably smaller than they could have been. It was my impression that study sites did not have their feet held to the fire when niacin compliance became problematic for subjects randomized to the larger dose of niacin.
The study design also contributed to blunting the difference between the 2 study groups. Subjects in the control group actually received 200 mg of immediate-release niacin to help blind the study by ensuring that all subjects experienced a niacin flush. The statin dose wound up being higher in the control group, and the use of the add-on lipid-lowering agent ezetimibe was also greater (22% vs 10%) in the control group. All these factors would tend to blunt the differences between the 2 groups, and indeed lipid levels did improve significantly in both groups.
To add insult to injury, the trial was stopped after just 3 years. A number of other lipid trials that were ultimately positive had not yet reached a statistically significant separation between the control and the experimental groups after that relatively brief study interval. Although these study flaws are hardly fatal, when taken together, they suggest the need to maintain an open mind. If niacin is like Brylcreem and “a little dab’ll do ya,” then the small dusting received by the control subjects might have been cardioprotective enough to blunt any differences in event rates between the 2 groups, especially over the truncated period of the actual trial.
What about the much larger HPS2-THRIVE study; surely there can’t be similar flaws in that study as well? Well, a critical review identifies a number of significant shortcomings. Although conducted by British academics through the Medical Research Council, the trial was funded and largely designed by Merck, which had hoped it would demonstrate the clinical utility of its new combination of extended-release niacin and an antiflushing agent called laropiprant, a prostaglandin-inhibiting compound. One has only to remember the fiasco with the cyclo-oxygenase-2 inhibitor celecoxib to recognize the potential increase in cardiovascular events of any agent that blocks prostaglandins. Any failure of the niacin/laropiprant arm to show a reduced cardiovascular event rate on top of baseline statin therapy might have been because the laropiprant was increasing events enough to cancel any reductions the niacin might have produced.
Related: You'll Have a Dickens of a Time
A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
I had thought that my long-standing romance with niacin was finally over. Although it was a very early love of mine, reluctantly I had gone along with the mainstream consensus. It seemed that niacin had been sent into near-permanent pharmaceutical exile by the devastating one-two punches of the AIM HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) and the HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events) studies. I had even stopped taking my own self- prescribed niacin 2,500 mg twice a day, which I had been religiously consuming for over 2 decades. But before long, I found that I had real difficulty divorcing myself completely from the charms of this lipid-lowering Lorelei. Now, after agonizing over the issue for some time, I’m here to tell you that niacin almost certainly did get a bum rap and should be restored as an important tool in your therapeutic armamentarium.
Related: Niacin: Not Dead Yet, but on Life Support
A recent report that niacin seems to function partially as an inhibitor of the PCSK-9 enzyme accelerated my reconsideration. The inhibition of PCSK-9, an enzyme that removes low-density lipoprotein cholesterol (LDL-C) receptors from hepatocytes, is the hot new way of dropping LDL-C levels. And I mean really dropping LDL-C levels. Studies conducted with investigational compounds developed by Amgen and Pfizer have shown truly dramatic drops in LDL-C levels by as much as 80%—often down to ridiculously low levels (around 25 mg/dL).
Of course, we are still waiting for outcome trials, which will answer the critical question: Are these dramatic falls in LDL-C levels actually associated with meaningful reductions in the occurrence rates for cardiovascular events such as myocardial infarction and stroke? For now, inhibiting PCSK-9 seems to be a good way to change the lipid profile dramatically. Even if niacin is not nearly as potent an inhibitor of the PCSK-9 enzymes as some newer compounds, the fact that it has measurable inhibiting activity seems enough to earn it a second look.
The concerns over niacin derive almost entirely from the results of the AIM HIGH study and the HPS2-THRIVE trials. Thus, any effort to rehabilitate niacin will require a reckoning with each of these major trials.
Related: The Niacin Debate Continues: Higher Doses, Please
I was one of the original AIM HIGH investigators, but our study site at the Phoenix VA eventually was removed from the trial because of poor enrollment. Nonetheless, I had a front-row seat to observe the conduct of the trial, and it seemed less than optimal. The relatively infrequent monitor visits for this study probably contributed to the finding that the lipid differences between the 2 study groups were considerably smaller than they could have been. It was my impression that study sites did not have their feet held to the fire when niacin compliance became problematic for subjects randomized to the larger dose of niacin.
The study design also contributed to blunting the difference between the 2 study groups. Subjects in the control group actually received 200 mg of immediate-release niacin to help blind the study by ensuring that all subjects experienced a niacin flush. The statin dose wound up being higher in the control group, and the use of the add-on lipid-lowering agent ezetimibe was also greater (22% vs 10%) in the control group. All these factors would tend to blunt the differences between the 2 groups, and indeed lipid levels did improve significantly in both groups.
To add insult to injury, the trial was stopped after just 3 years. A number of other lipid trials that were ultimately positive had not yet reached a statistically significant separation between the control and the experimental groups after that relatively brief study interval. Although these study flaws are hardly fatal, when taken together, they suggest the need to maintain an open mind. If niacin is like Brylcreem and “a little dab’ll do ya,” then the small dusting received by the control subjects might have been cardioprotective enough to blunt any differences in event rates between the 2 groups, especially over the truncated period of the actual trial.
What about the much larger HPS2-THRIVE study; surely there can’t be similar flaws in that study as well? Well, a critical review identifies a number of significant shortcomings. Although conducted by British academics through the Medical Research Council, the trial was funded and largely designed by Merck, which had hoped it would demonstrate the clinical utility of its new combination of extended-release niacin and an antiflushing agent called laropiprant, a prostaglandin-inhibiting compound. One has only to remember the fiasco with the cyclo-oxygenase-2 inhibitor celecoxib to recognize the potential increase in cardiovascular events of any agent that blocks prostaglandins. Any failure of the niacin/laropiprant arm to show a reduced cardiovascular event rate on top of baseline statin therapy might have been because the laropiprant was increasing events enough to cancel any reductions the niacin might have produced.
Related: You'll Have a Dickens of a Time
A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Failure to warn or report
Question: A patient who is a school bus driver is also an alcoholic, but he continues to drive despite his physician’s warning against drinking and driving. He already has had one prior driving under the influence (DUI) conviction. Fearing a potential vehicular accident with injuries to the schoolchildren, the physician, with permission, informed the patient’s wife of the situation; but that did not make a difference.
Under the circumstances, which of the following is best?
A. The physician has discharged his professional duty by warning the patient and informing his wife.
B. It is unethical for the physician to report this to the employer, because it violates the principle of confidentiality.
C. The physician may have an ethical and legal duty to report, because the risk of harm to the school children is foreseeable and outweighs other considerations.
D. A and B.
E. A and C.
Answer: C. The issue in this hypothetical revolves around the failure to warn and report when a doctor has determined that his or her patient poses a significant societal risk. It places the health care provider in a dilemma, because it pits patient confidentiality against the public interest in safety.
There does not appear to be an appellate case precisely on point, but the well known case of Tarasoff1 offers useful insight.
In Tarasoff, a California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, the girlfriend, whom the patient stabbed to death 2 months later.
The California court found the psychologist and the University of California (as the psychologist’s employer) liable, reasoning that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship.
The court wrote: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
However, the duty to warn a third party may not be as clear cut where there is no readily identifiable victim.2
Further, the law is unsettled regarding a physician’s duty to report negligent conduct that poses a significant risk to public safety, e.g., where a patient insists on operating a vehicle against medical advice. Obviously, the doctor should spare no effort in trying to persuade such a patient to discontinue driving. When this fails, however, and depending on the circumstances, the physician should seriously consider breaching patent confidentiality by notifying the driving licensing bureau.
This opinion is in accord with the AMA Code of Medical Ethics: “Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”3
What about informing the patient’s employer if the risk of harm arises in the work setting?
The duty to report is clearer if the physician is a company doctor specifically charged with the task of determining whether an employee is fit for work. However, a patient’s personal physician may be a different matter, because he or she does not share the same contractual obligation as a company employed doctor.
Still, the circumstances may well dictate the need to report. In the hypothetical scenario posed above, the patient is refusing to heed the advice of physician and spouse, and given the history of a DUI, can be said to be placing innocent children and others at risk. The physician may need to go beyond warning the patient and wife, even though revealing a patient’s diagnosis violates the principle of confidentiality.
Arguably controversial, the physician’s justification is that there is a higher ethical and legal duty to report, as the risk of harm to the school children is both unreasonable and foreseeable, outweighing other considerations.
The same analysis concerning reporting may be applied in uncooperative patients with certain medical diagnoses (e.g., uncontrolled epilepsy, serious mental illness, or disabling cardiac or cerebrovascular disease, to name a few) and in those taking mind-altering prescription medications or illicit drugs.
A key inquiry is whether the patient’s work activity is potentially hazardous, as in those who are entrusted with public transportation, e.g., bus drivers, pilots and train/ship engineers, or those who operate heavy machinery.
The most familiar example of the failure to warn (as opposed to report) is of course in informed consent litigation, where the physician is faulted for not warning the patient of the risk of harm and the patient in fact suffers that harm. It is framed as the failure to disclose material risks. The California Supreme Court has stated that “material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure”; that “a (material) fact must also be one which is not commonly appreciated”; and the scope of disclosure may be expanded in patients with “unique concerns or lack of familiarity with medical procedures.”4 There is, however, no legal requirement to deliver a “mini-course in medical science.”5
Another situation where there may have been a failure to warn is in medical products liability. Here, the plaintiff alleges that the defective product has caused injuries because the manufacturer has issued no prior warning to the health care provider or end user. A prime example is the current Lipitor and diabetes class action lawsuit against Pfizer.
In failing to warn a patient, a doctor may incur liability not only for injuries to the patient but also to nonpatient third parties.
In a 2002 Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old girl and crushing her against a cement planter.6 The driver alleged that the prescription medication prazosin caused him to develop hypotension and lose control of the car, and that the treating physician was negligent in failing to warn of this potential side effect.
The Hawaii Supreme Court held that physicians have a duty to their patients to warn of potential adverse effects, and this responsibility should therefore extend to third parties.
Court decisions elsewhere have also found liability where, for public policy reasons, a “special relationship” is deemed to exist between the doctor and the injured third party. Foreseeability is one important factor in construing its existence, notwithstanding the absence of the traditional doctor-patient relationship.
References
1. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
2. Furr v. Spring Grove State Hospital, 454 A.2d 414 (Md. 1983).
3. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed.].
4. Truman v. Thomas, 27 Cal.3d 285 (1980).
5. Cobbs v. Grant, 8 Cal.3d 229 (1972).
6. McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 (Haw. 2002).
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: A patient who is a school bus driver is also an alcoholic, but he continues to drive despite his physician’s warning against drinking and driving. He already has had one prior driving under the influence (DUI) conviction. Fearing a potential vehicular accident with injuries to the schoolchildren, the physician, with permission, informed the patient’s wife of the situation; but that did not make a difference.
Under the circumstances, which of the following is best?
A. The physician has discharged his professional duty by warning the patient and informing his wife.
B. It is unethical for the physician to report this to the employer, because it violates the principle of confidentiality.
C. The physician may have an ethical and legal duty to report, because the risk of harm to the school children is foreseeable and outweighs other considerations.
D. A and B.
E. A and C.
Answer: C. The issue in this hypothetical revolves around the failure to warn and report when a doctor has determined that his or her patient poses a significant societal risk. It places the health care provider in a dilemma, because it pits patient confidentiality against the public interest in safety.
There does not appear to be an appellate case precisely on point, but the well known case of Tarasoff1 offers useful insight.
In Tarasoff, a California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, the girlfriend, whom the patient stabbed to death 2 months later.
The California court found the psychologist and the University of California (as the psychologist’s employer) liable, reasoning that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship.
The court wrote: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
However, the duty to warn a third party may not be as clear cut where there is no readily identifiable victim.2
Further, the law is unsettled regarding a physician’s duty to report negligent conduct that poses a significant risk to public safety, e.g., where a patient insists on operating a vehicle against medical advice. Obviously, the doctor should spare no effort in trying to persuade such a patient to discontinue driving. When this fails, however, and depending on the circumstances, the physician should seriously consider breaching patent confidentiality by notifying the driving licensing bureau.
This opinion is in accord with the AMA Code of Medical Ethics: “Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”3
What about informing the patient’s employer if the risk of harm arises in the work setting?
The duty to report is clearer if the physician is a company doctor specifically charged with the task of determining whether an employee is fit for work. However, a patient’s personal physician may be a different matter, because he or she does not share the same contractual obligation as a company employed doctor.
Still, the circumstances may well dictate the need to report. In the hypothetical scenario posed above, the patient is refusing to heed the advice of physician and spouse, and given the history of a DUI, can be said to be placing innocent children and others at risk. The physician may need to go beyond warning the patient and wife, even though revealing a patient’s diagnosis violates the principle of confidentiality.
Arguably controversial, the physician’s justification is that there is a higher ethical and legal duty to report, as the risk of harm to the school children is both unreasonable and foreseeable, outweighing other considerations.
The same analysis concerning reporting may be applied in uncooperative patients with certain medical diagnoses (e.g., uncontrolled epilepsy, serious mental illness, or disabling cardiac or cerebrovascular disease, to name a few) and in those taking mind-altering prescription medications or illicit drugs.
A key inquiry is whether the patient’s work activity is potentially hazardous, as in those who are entrusted with public transportation, e.g., bus drivers, pilots and train/ship engineers, or those who operate heavy machinery.
The most familiar example of the failure to warn (as opposed to report) is of course in informed consent litigation, where the physician is faulted for not warning the patient of the risk of harm and the patient in fact suffers that harm. It is framed as the failure to disclose material risks. The California Supreme Court has stated that “material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure”; that “a (material) fact must also be one which is not commonly appreciated”; and the scope of disclosure may be expanded in patients with “unique concerns or lack of familiarity with medical procedures.”4 There is, however, no legal requirement to deliver a “mini-course in medical science.”5
Another situation where there may have been a failure to warn is in medical products liability. Here, the plaintiff alleges that the defective product has caused injuries because the manufacturer has issued no prior warning to the health care provider or end user. A prime example is the current Lipitor and diabetes class action lawsuit against Pfizer.
In failing to warn a patient, a doctor may incur liability not only for injuries to the patient but also to nonpatient third parties.
In a 2002 Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old girl and crushing her against a cement planter.6 The driver alleged that the prescription medication prazosin caused him to develop hypotension and lose control of the car, and that the treating physician was negligent in failing to warn of this potential side effect.
The Hawaii Supreme Court held that physicians have a duty to their patients to warn of potential adverse effects, and this responsibility should therefore extend to third parties.
Court decisions elsewhere have also found liability where, for public policy reasons, a “special relationship” is deemed to exist between the doctor and the injured third party. Foreseeability is one important factor in construing its existence, notwithstanding the absence of the traditional doctor-patient relationship.
References
1. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
2. Furr v. Spring Grove State Hospital, 454 A.2d 414 (Md. 1983).
3. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed.].
4. Truman v. Thomas, 27 Cal.3d 285 (1980).
5. Cobbs v. Grant, 8 Cal.3d 229 (1972).
6. McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 (Haw. 2002).
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: A patient who is a school bus driver is also an alcoholic, but he continues to drive despite his physician’s warning against drinking and driving. He already has had one prior driving under the influence (DUI) conviction. Fearing a potential vehicular accident with injuries to the schoolchildren, the physician, with permission, informed the patient’s wife of the situation; but that did not make a difference.
Under the circumstances, which of the following is best?
A. The physician has discharged his professional duty by warning the patient and informing his wife.
B. It is unethical for the physician to report this to the employer, because it violates the principle of confidentiality.
C. The physician may have an ethical and legal duty to report, because the risk of harm to the school children is foreseeable and outweighs other considerations.
D. A and B.
E. A and C.
Answer: C. The issue in this hypothetical revolves around the failure to warn and report when a doctor has determined that his or her patient poses a significant societal risk. It places the health care provider in a dilemma, because it pits patient confidentiality against the public interest in safety.
There does not appear to be an appellate case precisely on point, but the well known case of Tarasoff1 offers useful insight.
In Tarasoff, a California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, the girlfriend, whom the patient stabbed to death 2 months later.
The California court found the psychologist and the University of California (as the psychologist’s employer) liable, reasoning that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship.
The court wrote: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
However, the duty to warn a third party may not be as clear cut where there is no readily identifiable victim.2
Further, the law is unsettled regarding a physician’s duty to report negligent conduct that poses a significant risk to public safety, e.g., where a patient insists on operating a vehicle against medical advice. Obviously, the doctor should spare no effort in trying to persuade such a patient to discontinue driving. When this fails, however, and depending on the circumstances, the physician should seriously consider breaching patent confidentiality by notifying the driving licensing bureau.
This opinion is in accord with the AMA Code of Medical Ethics: “Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”3
What about informing the patient’s employer if the risk of harm arises in the work setting?
The duty to report is clearer if the physician is a company doctor specifically charged with the task of determining whether an employee is fit for work. However, a patient’s personal physician may be a different matter, because he or she does not share the same contractual obligation as a company employed doctor.
Still, the circumstances may well dictate the need to report. In the hypothetical scenario posed above, the patient is refusing to heed the advice of physician and spouse, and given the history of a DUI, can be said to be placing innocent children and others at risk. The physician may need to go beyond warning the patient and wife, even though revealing a patient’s diagnosis violates the principle of confidentiality.
Arguably controversial, the physician’s justification is that there is a higher ethical and legal duty to report, as the risk of harm to the school children is both unreasonable and foreseeable, outweighing other considerations.
The same analysis concerning reporting may be applied in uncooperative patients with certain medical diagnoses (e.g., uncontrolled epilepsy, serious mental illness, or disabling cardiac or cerebrovascular disease, to name a few) and in those taking mind-altering prescription medications or illicit drugs.
A key inquiry is whether the patient’s work activity is potentially hazardous, as in those who are entrusted with public transportation, e.g., bus drivers, pilots and train/ship engineers, or those who operate heavy machinery.
The most familiar example of the failure to warn (as opposed to report) is of course in informed consent litigation, where the physician is faulted for not warning the patient of the risk of harm and the patient in fact suffers that harm. It is framed as the failure to disclose material risks. The California Supreme Court has stated that “material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure”; that “a (material) fact must also be one which is not commonly appreciated”; and the scope of disclosure may be expanded in patients with “unique concerns or lack of familiarity with medical procedures.”4 There is, however, no legal requirement to deliver a “mini-course in medical science.”5
Another situation where there may have been a failure to warn is in medical products liability. Here, the plaintiff alleges that the defective product has caused injuries because the manufacturer has issued no prior warning to the health care provider or end user. A prime example is the current Lipitor and diabetes class action lawsuit against Pfizer.
In failing to warn a patient, a doctor may incur liability not only for injuries to the patient but also to nonpatient third parties.
In a 2002 Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old girl and crushing her against a cement planter.6 The driver alleged that the prescription medication prazosin caused him to develop hypotension and lose control of the car, and that the treating physician was negligent in failing to warn of this potential side effect.
The Hawaii Supreme Court held that physicians have a duty to their patients to warn of potential adverse effects, and this responsibility should therefore extend to third parties.
Court decisions elsewhere have also found liability where, for public policy reasons, a “special relationship” is deemed to exist between the doctor and the injured third party. Foreseeability is one important factor in construing its existence, notwithstanding the absence of the traditional doctor-patient relationship.
References
1. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
2. Furr v. Spring Grove State Hospital, 454 A.2d 414 (Md. 1983).
3. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed.].
4. Truman v. Thomas, 27 Cal.3d 285 (1980).
5. Cobbs v. Grant, 8 Cal.3d 229 (1972).
6. McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 (Haw. 2002).
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.
