Commentary

As orthopedic surgeons, we typically equate a quality outcome with the patient’s end result—resolved or diminished functional disability, fracture union, and/or pain relief, to name a few metrics. Although research has not identified a clear link between quality outcomes and patient satisfaction scores, patient satisfaction is increasingly used as a proxy for quality of care. It’s speculated that more personal care may result in better communication, more reasonable expectations, and more patient involvement, all of which may result in better quality of care. Regardless, it’s unclear whether satisfaction is an attribute of quality care or an indicator.

In a recent article in Modern Healthcare, Irwin Press,¹ cofounder of Press Ganey, challenges any campaign to cast doubt on satisfaction as a relevant indicator of quality care: “It can be argued that diagnostic procedures, surgeries and therapies constitute treatment, but not care. Treatment alone isn’t care…. One is objective, involving highly standardized technical, mechanical or chemical interventions. The other is subjective, composed of behaviors, decisions and interactions of humans with idiosyncratic personalities, stresses, agendas and sensitivities.”

As surgeons, we understandably focus on objective treatment and outcome and may underappreciate the importance of the process—the experience of care. Wellness probably requires mastery of both. Indeed, just as a patient’s poor coping skills, depression, anxiety, and proclivity to catastrophize may compromise their recovery and self-reported assessments of outcome,^2-5 so too do the qualitative components of our interaction with patients undoubtedly impact, not only their experience, but also their recovery. Patient self-efficacy (the feeling that they can do it), engagement (“activation”), compliance, and expectations all derive in part from the “Art” of our practice. Our “Heart” is as important to that Art, if not more so, than our “Head” (our intellect and knowledge). Whether we buy into this or not is a matter of personal opinion and experience, I suppose, but the reality is that the important singular metric of patient satisfaction is here to stay—patient satisfaction has become an important component of pay-for-performance metrics which expressly intend to reward quality over volume.

What does this mean for us? First, we need to adapt to the reality that the patient’s perception of their interaction with us impacts their experience and their level of satisfaction, and accept our role in their overall perception of quality. Being rewarded with a high satisfaction score is within our sphere of influence and requires more than just providing a good objective outcome. We might not revisit a restaurant with great food but lousy service and an underwhelming environment. We might also never eat at a place that was really nice inside and had great service, but which provided horrible food. So we must aspire to provide both objective quality outcomes and stellar patient care. As third-party payers increasingly follow the lead of the Centers for Medicare and Medicaid Services (CMS), the patient will not be at our table unless we both ask for feedback and respond to it. We all aspire to be great technicians and have a command of the knowledge base in our respective areas of practice. Some of us are privileged to have earned regional, national, or international reputations among our peers, but we all will be increasingly judged based on patient satisfaction with our care. This means that we must care about their experience and how they perceive our care: Do we spend enough time, listen attentively, answer questions, and explain the diagnosis and plan?

Just as we may hold our breath unknowingly during stressful situations when we are not mindful, so too might our “Heart” not be clearly evident in the complex health care environment today—too little time, too much paperwork, increasing patient demands. But practicing with heightened self-awareness, empathy, and unambiguous intention, and modeling our values during our interaction with our patients—“mindful practice”—is increasingly advocated as a necessary component to “best practice.” For truly rewarding practice, during which we can attain not only great results but also satisfied patients, we need to revisit why we do what we do, and rebalance our emphasis on what we do and how we do it. Mindful practice is both an objective and a strategy. It may require making structural adjustments to our practice, such as seeing fewer patients per hour, for, perhaps, an hour or two more in a day, completing some of our electronic medical record notes at day’s end, and maybe adding an extra clinic day every other week. We must also deliberately solicit feedback from our patients so that we can respond to any perceived room for improvement.

Thirteen years ago when I received my Master of Business Administration (MBA) degree, I felt that improving operational efficiency would enable me to do more in a day—and it did. But when patient satisfaction becomes the proxy for quality, sound business practice may not translate into sound clinical practice. After 21 years of practice, and deliberate attentiveness to patient feedback, I am increasingly aware that the Art of practice is as important as the Science—our Heart is as important as our Head. In this light, patient satisfaction is a very sound metric for quality.

As orthopedic surgeons, we typically equate a quality outcome with the patient’s end result—resolved or diminished functional disability, fracture union, and/or pain relief, to name a few metrics. Although research has not identified a clear link between quality outcomes and patient satisfaction scores, patient satisfaction is increasingly used as a proxy for quality of care. It’s speculated that more personal care may result in better communication, more reasonable expectations, and more patient involvement, all of which may result in better quality of care. Regardless, it’s unclear whether satisfaction is an attribute of quality care or an indicator.

In a recent article in Modern Healthcare, Irwin Press,¹ cofounder of Press Ganey, challenges any campaign to cast doubt on satisfaction as a relevant indicator of quality care: “It can be argued that diagnostic procedures, surgeries and therapies constitute treatment, but not care. Treatment alone isn’t care…. One is objective, involving highly standardized technical, mechanical or chemical interventions. The other is subjective, composed of behaviors, decisions and interactions of humans with idiosyncratic personalities, stresses, agendas and sensitivities.”

As surgeons, we understandably focus on objective treatment and outcome and may underappreciate the importance of the process—the experience of care. Wellness probably requires mastery of both. Indeed, just as a patient’s poor coping skills, depression, anxiety, and proclivity to catastrophize may compromise their recovery and self-reported assessments of outcome,^2-5 so too do the qualitative components of our interaction with patients undoubtedly impact, not only their experience, but also their recovery. Patient self-efficacy (the feeling that they can do it), engagement (“activation”), compliance, and expectations all derive in part from the “Art” of our practice. Our “Heart” is as important to that Art, if not more so, than our “Head” (our intellect and knowledge). Whether we buy into this or not is a matter of personal opinion and experience, I suppose, but the reality is that the important singular metric of patient satisfaction is here to stay—patient satisfaction has become an important component of pay-for-performance metrics which expressly intend to reward quality over volume.

What does this mean for us? First, we need to adapt to the reality that the patient’s perception of their interaction with us impacts their experience and their level of satisfaction, and accept our role in their overall perception of quality. Being rewarded with a high satisfaction score is within our sphere of influence and requires more than just providing a good objective outcome. We might not revisit a restaurant with great food but lousy service and an underwhelming environment. We might also never eat at a place that was really nice inside and had great service, but which provided horrible food. So we must aspire to provide both objective quality outcomes and stellar patient care. As third-party payers increasingly follow the lead of the Centers for Medicare and Medicaid Services (CMS), the patient will not be at our table unless we both ask for feedback and respond to it. We all aspire to be great technicians and have a command of the knowledge base in our respective areas of practice. Some of us are privileged to have earned regional, national, or international reputations among our peers, but we all will be increasingly judged based on patient satisfaction with our care. This means that we must care about their experience and how they perceive our care: Do we spend enough time, listen attentively, answer questions, and explain the diagnosis and plan?

Just as we may hold our breath unknowingly during stressful situations when we are not mindful, so too might our “Heart” not be clearly evident in the complex health care environment today—too little time, too much paperwork, increasing patient demands. But practicing with heightened self-awareness, empathy, and unambiguous intention, and modeling our values during our interaction with our patients—“mindful practice”—is increasingly advocated as a necessary component to “best practice.” For truly rewarding practice, during which we can attain not only great results but also satisfied patients, we need to revisit why we do what we do, and rebalance our emphasis on what we do and how we do it. Mindful practice is both an objective and a strategy. It may require making structural adjustments to our practice, such as seeing fewer patients per hour, for, perhaps, an hour or two more in a day, completing some of our electronic medical record notes at day’s end, and maybe adding an extra clinic day every other week. We must also deliberately solicit feedback from our patients so that we can respond to any perceived room for improvement.

Thirteen years ago when I received my Master of Business Administration (MBA) degree, I felt that improving operational efficiency would enable me to do more in a day—and it did. But when patient satisfaction becomes the proxy for quality, sound business practice may not translate into sound clinical practice. After 21 years of practice, and deliberate attentiveness to patient feedback, I am increasingly aware that the Art of practice is as important as the Science—our Heart is as important as our Head. In this light, patient satisfaction is a very sound metric for quality.

As orthopedic surgeons, we typically equate a quality outcome with the patient’s end result—resolved or diminished functional disability, fracture union, and/or pain relief, to name a few metrics. Although research has not identified a clear link between quality outcomes and patient satisfaction scores, patient satisfaction is increasingly used as a proxy for quality of care. It’s speculated that more personal care may result in better communication, more reasonable expectations, and more patient involvement, all of which may result in better quality of care. Regardless, it’s unclear whether satisfaction is an attribute of quality care or an indicator.

In a recent article in Modern Healthcare, Irwin Press,¹ cofounder of Press Ganey, challenges any campaign to cast doubt on satisfaction as a relevant indicator of quality care: “It can be argued that diagnostic procedures, surgeries and therapies constitute treatment, but not care. Treatment alone isn’t care…. One is objective, involving highly standardized technical, mechanical or chemical interventions. The other is subjective, composed of behaviors, decisions and interactions of humans with idiosyncratic personalities, stresses, agendas and sensitivities.”

As surgeons, we understandably focus on objective treatment and outcome and may underappreciate the importance of the process—the experience of care. Wellness probably requires mastery of both. Indeed, just as a patient’s poor coping skills, depression, anxiety, and proclivity to catastrophize may compromise their recovery and self-reported assessments of outcome,^2-5 so too do the qualitative components of our interaction with patients undoubtedly impact, not only their experience, but also their recovery. Patient self-efficacy (the feeling that they can do it), engagement (“activation”), compliance, and expectations all derive in part from the “Art” of our practice. Our “Heart” is as important to that Art, if not more so, than our “Head” (our intellect and knowledge). Whether we buy into this or not is a matter of personal opinion and experience, I suppose, but the reality is that the important singular metric of patient satisfaction is here to stay—patient satisfaction has become an important component of pay-for-performance metrics which expressly intend to reward quality over volume.

What does this mean for us? First, we need to adapt to the reality that the patient’s perception of their interaction with us impacts their experience and their level of satisfaction, and accept our role in their overall perception of quality. Being rewarded with a high satisfaction score is within our sphere of influence and requires more than just providing a good objective outcome. We might not revisit a restaurant with great food but lousy service and an underwhelming environment. We might also never eat at a place that was really nice inside and had great service, but which provided horrible food. So we must aspire to provide both objective quality outcomes and stellar patient care. As third-party payers increasingly follow the lead of the Centers for Medicare and Medicaid Services (CMS), the patient will not be at our table unless we both ask for feedback and respond to it. We all aspire to be great technicians and have a command of the knowledge base in our respective areas of practice. Some of us are privileged to have earned regional, national, or international reputations among our peers, but we all will be increasingly judged based on patient satisfaction with our care. This means that we must care about their experience and how they perceive our care: Do we spend enough time, listen attentively, answer questions, and explain the diagnosis and plan?

Just as we may hold our breath unknowingly during stressful situations when we are not mindful, so too might our “Heart” not be clearly evident in the complex health care environment today—too little time, too much paperwork, increasing patient demands. But practicing with heightened self-awareness, empathy, and unambiguous intention, and modeling our values during our interaction with our patients—“mindful practice”—is increasingly advocated as a necessary component to “best practice.” For truly rewarding practice, during which we can attain not only great results but also satisfied patients, we need to revisit why we do what we do, and rebalance our emphasis on what we do and how we do it. Mindful practice is both an objective and a strategy. It may require making structural adjustments to our practice, such as seeing fewer patients per hour, for, perhaps, an hour or two more in a day, completing some of our electronic medical record notes at day’s end, and maybe adding an extra clinic day every other week. We must also deliberately solicit feedback from our patients so that we can respond to any perceived room for improvement.

Thirteen years ago when I received my Master of Business Administration (MBA) degree, I felt that improving operational efficiency would enable me to do more in a day—and it did. But when patient satisfaction becomes the proxy for quality, sound business practice may not translate into sound clinical practice. After 21 years of practice, and deliberate attentiveness to patient feedback, I am increasingly aware that the Art of practice is as important as the Science—our Heart is as important as our Head. In this light, patient satisfaction is a very sound metric for quality.

Hoping to learn a bit more about the apparently healthy 8-year-old who has been deposited in your exam room for his biannual checkup, you take the opportunity to ask him a few questions with his mother in the waiting room. “So, Jason, what do you like to do for fun?”

“Well, yesterday I started a fire with my buddy Rudy, and we burned a whole bunch of sticks and stuff.”

“Does your mother know about this?”

“She wasn’t around, but I think so. We’ve done it a bunch of times before.”

Okay, here you are with an 8-year-old pyromaniac whose parents are clearly under-supervising him. Who do you call first? The folks at Child Protective Services or the State Fire Marshall’s Office? Clearly, he and your community are at significant risk.

If you were practicing in Wrexham, a town in North Wales, you would continue your questioning with, “So you like to go to The Land after school? I’ve heard it’s a fun place?”

The Land is 3-year-old adventure playground that I learned about in a thought-provoking article in The Atlantic (The Overprotected Kid, by Hanna Rosin, April 2014). The nearly acre-sized site would look like a junkyard to any adult whose imagination has atrophied with age. Strewn with used tires, wooden palettes, dirty old mattresses, and decrepit lawn furniture, it provides endless opportunities for children to create their own places for play and adventure. By stacking, rolling, hammering together, and rearranging the loose detritus of society, children can transform the junk into an ever-changing landscape for fun. A fire pit and an old oil drum – among the most popular items – are often smoldering with fires the children have started. The filthy mattresses become trampolines. The children are observed by professionally trained “playworkers” who are continually updating the risk assessments of the activities that were begun prior to the opening of the facility. The observers seldom have to intervene. Other than a few scraped knees, no children have been injured.

Although adventure playgrounds were relatively common in the U.K. during the 1940’s, their popularity faded until the last few years when they have enjoyed a modest resurgence. In the article in The Atlantic, author Hanna Rosin chronicles the de-riskification of playgrounds in America that began in the 1970’s. The process was fueled by an unfortunate incident in which a toddler supervised by his mother fell off a 12-foot playground slide in a Chicago playground. The child sustained a significant and permanent brain injury and received a multimillion dollar award in the suit that followed.

A commentary in Pediatrics entitled “X-rated playgrounds?” (Pediatrics 1979;64:961) and a crusade by its author, Theodora Briggs Sweeney culminated in the release of the Handbook for Public Playground Safety (U.S. Consumer Product Safety Commission, 1981) which listed in minute detail guidelines for dimensions and materials for playground equipment and play surfaces. Although these were only “guidelines,” only the most foolish manufacturer would ignore them. Little thought was given to the validity of the alarming statistics that had prompted these changes. What were the denominators? Can you compare 1970’s hospital data with those from the 1950’s when injured children were managed at home or in their doctors’ offices?

Regardless of the validity of the data, the result was that these redesigned playgrounds offered so little sense of risk that they were abandoned by all but the youngest children. Numerous studies suggest that by eliminating risk or at least the appearance of risk, we are robbing children of important learning experiences on which they can build fuller, more creative, successful, and less anxiety-dominated lives. I urge you to look at that Atlantic article for a more robust description of the evidence.

I suspect that you may be a bit uncomfortable with 8-year-old boys playing with fire, but do you agree that we need to seriously rethink our attempts to protect children from the ordinary risks of an active life? Or do you think those of us who believe children will benefit from more perceived risk are just a bunch of fogys who begin every other sentence, “When I was your age ... .”

Do you encourage parents to allow their children to walk to school unattended? Do you caution parents about being overprotective? Have I ignited a spark of concern in you, or am I just playing with fire?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

Hoping to learn a bit more about the apparently healthy 8-year-old who has been deposited in your exam room for his biannual checkup, you take the opportunity to ask him a few questions with his mother in the waiting room. “So, Jason, what do you like to do for fun?”

“Well, yesterday I started a fire with my buddy Rudy, and we burned a whole bunch of sticks and stuff.”

“Does your mother know about this?”

“She wasn’t around, but I think so. We’ve done it a bunch of times before.”

Okay, here you are with an 8-year-old pyromaniac whose parents are clearly under-supervising him. Who do you call first? The folks at Child Protective Services or the State Fire Marshall’s Office? Clearly, he and your community are at significant risk.

If you were practicing in Wrexham, a town in North Wales, you would continue your questioning with, “So you like to go to The Land after school? I’ve heard it’s a fun place?”

The Land is 3-year-old adventure playground that I learned about in a thought-provoking article in The Atlantic (The Overprotected Kid, by Hanna Rosin, April 2014). The nearly acre-sized site would look like a junkyard to any adult whose imagination has atrophied with age. Strewn with used tires, wooden palettes, dirty old mattresses, and decrepit lawn furniture, it provides endless opportunities for children to create their own places for play and adventure. By stacking, rolling, hammering together, and rearranging the loose detritus of society, children can transform the junk into an ever-changing landscape for fun. A fire pit and an old oil drum – among the most popular items – are often smoldering with fires the children have started. The filthy mattresses become trampolines. The children are observed by professionally trained “playworkers” who are continually updating the risk assessments of the activities that were begun prior to the opening of the facility. The observers seldom have to intervene. Other than a few scraped knees, no children have been injured.

Although adventure playgrounds were relatively common in the U.K. during the 1940’s, their popularity faded until the last few years when they have enjoyed a modest resurgence. In the article in The Atlantic, author Hanna Rosin chronicles the de-riskification of playgrounds in America that began in the 1970’s. The process was fueled by an unfortunate incident in which a toddler supervised by his mother fell off a 12-foot playground slide in a Chicago playground. The child sustained a significant and permanent brain injury and received a multimillion dollar award in the suit that followed.

A commentary in Pediatrics entitled “X-rated playgrounds?” (Pediatrics 1979;64:961) and a crusade by its author, Theodora Briggs Sweeney culminated in the release of the Handbook for Public Playground Safety (U.S. Consumer Product Safety Commission, 1981) which listed in minute detail guidelines for dimensions and materials for playground equipment and play surfaces. Although these were only “guidelines,” only the most foolish manufacturer would ignore them. Little thought was given to the validity of the alarming statistics that had prompted these changes. What were the denominators? Can you compare 1970’s hospital data with those from the 1950’s when injured children were managed at home or in their doctors’ offices?

Regardless of the validity of the data, the result was that these redesigned playgrounds offered so little sense of risk that they were abandoned by all but the youngest children. Numerous studies suggest that by eliminating risk or at least the appearance of risk, we are robbing children of important learning experiences on which they can build fuller, more creative, successful, and less anxiety-dominated lives. I urge you to look at that Atlantic article for a more robust description of the evidence.

I suspect that you may be a bit uncomfortable with 8-year-old boys playing with fire, but do you agree that we need to seriously rethink our attempts to protect children from the ordinary risks of an active life? Or do you think those of us who believe children will benefit from more perceived risk are just a bunch of fogys who begin every other sentence, “When I was your age ... .”

Do you encourage parents to allow their children to walk to school unattended? Do you caution parents about being overprotective? Have I ignited a spark of concern in you, or am I just playing with fire?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

Hoping to learn a bit more about the apparently healthy 8-year-old who has been deposited in your exam room for his biannual checkup, you take the opportunity to ask him a few questions with his mother in the waiting room. “So, Jason, what do you like to do for fun?”

“Well, yesterday I started a fire with my buddy Rudy, and we burned a whole bunch of sticks and stuff.”

“Does your mother know about this?”

“She wasn’t around, but I think so. We’ve done it a bunch of times before.”

Okay, here you are with an 8-year-old pyromaniac whose parents are clearly under-supervising him. Who do you call first? The folks at Child Protective Services or the State Fire Marshall’s Office? Clearly, he and your community are at significant risk.

If you were practicing in Wrexham, a town in North Wales, you would continue your questioning with, “So you like to go to The Land after school? I’ve heard it’s a fun place?”

The Land is 3-year-old adventure playground that I learned about in a thought-provoking article in The Atlantic (The Overprotected Kid, by Hanna Rosin, April 2014). The nearly acre-sized site would look like a junkyard to any adult whose imagination has atrophied with age. Strewn with used tires, wooden palettes, dirty old mattresses, and decrepit lawn furniture, it provides endless opportunities for children to create their own places for play and adventure. By stacking, rolling, hammering together, and rearranging the loose detritus of society, children can transform the junk into an ever-changing landscape for fun. A fire pit and an old oil drum – among the most popular items – are often smoldering with fires the children have started. The filthy mattresses become trampolines. The children are observed by professionally trained “playworkers” who are continually updating the risk assessments of the activities that were begun prior to the opening of the facility. The observers seldom have to intervene. Other than a few scraped knees, no children have been injured.

Although adventure playgrounds were relatively common in the U.K. during the 1940’s, their popularity faded until the last few years when they have enjoyed a modest resurgence. In the article in The Atlantic, author Hanna Rosin chronicles the de-riskification of playgrounds in America that began in the 1970’s. The process was fueled by an unfortunate incident in which a toddler supervised by his mother fell off a 12-foot playground slide in a Chicago playground. The child sustained a significant and permanent brain injury and received a multimillion dollar award in the suit that followed.

A commentary in Pediatrics entitled “X-rated playgrounds?” (Pediatrics 1979;64:961) and a crusade by its author, Theodora Briggs Sweeney culminated in the release of the Handbook for Public Playground Safety (U.S. Consumer Product Safety Commission, 1981) which listed in minute detail guidelines for dimensions and materials for playground equipment and play surfaces. Although these were only “guidelines,” only the most foolish manufacturer would ignore them. Little thought was given to the validity of the alarming statistics that had prompted these changes. What were the denominators? Can you compare 1970’s hospital data with those from the 1950’s when injured children were managed at home or in their doctors’ offices?

Regardless of the validity of the data, the result was that these redesigned playgrounds offered so little sense of risk that they were abandoned by all but the youngest children. Numerous studies suggest that by eliminating risk or at least the appearance of risk, we are robbing children of important learning experiences on which they can build fuller, more creative, successful, and less anxiety-dominated lives. I urge you to look at that Atlantic article for a more robust description of the evidence.

I suspect that you may be a bit uncomfortable with 8-year-old boys playing with fire, but do you agree that we need to seriously rethink our attempts to protect children from the ordinary risks of an active life? Or do you think those of us who believe children will benefit from more perceived risk are just a bunch of fogys who begin every other sentence, “When I was your age ... .”

Do you encourage parents to allow their children to walk to school unattended? Do you caution parents about being overprotective? Have I ignited a spark of concern in you, or am I just playing with fire?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

Despite all the hoopla about Ebola and measles this winter, the most common reason for admitting an infant or young child to the hospital continues to be bronchiolitis. Yet clinical practice guidelines for diagnosing and treating this common infection have not been incorporated into clinical practice.

The use of over-the-counter cold medications to treat upper respiratory infections in young children was shown by meta-analysis in the mid-1990’s to be ineffective, but that use continued until the Food and Drug Administration mandated revisions to packaging in 2008. Antibiotics have been commonly prescribed to treat the ear infections and sinusitis that frequently occur with bronchiolitis. But over the past 20 years, the use of antibiotics has become less prevalent. I date that trend to the work of Dr. Jack Paradise, professor emeritus of pediatrics at the University of Pittsburgh, and Dr. Ellen Wald, now chair of pediatrics at the University of Wisconsin, Madison, in the mid-1990’s. RespiGam was approved in 1996, then supplanted with palivizumab, as a medication to reduce the burden of respiratory syncytial virus disease. In the summer of 2014, an updated analysis of the costs, risks, and benefits of RSV prophylaxis led to new recommendations that curtailed the indications for that treatment (Pediatrics 2014:134;415-20). What do these trends have in common? The time frame.

It is often cited that it takes 17 years for new evidence to be assimilated into clinical practice (J.R. Soc. Med. 2011;104:510-20). An Institute of Medicine report in 2001, “Crossing the Quality Chasm,” emphasized the importance of becoming more efficient at making progress. Those recommendations themselves are now 14 years old, and I’m not expecting a revolution in human behavior within the next 3 years.

In the new clinical practice guideline issued by the American Academy of Pediatrics in November 2014 for the treatment of young children with bronchiolitis, Dr. Shawn L. Ralston and her colleagues assessed various treatment modalities, found many to be ineffective, and recommended discontinuing their routine use (Pediatrics 2014;134:e1474-e1502). Beta-agonists were at the forefront of this. Was the new guideline based on new data? For the most part, no. In my reading, itmostly reiterated the concerns about effectiveness that were expressed at the time of the prior guidelines from 2006, but removed the weasel words. I admire the dedication of this committee to evidence-based medicine. But will this revised clinical practice guideline actually change practice?

The saying is, “Build a better mousetrap and the world will beat a path to your door.” That quote has been attributed (without adequate documentation) to Ralph Waldo Emerson. He was a great poet, but not a scientist.

During the same month that the new bronchiolitis guidelinewas being released, America held some elections. In the post mortem, President Obama said, “There is a tendency sometimes for me to start thinking: As long as I get the policy right, then that’s what should matter.” He elaborated that “one thing that I do need to constantly remind myself and my team of is it’s not enough just to build the better mousetrap. People don’t automatically come beating to your door. We’ve got to sell it; we’ve got to reach out to the other side and where possible, persuade” (The Wall Street Journal, Nov. 10, 2014).

That isn’t poetry, but the President’s idea is probably more accurate than Emerson’s.

The bronchiolitis clinical practice guidelinewas written in a standardized fashion with 14 key action statements and 242 references. That makes for a good evidence-based medicine document, but is not the best sales pitch.

What will it take to translate these new guidelines into practice? One option is to teach new residents the new guidelines and expect dinosaurs such as myself to retire. If the average pediatrician works for about 34 years, then over a period of 17 years, we will have replaced half the miscreants simply by attrition.

A program of reaching out to the other side and persuading them to change is a better option.

In discussions about this topic on a listserv for pediatric hospitalists, I focused on my concerns. We need to clarify the harms associated with therapies such as beta-agonists, deep nasal suctioning, and continuous pulse oximetry. We need to clarify the goals of treatment, which might include a shorter length of stay, patient comfort, meeting parents’ expectations that we will do something, and/or explaining why we are contradicting any previous recommendations made to the parents. We need to mesh these bronchiolitis guidelines with the asthma action plans and medication lists advocated for wheezing children who are 24 months of age. My colleagues pointed out that all of that is just continuing to refine the policy.

Getting the policy right is necessary but insufficient. What we are really missing is a campaign strategy to sell it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine.

Despite all the hoopla about Ebola and measles this winter, the most common reason for admitting an infant or young child to the hospital continues to be bronchiolitis. Yet clinical practice guidelines for diagnosing and treating this common infection have not been incorporated into clinical practice.

The use of over-the-counter cold medications to treat upper respiratory infections in young children was shown by meta-analysis in the mid-1990’s to be ineffective, but that use continued until the Food and Drug Administration mandated revisions to packaging in 2008. Antibiotics have been commonly prescribed to treat the ear infections and sinusitis that frequently occur with bronchiolitis. But over the past 20 years, the use of antibiotics has become less prevalent. I date that trend to the work of Dr. Jack Paradise, professor emeritus of pediatrics at the University of Pittsburgh, and Dr. Ellen Wald, now chair of pediatrics at the University of Wisconsin, Madison, in the mid-1990’s. RespiGam was approved in 1996, then supplanted with palivizumab, as a medication to reduce the burden of respiratory syncytial virus disease. In the summer of 2014, an updated analysis of the costs, risks, and benefits of RSV prophylaxis led to new recommendations that curtailed the indications for that treatment (Pediatrics 2014:134;415-20). What do these trends have in common? The time frame.

It is often cited that it takes 17 years for new evidence to be assimilated into clinical practice (J.R. Soc. Med. 2011;104:510-20). An Institute of Medicine report in 2001, “Crossing the Quality Chasm,” emphasized the importance of becoming more efficient at making progress. Those recommendations themselves are now 14 years old, and I’m not expecting a revolution in human behavior within the next 3 years.

In the new clinical practice guideline issued by the American Academy of Pediatrics in November 2014 for the treatment of young children with bronchiolitis, Dr. Shawn L. Ralston and her colleagues assessed various treatment modalities, found many to be ineffective, and recommended discontinuing their routine use (Pediatrics 2014;134:e1474-e1502). Beta-agonists were at the forefront of this. Was the new guideline based on new data? For the most part, no. In my reading, itmostly reiterated the concerns about effectiveness that were expressed at the time of the prior guidelines from 2006, but removed the weasel words. I admire the dedication of this committee to evidence-based medicine. But will this revised clinical practice guideline actually change practice?

The saying is, “Build a better mousetrap and the world will beat a path to your door.” That quote has been attributed (without adequate documentation) to Ralph Waldo Emerson. He was a great poet, but not a scientist.

During the same month that the new bronchiolitis guidelinewas being released, America held some elections. In the post mortem, President Obama said, “There is a tendency sometimes for me to start thinking: As long as I get the policy right, then that’s what should matter.” He elaborated that “one thing that I do need to constantly remind myself and my team of is it’s not enough just to build the better mousetrap. People don’t automatically come beating to your door. We’ve got to sell it; we’ve got to reach out to the other side and where possible, persuade” (The Wall Street Journal, Nov. 10, 2014).

That isn’t poetry, but the President’s idea is probably more accurate than Emerson’s.

The bronchiolitis clinical practice guidelinewas written in a standardized fashion with 14 key action statements and 242 references. That makes for a good evidence-based medicine document, but is not the best sales pitch.

What will it take to translate these new guidelines into practice? One option is to teach new residents the new guidelines and expect dinosaurs such as myself to retire. If the average pediatrician works for about 34 years, then over a period of 17 years, we will have replaced half the miscreants simply by attrition.

A program of reaching out to the other side and persuading them to change is a better option.

In discussions about this topic on a listserv for pediatric hospitalists, I focused on my concerns. We need to clarify the harms associated with therapies such as beta-agonists, deep nasal suctioning, and continuous pulse oximetry. We need to clarify the goals of treatment, which might include a shorter length of stay, patient comfort, meeting parents’ expectations that we will do something, and/or explaining why we are contradicting any previous recommendations made to the parents. We need to mesh these bronchiolitis guidelines with the asthma action plans and medication lists advocated for wheezing children who are 24 months of age. My colleagues pointed out that all of that is just continuing to refine the policy.

Getting the policy right is necessary but insufficient. What we are really missing is a campaign strategy to sell it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine.

Despite all the hoopla about Ebola and measles this winter, the most common reason for admitting an infant or young child to the hospital continues to be bronchiolitis. Yet clinical practice guidelines for diagnosing and treating this common infection have not been incorporated into clinical practice.

The use of over-the-counter cold medications to treat upper respiratory infections in young children was shown by meta-analysis in the mid-1990’s to be ineffective, but that use continued until the Food and Drug Administration mandated revisions to packaging in 2008. Antibiotics have been commonly prescribed to treat the ear infections and sinusitis that frequently occur with bronchiolitis. But over the past 20 years, the use of antibiotics has become less prevalent. I date that trend to the work of Dr. Jack Paradise, professor emeritus of pediatrics at the University of Pittsburgh, and Dr. Ellen Wald, now chair of pediatrics at the University of Wisconsin, Madison, in the mid-1990’s. RespiGam was approved in 1996, then supplanted with palivizumab, as a medication to reduce the burden of respiratory syncytial virus disease. In the summer of 2014, an updated analysis of the costs, risks, and benefits of RSV prophylaxis led to new recommendations that curtailed the indications for that treatment (Pediatrics 2014:134;415-20). What do these trends have in common? The time frame.

It is often cited that it takes 17 years for new evidence to be assimilated into clinical practice (J.R. Soc. Med. 2011;104:510-20). An Institute of Medicine report in 2001, “Crossing the Quality Chasm,” emphasized the importance of becoming more efficient at making progress. Those recommendations themselves are now 14 years old, and I’m not expecting a revolution in human behavior within the next 3 years.

In the new clinical practice guideline issued by the American Academy of Pediatrics in November 2014 for the treatment of young children with bronchiolitis, Dr. Shawn L. Ralston and her colleagues assessed various treatment modalities, found many to be ineffective, and recommended discontinuing their routine use (Pediatrics 2014;134:e1474-e1502). Beta-agonists were at the forefront of this. Was the new guideline based on new data? For the most part, no. In my reading, itmostly reiterated the concerns about effectiveness that were expressed at the time of the prior guidelines from 2006, but removed the weasel words. I admire the dedication of this committee to evidence-based medicine. But will this revised clinical practice guideline actually change practice?

The saying is, “Build a better mousetrap and the world will beat a path to your door.” That quote has been attributed (without adequate documentation) to Ralph Waldo Emerson. He was a great poet, but not a scientist.

During the same month that the new bronchiolitis guidelinewas being released, America held some elections. In the post mortem, President Obama said, “There is a tendency sometimes for me to start thinking: As long as I get the policy right, then that’s what should matter.” He elaborated that “one thing that I do need to constantly remind myself and my team of is it’s not enough just to build the better mousetrap. People don’t automatically come beating to your door. We’ve got to sell it; we’ve got to reach out to the other side and where possible, persuade” (The Wall Street Journal, Nov. 10, 2014).

That isn’t poetry, but the President’s idea is probably more accurate than Emerson’s.

The bronchiolitis clinical practice guidelinewas written in a standardized fashion with 14 key action statements and 242 references. That makes for a good evidence-based medicine document, but is not the best sales pitch.

What will it take to translate these new guidelines into practice? One option is to teach new residents the new guidelines and expect dinosaurs such as myself to retire. If the average pediatrician works for about 34 years, then over a period of 17 years, we will have replaced half the miscreants simply by attrition.

A program of reaching out to the other side and persuading them to change is a better option.

In discussions about this topic on a listserv for pediatric hospitalists, I focused on my concerns. We need to clarify the harms associated with therapies such as beta-agonists, deep nasal suctioning, and continuous pulse oximetry. We need to clarify the goals of treatment, which might include a shorter length of stay, patient comfort, meeting parents’ expectations that we will do something, and/or explaining why we are contradicting any previous recommendations made to the parents. We need to mesh these bronchiolitis guidelines with the asthma action plans and medication lists advocated for wheezing children who are 24 months of age. My colleagues pointed out that all of that is just continuing to refine the policy.

Getting the policy right is necessary but insufficient. What we are really missing is a campaign strategy to sell it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine.

By yesterday at lunch time, you knew you were sick. The sniffly nose and scratchy throat of the previous 2 days were maturing into a full-blown cold or worse. You woke this morning feeling achy and a bit feverish. The only thermometer in the house is a scary looking thing in the cutlery drawer next to the kitchen stove. There have been no cases of influenza reported in the country or even the state.

It is Thursday, and it is your partner’s traditional day off. You think you remember him saying that he was planning on driving out of state to visit his daughter who was struggling in her freshman year in college. Your new associate is in St. Louis taking her boards. The questions that need to be answered by 7:30 this morning are: Do I see if I can reach my partner before he leaves town and ask him if can work for me? If he is already on the road, do I call the office and tell them to cancel the day’s schedule because I am too sick to work?

This is the kind of scenario that most have us have faced more than once in our working lives. Who will I be putting at risk by going to work when I am sick? Of course, there are my patients. Is my patient population particularly fragile because of their age or immunological vulnerabilities? And there are my coworkers. Last of all, will going to work make me even sicker so that I will miss more work?

Where do you go for help in answering the question of whether you are too sick to go to work? Should you try to find a thermometer at an all-night convenience store? If you find one, exactly what temperature is the threshold that will prompt you to call in sick? How many sneezes per hour will render you too contagious to work? How many coughs? If your illness is primarily gastrointestinal, are you still a threat to your patients if your trips to the bathroom are spaced far enough apart to allow you to spend 15 minutes trapped in an examining room?

Would wearing a mask be of any benefit? My sense is that it wouldn’t help and may make you more of a threat if you keeping fiddling with it to readjust it for comfort. And a mask will certainly alarm some parents.

There are situations in which you look or sound worse than you are. I seem to develop laryngitis several days after the worst of my cold has passed. Unfortunately, this scenario is not one of those situations. If you show up in the office, you are going to sound and maybe look like you are as sick as you feel.

What are you going to do? I am embarrassed to admit that I was one of those masochists who would have gone to work regardless of my state of health. You would have had to tether me to an IV bottle to keep me at home. As a recovering workaholic, I have had to accept the fact that I may have jeopardized the health of some of my patients by my pigheaded and at times selfish devotion to showing up in the office come hell or high fever. But, on days when I was the only show in town, it was easy to fall into the trap of believing that I was indispensable. Although full-time emergency room physicians and hospitalists hadn’t been invented yet, there were a few other primary care physicians. I guess it was pride that prevented me from admitting that I could have called on them for help, even though they weren’t board certified pediatricians.

On the other hand, I still wonder how much harm I did by dragging myself to work when I was sick. Because Brunswick is a small town, I know my overly intense devotion to work didn’t result in any deaths. But how great was the collateral damage in the form of lost days from school and work for my patients, their parents, and my coworkers? There is no way to know, but I am sure there was some.

It is unreasonable to say, “I won’t ever go to work if I am ill.” I may have set the bar too high, but I am interested to hear how you decide when you are too sick to go to work.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

By yesterday at lunch time, you knew you were sick. The sniffly nose and scratchy throat of the previous 2 days were maturing into a full-blown cold or worse. You woke this morning feeling achy and a bit feverish. The only thermometer in the house is a scary looking thing in the cutlery drawer next to the kitchen stove. There have been no cases of influenza reported in the country or even the state.

It is Thursday, and it is your partner’s traditional day off. You think you remember him saying that he was planning on driving out of state to visit his daughter who was struggling in her freshman year in college. Your new associate is in St. Louis taking her boards. The questions that need to be answered by 7:30 this morning are: Do I see if I can reach my partner before he leaves town and ask him if can work for me? If he is already on the road, do I call the office and tell them to cancel the day’s schedule because I am too sick to work?

This is the kind of scenario that most have us have faced more than once in our working lives. Who will I be putting at risk by going to work when I am sick? Of course, there are my patients. Is my patient population particularly fragile because of their age or immunological vulnerabilities? And there are my coworkers. Last of all, will going to work make me even sicker so that I will miss more work?

Where do you go for help in answering the question of whether you are too sick to go to work? Should you try to find a thermometer at an all-night convenience store? If you find one, exactly what temperature is the threshold that will prompt you to call in sick? How many sneezes per hour will render you too contagious to work? How many coughs? If your illness is primarily gastrointestinal, are you still a threat to your patients if your trips to the bathroom are spaced far enough apart to allow you to spend 15 minutes trapped in an examining room?

Would wearing a mask be of any benefit? My sense is that it wouldn’t help and may make you more of a threat if you keeping fiddling with it to readjust it for comfort. And a mask will certainly alarm some parents.

There are situations in which you look or sound worse than you are. I seem to develop laryngitis several days after the worst of my cold has passed. Unfortunately, this scenario is not one of those situations. If you show up in the office, you are going to sound and maybe look like you are as sick as you feel.

What are you going to do? I am embarrassed to admit that I was one of those masochists who would have gone to work regardless of my state of health. You would have had to tether me to an IV bottle to keep me at home. As a recovering workaholic, I have had to accept the fact that I may have jeopardized the health of some of my patients by my pigheaded and at times selfish devotion to showing up in the office come hell or high fever. But, on days when I was the only show in town, it was easy to fall into the trap of believing that I was indispensable. Although full-time emergency room physicians and hospitalists hadn’t been invented yet, there were a few other primary care physicians. I guess it was pride that prevented me from admitting that I could have called on them for help, even though they weren’t board certified pediatricians.

On the other hand, I still wonder how much harm I did by dragging myself to work when I was sick. Because Brunswick is a small town, I know my overly intense devotion to work didn’t result in any deaths. But how great was the collateral damage in the form of lost days from school and work for my patients, their parents, and my coworkers? There is no way to know, but I am sure there was some.

It is unreasonable to say, “I won’t ever go to work if I am ill.” I may have set the bar too high, but I am interested to hear how you decide when you are too sick to go to work.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

By yesterday at lunch time, you knew you were sick. The sniffly nose and scratchy throat of the previous 2 days were maturing into a full-blown cold or worse. You woke this morning feeling achy and a bit feverish. The only thermometer in the house is a scary looking thing in the cutlery drawer next to the kitchen stove. There have been no cases of influenza reported in the country or even the state.

It is Thursday, and it is your partner’s traditional day off. You think you remember him saying that he was planning on driving out of state to visit his daughter who was struggling in her freshman year in college. Your new associate is in St. Louis taking her boards. The questions that need to be answered by 7:30 this morning are: Do I see if I can reach my partner before he leaves town and ask him if can work for me? If he is already on the road, do I call the office and tell them to cancel the day’s schedule because I am too sick to work?

This is the kind of scenario that most have us have faced more than once in our working lives. Who will I be putting at risk by going to work when I am sick? Of course, there are my patients. Is my patient population particularly fragile because of their age or immunological vulnerabilities? And there are my coworkers. Last of all, will going to work make me even sicker so that I will miss more work?

Where do you go for help in answering the question of whether you are too sick to go to work? Should you try to find a thermometer at an all-night convenience store? If you find one, exactly what temperature is the threshold that will prompt you to call in sick? How many sneezes per hour will render you too contagious to work? How many coughs? If your illness is primarily gastrointestinal, are you still a threat to your patients if your trips to the bathroom are spaced far enough apart to allow you to spend 15 minutes trapped in an examining room?

Would wearing a mask be of any benefit? My sense is that it wouldn’t help and may make you more of a threat if you keeping fiddling with it to readjust it for comfort. And a mask will certainly alarm some parents.

There are situations in which you look or sound worse than you are. I seem to develop laryngitis several days after the worst of my cold has passed. Unfortunately, this scenario is not one of those situations. If you show up in the office, you are going to sound and maybe look like you are as sick as you feel.

What are you going to do? I am embarrassed to admit that I was one of those masochists who would have gone to work regardless of my state of health. You would have had to tether me to an IV bottle to keep me at home. As a recovering workaholic, I have had to accept the fact that I may have jeopardized the health of some of my patients by my pigheaded and at times selfish devotion to showing up in the office come hell or high fever. But, on days when I was the only show in town, it was easy to fall into the trap of believing that I was indispensable. Although full-time emergency room physicians and hospitalists hadn’t been invented yet, there were a few other primary care physicians. I guess it was pride that prevented me from admitting that I could have called on them for help, even though they weren’t board certified pediatricians.

On the other hand, I still wonder how much harm I did by dragging myself to work when I was sick. Because Brunswick is a small town, I know my overly intense devotion to work didn’t result in any deaths. But how great was the collateral damage in the form of lost days from school and work for my patients, their parents, and my coworkers? There is no way to know, but I am sure there was some.

It is unreasonable to say, “I won’t ever go to work if I am ill.” I may have set the bar too high, but I am interested to hear how you decide when you are too sick to go to work.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

The American Academy of Pediatrics Committee on Infectious Diseases released a 2014 policy statement (Pediatrics 2014:134;415-20) updating guidance on use of palivizumab in high-risk patients infected with respiratory syncytial virus (RSV). The policy statement was accompanied by a detailed technical report to explain the committee’s rationale for the changes made since the previous update in 2012.

Since 2012, several observational studies were published related to risk factors associated with the need for hospitalization for RSV infection. The Committee on Infectious Diseases (COID) referred to these observational studies, along with other historical studies, in its 2014 technical report.

Some aspects of the updated guidance have met with controversy because the new advice limits palivizumab use among premature infants. The 2014 COID policy asserts that preterm infants born at greater than 29 weeks’ gestational age (GA) do not benefit substantially from palivizumab dosing during RSV season. This assertion has met with controversy because the justification detailed in the technical report cites several observational studies that don’t appear to support that conclusion. What percentage of a cohort would need to be hospitalized for RSV infection to identify them as high risk? COID doesn’t draw that line for us. Because approximately 3% of the term birth cohort is hospitalized with RSV, should we use this as the “baseline” and predetermine a percentage of hospitalization beyond baseline to define “at increased risk”?

The 2014 technical report states that RSV hospitalization rates from Stevens et al. (Arch. Pediatr. Adolesc. Med. 2000;154:55-61) were 7.5% and 4.4% for infants 28-30 weeks’ gestational age (GA) and 30-32 weeks’ GA, respectively. However, the rates quoted by COID were not the generalizable rates reported by Dr. T. P. Stevens and his team in their study. The authors calculated community-wide hospitalization rates for these groups to be 10% and 6.4%, respectively. These author-reported community-wide rates closely mirror rates reported in several other large observational studies, and still likely underestimate the true burden of RSV hospitalization based on the lower sensitivity of RSV detection testing done 15 years ago when that study was performed.

Similarly, the COID states that Dr. A.G. Winterstein’s study (JAMA Pediatrics 2013;167:1118-24) shows hospitalization rates among 32-34 weeks’ GA infants of 3.1% and 4.5% in two states based on health care insurance claims. Because fewer than half of infants are ever tested for RSV as the possible cause of their lower respiratory tract infection, these claims data are most certainly an underestimate of true rates. When active testing for RSV is done among hospitalized infants in this same GA category, using sensitive and specific PCR-based technology, hospitalization rates are 9.1%. Dr. Winterstein and associates also reported that RSV hospitalization rates increase as gestational age decreases.

In Dr. Caroline Breese Hall’s 2013 observational study (Pediatrics 2013;132:341-8) she and her associates recognized that hospitalization rates in children under 2 years of age were similar among term and preterm infants. The COID used these data in its 2014 technical report to suggest that preterm infants are no longer at high risk. The detail omitted from the report was that approximately 70% of eligible preterm infants in Dr. Hall’s study (according to the 2012 COID guidelines) had received palivizumab prophylaxis. This suggests that maintaining RSV prophylaxis according to the 2012 COID policy statement (and not the 2014 policy statement) can be successful in reducing the rate of RSV hospitalizations in preterm infants to that observed in term infants.

Finally, the technical report cites “overall declining incidence of hospitalizations for bronchiolitis in the United States” from the 2013 publication by Hasegawa et al. (Pediatrics 2013:132:28-36) without defining this observation for the AAP readers. While Hasegawa did report such a decline, the decline was specific to term infants, as no such decline was observed in the higher-risk preterm infants.

Based on careful review of several of the manuscripts referenced by COID, it’s difficult to determine why the committee’s recommendations changed so dramatically in the most recent iteration. It appears that the data need another look.

Dr. Domachowske is professor of pediatrics and professor of microbiology and immunology at the State University of New York Upstate Medical University in Syracuse. He serves on the New York State American Academy of Pediatrics Chapter 1 executive committee, volunteers as his district’s immunization champion, and is an appointed member of the New York State Immunization Advisory Council. He is a Pediatric News Editorial Advisory Board member. Dr. Domachowske disclosed he does consulting for the vaccine divisions of GlaxoSmithKline, Medimmune, Pfizer, Merck, Sanofi Pasteur, and Novartis; he performs clinical trials with GlaxoSmithKline, Medimmune, Merck, and Novartis; and he does basic and translational research with GlaxoSmithKline. E-mail him at pdnews@frontlinemedcom.com.

The American Academy of Pediatrics Committee on Infectious Diseases released a 2014 policy statement (Pediatrics 2014:134;415-20) updating guidance on use of palivizumab in high-risk patients infected with respiratory syncytial virus (RSV). The policy statement was accompanied by a detailed technical report to explain the committee’s rationale for the changes made since the previous update in 2012.

Since 2012, several observational studies were published related to risk factors associated with the need for hospitalization for RSV infection. The Committee on Infectious Diseases (COID) referred to these observational studies, along with other historical studies, in its 2014 technical report.

Some aspects of the updated guidance have met with controversy because the new advice limits palivizumab use among premature infants. The 2014 COID policy asserts that preterm infants born at greater than 29 weeks’ gestational age (GA) do not benefit substantially from palivizumab dosing during RSV season. This assertion has met with controversy because the justification detailed in the technical report cites several observational studies that don’t appear to support that conclusion. What percentage of a cohort would need to be hospitalized for RSV infection to identify them as high risk? COID doesn’t draw that line for us. Because approximately 3% of the term birth cohort is hospitalized with RSV, should we use this as the “baseline” and predetermine a percentage of hospitalization beyond baseline to define “at increased risk”?

The 2014 technical report states that RSV hospitalization rates from Stevens et al. (Arch. Pediatr. Adolesc. Med. 2000;154:55-61) were 7.5% and 4.4% for infants 28-30 weeks’ gestational age (GA) and 30-32 weeks’ GA, respectively. However, the rates quoted by COID were not the generalizable rates reported by Dr. T. P. Stevens and his team in their study. The authors calculated community-wide hospitalization rates for these groups to be 10% and 6.4%, respectively. These author-reported community-wide rates closely mirror rates reported in several other large observational studies, and still likely underestimate the true burden of RSV hospitalization based on the lower sensitivity of RSV detection testing done 15 years ago when that study was performed.

Similarly, the COID states that Dr. A.G. Winterstein’s study (JAMA Pediatrics 2013;167:1118-24) shows hospitalization rates among 32-34 weeks’ GA infants of 3.1% and 4.5% in two states based on health care insurance claims. Because fewer than half of infants are ever tested for RSV as the possible cause of their lower respiratory tract infection, these claims data are most certainly an underestimate of true rates. When active testing for RSV is done among hospitalized infants in this same GA category, using sensitive and specific PCR-based technology, hospitalization rates are 9.1%. Dr. Winterstein and associates also reported that RSV hospitalization rates increase as gestational age decreases.

In Dr. Caroline Breese Hall’s 2013 observational study (Pediatrics 2013;132:341-8) she and her associates recognized that hospitalization rates in children under 2 years of age were similar among term and preterm infants. The COID used these data in its 2014 technical report to suggest that preterm infants are no longer at high risk. The detail omitted from the report was that approximately 70% of eligible preterm infants in Dr. Hall’s study (according to the 2012 COID guidelines) had received palivizumab prophylaxis. This suggests that maintaining RSV prophylaxis according to the 2012 COID policy statement (and not the 2014 policy statement) can be successful in reducing the rate of RSV hospitalizations in preterm infants to that observed in term infants.

Finally, the technical report cites “overall declining incidence of hospitalizations for bronchiolitis in the United States” from the 2013 publication by Hasegawa et al. (Pediatrics 2013:132:28-36) without defining this observation for the AAP readers. While Hasegawa did report such a decline, the decline was specific to term infants, as no such decline was observed in the higher-risk preterm infants.

Based on careful review of several of the manuscripts referenced by COID, it’s difficult to determine why the committee’s recommendations changed so dramatically in the most recent iteration. It appears that the data need another look.

Dr. Domachowske is professor of pediatrics and professor of microbiology and immunology at the State University of New York Upstate Medical University in Syracuse. He serves on the New York State American Academy of Pediatrics Chapter 1 executive committee, volunteers as his district’s immunization champion, and is an appointed member of the New York State Immunization Advisory Council. He is a Pediatric News Editorial Advisory Board member. Dr. Domachowske disclosed he does consulting for the vaccine divisions of GlaxoSmithKline, Medimmune, Pfizer, Merck, Sanofi Pasteur, and Novartis; he performs clinical trials with GlaxoSmithKline, Medimmune, Merck, and Novartis; and he does basic and translational research with GlaxoSmithKline. E-mail him at pdnews@frontlinemedcom.com.

The American Academy of Pediatrics Committee on Infectious Diseases released a 2014 policy statement (Pediatrics 2014:134;415-20) updating guidance on use of palivizumab in high-risk patients infected with respiratory syncytial virus (RSV). The policy statement was accompanied by a detailed technical report to explain the committee’s rationale for the changes made since the previous update in 2012.

Since 2012, several observational studies were published related to risk factors associated with the need for hospitalization for RSV infection. The Committee on Infectious Diseases (COID) referred to these observational studies, along with other historical studies, in its 2014 technical report.

Some aspects of the updated guidance have met with controversy because the new advice limits palivizumab use among premature infants. The 2014 COID policy asserts that preterm infants born at greater than 29 weeks’ gestational age (GA) do not benefit substantially from palivizumab dosing during RSV season. This assertion has met with controversy because the justification detailed in the technical report cites several observational studies that don’t appear to support that conclusion. What percentage of a cohort would need to be hospitalized for RSV infection to identify them as high risk? COID doesn’t draw that line for us. Because approximately 3% of the term birth cohort is hospitalized with RSV, should we use this as the “baseline” and predetermine a percentage of hospitalization beyond baseline to define “at increased risk”?

The 2014 technical report states that RSV hospitalization rates from Stevens et al. (Arch. Pediatr. Adolesc. Med. 2000;154:55-61) were 7.5% and 4.4% for infants 28-30 weeks’ gestational age (GA) and 30-32 weeks’ GA, respectively. However, the rates quoted by COID were not the generalizable rates reported by Dr. T. P. Stevens and his team in their study. The authors calculated community-wide hospitalization rates for these groups to be 10% and 6.4%, respectively. These author-reported community-wide rates closely mirror rates reported in several other large observational studies, and still likely underestimate the true burden of RSV hospitalization based on the lower sensitivity of RSV detection testing done 15 years ago when that study was performed.

Similarly, the COID states that Dr. A.G. Winterstein’s study (JAMA Pediatrics 2013;167:1118-24) shows hospitalization rates among 32-34 weeks’ GA infants of 3.1% and 4.5% in two states based on health care insurance claims. Because fewer than half of infants are ever tested for RSV as the possible cause of their lower respiratory tract infection, these claims data are most certainly an underestimate of true rates. When active testing for RSV is done among hospitalized infants in this same GA category, using sensitive and specific PCR-based technology, hospitalization rates are 9.1%. Dr. Winterstein and associates also reported that RSV hospitalization rates increase as gestational age decreases.

In Dr. Caroline Breese Hall’s 2013 observational study (Pediatrics 2013;132:341-8) she and her associates recognized that hospitalization rates in children under 2 years of age were similar among term and preterm infants. The COID used these data in its 2014 technical report to suggest that preterm infants are no longer at high risk. The detail omitted from the report was that approximately 70% of eligible preterm infants in Dr. Hall’s study (according to the 2012 COID guidelines) had received palivizumab prophylaxis. This suggests that maintaining RSV prophylaxis according to the 2012 COID policy statement (and not the 2014 policy statement) can be successful in reducing the rate of RSV hospitalizations in preterm infants to that observed in term infants.

Finally, the technical report cites “overall declining incidence of hospitalizations for bronchiolitis in the United States” from the 2013 publication by Hasegawa et al. (Pediatrics 2013:132:28-36) without defining this observation for the AAP readers. While Hasegawa did report such a decline, the decline was specific to term infants, as no such decline was observed in the higher-risk preterm infants.

Based on careful review of several of the manuscripts referenced by COID, it’s difficult to determine why the committee’s recommendations changed so dramatically in the most recent iteration. It appears that the data need another look.

Dr. Domachowske is professor of pediatrics and professor of microbiology and immunology at the State University of New York Upstate Medical University in Syracuse. He serves on the New York State American Academy of Pediatrics Chapter 1 executive committee, volunteers as his district’s immunization champion, and is an appointed member of the New York State Immunization Advisory Council. He is a Pediatric News Editorial Advisory Board member. Dr. Domachowske disclosed he does consulting for the vaccine divisions of GlaxoSmithKline, Medimmune, Pfizer, Merck, Sanofi Pasteur, and Novartis; he performs clinical trials with GlaxoSmithKline, Medimmune, Merck, and Novartis; and he does basic and translational research with GlaxoSmithKline. E-mail him at pdnews@frontlinemedcom.com.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.

The development of an electronic health care system has revolutionized the way in which patients receive medical treatment. Every physician in practice is familiar with how EHRs have changed the way we record and retrieve information and even interact with patients.

Many of us are just beginning to become aware of a new trend: telemedicine. Proponents of telemedicine believe that it will give patients increased ease of access to trained health care professionals at low cost and skeptics feel that the quality of care will be low without either a physical exam or an ongoing relationship to help guide care. One thing, unfortunately, is for certain, with the evolution of health care comes the evolution of health care litigation. Physicians who are considering seeing patients through a telemedicine service should be aware of liability issues that may arise when seeing patients without actually seeing patients.

In 2009, Congress enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to develop a national health care infrastructure fueled by modern technology. In addition to offering health care providers financial incentives to replace patient medical charts with EHRs, leading over 400,000 health care providers to participate in the Medicaid and Medicare incentive programs, the HITECH Act also has encouraged the advancement of telemedicine through the use of virtual visits and electronic doctor/patient communication.

Telemedicine allows physicians and patients to exchange health information through telecommunication technologies while in different geographic locations (Model policy for appropriate use of telemedicine technologies in the practice of medicine, Federation of State Medical Boards, April 2014). Telemedicine emerged in the 1960s after NASA funded early research to allow astronauts to communicate with physicians while traveling in space. In recent years, telemedical practice has evolved into a much more practical and convenient method of practicing medicine.

Virtual visits now allow a patient to use a computer or other videoconference device to have a virtual visit with a doctor in lieu of having an in-person physical examination. Jason Gorevic, CEO of Teladoc, a leading telemedicine company, expects Teladoc to conduct a half a million telemedicine visits in 2015 (“Video visits, telemedicine today are like retail clinics were in the 1990s,” mobihealthnews, Nov. 4, 2014). The increase in the use of virtual visits comes largely from the high use of telemedicine in rural areas, where long distances exists between a patient and his/her physician.

Telemedicine has expanded rapidly, and state licensure requirements and regulation of telemedicine have not caught up with its use, leading regulations to vary from state to state. In an attempt to eliminate the state regulation disparities, the Federation of State Medical Boards (FSMB) has provided a framework for standards of care in regulating the practice of telemedicine, but each state still has its own requirements for telemedical practice (50 State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure, American Telemedicine Association, September 2014).

Only nine states offer a conditional or telemedicine license that allows out-of-state physicians to practice telemedicine, and Maryland, New York, and Virginia are the only states that offer reciprocity to licensed physicians in bordering states. In California, a Colorado doctor was criminally prosecuted for prescribing medication via the web to a patient in California (Hageseth v. Superior Court). The California Court of Appeals found that jurisdiction was proper in California because the doctor willfully practiced medicine in that state by agreeing to prescribe medication to a California resident online.

Physicians also should be aware of the need to obtain informed consent from the patient before conducting any telemedicine visit or examination. Most states require a physician to obtain written or verbal informed consent from a telehealth patient. Although research is slowly establishing the reliability of telemedicine, there are inherent risks associated with receiving a consultation via telecommunication of which a patient should be aware, such as the limits of the evaluation given that a complete physical exam cannot be performed. The physician should inform the patient when the visit is being recorded and receive his/her consent before proceeding.

The physician also should be very careful when selecting telemedical technology to ensure that the technology is HIPAA/HITECH certified and permitted under the state regulations in the state in which the doctor is practicing. In Oklahoma, a physician was sanctioned by the state’s medical board for conducting a virtual visit via Skype. (“Oklahoma state medical board adopts policy following Skype case,” The Oklahoman, Sept. 25, 2013). Although Oklahoma permits the use of virtual visits, the state prohibits a physician from conducting these visits via Skype. The Oklahoma doctor turned out to not be subject to a HIPAA violation because the Skype website is encrypted.

Given telemedicine’s rapid expansion, experience and litigation in this area are limited. The one thing that the current litigation trend shows is that physicians must be particularly careful when treating patients outside of the state in which they practice, both with regard to entering into a patient-physician relationship, making a diagnosis, and particularly when prescribing medication. As patients and physicians enjoy the benefits of this new method of providing medical care, they must be careful to follow the evolving telemedicine litigation and legislative landscape.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Mr. Jones and Ms. Dandy are both attorneys at Marks, O’Neill, O’Brien, Doherty & Kelly, P.C. in Philadelphia.

Note: An earlier version of this article incorrectly stated that the FSMB had recommended a national licensure and practice standard.