Practice Management

Study 1 Overview (Bayliss et al)

Objective: To examine the effect of a deprescribing educational intervention on medication use in older adults with cognitive impairment.

Design: This was a pragmatic, cluster randomized trial conducted in 8 primary care clinics that are part of a nonprofit health care system.

Setting and participants: The primary care clinic populations ranged from 170 to 1125 patients per clinic. The primary care clinics were randomly assigned to intervention or control using a uniform distribution in blocks by clinic size. Eligibility criteria for participants at those practices included age 65 years or older; health plan enrollment at least 1 year prior to intervention; diagnosis of Alzheimer disease and related dementia (ADRD) or mild cognitive impairment (MCI) by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code or from problem list; 1 or more chronic conditions from those in the Chronic Conditions Warehouse; and 5 or more long-term medications. Those who scheduled a visit at their primary care clinic in advance were eligible for the intervention. Primary care clinicians in intervention clinics were eligible to receive the clinician portion of the intervention. A total of 1433 participants were enrolled in the intervention group, and 1579 participants were enrolled in the control group.

Intervention: The intervention included 2 components: a patient and family component with materials mailed in advance of their primary care visits and a clinician component comprising monthly educational materials on deprescribing and notification in the electronic health record about visits with patient participants. The patient and family component consisted of a brochure titled “Managing Medication” and a questionnaire on attitudes toward deprescribing intended to educate patients and family about deprescribing. Clinicians at intervention clinics received an educational presentation at a monthly clinician meeting as well as tip sheets and a poster on deprescribing topics, and they also were notified of upcoming appointments with patients who received the patient component of the intervention. For the control group, patients and family did not receive any materials, and clinicians did not receive intervention materials or notification of participants enrolled in the trial. Usual care in both intervention and control groups included medication reconciliation and electronic health record alerts for potentially high-risk medications.

Main outcome measures: The primary outcomes of the study were the number of long-term medications per individual and the proportion of patients prescribed 1 or more potentially inappropriate medications. Outcome measurements were extracted from the electronic clinical data, and outcomes were assessed at 6 months, which involved comparing counts of medications at baseline with medications at 6 months. Long-term medications were defined as medications that are prescribed for 28 days or more based on pharmacy dispensing data. Potentially inappropriate medications (PIMs) were defined using the Beers list of medications to avoid in those with cognitive impairment and opioid medications. Analyses were conducted as intention to treat.

Main results: In the intervention group and control group, 56.2% and 54.4% of participants were women, and the mean age was 80.1 years (SD, 7.2) and 79.9 years (SD, 7.5), respectively. At baseline, the mean number of long-term medications was 7.0 (SD, 2.1) in the intervention group and 7.0 (SD, 2.2) in the control group. The proportion of patients taking any PIMs was 30.5% in the intervention group and 29.6% in the control group. At 6 months, the mean number of long-term medications was 6.4 in the intervention group and 6.5 in the control group, with an adjusted difference of –0.1 (95% CI, –0.2 to 0.04; P = .14); the proportion of patients with any PIMs was 17.8% in the intervention group and 20.9% in the control group, with an adjusted difference of –3.2% (95% CI, –6.2 to 0.4; P = .08). Preplanned analyses to examine subgroup differences for those with a higher number of medications (7+ vs 5 or 6 medications) did not find different effects of the intervention.

Conclusion: This educational intervention on deprescribing did not result in reductions in the number of medications or the use of PIMs in patients with cognitive impairment.

Study 2 Overview (Gedde et al)

Objective: To examine the effect of a deprescribing intervention (COSMOS) on medication use for nursing home residents.

Design: This was a randomized clinical trial.

Setting and participants: This trial was conducted in 67 units in 33 nursing homes in Norway. Participants were nursing home residents recruited from August 2014 to March 2015. Inclusion criteria included adults aged 65 years and older with at least 2 years of residency in nursing homes. Exclusion criteria included diagnosis of schizophrenia and a life expectancy of 6 months or less. Participants were followed for 4 months; participants were considered lost to follow-up if they died or moved from the nursing home unit. The analyses were per protocol and did not include those lost to follow-up or those who did not undergo a medication review in the intervention group. A total of 217 and 211 residents were included in the intervention and control groups, respectively.

Intervention: The intervention contained 5 components: communication and advance care planning, systematic pain management, medication reviews with collegial mentoring, organization of activities adjusted to needs and preferences, and safety. For medication review, the nursing home physician reviewed medications together with a nurse and study physicians who provided mentoring. The medication review involved a structured process that used assessment tools for behavioral and psychological symptoms of dementia (BPSD), activities of daily living (ADL), pain, cognitive status, well-being and quality of life, and clinical metrics of blood pressure, pulse, and body mass index. The study utilized the START/STOPP criteria¹ for medication use in addition to a list of medications with anticholinergic properties for the medication review. In addition, drug interactions were documented through a drug interaction database; the team also incorporated patient wishes and concerns in the medication reviews. The nursing home physician made final decisions on medications. For the control group, nursing home residents received usual care without this intervention.

Main outcome measures: The primary outcome of the study was the mean change in the number of prescribed psychotropic medications, both regularly scheduled and total medications (which also included on-demand drugs) received at 4 months when compared to baseline. Psychotropic medications included antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs. Secondary outcomes included mean changes in BPSD using the Neuropsychiatric Inventory-Nursing home version (NPI-NH) and the Cornell Scale for Depression for Dementia (CSDD) and ADL using the Physical Self Maintenance Scale (PSMS).

Main results: In both the intervention and control groups, 76% of participants were women, and mean age was 86.3 years (SD, 7.95) in the intervention group and 86.6 years (SD, 7.21) in the control group. At baseline, the mean number of total medications was 10.9 (SD, 4.6) in the intervention group and 10.9 (SD, 4.7) in the control group, and the mean number of psychotropic medications was 2.2 (SD, 1.6) and 2.2 (SD, 1.7) in the intervention and control groups, respectively. At 4 months, the mean change from baseline of total psychotropic medications was –0.34 in the intervention group and 0.01 in the control group (P < .001), and the mean change of regularly scheduled psychotropic medications was –0.21 in the intervention group and 0.02 in the control group (P < .001). Measures of BPSD and depression did not differ between intervention and control groups, and ADL showed a small improvement in the intervention group.

Conclusion: This intervention reduced the use of psychotropic medications in nursing home residents without worsening BPSD or depression and may have yielded improvements in ADL.

Commentary

Polypharmacy is common among older adults, as many of them have multiple chronic conditions and often take multiple medications for managing them. Polypharmacy increases the risk of drug interactions and adverse effects from medications; older adults who are frail and/or who have cognitive impairment are especially at risk. Reducing medication use, especially medications likely to cause adverse effects such as those with anticholinergic properties, has the potential to yield beneficial effects while reducing the burden of taking medications. A large randomized trial found that a pharmacist-led education intervention can be effective in reducing PIM use in community-dwelling older adults,² and that targeting patient motivation and capacity to deprescribe could be effective.³ This study by Bayliss and colleagues (Study 1), however, fell short of the effects seen in the earlier D-PRESCRIBE trial. One of the reasons for these findings may be that the clinician portion of the intervention was less intensive than that used in the earlier trial; specifically, in the present study, clinicians were not provided with or expected to utilize tools for structured medication review or deprescribing. Although the intervention primes the patient and family for discussions around deprescribing through the use of a brochure and questionnaire, the clinician portion of the intervention was less structured. Another example of an effective intervention that provided a more structured deprescribing intervention beyond education of clinicians utilized electronic decision-support to assist with deprescribing.⁴

The findings from the Gedde et al study (Study 2) are comparable to those of prior studies in the nursing home population,⁵ where participants are likely to take a large number of medications, including psychotropic medications, and are more likely to be frail. However, Gedde and colleagues employed a bundled intervention⁶ that included other components besides medication review, and thus it is unclear whether the effect on ADL can be attributed to the deprescribing of medications alone. Gedde et al’s finding that deprescribing can reduce the use of psychotropic medications while not leading to differences in behavioral and psychologic symptoms or depression is an important contribution to our knowledge about polypharmacy and deprescribing in older patients. Thus, nursing home residents, their families, and clinicians could expect that the deprescribing of psychotropic medications does not lead to worsening symptoms. Of note, the clinician portion of the intervention in the Gedde et al study was quite structured, and this structure may have contributed to the observed effects.

Applications for Clinical Practice and System Implementation

Both studies add to the literature on deprescribing and may offer options for researchers and clinicians who are considering potential components of an effective deprescribing intervention. Patient activation for deprescribing via the methods used in these 2 studies may help to prime patients for conversations about deprescribing; however, as shown by the Bayliss et al study, a more structured approach to clinical encounters may be needed when deprescribing, such as the use of tools in the electronic health record, in order to reduce the use of medication deemed unnecessary or potentially harmful. Further studies should examine the effect of deprescribing on medication use, but perhaps even more importantly, how deprescribing impacts patient outcomes both in terms of risks and benefits.

Practice Points

• A more structured approach to clinical encounters (eg, the use of tools in the electronic health record) may be needed when deprescribing unnecessary or potentially harmful medications in older patients in community settings.
• In the nursing home setting, structured deprescribing intervention can reduce the use of psychotropic medications while not leading to differences in behavioral and psychologic symptoms or depression.

–William W. Hung, MD, MPH

Study 1 Overview (Bayliss et al)

Objective: To examine the effect of a deprescribing educational intervention on medication use in older adults with cognitive impairment.

Design: This was a pragmatic, cluster randomized trial conducted in 8 primary care clinics that are part of a nonprofit health care system.

Setting and participants: The primary care clinic populations ranged from 170 to 1125 patients per clinic. The primary care clinics were randomly assigned to intervention or control using a uniform distribution in blocks by clinic size. Eligibility criteria for participants at those practices included age 65 years or older; health plan enrollment at least 1 year prior to intervention; diagnosis of Alzheimer disease and related dementia (ADRD) or mild cognitive impairment (MCI) by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code or from problem list; 1 or more chronic conditions from those in the Chronic Conditions Warehouse; and 5 or more long-term medications. Those who scheduled a visit at their primary care clinic in advance were eligible for the intervention. Primary care clinicians in intervention clinics were eligible to receive the clinician portion of the intervention. A total of 1433 participants were enrolled in the intervention group, and 1579 participants were enrolled in the control group.

Intervention: The intervention included 2 components: a patient and family component with materials mailed in advance of their primary care visits and a clinician component comprising monthly educational materials on deprescribing and notification in the electronic health record about visits with patient participants. The patient and family component consisted of a brochure titled “Managing Medication” and a questionnaire on attitudes toward deprescribing intended to educate patients and family about deprescribing. Clinicians at intervention clinics received an educational presentation at a monthly clinician meeting as well as tip sheets and a poster on deprescribing topics, and they also were notified of upcoming appointments with patients who received the patient component of the intervention. For the control group, patients and family did not receive any materials, and clinicians did not receive intervention materials or notification of participants enrolled in the trial. Usual care in both intervention and control groups included medication reconciliation and electronic health record alerts for potentially high-risk medications.

Main outcome measures: The primary outcomes of the study were the number of long-term medications per individual and the proportion of patients prescribed 1 or more potentially inappropriate medications. Outcome measurements were extracted from the electronic clinical data, and outcomes were assessed at 6 months, which involved comparing counts of medications at baseline with medications at 6 months. Long-term medications were defined as medications that are prescribed for 28 days or more based on pharmacy dispensing data. Potentially inappropriate medications (PIMs) were defined using the Beers list of medications to avoid in those with cognitive impairment and opioid medications. Analyses were conducted as intention to treat.

Main results: In the intervention group and control group, 56.2% and 54.4% of participants were women, and the mean age was 80.1 years (SD, 7.2) and 79.9 years (SD, 7.5), respectively. At baseline, the mean number of long-term medications was 7.0 (SD, 2.1) in the intervention group and 7.0 (SD, 2.2) in the control group. The proportion of patients taking any PIMs was 30.5% in the intervention group and 29.6% in the control group. At 6 months, the mean number of long-term medications was 6.4 in the intervention group and 6.5 in the control group, with an adjusted difference of –0.1 (95% CI, –0.2 to 0.04; P = .14); the proportion of patients with any PIMs was 17.8% in the intervention group and 20.9% in the control group, with an adjusted difference of –3.2% (95% CI, –6.2 to 0.4; P = .08). Preplanned analyses to examine subgroup differences for those with a higher number of medications (7+ vs 5 or 6 medications) did not find different effects of the intervention.

Conclusion: This educational intervention on deprescribing did not result in reductions in the number of medications or the use of PIMs in patients with cognitive impairment.

Study 2 Overview (Gedde et al)

Objective: To examine the effect of a deprescribing intervention (COSMOS) on medication use for nursing home residents.

Design: This was a randomized clinical trial.

Setting and participants: This trial was conducted in 67 units in 33 nursing homes in Norway. Participants were nursing home residents recruited from August 2014 to March 2015. Inclusion criteria included adults aged 65 years and older with at least 2 years of residency in nursing homes. Exclusion criteria included diagnosis of schizophrenia and a life expectancy of 6 months or less. Participants were followed for 4 months; participants were considered lost to follow-up if they died or moved from the nursing home unit. The analyses were per protocol and did not include those lost to follow-up or those who did not undergo a medication review in the intervention group. A total of 217 and 211 residents were included in the intervention and control groups, respectively.

Intervention: The intervention contained 5 components: communication and advance care planning, systematic pain management, medication reviews with collegial mentoring, organization of activities adjusted to needs and preferences, and safety. For medication review, the nursing home physician reviewed medications together with a nurse and study physicians who provided mentoring. The medication review involved a structured process that used assessment tools for behavioral and psychological symptoms of dementia (BPSD), activities of daily living (ADL), pain, cognitive status, well-being and quality of life, and clinical metrics of blood pressure, pulse, and body mass index. The study utilized the START/STOPP criteria¹ for medication use in addition to a list of medications with anticholinergic properties for the medication review. In addition, drug interactions were documented through a drug interaction database; the team also incorporated patient wishes and concerns in the medication reviews. The nursing home physician made final decisions on medications. For the control group, nursing home residents received usual care without this intervention.

Main outcome measures: The primary outcome of the study was the mean change in the number of prescribed psychotropic medications, both regularly scheduled and total medications (which also included on-demand drugs) received at 4 months when compared to baseline. Psychotropic medications included antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs. Secondary outcomes included mean changes in BPSD using the Neuropsychiatric Inventory-Nursing home version (NPI-NH) and the Cornell Scale for Depression for Dementia (CSDD) and ADL using the Physical Self Maintenance Scale (PSMS).

Main results: In both the intervention and control groups, 76% of participants were women, and mean age was 86.3 years (SD, 7.95) in the intervention group and 86.6 years (SD, 7.21) in the control group. At baseline, the mean number of total medications was 10.9 (SD, 4.6) in the intervention group and 10.9 (SD, 4.7) in the control group, and the mean number of psychotropic medications was 2.2 (SD, 1.6) and 2.2 (SD, 1.7) in the intervention and control groups, respectively. At 4 months, the mean change from baseline of total psychotropic medications was –0.34 in the intervention group and 0.01 in the control group (P < .001), and the mean change of regularly scheduled psychotropic medications was –0.21 in the intervention group and 0.02 in the control group (P < .001). Measures of BPSD and depression did not differ between intervention and control groups, and ADL showed a small improvement in the intervention group.

Conclusion: This intervention reduced the use of psychotropic medications in nursing home residents without worsening BPSD or depression and may have yielded improvements in ADL.

Commentary

Polypharmacy is common among older adults, as many of them have multiple chronic conditions and often take multiple medications for managing them. Polypharmacy increases the risk of drug interactions and adverse effects from medications; older adults who are frail and/or who have cognitive impairment are especially at risk. Reducing medication use, especially medications likely to cause adverse effects such as those with anticholinergic properties, has the potential to yield beneficial effects while reducing the burden of taking medications. A large randomized trial found that a pharmacist-led education intervention can be effective in reducing PIM use in community-dwelling older adults,² and that targeting patient motivation and capacity to deprescribe could be effective.³ This study by Bayliss and colleagues (Study 1), however, fell short of the effects seen in the earlier D-PRESCRIBE trial. One of the reasons for these findings may be that the clinician portion of the intervention was less intensive than that used in the earlier trial; specifically, in the present study, clinicians were not provided with or expected to utilize tools for structured medication review or deprescribing. Although the intervention primes the patient and family for discussions around deprescribing through the use of a brochure and questionnaire, the clinician portion of the intervention was less structured. Another example of an effective intervention that provided a more structured deprescribing intervention beyond education of clinicians utilized electronic decision-support to assist with deprescribing.⁴

The findings from the Gedde et al study (Study 2) are comparable to those of prior studies in the nursing home population,⁵ where participants are likely to take a large number of medications, including psychotropic medications, and are more likely to be frail. However, Gedde and colleagues employed a bundled intervention⁶ that included other components besides medication review, and thus it is unclear whether the effect on ADL can be attributed to the deprescribing of medications alone. Gedde et al’s finding that deprescribing can reduce the use of psychotropic medications while not leading to differences in behavioral and psychologic symptoms or depression is an important contribution to our knowledge about polypharmacy and deprescribing in older patients. Thus, nursing home residents, their families, and clinicians could expect that the deprescribing of psychotropic medications does not lead to worsening symptoms. Of note, the clinician portion of the intervention in the Gedde et al study was quite structured, and this structure may have contributed to the observed effects.

Applications for Clinical Practice and System Implementation

Both studies add to the literature on deprescribing and may offer options for researchers and clinicians who are considering potential components of an effective deprescribing intervention. Patient activation for deprescribing via the methods used in these 2 studies may help to prime patients for conversations about deprescribing; however, as shown by the Bayliss et al study, a more structured approach to clinical encounters may be needed when deprescribing, such as the use of tools in the electronic health record, in order to reduce the use of medication deemed unnecessary or potentially harmful. Further studies should examine the effect of deprescribing on medication use, but perhaps even more importantly, how deprescribing impacts patient outcomes both in terms of risks and benefits.

Practice Points

• A more structured approach to clinical encounters (eg, the use of tools in the electronic health record) may be needed when deprescribing unnecessary or potentially harmful medications in older patients in community settings.
• In the nursing home setting, structured deprescribing intervention can reduce the use of psychotropic medications while not leading to differences in behavioral and psychologic symptoms or depression.

–William W. Hung, MD, MPH

Study 1 Overview (Bayliss et al)

Objective: To examine the effect of a deprescribing educational intervention on medication use in older adults with cognitive impairment.

Design: This was a pragmatic, cluster randomized trial conducted in 8 primary care clinics that are part of a nonprofit health care system.

Setting and participants: The primary care clinic populations ranged from 170 to 1125 patients per clinic. The primary care clinics were randomly assigned to intervention or control using a uniform distribution in blocks by clinic size. Eligibility criteria for participants at those practices included age 65 years or older; health plan enrollment at least 1 year prior to intervention; diagnosis of Alzheimer disease and related dementia (ADRD) or mild cognitive impairment (MCI) by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code or from problem list; 1 or more chronic conditions from those in the Chronic Conditions Warehouse; and 5 or more long-term medications. Those who scheduled a visit at their primary care clinic in advance were eligible for the intervention. Primary care clinicians in intervention clinics were eligible to receive the clinician portion of the intervention. A total of 1433 participants were enrolled in the intervention group, and 1579 participants were enrolled in the control group.

Intervention: The intervention included 2 components: a patient and family component with materials mailed in advance of their primary care visits and a clinician component comprising monthly educational materials on deprescribing and notification in the electronic health record about visits with patient participants. The patient and family component consisted of a brochure titled “Managing Medication” and a questionnaire on attitudes toward deprescribing intended to educate patients and family about deprescribing. Clinicians at intervention clinics received an educational presentation at a monthly clinician meeting as well as tip sheets and a poster on deprescribing topics, and they also were notified of upcoming appointments with patients who received the patient component of the intervention. For the control group, patients and family did not receive any materials, and clinicians did not receive intervention materials or notification of participants enrolled in the trial. Usual care in both intervention and control groups included medication reconciliation and electronic health record alerts for potentially high-risk medications.

Main outcome measures: The primary outcomes of the study were the number of long-term medications per individual and the proportion of patients prescribed 1 or more potentially inappropriate medications. Outcome measurements were extracted from the electronic clinical data, and outcomes were assessed at 6 months, which involved comparing counts of medications at baseline with medications at 6 months. Long-term medications were defined as medications that are prescribed for 28 days or more based on pharmacy dispensing data. Potentially inappropriate medications (PIMs) were defined using the Beers list of medications to avoid in those with cognitive impairment and opioid medications. Analyses were conducted as intention to treat.

Main results: In the intervention group and control group, 56.2% and 54.4% of participants were women, and the mean age was 80.1 years (SD, 7.2) and 79.9 years (SD, 7.5), respectively. At baseline, the mean number of long-term medications was 7.0 (SD, 2.1) in the intervention group and 7.0 (SD, 2.2) in the control group. The proportion of patients taking any PIMs was 30.5% in the intervention group and 29.6% in the control group. At 6 months, the mean number of long-term medications was 6.4 in the intervention group and 6.5 in the control group, with an adjusted difference of –0.1 (95% CI, –0.2 to 0.04; P = .14); the proportion of patients with any PIMs was 17.8% in the intervention group and 20.9% in the control group, with an adjusted difference of –3.2% (95% CI, –6.2 to 0.4; P = .08). Preplanned analyses to examine subgroup differences for those with a higher number of medications (7+ vs 5 or 6 medications) did not find different effects of the intervention.

Conclusion: This educational intervention on deprescribing did not result in reductions in the number of medications or the use of PIMs in patients with cognitive impairment.

Study 2 Overview (Gedde et al)

Objective: To examine the effect of a deprescribing intervention (COSMOS) on medication use for nursing home residents.

Design: This was a randomized clinical trial.

Setting and participants: This trial was conducted in 67 units in 33 nursing homes in Norway. Participants were nursing home residents recruited from August 2014 to March 2015. Inclusion criteria included adults aged 65 years and older with at least 2 years of residency in nursing homes. Exclusion criteria included diagnosis of schizophrenia and a life expectancy of 6 months or less. Participants were followed for 4 months; participants were considered lost to follow-up if they died or moved from the nursing home unit. The analyses were per protocol and did not include those lost to follow-up or those who did not undergo a medication review in the intervention group. A total of 217 and 211 residents were included in the intervention and control groups, respectively.

Intervention: The intervention contained 5 components: communication and advance care planning, systematic pain management, medication reviews with collegial mentoring, organization of activities adjusted to needs and preferences, and safety. For medication review, the nursing home physician reviewed medications together with a nurse and study physicians who provided mentoring. The medication review involved a structured process that used assessment tools for behavioral and psychological symptoms of dementia (BPSD), activities of daily living (ADL), pain, cognitive status, well-being and quality of life, and clinical metrics of blood pressure, pulse, and body mass index. The study utilized the START/STOPP criteria¹ for medication use in addition to a list of medications with anticholinergic properties for the medication review. In addition, drug interactions were documented through a drug interaction database; the team also incorporated patient wishes and concerns in the medication reviews. The nursing home physician made final decisions on medications. For the control group, nursing home residents received usual care without this intervention.

Main outcome measures: The primary outcome of the study was the mean change in the number of prescribed psychotropic medications, both regularly scheduled and total medications (which also included on-demand drugs) received at 4 months when compared to baseline. Psychotropic medications included antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs. Secondary outcomes included mean changes in BPSD using the Neuropsychiatric Inventory-Nursing home version (NPI-NH) and the Cornell Scale for Depression for Dementia (CSDD) and ADL using the Physical Self Maintenance Scale (PSMS).

Main results: In both the intervention and control groups, 76% of participants were women, and mean age was 86.3 years (SD, 7.95) in the intervention group and 86.6 years (SD, 7.21) in the control group. At baseline, the mean number of total medications was 10.9 (SD, 4.6) in the intervention group and 10.9 (SD, 4.7) in the control group, and the mean number of psychotropic medications was 2.2 (SD, 1.6) and 2.2 (SD, 1.7) in the intervention and control groups, respectively. At 4 months, the mean change from baseline of total psychotropic medications was –0.34 in the intervention group and 0.01 in the control group (P < .001), and the mean change of regularly scheduled psychotropic medications was –0.21 in the intervention group and 0.02 in the control group (P < .001). Measures of BPSD and depression did not differ between intervention and control groups, and ADL showed a small improvement in the intervention group.

Conclusion: This intervention reduced the use of psychotropic medications in nursing home residents without worsening BPSD or depression and may have yielded improvements in ADL.

Commentary

Polypharmacy is common among older adults, as many of them have multiple chronic conditions and often take multiple medications for managing them. Polypharmacy increases the risk of drug interactions and adverse effects from medications; older adults who are frail and/or who have cognitive impairment are especially at risk. Reducing medication use, especially medications likely to cause adverse effects such as those with anticholinergic properties, has the potential to yield beneficial effects while reducing the burden of taking medications. A large randomized trial found that a pharmacist-led education intervention can be effective in reducing PIM use in community-dwelling older adults,² and that targeting patient motivation and capacity to deprescribe could be effective.³ This study by Bayliss and colleagues (Study 1), however, fell short of the effects seen in the earlier D-PRESCRIBE trial. One of the reasons for these findings may be that the clinician portion of the intervention was less intensive than that used in the earlier trial; specifically, in the present study, clinicians were not provided with or expected to utilize tools for structured medication review or deprescribing. Although the intervention primes the patient and family for discussions around deprescribing through the use of a brochure and questionnaire, the clinician portion of the intervention was less structured. Another example of an effective intervention that provided a more structured deprescribing intervention beyond education of clinicians utilized electronic decision-support to assist with deprescribing.⁴

The findings from the Gedde et al study (Study 2) are comparable to those of prior studies in the nursing home population,⁵ where participants are likely to take a large number of medications, including psychotropic medications, and are more likely to be frail. However, Gedde and colleagues employed a bundled intervention⁶ that included other components besides medication review, and thus it is unclear whether the effect on ADL can be attributed to the deprescribing of medications alone. Gedde et al’s finding that deprescribing can reduce the use of psychotropic medications while not leading to differences in behavioral and psychologic symptoms or depression is an important contribution to our knowledge about polypharmacy and deprescribing in older patients. Thus, nursing home residents, their families, and clinicians could expect that the deprescribing of psychotropic medications does not lead to worsening symptoms. Of note, the clinician portion of the intervention in the Gedde et al study was quite structured, and this structure may have contributed to the observed effects.

Applications for Clinical Practice and System Implementation

Both studies add to the literature on deprescribing and may offer options for researchers and clinicians who are considering potential components of an effective deprescribing intervention. Patient activation for deprescribing via the methods used in these 2 studies may help to prime patients for conversations about deprescribing; however, as shown by the Bayliss et al study, a more structured approach to clinical encounters may be needed when deprescribing, such as the use of tools in the electronic health record, in order to reduce the use of medication deemed unnecessary or potentially harmful. Further studies should examine the effect of deprescribing on medication use, but perhaps even more importantly, how deprescribing impacts patient outcomes both in terms of risks and benefits.

Practice Points

• A more structured approach to clinical encounters (eg, the use of tools in the electronic health record) may be needed when deprescribing unnecessary or potentially harmful medications in older patients in community settings.
• In the nursing home setting, structured deprescribing intervention can reduce the use of psychotropic medications while not leading to differences in behavioral and psychologic symptoms or depression.

–William W. Hung, MD, MPH

Study 1 Overview (Oberhaus et al)

Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.

Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.

Setting and participants: Eligible participants were patients aged 60 years or older undergoing major elective surgery at Barnes Jewish Hospital (St. Louis, Missouri) who were enrolled in ongoing clinical trials (PODCAST, ENGAGES, SATISFY-SOS) between 2015 and 2018. Surgeries were at least 2 hours in length and required general anesthesia, planned extubation, and a minimum 2-day hospital stay. Investigators were extensively trained in administering 3D-CAM and CAM instruments. Participants were evaluated 2 hours after the end of anesthesia care on the day of surgery, then daily until follow-up was completed per clinical trial protocol or until the participant was determined by CAM to be nondelirious for 3 consecutive days. For each evaluation, both 3D-CAM and CAM assessors approached the participant together, but the evaluation was conducted such that the 3D-CAM assessor was masked to the additional questions ascertained by the long-form CAM assessment. The 3D-CAM or CAM assessor independently scored their respective assessments blinded to the results of the other assessor.

Main outcome measures: Participants were concurrently evaluated for postoperative delirium by both 3D-CAM and long-form CAM assessments. Comparisons between 3D-CAM and CAM scores were made using Cohen κ with repeated measures, generalized linear mixed-effects model, and Bland-Altman analysis.

Main results: Sixteen raters performed 471 concurrent 3D-CAM and CAM assessments in 299 participants (mean [SD] age, 69 [6.5] years). Of these participants, 152 (50.8%) were men, 263 (88.0%) were White, and 211 (70.6%) underwent noncardiac surgery. Both instruments showed good intraclass correlation (0.98 for 3D-CAM, 0.84 for CAM) with good overall agreement (Cohen κ = 0.71; 95% CI, 0.58-0.83). The mixed-effects model indicated a significant disagreement between the 3D-CAM and CAM assessments (estimated difference in fixed effect, –0.68; 95% CI, –1.32 to –0.05; P = .04). The Bland-Altman analysis showed that the probability of a delirium diagnosis with the 3D-CAM was more than twice that with the CAM (probability ratio, 2.78; 95% CI, 2.44-3.23).

Conclusion: The high degree of agreement between 3D-CAM and long-form CAM assessments suggests that the former may be a pragmatic and easy-to-administer clinical tool to screen for postoperative delirium in vulnerable older surgical patients.

Study 2 Overview (Shenkin et al)

Objective: To assess the accuracy of the 4 ‘A’s Test (4AT) for delirium detection in the medical inpatient setting and to compare the 4AT to the CAM.

Design: Prospective randomized diagnostic test accuracy study.

Setting and participants: This study was conducted in emergency departments and acute medical wards at 3 UK sites (Edinburgh, Bradford, and Sheffield) and enrolled acute medical patients aged 70 years or older without acute life-threatening illnesses and/or coma. Assessors administering the delirium evaluation were nurses or graduate clinical research associates who underwent systematic training in delirium and delirium assessment. Additional training was provided to those administering the CAM but not to those administering the 4AT as the latter is designed to be administered without special training. First, all participants underwent a reference standard delirium assessment using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria to derive a final definitive diagnosis of delirium via expert consensus (1 psychiatrist and 2 geriatricians). Then, the participants were randomized to either the 4AT or the comparator CAM group using computer-generated pseudo-random numbers, stratified by study site, with block allocation. All assessments were performed by pairs of independent assessors blinded to the results of the other assessment.

Main outcome measures: All participants were evaluated by the reference standard (DSM-IV criteria for delirium) and by either 4AT or CAM instruments for delirium. The accuracy of the 4AT instrument was evaluated by comparing its positive and negative predictive values, sensitivity, and specificity to the reference standard and analyzed via the area under the receiver operating characteristic curve. The diagnostic accuracy of 4AT, compared to the CAM, was evaluated by comparing positive and negative predictive values, sensitivity, and specificity using Fisher’s exact test. The overall performance of 4AT and CAM was summarized using Youden’s Index and the diagnostic odds ratio of sensitivity to specificity.

Results: All 843 individuals enrolled in the study were randomized and 785 were included in the analysis (23 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome). Of the participants analyzed, the mean age was 81.4 [6.4] years, and 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT group had an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.84-0.96), a sensitivity of 76% (95% CI, 61%-87%), and a specificity of 94% (95% CI, 92%-97%). In comparison, the CAM group had a sensitivity of 40% (95% CI, 26%-57%) and a specificity of 100% (95% CI, 98%-100%).

Conclusions: The 4AT is a pragmatic screening test for delirium in a medical space that does not require special training to administer. The use of this instrument may help to improve delirium detection as a part of routine clinical care in hospitalized older adults.

 

 

Commentary

Delirium is an acute confusional state marked by fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is exceedingly common in older patients in both surgical and medical settings and is associated with increased morbidity, mortality, hospital length of stay, institutionalization, and health care costs. Delirium is frequently underdiagnosed in the hospitalized setting, perhaps due to a combination of its waxing and waning nature and a lack of pragmatic and easily implementable screening tools that can be readily administered by clinicians and nonclinicians alike.¹ While the CAM is a well-validated instrument to diagnose delirium, it requires specific training in the rating of each of the cardinal features ascertained through a brief cognitive assessment and takes 5 to 10 minutes to complete. Taken together, given the high patient load for clinicians in the hospital setting, the validation and application of brief delirium screening instruments that can be reliably administered by nonphysicians and nonclinicians may enhance delirium detection in vulnerable patients and consequently improve their outcomes.

In Study 1, Oberhaus et al approach the challenge of underdiagnosing delirium in the postoperative setting by investigating whether the widely accepted long-form CAM and an abbreviated 3-minute version, the 3D-CAM, provide similar delirium detection in older surgical patients. The authors found that both instruments were reliable tests individually (high interrater reliability) and had good overall agreement. However, the 3D-CAM was more likely to yield a positive diagnosis of delirium compared to the long-form CAM, consistent with its purpose as a screening tool with a high sensitivity. It is important to emphasize that the 3D-CAM takes less time to administer, but also requires less extensive training and clinical knowledge than the long-form CAM. Therefore, this instrument meets the prerequisite of a brief screening test that can be rapidly administered by nonclinicians, and if affirmative, followed by a more extensive confirmatory test performed by a clinician. Limitations of this study include a lack of a reference standard structured interview conducted by a physician-rater to better determine the true diagnostic accuracy of both 3D-CAM and CAM assessments, and the use of convenience sampling at a single center, which reduces the generalizability of its findings.

In a similar vein, Shenkin et al in Study 2 attempt to evaluate the utility of the 4AT instrument in diagnosing delirium in older medical inpatients by testing the diagnostic accuracy of the 4AT against a reference standard (ie, DSM-IV–based evaluation by physicians) as well as comparing it to CAM. The 4AT takes less time (~2 minutes) and requires less knowledge and training to administer as compared to the CAM. The study showed that the abbreviated 4AT, compared to CAM, had a higher sensitivity (76% vs 40%) and lower specificity (94% vs 100%) in delirium detection. Thus, akin to the application of 3D-CAM in the postoperative setting, 4AT possesses key characteristics of a brief delirium screening test for older patients in the acute medical setting. In contrast to the Oberhaus et al study, a major strength of this study was the utilization of a reference standard that was validated by expert consensus. This allowed the 4AT and CAM assessments to be compared to a more objective standard, thereby directly testing their diagnostic performance in detecting delirium.

Application for Clinical Practice and System Implementation

The findings from both Study 1 and 2 suggest that using an abbreviated delirium instrument in both surgical and acute medical settings may provide a pragmatic and sensitive method to detect delirium in older patients. The brevity of administration of 3D-CAM (~3 minutes) and 4AT (~2 minutes), combined with their higher sensitivity for detecting delirium compared to CAM, make these instruments potentially effective rapid screening tests for delirium in hospitalized older patients. Importantly, the utilization of such instruments might be a feasible way to mitigate the issue of underdiagnosing delirium in the hospital.

Several additional aspects of these abbreviated delirium instruments increase their suitability for clinical application. Specifically, the 3D-CAM and 4AT require less extensive training and clinical knowledge to both administer and interpret the results than the CAM.² For instance, a multistage, multiday training for CAM is a key factor in maintaining its diagnostic accuracy.^3,4 In contrast, the 3D-CAM requires only a 1- to 2-hour training session, and the 4AT can be administered by a nonclinician without the need for instrument-specific training. Thus, implementation of these instruments can be particularly pragmatic in clinical settings in which the staff involved in delirium screening cannot undergo the substantial training required to administer CAM. Moreover, these abbreviated tests enable nonphysician care team members to assume the role of delirium screener in the hospital. Taken together, the adoption of these abbreviated instruments may facilitate brief screenings of delirium in older patients by caregivers who see them most often—nurses and certified nursing assistants—thereby improving early detection and prevention of delirium-related complications in the hospital.

The feasibility of using abbreviated delirium screening instruments in the hospital setting raises a system implementation question—if these instruments are designed to be administered by those with limited to no training, could nonclinicians, such as hospital volunteers, effectively take on delirium screening roles in the hospital? If volunteers are able to take on this role, the integration of hospital volunteers into the clinical team can greatly expand the capacity for delirium screening in the hospital setting. Further research is warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Practice Points

• Abbreviated delirium screening tools such as 3D-CAM and 4AT may be pragmatic instruments to improve delirium detection in surgical and hospitalized older patients, respectively.
• Further studies are warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Jared Doan, BS, and Fred Ko, MD
Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai

Study 1 Overview (Oberhaus et al)

Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.

Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.

Setting and participants: Eligible participants were patients aged 60 years or older undergoing major elective surgery at Barnes Jewish Hospital (St. Louis, Missouri) who were enrolled in ongoing clinical trials (PODCAST, ENGAGES, SATISFY-SOS) between 2015 and 2018. Surgeries were at least 2 hours in length and required general anesthesia, planned extubation, and a minimum 2-day hospital stay. Investigators were extensively trained in administering 3D-CAM and CAM instruments. Participants were evaluated 2 hours after the end of anesthesia care on the day of surgery, then daily until follow-up was completed per clinical trial protocol or until the participant was determined by CAM to be nondelirious for 3 consecutive days. For each evaluation, both 3D-CAM and CAM assessors approached the participant together, but the evaluation was conducted such that the 3D-CAM assessor was masked to the additional questions ascertained by the long-form CAM assessment. The 3D-CAM or CAM assessor independently scored their respective assessments blinded to the results of the other assessor.

Main outcome measures: Participants were concurrently evaluated for postoperative delirium by both 3D-CAM and long-form CAM assessments. Comparisons between 3D-CAM and CAM scores were made using Cohen κ with repeated measures, generalized linear mixed-effects model, and Bland-Altman analysis.

Main results: Sixteen raters performed 471 concurrent 3D-CAM and CAM assessments in 299 participants (mean [SD] age, 69 [6.5] years). Of these participants, 152 (50.8%) were men, 263 (88.0%) were White, and 211 (70.6%) underwent noncardiac surgery. Both instruments showed good intraclass correlation (0.98 for 3D-CAM, 0.84 for CAM) with good overall agreement (Cohen κ = 0.71; 95% CI, 0.58-0.83). The mixed-effects model indicated a significant disagreement between the 3D-CAM and CAM assessments (estimated difference in fixed effect, –0.68; 95% CI, –1.32 to –0.05; P = .04). The Bland-Altman analysis showed that the probability of a delirium diagnosis with the 3D-CAM was more than twice that with the CAM (probability ratio, 2.78; 95% CI, 2.44-3.23).

Conclusion: The high degree of agreement between 3D-CAM and long-form CAM assessments suggests that the former may be a pragmatic and easy-to-administer clinical tool to screen for postoperative delirium in vulnerable older surgical patients.

Study 2 Overview (Shenkin et al)

Objective: To assess the accuracy of the 4 ‘A’s Test (4AT) for delirium detection in the medical inpatient setting and to compare the 4AT to the CAM.

Design: Prospective randomized diagnostic test accuracy study.

Setting and participants: This study was conducted in emergency departments and acute medical wards at 3 UK sites (Edinburgh, Bradford, and Sheffield) and enrolled acute medical patients aged 70 years or older without acute life-threatening illnesses and/or coma. Assessors administering the delirium evaluation were nurses or graduate clinical research associates who underwent systematic training in delirium and delirium assessment. Additional training was provided to those administering the CAM but not to those administering the 4AT as the latter is designed to be administered without special training. First, all participants underwent a reference standard delirium assessment using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria to derive a final definitive diagnosis of delirium via expert consensus (1 psychiatrist and 2 geriatricians). Then, the participants were randomized to either the 4AT or the comparator CAM group using computer-generated pseudo-random numbers, stratified by study site, with block allocation. All assessments were performed by pairs of independent assessors blinded to the results of the other assessment.

Main outcome measures: All participants were evaluated by the reference standard (DSM-IV criteria for delirium) and by either 4AT or CAM instruments for delirium. The accuracy of the 4AT instrument was evaluated by comparing its positive and negative predictive values, sensitivity, and specificity to the reference standard and analyzed via the area under the receiver operating characteristic curve. The diagnostic accuracy of 4AT, compared to the CAM, was evaluated by comparing positive and negative predictive values, sensitivity, and specificity using Fisher’s exact test. The overall performance of 4AT and CAM was summarized using Youden’s Index and the diagnostic odds ratio of sensitivity to specificity.

Results: All 843 individuals enrolled in the study were randomized and 785 were included in the analysis (23 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome). Of the participants analyzed, the mean age was 81.4 [6.4] years, and 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT group had an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.84-0.96), a sensitivity of 76% (95% CI, 61%-87%), and a specificity of 94% (95% CI, 92%-97%). In comparison, the CAM group had a sensitivity of 40% (95% CI, 26%-57%) and a specificity of 100% (95% CI, 98%-100%).

Conclusions: The 4AT is a pragmatic screening test for delirium in a medical space that does not require special training to administer. The use of this instrument may help to improve delirium detection as a part of routine clinical care in hospitalized older adults.

 

 

Commentary

Delirium is an acute confusional state marked by fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is exceedingly common in older patients in both surgical and medical settings and is associated with increased morbidity, mortality, hospital length of stay, institutionalization, and health care costs. Delirium is frequently underdiagnosed in the hospitalized setting, perhaps due to a combination of its waxing and waning nature and a lack of pragmatic and easily implementable screening tools that can be readily administered by clinicians and nonclinicians alike.¹ While the CAM is a well-validated instrument to diagnose delirium, it requires specific training in the rating of each of the cardinal features ascertained through a brief cognitive assessment and takes 5 to 10 minutes to complete. Taken together, given the high patient load for clinicians in the hospital setting, the validation and application of brief delirium screening instruments that can be reliably administered by nonphysicians and nonclinicians may enhance delirium detection in vulnerable patients and consequently improve their outcomes.

In Study 1, Oberhaus et al approach the challenge of underdiagnosing delirium in the postoperative setting by investigating whether the widely accepted long-form CAM and an abbreviated 3-minute version, the 3D-CAM, provide similar delirium detection in older surgical patients. The authors found that both instruments were reliable tests individually (high interrater reliability) and had good overall agreement. However, the 3D-CAM was more likely to yield a positive diagnosis of delirium compared to the long-form CAM, consistent with its purpose as a screening tool with a high sensitivity. It is important to emphasize that the 3D-CAM takes less time to administer, but also requires less extensive training and clinical knowledge than the long-form CAM. Therefore, this instrument meets the prerequisite of a brief screening test that can be rapidly administered by nonclinicians, and if affirmative, followed by a more extensive confirmatory test performed by a clinician. Limitations of this study include a lack of a reference standard structured interview conducted by a physician-rater to better determine the true diagnostic accuracy of both 3D-CAM and CAM assessments, and the use of convenience sampling at a single center, which reduces the generalizability of its findings.

In a similar vein, Shenkin et al in Study 2 attempt to evaluate the utility of the 4AT instrument in diagnosing delirium in older medical inpatients by testing the diagnostic accuracy of the 4AT against a reference standard (ie, DSM-IV–based evaluation by physicians) as well as comparing it to CAM. The 4AT takes less time (~2 minutes) and requires less knowledge and training to administer as compared to the CAM. The study showed that the abbreviated 4AT, compared to CAM, had a higher sensitivity (76% vs 40%) and lower specificity (94% vs 100%) in delirium detection. Thus, akin to the application of 3D-CAM in the postoperative setting, 4AT possesses key characteristics of a brief delirium screening test for older patients in the acute medical setting. In contrast to the Oberhaus et al study, a major strength of this study was the utilization of a reference standard that was validated by expert consensus. This allowed the 4AT and CAM assessments to be compared to a more objective standard, thereby directly testing their diagnostic performance in detecting delirium.

Application for Clinical Practice and System Implementation

The findings from both Study 1 and 2 suggest that using an abbreviated delirium instrument in both surgical and acute medical settings may provide a pragmatic and sensitive method to detect delirium in older patients. The brevity of administration of 3D-CAM (~3 minutes) and 4AT (~2 minutes), combined with their higher sensitivity for detecting delirium compared to CAM, make these instruments potentially effective rapid screening tests for delirium in hospitalized older patients. Importantly, the utilization of such instruments might be a feasible way to mitigate the issue of underdiagnosing delirium in the hospital.

Several additional aspects of these abbreviated delirium instruments increase their suitability for clinical application. Specifically, the 3D-CAM and 4AT require less extensive training and clinical knowledge to both administer and interpret the results than the CAM.² For instance, a multistage, multiday training for CAM is a key factor in maintaining its diagnostic accuracy.^3,4 In contrast, the 3D-CAM requires only a 1- to 2-hour training session, and the 4AT can be administered by a nonclinician without the need for instrument-specific training. Thus, implementation of these instruments can be particularly pragmatic in clinical settings in which the staff involved in delirium screening cannot undergo the substantial training required to administer CAM. Moreover, these abbreviated tests enable nonphysician care team members to assume the role of delirium screener in the hospital. Taken together, the adoption of these abbreviated instruments may facilitate brief screenings of delirium in older patients by caregivers who see them most often—nurses and certified nursing assistants—thereby improving early detection and prevention of delirium-related complications in the hospital.

The feasibility of using abbreviated delirium screening instruments in the hospital setting raises a system implementation question—if these instruments are designed to be administered by those with limited to no training, could nonclinicians, such as hospital volunteers, effectively take on delirium screening roles in the hospital? If volunteers are able to take on this role, the integration of hospital volunteers into the clinical team can greatly expand the capacity for delirium screening in the hospital setting. Further research is warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Practice Points

• Abbreviated delirium screening tools such as 3D-CAM and 4AT may be pragmatic instruments to improve delirium detection in surgical and hospitalized older patients, respectively.
• Further studies are warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Jared Doan, BS, and Fred Ko, MD
Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai

Study 1 Overview (Oberhaus et al)

Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.

Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.

Setting and participants: Eligible participants were patients aged 60 years or older undergoing major elective surgery at Barnes Jewish Hospital (St. Louis, Missouri) who were enrolled in ongoing clinical trials (PODCAST, ENGAGES, SATISFY-SOS) between 2015 and 2018. Surgeries were at least 2 hours in length and required general anesthesia, planned extubation, and a minimum 2-day hospital stay. Investigators were extensively trained in administering 3D-CAM and CAM instruments. Participants were evaluated 2 hours after the end of anesthesia care on the day of surgery, then daily until follow-up was completed per clinical trial protocol or until the participant was determined by CAM to be nondelirious for 3 consecutive days. For each evaluation, both 3D-CAM and CAM assessors approached the participant together, but the evaluation was conducted such that the 3D-CAM assessor was masked to the additional questions ascertained by the long-form CAM assessment. The 3D-CAM or CAM assessor independently scored their respective assessments blinded to the results of the other assessor.

Main outcome measures: Participants were concurrently evaluated for postoperative delirium by both 3D-CAM and long-form CAM assessments. Comparisons between 3D-CAM and CAM scores were made using Cohen κ with repeated measures, generalized linear mixed-effects model, and Bland-Altman analysis.

Main results: Sixteen raters performed 471 concurrent 3D-CAM and CAM assessments in 299 participants (mean [SD] age, 69 [6.5] years). Of these participants, 152 (50.8%) were men, 263 (88.0%) were White, and 211 (70.6%) underwent noncardiac surgery. Both instruments showed good intraclass correlation (0.98 for 3D-CAM, 0.84 for CAM) with good overall agreement (Cohen κ = 0.71; 95% CI, 0.58-0.83). The mixed-effects model indicated a significant disagreement between the 3D-CAM and CAM assessments (estimated difference in fixed effect, –0.68; 95% CI, –1.32 to –0.05; P = .04). The Bland-Altman analysis showed that the probability of a delirium diagnosis with the 3D-CAM was more than twice that with the CAM (probability ratio, 2.78; 95% CI, 2.44-3.23).

Conclusion: The high degree of agreement between 3D-CAM and long-form CAM assessments suggests that the former may be a pragmatic and easy-to-administer clinical tool to screen for postoperative delirium in vulnerable older surgical patients.

Study 2 Overview (Shenkin et al)

Objective: To assess the accuracy of the 4 ‘A’s Test (4AT) for delirium detection in the medical inpatient setting and to compare the 4AT to the CAM.

Design: Prospective randomized diagnostic test accuracy study.

Setting and participants: This study was conducted in emergency departments and acute medical wards at 3 UK sites (Edinburgh, Bradford, and Sheffield) and enrolled acute medical patients aged 70 years or older without acute life-threatening illnesses and/or coma. Assessors administering the delirium evaluation were nurses or graduate clinical research associates who underwent systematic training in delirium and delirium assessment. Additional training was provided to those administering the CAM but not to those administering the 4AT as the latter is designed to be administered without special training. First, all participants underwent a reference standard delirium assessment using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria to derive a final definitive diagnosis of delirium via expert consensus (1 psychiatrist and 2 geriatricians). Then, the participants were randomized to either the 4AT or the comparator CAM group using computer-generated pseudo-random numbers, stratified by study site, with block allocation. All assessments were performed by pairs of independent assessors blinded to the results of the other assessment.

Main outcome measures: All participants were evaluated by the reference standard (DSM-IV criteria for delirium) and by either 4AT or CAM instruments for delirium. The accuracy of the 4AT instrument was evaluated by comparing its positive and negative predictive values, sensitivity, and specificity to the reference standard and analyzed via the area under the receiver operating characteristic curve. The diagnostic accuracy of 4AT, compared to the CAM, was evaluated by comparing positive and negative predictive values, sensitivity, and specificity using Fisher’s exact test. The overall performance of 4AT and CAM was summarized using Youden’s Index and the diagnostic odds ratio of sensitivity to specificity.

Results: All 843 individuals enrolled in the study were randomized and 785 were included in the analysis (23 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome). Of the participants analyzed, the mean age was 81.4 [6.4] years, and 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT group had an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.84-0.96), a sensitivity of 76% (95% CI, 61%-87%), and a specificity of 94% (95% CI, 92%-97%). In comparison, the CAM group had a sensitivity of 40% (95% CI, 26%-57%) and a specificity of 100% (95% CI, 98%-100%).

Conclusions: The 4AT is a pragmatic screening test for delirium in a medical space that does not require special training to administer. The use of this instrument may help to improve delirium detection as a part of routine clinical care in hospitalized older adults.

 

 

Commentary

Delirium is an acute confusional state marked by fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is exceedingly common in older patients in both surgical and medical settings and is associated with increased morbidity, mortality, hospital length of stay, institutionalization, and health care costs. Delirium is frequently underdiagnosed in the hospitalized setting, perhaps due to a combination of its waxing and waning nature and a lack of pragmatic and easily implementable screening tools that can be readily administered by clinicians and nonclinicians alike.¹ While the CAM is a well-validated instrument to diagnose delirium, it requires specific training in the rating of each of the cardinal features ascertained through a brief cognitive assessment and takes 5 to 10 minutes to complete. Taken together, given the high patient load for clinicians in the hospital setting, the validation and application of brief delirium screening instruments that can be reliably administered by nonphysicians and nonclinicians may enhance delirium detection in vulnerable patients and consequently improve their outcomes.

In Study 1, Oberhaus et al approach the challenge of underdiagnosing delirium in the postoperative setting by investigating whether the widely accepted long-form CAM and an abbreviated 3-minute version, the 3D-CAM, provide similar delirium detection in older surgical patients. The authors found that both instruments were reliable tests individually (high interrater reliability) and had good overall agreement. However, the 3D-CAM was more likely to yield a positive diagnosis of delirium compared to the long-form CAM, consistent with its purpose as a screening tool with a high sensitivity. It is important to emphasize that the 3D-CAM takes less time to administer, but also requires less extensive training and clinical knowledge than the long-form CAM. Therefore, this instrument meets the prerequisite of a brief screening test that can be rapidly administered by nonclinicians, and if affirmative, followed by a more extensive confirmatory test performed by a clinician. Limitations of this study include a lack of a reference standard structured interview conducted by a physician-rater to better determine the true diagnostic accuracy of both 3D-CAM and CAM assessments, and the use of convenience sampling at a single center, which reduces the generalizability of its findings.

In a similar vein, Shenkin et al in Study 2 attempt to evaluate the utility of the 4AT instrument in diagnosing delirium in older medical inpatients by testing the diagnostic accuracy of the 4AT against a reference standard (ie, DSM-IV–based evaluation by physicians) as well as comparing it to CAM. The 4AT takes less time (~2 minutes) and requires less knowledge and training to administer as compared to the CAM. The study showed that the abbreviated 4AT, compared to CAM, had a higher sensitivity (76% vs 40%) and lower specificity (94% vs 100%) in delirium detection. Thus, akin to the application of 3D-CAM in the postoperative setting, 4AT possesses key characteristics of a brief delirium screening test for older patients in the acute medical setting. In contrast to the Oberhaus et al study, a major strength of this study was the utilization of a reference standard that was validated by expert consensus. This allowed the 4AT and CAM assessments to be compared to a more objective standard, thereby directly testing their diagnostic performance in detecting delirium.

Application for Clinical Practice and System Implementation

The findings from both Study 1 and 2 suggest that using an abbreviated delirium instrument in both surgical and acute medical settings may provide a pragmatic and sensitive method to detect delirium in older patients. The brevity of administration of 3D-CAM (~3 minutes) and 4AT (~2 minutes), combined with their higher sensitivity for detecting delirium compared to CAM, make these instruments potentially effective rapid screening tests for delirium in hospitalized older patients. Importantly, the utilization of such instruments might be a feasible way to mitigate the issue of underdiagnosing delirium in the hospital.

Several additional aspects of these abbreviated delirium instruments increase their suitability for clinical application. Specifically, the 3D-CAM and 4AT require less extensive training and clinical knowledge to both administer and interpret the results than the CAM.² For instance, a multistage, multiday training for CAM is a key factor in maintaining its diagnostic accuracy.^3,4 In contrast, the 3D-CAM requires only a 1- to 2-hour training session, and the 4AT can be administered by a nonclinician without the need for instrument-specific training. Thus, implementation of these instruments can be particularly pragmatic in clinical settings in which the staff involved in delirium screening cannot undergo the substantial training required to administer CAM. Moreover, these abbreviated tests enable nonphysician care team members to assume the role of delirium screener in the hospital. Taken together, the adoption of these abbreviated instruments may facilitate brief screenings of delirium in older patients by caregivers who see them most often—nurses and certified nursing assistants—thereby improving early detection and prevention of delirium-related complications in the hospital.

The feasibility of using abbreviated delirium screening instruments in the hospital setting raises a system implementation question—if these instruments are designed to be administered by those with limited to no training, could nonclinicians, such as hospital volunteers, effectively take on delirium screening roles in the hospital? If volunteers are able to take on this role, the integration of hospital volunteers into the clinical team can greatly expand the capacity for delirium screening in the hospital setting. Further research is warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Practice Points

• Abbreviated delirium screening tools such as 3D-CAM and 4AT may be pragmatic instruments to improve delirium detection in surgical and hospitalized older patients, respectively.
• Further studies are warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Jared Doan, BS, and Fred Ko, MD
Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Process improvement in any industry sector aims to increase the efficiency of resource utilization and delivery methods (cost) and the quality of the product (outcomes), with the goal of ultimately achieving continuous development.¹ In the health care industry, variation in processes and outcomes along with inefficiency in resource use that result in changes in value (the product of outcomes/costs) are the general targets of quality improvement (QI) efforts employing various implementation methodologies.² When the ultimate aim is to serve the patient (customer), best clinical practice includes both maintaining high quality (individual care delivery) and controlling costs (efficient care system delivery), leading to optimal delivery (value-based care). High-quality individual care and efficient care delivery are not competing concepts, but when working to improve both health care outcomes and cost, traditional and nontraditional barriers to system QI often arise.³

The possible scenarios after a QI intervention include backsliding (regression to the mean over time), steady-state (minimal fixed improvement that could sustain), and continuous improvement (tangible enhancement after completing the intervention with legacy effect).⁴ The scalability of results can be considered during the process measurement and the intervention design phases of all QI projects; however, the complex nature of barriers in the health care environment during each level of implementation should be accounted for to prevent failure in the scalability phase.⁵

The barriers to optimal QI outcomes leading to continuous improvement are multifactorial and are related to intrinsic and extrinsic factors.⁶ These factors include 3 fundamental levels: (1) individual level inertia/beliefs, prior personal knowledge, and team-related factors^7,8; (2) intervention-related and process-specific barriers and clinical practice obstacles; and (3) organizational level challenges and macro-level and population-level barriers (Figure). The obstacles faced during the implementation phase will likely include 2 of these levels simultaneously, which could add complexity and hinder or prevent the implementation of a tangible successful QI process and eventually lead to backsliding or minimal fixed improvement rather than continuous improvement. Furthermore, a patient-centered approach to QI would contribute to further complexity in design and execution, given the importance of reaching sustainable, meaningful improvement by adding elements of patient’s preferences, caregiver engagement, and the shared decision-making processes.⁹

Overcoming these multidomain barriers and reaching resilience and sustainability requires thoughtful planning and execution through a multifaceted approach.¹⁰ A meaningful start could include addressing the clinical inertia for the individual and the team by promoting open innovation and allowing outside institutional collaborations and ideas through networks.¹¹ On the individual level, encouraging participation and motivating health care workers in QI to reach a multidisciplinary operation approach will lead to harmony in collaboration. Concurrently, the organization should support the QI capability and scalability by removing competing priorities and establishing effective leadership that ensures resource allocation, communicates clear value-based principles, and engenders a psychological safety environment.

A continuous improvement state is the optimal QI target, a target that can be attained by removing obstacles and paving a clear pathway to implementation. Focusing on the 3 levels of barriers will position the organization for meaningful and successful QI phases to achieve continuous improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Process improvement in any industry sector aims to increase the efficiency of resource utilization and delivery methods (cost) and the quality of the product (outcomes), with the goal of ultimately achieving continuous development.¹ In the health care industry, variation in processes and outcomes along with inefficiency in resource use that result in changes in value (the product of outcomes/costs) are the general targets of quality improvement (QI) efforts employing various implementation methodologies.² When the ultimate aim is to serve the patient (customer), best clinical practice includes both maintaining high quality (individual care delivery) and controlling costs (efficient care system delivery), leading to optimal delivery (value-based care). High-quality individual care and efficient care delivery are not competing concepts, but when working to improve both health care outcomes and cost, traditional and nontraditional barriers to system QI often arise.³

The possible scenarios after a QI intervention include backsliding (regression to the mean over time), steady-state (minimal fixed improvement that could sustain), and continuous improvement (tangible enhancement after completing the intervention with legacy effect).⁴ The scalability of results can be considered during the process measurement and the intervention design phases of all QI projects; however, the complex nature of barriers in the health care environment during each level of implementation should be accounted for to prevent failure in the scalability phase.⁵

The barriers to optimal QI outcomes leading to continuous improvement are multifactorial and are related to intrinsic and extrinsic factors.⁶ These factors include 3 fundamental levels: (1) individual level inertia/beliefs, prior personal knowledge, and team-related factors^7,8; (2) intervention-related and process-specific barriers and clinical practice obstacles; and (3) organizational level challenges and macro-level and population-level barriers (Figure). The obstacles faced during the implementation phase will likely include 2 of these levels simultaneously, which could add complexity and hinder or prevent the implementation of a tangible successful QI process and eventually lead to backsliding or minimal fixed improvement rather than continuous improvement. Furthermore, a patient-centered approach to QI would contribute to further complexity in design and execution, given the importance of reaching sustainable, meaningful improvement by adding elements of patient’s preferences, caregiver engagement, and the shared decision-making processes.⁹

Overcoming these multidomain barriers and reaching resilience and sustainability requires thoughtful planning and execution through a multifaceted approach.¹⁰ A meaningful start could include addressing the clinical inertia for the individual and the team by promoting open innovation and allowing outside institutional collaborations and ideas through networks.¹¹ On the individual level, encouraging participation and motivating health care workers in QI to reach a multidisciplinary operation approach will lead to harmony in collaboration. Concurrently, the organization should support the QI capability and scalability by removing competing priorities and establishing effective leadership that ensures resource allocation, communicates clear value-based principles, and engenders a psychological safety environment.

A continuous improvement state is the optimal QI target, a target that can be attained by removing obstacles and paving a clear pathway to implementation. Focusing on the 3 levels of barriers will position the organization for meaningful and successful QI phases to achieve continuous improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; ebarkoudah@bwh.harvard.edu

Process improvement in any industry sector aims to increase the efficiency of resource utilization and delivery methods (cost) and the quality of the product (outcomes), with the goal of ultimately achieving continuous development.¹ In the health care industry, variation in processes and outcomes along with inefficiency in resource use that result in changes in value (the product of outcomes/costs) are the general targets of quality improvement (QI) efforts employing various implementation methodologies.² When the ultimate aim is to serve the patient (customer), best clinical practice includes both maintaining high quality (individual care delivery) and controlling costs (efficient care system delivery), leading to optimal delivery (value-based care). High-quality individual care and efficient care delivery are not competing concepts, but when working to improve both health care outcomes and cost, traditional and nontraditional barriers to system QI often arise.³

The possible scenarios after a QI intervention include backsliding (regression to the mean over time), steady-state (minimal fixed improvement that could sustain), and continuous improvement (tangible enhancement after completing the intervention with legacy effect).⁴ The scalability of results can be considered during the process measurement and the intervention design phases of all QI projects; however, the complex nature of barriers in the health care environment during each level of implementation should be accounted for to prevent failure in the scalability phase.⁵

The barriers to optimal QI outcomes leading to continuous improvement are multifactorial and are related to intrinsic and extrinsic factors.⁶ These factors include 3 fundamental levels: (1) individual level inertia/beliefs, prior personal knowledge, and team-related factors^7,8; (2) intervention-related and process-specific barriers and clinical practice obstacles; and (3) organizational level challenges and macro-level and population-level barriers (Figure). The obstacles faced during the implementation phase will likely include 2 of these levels simultaneously, which could add complexity and hinder or prevent the implementation of a tangible successful QI process and eventually lead to backsliding or minimal fixed improvement rather than continuous improvement. Furthermore, a patient-centered approach to QI would contribute to further complexity in design and execution, given the importance of reaching sustainable, meaningful improvement by adding elements of patient’s preferences, caregiver engagement, and the shared decision-making processes.⁹

Overcoming these multidomain barriers and reaching resilience and sustainability requires thoughtful planning and execution through a multifaceted approach.¹⁰ A meaningful start could include addressing the clinical inertia for the individual and the team by promoting open innovation and allowing outside institutional collaborations and ideas through networks.¹¹ On the individual level, encouraging participation and motivating health care workers in QI to reach a multidisciplinary operation approach will lead to harmony in collaboration. Concurrently, the organization should support the QI capability and scalability by removing competing priorities and establishing effective leadership that ensures resource allocation, communicates clear value-based principles, and engenders a psychological safety environment.

A continuous improvement state is the optimal QI target, a target that can be attained by removing obstacles and paving a clear pathway to implementation. Focusing on the 3 levels of barriers will position the organization for meaningful and successful QI phases to achieve continuous improvement.

During a medical malpractice trial in New Jersey, jurors waited nearly 4 hours for the physician defendant to show up. When he did arrive, the body-building surgeon was sporting two thick gold chains and a diamond pinky ring, and had the top buttons of his shirt open enough to reveal his chest hair.

“This trial was in a very rural, farming community,” recalls medical liability defense attorney Catherine Flynn, of Flynn Watts LLC, based in Parsippany, N.J. “Many of the jurors were wearing flannel shirts and jeans. The doctor’s wife walked in wearing a five-carat diamond ring and other jewelry.”

Ms. Flynn took the couple aside and asked them to remove the jewelry. She explained that the opulent accessories could damage the jury’s view of the physician. The surgeon and his wife, however, refused to remove their jewelry, she said. They didn’t think it was a big deal.

The case against the surgeon involved intraoperative damage to a patient when the physician inadvertently removed a portion of nerve in the area of the procedure. After repair of the nerve, the patient had a positive result. However, the patient alleged the surgeon’s negligence resulted in permanent damage despite the successful repair.

Jurors ultimately found the physician negligent in the case and awarded the plaintiff $1.2 million. Ms. Flynn believes that physician’s flamboyant attire and arrogant nature tainted the jury’s decision.

“In certain counties in New Jersey, his attire would not have been a problem,” she said. “In this rural, farming county, it was a huge problem. You have to know your audience. There are a lot of other things that come into play in a medical malpractice case, but when it comes to damages in a case, you don’t want to be sending the message that supports what somebody’s bias may already be telling them about a doctor.”

The surgeon appealed the verdict, and the case ultimately settled for a lesser amount, according to Ms. Flynn.

An over-the-top wardrobe is just one way that physicians can negatively influence jurors during legal trials. From subtle facial expressions to sudden outbursts to downright rudeness, attorneys have witnessed countless examples of physicians sabotaging their own trials. Legal experts say the cringeworthy experiences are good reminders that jurors are often judging more than just evidence.  

“The minute you enter the courthouse, jurors or potential jurors are sizing you up,” says health law attorney Michael Clark, of Womble Bond Dickinson (US) LLP, based in Houston. “The same phenomenon occurs in a deposition. Awareness of how you are being assessed at all times, and the image that is needed, is important since a negative impression by jurors can have a detrimental effect on a physician’s case.”
 

Juror: We didn’t like the doctor’s shoes

In another case, attorneys warned a physician defendant against dressing in his signature wardrobe during his trial. Against their advice, the doctor showed up daily to his trial in bright pastel, monochromatic suits with matching Gucci-brand shoes, said medical liability defense attorney Meredith C. Lander, of Kaufman Borgeest & Ryan LLP, based in Connecticut. On the witness stand, the doctor was long-winded and wasn’t “terribly likable,” Ms. Lander said.

However, the evidence weighed in the physician’s favor, and there was strong testimony by defense experts. The physician won the case, Ms. Lander said, but after the verdict, the jury foreperson approached the trial attorney and made some disparaging remarks about the defendant.

“The foreperson said the jury didn’t like the doctor or his ‘Gucci suits and shoes,’ but they believed the experts,” Ms. Lander said.

Disruptive behavior can also harm jurors’ perception of physicians, Ms. Flynn adds. During one instance, a surgeon insisted on sitting next to Ms. Flynn, although she generally requests clients sit in the first row so that jurors are not so focused on their reactions during testimony. The surgeon loudly peppered Ms. Flynn with questions as witnesses testified, prompting a reprimand from the judge.

“The judge admonished the doctor several times and said, ‘Doctor, you’re raising your voice. You’ll get a chance to speak with your attorney during the break,’ ” Ms. Flynn recalled. “The doctor refused to stop talking, and the judge told him in front of the jury to go sit in the back of the courtroom. His reaction was, ‘Why do I have to move?! I need to sit here!’ ”

The surgeon eventually moved to the back of the courtroom and a sheriff’s deputy stood next to him. Testimony continued until a note in the form of a paper airplane landed on the table in front of Ms. Flynn. She carefully crumpled the note and tossed it in the wastebasket. Luckily, this drew a laugh from jurors, she said. 

But things got worse when the surgeon testified. Rather than answer the questions, he interrupted and started telling jurors his own version of events.

“The judge finally said, ‘Doctor, if you don’t listen to your attorney and answer her questions, I’m going to make you get off the stand,’ ” Ms. Flynn said. “That was the most unbelievable, egregious self-sabotage trial moment I’ve ever experienced.”

Fortunately, the physician’s legal case was strong, and the experts who testified drove the defense’s side home, Ms. Flynn said. The surgeon won the case.
 

Attorney: Watch what you say in the elevator

Other, more subtle behaviors – while often unintentional – can also be damaging.

Physicians often let their guard down while outside the courtroom and can unknowingly wind up next to a juror in an elevator or standing in a hallway, said Laura Postilion, a partner at Quintairos, Prieto, Wood & Boyer, P.A., based in Chicago.

“For instance, a doctor is in an elevator and feels that some witness on the stand was lying,” Ms. Postilion said. “They might be very upset about it and start ranting about a witness lying, not realizing there is a juror is in the elevator with you.”

Physicians should also be cautious when speaking on the phone to their family or friends during a trial break.

“At the Daley Center in downtown Chicago, there are these long corridors and long line of windows; a lot of people will stand there during breaks. A doctor may be talking to his or her spouse and saying, ‘Yeah, this juror is sleeping!’ Jurors are [often] looking for drama. They’re looking for somebody letting their guard down. Hearing a doctor speak badly about them would certainly give them a reason to dislike the physician.”

Ms. Postilion warns against talking about jurors in or outside of the courtroom. This includes parking structures, she said.

Physicians can take additional steps to save themselves from negative judgment from jurors, attorneys say. Even before the trial starts, Ms. Postilion advises clients to make their social media accounts private. Some curious jurors may look up a physician’s social media accounts to learn more about their personal life, political leanings, or social beliefs, which could prejudice them against the doctor, she said.

Once on the stand, the words and tone used are key. The last thing a physician defendant wants is to come across as arrogant or condescending to jurors, said medical liability defense attorney Michael Moroney, of Flynn Watts LLC.

“For instance, a defendant might say, ‘Well, let me make this simple for you,’ as if they’re talking to a bunch of schoolchildren,” he said. “You don’t know who’s on the jury. That type of language can be offensive.”

Ms. Lander counsels her clients to refrain from using the common phrase, “honestly,” before answering questions on the stand.

“Everything you’re saying on the stand is presumed to be honest,” she said. “When you start an answer with, ‘Honestly…’ out of habit, it really does undercut everything that follows and everything else that’s already been said. It suggests that you were not being honest in your other answers.”
 

Attitude, body language speak volumes

Keep in mind that plaintiffs’ attorneys will try their best to rattle physicians on the stand and get them to appear unlikeable, says Mr. Clark, the Houston-based health law attorney. Physicians who lose their cool and begin arguing with attorneys play into their strategy.

“Plaintiffs’ attorneys have been trained in ways to get under their skin,” he said. “Righteous indignation and annoyance are best left for a rare occasion. Think about how you feel in a social setting when people are bickering in front of you. It’s uncomfortable at best. That’s how a jury feels too.”

Body language is also important, Mr. Clark notes. Physicians should avoid crossed arms, leaning back and rocking, or putting a hand on their mouth while testifying, he said. Many attorneys have practice sessions with their clients and record the interaction so that doctors can watch it and see how they look.

“Know your strengths and weaknesses,” he said. “Get help from your lawyer and perhaps consultants about how to improve these skills. Practice and preparation are important.”

Ms. Postilion goes over courtroom clothing with physician clients before trial. Anything “too flashy, too high-end, or too dumpy” should be avoided, she said. Getting accustomed to the courtroom and practicing in an empty courtroom are good ways to ensure that a physician’s voice is loud enough and projecting far enough in the courtroom, she adds.

“The doctor should try to be the best version of him- or herself to jurors,” she said. “A jury can pick up someone who’s trying to be something they’re not. A good attorney can help the doctor find the best version of themselves and capitalize on it. What is it that you want the jury to know about your care of the patient? Take that overall feeling and make sure it’s clearly expressed to the jury.”

A version of this article first appeared on Medscape.com.

During a medical malpractice trial in New Jersey, jurors waited nearly 4 hours for the physician defendant to show up. When he did arrive, the body-building surgeon was sporting two thick gold chains and a diamond pinky ring, and had the top buttons of his shirt open enough to reveal his chest hair.

“This trial was in a very rural, farming community,” recalls medical liability defense attorney Catherine Flynn, of Flynn Watts LLC, based in Parsippany, N.J. “Many of the jurors were wearing flannel shirts and jeans. The doctor’s wife walked in wearing a five-carat diamond ring and other jewelry.”

Ms. Flynn took the couple aside and asked them to remove the jewelry. She explained that the opulent accessories could damage the jury’s view of the physician. The surgeon and his wife, however, refused to remove their jewelry, she said. They didn’t think it was a big deal.

The case against the surgeon involved intraoperative damage to a patient when the physician inadvertently removed a portion of nerve in the area of the procedure. After repair of the nerve, the patient had a positive result. However, the patient alleged the surgeon’s negligence resulted in permanent damage despite the successful repair.

Jurors ultimately found the physician negligent in the case and awarded the plaintiff $1.2 million. Ms. Flynn believes that physician’s flamboyant attire and arrogant nature tainted the jury’s decision.

“In certain counties in New Jersey, his attire would not have been a problem,” she said. “In this rural, farming county, it was a huge problem. You have to know your audience. There are a lot of other things that come into play in a medical malpractice case, but when it comes to damages in a case, you don’t want to be sending the message that supports what somebody’s bias may already be telling them about a doctor.”

The surgeon appealed the verdict, and the case ultimately settled for a lesser amount, according to Ms. Flynn.

An over-the-top wardrobe is just one way that physicians can negatively influence jurors during legal trials. From subtle facial expressions to sudden outbursts to downright rudeness, attorneys have witnessed countless examples of physicians sabotaging their own trials. Legal experts say the cringeworthy experiences are good reminders that jurors are often judging more than just evidence.  

“The minute you enter the courthouse, jurors or potential jurors are sizing you up,” says health law attorney Michael Clark, of Womble Bond Dickinson (US) LLP, based in Houston. “The same phenomenon occurs in a deposition. Awareness of how you are being assessed at all times, and the image that is needed, is important since a negative impression by jurors can have a detrimental effect on a physician’s case.”
 

Juror: We didn’t like the doctor’s shoes

In another case, attorneys warned a physician defendant against dressing in his signature wardrobe during his trial. Against their advice, the doctor showed up daily to his trial in bright pastel, monochromatic suits with matching Gucci-brand shoes, said medical liability defense attorney Meredith C. Lander, of Kaufman Borgeest & Ryan LLP, based in Connecticut. On the witness stand, the doctor was long-winded and wasn’t “terribly likable,” Ms. Lander said.

However, the evidence weighed in the physician’s favor, and there was strong testimony by defense experts. The physician won the case, Ms. Lander said, but after the verdict, the jury foreperson approached the trial attorney and made some disparaging remarks about the defendant.

“The foreperson said the jury didn’t like the doctor or his ‘Gucci suits and shoes,’ but they believed the experts,” Ms. Lander said.

Disruptive behavior can also harm jurors’ perception of physicians, Ms. Flynn adds. During one instance, a surgeon insisted on sitting next to Ms. Flynn, although she generally requests clients sit in the first row so that jurors are not so focused on their reactions during testimony. The surgeon loudly peppered Ms. Flynn with questions as witnesses testified, prompting a reprimand from the judge.

“The judge admonished the doctor several times and said, ‘Doctor, you’re raising your voice. You’ll get a chance to speak with your attorney during the break,’ ” Ms. Flynn recalled. “The doctor refused to stop talking, and the judge told him in front of the jury to go sit in the back of the courtroom. His reaction was, ‘Why do I have to move?! I need to sit here!’ ”

The surgeon eventually moved to the back of the courtroom and a sheriff’s deputy stood next to him. Testimony continued until a note in the form of a paper airplane landed on the table in front of Ms. Flynn. She carefully crumpled the note and tossed it in the wastebasket. Luckily, this drew a laugh from jurors, she said. 

But things got worse when the surgeon testified. Rather than answer the questions, he interrupted and started telling jurors his own version of events.

“The judge finally said, ‘Doctor, if you don’t listen to your attorney and answer her questions, I’m going to make you get off the stand,’ ” Ms. Flynn said. “That was the most unbelievable, egregious self-sabotage trial moment I’ve ever experienced.”

Fortunately, the physician’s legal case was strong, and the experts who testified drove the defense’s side home, Ms. Flynn said. The surgeon won the case.
 

Attorney: Watch what you say in the elevator

Other, more subtle behaviors – while often unintentional – can also be damaging.

Physicians often let their guard down while outside the courtroom and can unknowingly wind up next to a juror in an elevator or standing in a hallway, said Laura Postilion, a partner at Quintairos, Prieto, Wood & Boyer, P.A., based in Chicago.

“For instance, a doctor is in an elevator and feels that some witness on the stand was lying,” Ms. Postilion said. “They might be very upset about it and start ranting about a witness lying, not realizing there is a juror is in the elevator with you.”

Physicians should also be cautious when speaking on the phone to their family or friends during a trial break.

“At the Daley Center in downtown Chicago, there are these long corridors and long line of windows; a lot of people will stand there during breaks. A doctor may be talking to his or her spouse and saying, ‘Yeah, this juror is sleeping!’ Jurors are [often] looking for drama. They’re looking for somebody letting their guard down. Hearing a doctor speak badly about them would certainly give them a reason to dislike the physician.”

Ms. Postilion warns against talking about jurors in or outside of the courtroom. This includes parking structures, she said.

Physicians can take additional steps to save themselves from negative judgment from jurors, attorneys say. Even before the trial starts, Ms. Postilion advises clients to make their social media accounts private. Some curious jurors may look up a physician’s social media accounts to learn more about their personal life, political leanings, or social beliefs, which could prejudice them against the doctor, she said.

Once on the stand, the words and tone used are key. The last thing a physician defendant wants is to come across as arrogant or condescending to jurors, said medical liability defense attorney Michael Moroney, of Flynn Watts LLC.

“For instance, a defendant might say, ‘Well, let me make this simple for you,’ as if they’re talking to a bunch of schoolchildren,” he said. “You don’t know who’s on the jury. That type of language can be offensive.”

Ms. Lander counsels her clients to refrain from using the common phrase, “honestly,” before answering questions on the stand.

“Everything you’re saying on the stand is presumed to be honest,” she said. “When you start an answer with, ‘Honestly…’ out of habit, it really does undercut everything that follows and everything else that’s already been said. It suggests that you were not being honest in your other answers.”
 

Attitude, body language speak volumes

Keep in mind that plaintiffs’ attorneys will try their best to rattle physicians on the stand and get them to appear unlikeable, says Mr. Clark, the Houston-based health law attorney. Physicians who lose their cool and begin arguing with attorneys play into their strategy.

“Plaintiffs’ attorneys have been trained in ways to get under their skin,” he said. “Righteous indignation and annoyance are best left for a rare occasion. Think about how you feel in a social setting when people are bickering in front of you. It’s uncomfortable at best. That’s how a jury feels too.”

Body language is also important, Mr. Clark notes. Physicians should avoid crossed arms, leaning back and rocking, or putting a hand on their mouth while testifying, he said. Many attorneys have practice sessions with their clients and record the interaction so that doctors can watch it and see how they look.

“Know your strengths and weaknesses,” he said. “Get help from your lawyer and perhaps consultants about how to improve these skills. Practice and preparation are important.”

Ms. Postilion goes over courtroom clothing with physician clients before trial. Anything “too flashy, too high-end, or too dumpy” should be avoided, she said. Getting accustomed to the courtroom and practicing in an empty courtroom are good ways to ensure that a physician’s voice is loud enough and projecting far enough in the courtroom, she adds.

“The doctor should try to be the best version of him- or herself to jurors,” she said. “A jury can pick up someone who’s trying to be something they’re not. A good attorney can help the doctor find the best version of themselves and capitalize on it. What is it that you want the jury to know about your care of the patient? Take that overall feeling and make sure it’s clearly expressed to the jury.”

A version of this article first appeared on Medscape.com.

During a medical malpractice trial in New Jersey, jurors waited nearly 4 hours for the physician defendant to show up. When he did arrive, the body-building surgeon was sporting two thick gold chains and a diamond pinky ring, and had the top buttons of his shirt open enough to reveal his chest hair.

“This trial was in a very rural, farming community,” recalls medical liability defense attorney Catherine Flynn, of Flynn Watts LLC, based in Parsippany, N.J. “Many of the jurors were wearing flannel shirts and jeans. The doctor’s wife walked in wearing a five-carat diamond ring and other jewelry.”

Ms. Flynn took the couple aside and asked them to remove the jewelry. She explained that the opulent accessories could damage the jury’s view of the physician. The surgeon and his wife, however, refused to remove their jewelry, she said. They didn’t think it was a big deal.

The case against the surgeon involved intraoperative damage to a patient when the physician inadvertently removed a portion of nerve in the area of the procedure. After repair of the nerve, the patient had a positive result. However, the patient alleged the surgeon’s negligence resulted in permanent damage despite the successful repair.

Jurors ultimately found the physician negligent in the case and awarded the plaintiff $1.2 million. Ms. Flynn believes that physician’s flamboyant attire and arrogant nature tainted the jury’s decision.

“In certain counties in New Jersey, his attire would not have been a problem,” she said. “In this rural, farming county, it was a huge problem. You have to know your audience. There are a lot of other things that come into play in a medical malpractice case, but when it comes to damages in a case, you don’t want to be sending the message that supports what somebody’s bias may already be telling them about a doctor.”

The surgeon appealed the verdict, and the case ultimately settled for a lesser amount, according to Ms. Flynn.

An over-the-top wardrobe is just one way that physicians can negatively influence jurors during legal trials. From subtle facial expressions to sudden outbursts to downright rudeness, attorneys have witnessed countless examples of physicians sabotaging their own trials. Legal experts say the cringeworthy experiences are good reminders that jurors are often judging more than just evidence.  

“The minute you enter the courthouse, jurors or potential jurors are sizing you up,” says health law attorney Michael Clark, of Womble Bond Dickinson (US) LLP, based in Houston. “The same phenomenon occurs in a deposition. Awareness of how you are being assessed at all times, and the image that is needed, is important since a negative impression by jurors can have a detrimental effect on a physician’s case.”
 

Juror: We didn’t like the doctor’s shoes

In another case, attorneys warned a physician defendant against dressing in his signature wardrobe during his trial. Against their advice, the doctor showed up daily to his trial in bright pastel, monochromatic suits with matching Gucci-brand shoes, said medical liability defense attorney Meredith C. Lander, of Kaufman Borgeest & Ryan LLP, based in Connecticut. On the witness stand, the doctor was long-winded and wasn’t “terribly likable,” Ms. Lander said.

However, the evidence weighed in the physician’s favor, and there was strong testimony by defense experts. The physician won the case, Ms. Lander said, but after the verdict, the jury foreperson approached the trial attorney and made some disparaging remarks about the defendant.

“The foreperson said the jury didn’t like the doctor or his ‘Gucci suits and shoes,’ but they believed the experts,” Ms. Lander said.

Disruptive behavior can also harm jurors’ perception of physicians, Ms. Flynn adds. During one instance, a surgeon insisted on sitting next to Ms. Flynn, although she generally requests clients sit in the first row so that jurors are not so focused on their reactions during testimony. The surgeon loudly peppered Ms. Flynn with questions as witnesses testified, prompting a reprimand from the judge.

“The judge admonished the doctor several times and said, ‘Doctor, you’re raising your voice. You’ll get a chance to speak with your attorney during the break,’ ” Ms. Flynn recalled. “The doctor refused to stop talking, and the judge told him in front of the jury to go sit in the back of the courtroom. His reaction was, ‘Why do I have to move?! I need to sit here!’ ”

The surgeon eventually moved to the back of the courtroom and a sheriff’s deputy stood next to him. Testimony continued until a note in the form of a paper airplane landed on the table in front of Ms. Flynn. She carefully crumpled the note and tossed it in the wastebasket. Luckily, this drew a laugh from jurors, she said. 

But things got worse when the surgeon testified. Rather than answer the questions, he interrupted and started telling jurors his own version of events.

“The judge finally said, ‘Doctor, if you don’t listen to your attorney and answer her questions, I’m going to make you get off the stand,’ ” Ms. Flynn said. “That was the most unbelievable, egregious self-sabotage trial moment I’ve ever experienced.”

Fortunately, the physician’s legal case was strong, and the experts who testified drove the defense’s side home, Ms. Flynn said. The surgeon won the case.
 

Attorney: Watch what you say in the elevator

Other, more subtle behaviors – while often unintentional – can also be damaging.

Physicians often let their guard down while outside the courtroom and can unknowingly wind up next to a juror in an elevator or standing in a hallway, said Laura Postilion, a partner at Quintairos, Prieto, Wood & Boyer, P.A., based in Chicago.

“For instance, a doctor is in an elevator and feels that some witness on the stand was lying,” Ms. Postilion said. “They might be very upset about it and start ranting about a witness lying, not realizing there is a juror is in the elevator with you.”

Physicians should also be cautious when speaking on the phone to their family or friends during a trial break.

“At the Daley Center in downtown Chicago, there are these long corridors and long line of windows; a lot of people will stand there during breaks. A doctor may be talking to his or her spouse and saying, ‘Yeah, this juror is sleeping!’ Jurors are [often] looking for drama. They’re looking for somebody letting their guard down. Hearing a doctor speak badly about them would certainly give them a reason to dislike the physician.”

Ms. Postilion warns against talking about jurors in or outside of the courtroom. This includes parking structures, she said.

Physicians can take additional steps to save themselves from negative judgment from jurors, attorneys say. Even before the trial starts, Ms. Postilion advises clients to make their social media accounts private. Some curious jurors may look up a physician’s social media accounts to learn more about their personal life, political leanings, or social beliefs, which could prejudice them against the doctor, she said.

Once on the stand, the words and tone used are key. The last thing a physician defendant wants is to come across as arrogant or condescending to jurors, said medical liability defense attorney Michael Moroney, of Flynn Watts LLC.

“For instance, a defendant might say, ‘Well, let me make this simple for you,’ as if they’re talking to a bunch of schoolchildren,” he said. “You don’t know who’s on the jury. That type of language can be offensive.”

Ms. Lander counsels her clients to refrain from using the common phrase, “honestly,” before answering questions on the stand.

“Everything you’re saying on the stand is presumed to be honest,” she said. “When you start an answer with, ‘Honestly…’ out of habit, it really does undercut everything that follows and everything else that’s already been said. It suggests that you were not being honest in your other answers.”
 

Attitude, body language speak volumes

Keep in mind that plaintiffs’ attorneys will try their best to rattle physicians on the stand and get them to appear unlikeable, says Mr. Clark, the Houston-based health law attorney. Physicians who lose their cool and begin arguing with attorneys play into their strategy.

“Plaintiffs’ attorneys have been trained in ways to get under their skin,” he said. “Righteous indignation and annoyance are best left for a rare occasion. Think about how you feel in a social setting when people are bickering in front of you. It’s uncomfortable at best. That’s how a jury feels too.”

Body language is also important, Mr. Clark notes. Physicians should avoid crossed arms, leaning back and rocking, or putting a hand on their mouth while testifying, he said. Many attorneys have practice sessions with their clients and record the interaction so that doctors can watch it and see how they look.

“Know your strengths and weaknesses,” he said. “Get help from your lawyer and perhaps consultants about how to improve these skills. Practice and preparation are important.”

Ms. Postilion goes over courtroom clothing with physician clients before trial. Anything “too flashy, too high-end, or too dumpy” should be avoided, she said. Getting accustomed to the courtroom and practicing in an empty courtroom are good ways to ensure that a physician’s voice is loud enough and projecting far enough in the courtroom, she adds.

“The doctor should try to be the best version of him- or herself to jurors,” she said. “A jury can pick up someone who’s trying to be something they’re not. A good attorney can help the doctor find the best version of themselves and capitalize on it. What is it that you want the jury to know about your care of the patient? Take that overall feeling and make sure it’s clearly expressed to the jury.”

A version of this article first appeared on Medscape.com.

Not long ago, the grandmother of my son’s friend died of COVID-19 infection. She was elderly and unvaccinated. Her grandson had no regrets over her unvaccinated status. “Why would she inject poison into her body?” he said, and then expressed a strong opinion that she had died because the hospital physicians refused to give her ivermectin and hydroxychloroquine. My son, wisely, did not push the issue.

Soon thereafter, my personal family physician emailed a newsletter to his patients (me included) with 3 important messages: (1) COVID vaccines were available in the office; (2) He was not going to prescribe hydroxychloroquine, no matter how adamantly it was requested; and (3) He warned against threatening him or his staff with lawsuits or violence over refusal to prescribe any unproven medication.

Mistakes will be made; corrections will be issued. This is the scientific process in action.

How, as a country, have we come to this? A sizeable portion of the public trusts the advice of quacks, hacks, and political opportunists over that of the nation’s most expert scientists and physicians. The National Institutes of Health maintains a website with up-to-date recommendations on the use of treatments for COVID-19. They assess the existing evidence and make recommendations for or against a wide array of interventions. (They recommend against the use of both ivermectin and hydroxychloroquine.) The Centers for Disease Control and Prevention publishes extensively about the current knowledge on the safety and efficacy of vaccines. Neither agency is part of a “deep state” or conspiracy. They are comprised of some of the nation’s leading scientists, including physicians, trying to protect the public from disease and foster good health.

Sadly, some physicians have been a source of inaccurate vaccine information; some even prescribe ineffective treatments despite the evidence. These physicians are either letting their politics override their good sense or are improperly assessing the scientific literature, or both. Medical licensing agencies, and specialty certification boards, need to find ways to prevent this—ways that can survive judicial scrutiny and allow for legitimate scientific debate.

I have been tempted to just accept the current situation as the inevitable outcome of social media–fueled tribalism. But when we know that the COVID death rate among the unvaccinated is 9 times that of people who have received a booster dose,¹ I can’t sit idly and watch the Internet pundits prevail. Instead, I continue to advise and teach my students to have confidence in trustworthy authorities and websites. Mistakes will be made; corrections will be issued. However, this is not evidence of malintent or incompetence, but rather, the scientific process in action.

I tell my students that one of the biggest challenges facing them and society is to figure out how to stop, or at least minimize the effects of, incorrect information, misleading statements, and outright lies in a society that values free speech. Physicians—young and old alike—must remain committed to communicating factual information to a not-always-receptive audience. And I wish my young colleagues luck; I hope that their passion for family medicine and their insights into social media may be just the combination that’s needed to redirect the public’s trust back to where it belongs during a health care crisis.

Not long ago, the grandmother of my son’s friend died of COVID-19 infection. She was elderly and unvaccinated. Her grandson had no regrets over her unvaccinated status. “Why would she inject poison into her body?” he said, and then expressed a strong opinion that she had died because the hospital physicians refused to give her ivermectin and hydroxychloroquine. My son, wisely, did not push the issue.

Soon thereafter, my personal family physician emailed a newsletter to his patients (me included) with 3 important messages: (1) COVID vaccines were available in the office; (2) He was not going to prescribe hydroxychloroquine, no matter how adamantly it was requested; and (3) He warned against threatening him or his staff with lawsuits or violence over refusal to prescribe any unproven medication.

Mistakes will be made; corrections will be issued. This is the scientific process in action.

How, as a country, have we come to this? A sizeable portion of the public trusts the advice of quacks, hacks, and political opportunists over that of the nation’s most expert scientists and physicians. The National Institutes of Health maintains a website with up-to-date recommendations on the use of treatments for COVID-19. They assess the existing evidence and make recommendations for or against a wide array of interventions. (They recommend against the use of both ivermectin and hydroxychloroquine.) The Centers for Disease Control and Prevention publishes extensively about the current knowledge on the safety and efficacy of vaccines. Neither agency is part of a “deep state” or conspiracy. They are comprised of some of the nation’s leading scientists, including physicians, trying to protect the public from disease and foster good health.

Sadly, some physicians have been a source of inaccurate vaccine information; some even prescribe ineffective treatments despite the evidence. These physicians are either letting their politics override their good sense or are improperly assessing the scientific literature, or both. Medical licensing agencies, and specialty certification boards, need to find ways to prevent this—ways that can survive judicial scrutiny and allow for legitimate scientific debate.

I have been tempted to just accept the current situation as the inevitable outcome of social media–fueled tribalism. But when we know that the COVID death rate among the unvaccinated is 9 times that of people who have received a booster dose,¹ I can’t sit idly and watch the Internet pundits prevail. Instead, I continue to advise and teach my students to have confidence in trustworthy authorities and websites. Mistakes will be made; corrections will be issued. However, this is not evidence of malintent or incompetence, but rather, the scientific process in action.

I tell my students that one of the biggest challenges facing them and society is to figure out how to stop, or at least minimize the effects of, incorrect information, misleading statements, and outright lies in a society that values free speech. Physicians—young and old alike—must remain committed to communicating factual information to a not-always-receptive audience. And I wish my young colleagues luck; I hope that their passion for family medicine and their insights into social media may be just the combination that’s needed to redirect the public’s trust back to where it belongs during a health care crisis.

Not long ago, the grandmother of my son’s friend died of COVID-19 infection. She was elderly and unvaccinated. Her grandson had no regrets over her unvaccinated status. “Why would she inject poison into her body?” he said, and then expressed a strong opinion that she had died because the hospital physicians refused to give her ivermectin and hydroxychloroquine. My son, wisely, did not push the issue.

Soon thereafter, my personal family physician emailed a newsletter to his patients (me included) with 3 important messages: (1) COVID vaccines were available in the office; (2) He was not going to prescribe hydroxychloroquine, no matter how adamantly it was requested; and (3) He warned against threatening him or his staff with lawsuits or violence over refusal to prescribe any unproven medication.

Mistakes will be made; corrections will be issued. This is the scientific process in action.

How, as a country, have we come to this? A sizeable portion of the public trusts the advice of quacks, hacks, and political opportunists over that of the nation’s most expert scientists and physicians. The National Institutes of Health maintains a website with up-to-date recommendations on the use of treatments for COVID-19. They assess the existing evidence and make recommendations for or against a wide array of interventions. (They recommend against the use of both ivermectin and hydroxychloroquine.) The Centers for Disease Control and Prevention publishes extensively about the current knowledge on the safety and efficacy of vaccines. Neither agency is part of a “deep state” or conspiracy. They are comprised of some of the nation’s leading scientists, including physicians, trying to protect the public from disease and foster good health.

Sadly, some physicians have been a source of inaccurate vaccine information; some even prescribe ineffective treatments despite the evidence. These physicians are either letting their politics override their good sense or are improperly assessing the scientific literature, or both. Medical licensing agencies, and specialty certification boards, need to find ways to prevent this—ways that can survive judicial scrutiny and allow for legitimate scientific debate.

I have been tempted to just accept the current situation as the inevitable outcome of social media–fueled tribalism. But when we know that the COVID death rate among the unvaccinated is 9 times that of people who have received a booster dose,¹ I can’t sit idly and watch the Internet pundits prevail. Instead, I continue to advise and teach my students to have confidence in trustworthy authorities and websites. Mistakes will be made; corrections will be issued. However, this is not evidence of malintent or incompetence, but rather, the scientific process in action.

I tell my students that one of the biggest challenges facing them and society is to figure out how to stop, or at least minimize the effects of, incorrect information, misleading statements, and outright lies in a society that values free speech. Physicians—young and old alike—must remain committed to communicating factual information to a not-always-receptive audience. And I wish my young colleagues luck; I hope that their passion for family medicine and their insights into social media may be just the combination that’s needed to redirect the public’s trust back to where it belongs during a health care crisis.

Recruiting health care workers is a challenge these days for both private practice and hospital employers, and competition can be fierce. In order to be competitive, employers need to review the package they are offering potential candidates and understand that it’s more than just compensation and benefits that matter.

When all else is equal, contract language can end up being the difference between capturing or losing a candidate.

As someone who reviews physician contracts extensively, there are some common examples of language that may cause a candidate to choose a different position.
 

Probationary period

Although every employer wants to find out if they like the physician or midlevel employee that they have just hired before fully committing, the inclusion of a probationary period (usually 90 days) is offensive to a candidate, especially one with a choice of contracts.

Essentially, the employer is asking the employee to (potentially) relocate, go through the credentialing process, and turn down other potential offers, all for the possibility that they could easily be terminated. Probationary periods typically allow an employee to be immediately terminated without notice or cause, which can then leave them stranded without a paycheck (and with a new home and/or other recent commitments).

Moreover, contracts with probationary periods tend to terminate the employee without covering any tail costs or clarifying that the employer will not enforce restrictive provisions (even if unlikely to be legally enforceable based on the short relationship).

It is important to understand that the process of a person finding a new position, which includes interviewing, contract negotiation, and credentialing, can take up to 6 months. For this reason, probationary provisions create real job insecurity for a candidate.

Entering into a new affiliation is a leap of faith both for the employer and the employee. If the circumstances do not work out, the employer should fairly compensate the employee for the notice period and ask them not to return to work or otherwise allow them to keep working the notice period while they search for a new position.
 

Acceleration of notice

Another objectionable provision that employers like to include in their contracts is one which allows the employer to accelerate and immediately terminate an employee who has given proper notice.

The contract will contain a standard notice provision, but when the health care professional submits notice, their last date is suddenly accelerated, and they are released without further compensation, notice, or benefits. This type of provision is particularly offensive to health care employees who take the step of giving proper contractual notice and, similar to the probationary language, can create real job insecurity for an employee who suddenly loses their paycheck and has no new job to start.

Medical workers should be paid for the entire notice period whether or not they are allowed to work. Unfortunately, this type of provision is sometimes hidden in contracts and not noticed by employees, who tend to focus on the notice provision itself. I consider this provision to be a red flag about the employer when I review clients’ contracts.
 

Malpractice tail

Although many employers will claim it is not unusual for an employee to pay for their own malpractice tail, in the current marketplace, the payment of tail can be a deciding factor in whether a candidate accepts a contract.

At a minimum, employers should consider paying for the tail under circumstances where they non-renew a contract, terminate without cause, or the contract is terminated for the employer’s breach. Similarly, I like to seek out payment of the tail by the employer where the contract is terminated owing to a change in the law, use of a force majeure provision, loss of the employer’s hospital contract, or similar provisions where termination is outside the control of the employee.

Employers should also consider a provision where they share the cost of a tail or cover the entire cost on the basis of years of service in order to stand out to a potential candidate.
 

Noncompete provisions

I do not find noncompete provisions to be generally unacceptable when properly written; however, employers should reevaluate the reasonableness of their noncompete language frequently, because such language can make the difference in whether a candidate accepts a contract.

A reasonable noncompete that only protects the employer as necessary and does not restrict the reasonable practice of medicine is always preferable and can be the deciding factor for a candidate. Tying enforcement of a noncompete to reasons for termination (similar to the tail) can also make a positive difference in a candidate’s review of a contract.

Egregious noncompetes, where the candidate is simply informed that the language is “not negotiable,” are unlikely to be compelling to a candidate with other options.
 

Specifics on location, call, schedule

One item potential employees find extremely frustrating about contracts is when it fails to include promises made regarding location, call, and schedule.

These particular items affect a physician’s expectations about a job, including commute time, family life, and lifestyle. An employer or recruiter that makes a lot of promises on these points but won’t commit to the details in writing (or at least offer mutual agreement on these issues) can cause an uncertain candidate to choose the job that offers greater certainty.

There are many provisions of a contract that can make a difference to a particular job applicant. A savvy employer seeking to capture a particular health care professional should find out what the specific goals and needs of the candidate might be and consider adjusting the contract to best satisfy the candidate.

At the end of the day, however, at least for those physicians and others reviewing contracts that are fairly equivalent, it may be the fairness of the contract provisions that end up being the deciding factor.

Ms. Adler is Health Law Group Practice Leader for the law firm Roetzel in Chicago. She reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Recruiting health care workers is a challenge these days for both private practice and hospital employers, and competition can be fierce. In order to be competitive, employers need to review the package they are offering potential candidates and understand that it’s more than just compensation and benefits that matter.

When all else is equal, contract language can end up being the difference between capturing or losing a candidate.

As someone who reviews physician contracts extensively, there are some common examples of language that may cause a candidate to choose a different position.
 

Probationary period

Although every employer wants to find out if they like the physician or midlevel employee that they have just hired before fully committing, the inclusion of a probationary period (usually 90 days) is offensive to a candidate, especially one with a choice of contracts.

Essentially, the employer is asking the employee to (potentially) relocate, go through the credentialing process, and turn down other potential offers, all for the possibility that they could easily be terminated. Probationary periods typically allow an employee to be immediately terminated without notice or cause, which can then leave them stranded without a paycheck (and with a new home and/or other recent commitments).

Moreover, contracts with probationary periods tend to terminate the employee without covering any tail costs or clarifying that the employer will not enforce restrictive provisions (even if unlikely to be legally enforceable based on the short relationship).

It is important to understand that the process of a person finding a new position, which includes interviewing, contract negotiation, and credentialing, can take up to 6 months. For this reason, probationary provisions create real job insecurity for a candidate.

Entering into a new affiliation is a leap of faith both for the employer and the employee. If the circumstances do not work out, the employer should fairly compensate the employee for the notice period and ask them not to return to work or otherwise allow them to keep working the notice period while they search for a new position.
 

Acceleration of notice

Another objectionable provision that employers like to include in their contracts is one which allows the employer to accelerate and immediately terminate an employee who has given proper notice.

The contract will contain a standard notice provision, but when the health care professional submits notice, their last date is suddenly accelerated, and they are released without further compensation, notice, or benefits. This type of provision is particularly offensive to health care employees who take the step of giving proper contractual notice and, similar to the probationary language, can create real job insecurity for an employee who suddenly loses their paycheck and has no new job to start.

Medical workers should be paid for the entire notice period whether or not they are allowed to work. Unfortunately, this type of provision is sometimes hidden in contracts and not noticed by employees, who tend to focus on the notice provision itself. I consider this provision to be a red flag about the employer when I review clients’ contracts.
 

Malpractice tail

Although many employers will claim it is not unusual for an employee to pay for their own malpractice tail, in the current marketplace, the payment of tail can be a deciding factor in whether a candidate accepts a contract.

At a minimum, employers should consider paying for the tail under circumstances where they non-renew a contract, terminate without cause, or the contract is terminated for the employer’s breach. Similarly, I like to seek out payment of the tail by the employer where the contract is terminated owing to a change in the law, use of a force majeure provision, loss of the employer’s hospital contract, or similar provisions where termination is outside the control of the employee.

Employers should also consider a provision where they share the cost of a tail or cover the entire cost on the basis of years of service in order to stand out to a potential candidate.
 

Noncompete provisions

I do not find noncompete provisions to be generally unacceptable when properly written; however, employers should reevaluate the reasonableness of their noncompete language frequently, because such language can make the difference in whether a candidate accepts a contract.

A reasonable noncompete that only protects the employer as necessary and does not restrict the reasonable practice of medicine is always preferable and can be the deciding factor for a candidate. Tying enforcement of a noncompete to reasons for termination (similar to the tail) can also make a positive difference in a candidate’s review of a contract.

Egregious noncompetes, where the candidate is simply informed that the language is “not negotiable,” are unlikely to be compelling to a candidate with other options.
 

Specifics on location, call, schedule

One item potential employees find extremely frustrating about contracts is when it fails to include promises made regarding location, call, and schedule.

These particular items affect a physician’s expectations about a job, including commute time, family life, and lifestyle. An employer or recruiter that makes a lot of promises on these points but won’t commit to the details in writing (or at least offer mutual agreement on these issues) can cause an uncertain candidate to choose the job that offers greater certainty.

There are many provisions of a contract that can make a difference to a particular job applicant. A savvy employer seeking to capture a particular health care professional should find out what the specific goals and needs of the candidate might be and consider adjusting the contract to best satisfy the candidate.

At the end of the day, however, at least for those physicians and others reviewing contracts that are fairly equivalent, it may be the fairness of the contract provisions that end up being the deciding factor.

Ms. Adler is Health Law Group Practice Leader for the law firm Roetzel in Chicago. She reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Recruiting health care workers is a challenge these days for both private practice and hospital employers, and competition can be fierce. In order to be competitive, employers need to review the package they are offering potential candidates and understand that it’s more than just compensation and benefits that matter.

When all else is equal, contract language can end up being the difference between capturing or losing a candidate.

As someone who reviews physician contracts extensively, there are some common examples of language that may cause a candidate to choose a different position.
 

Probationary period

Although every employer wants to find out if they like the physician or midlevel employee that they have just hired before fully committing, the inclusion of a probationary period (usually 90 days) is offensive to a candidate, especially one with a choice of contracts.

Essentially, the employer is asking the employee to (potentially) relocate, go through the credentialing process, and turn down other potential offers, all for the possibility that they could easily be terminated. Probationary periods typically allow an employee to be immediately terminated without notice or cause, which can then leave them stranded without a paycheck (and with a new home and/or other recent commitments).

Moreover, contracts with probationary periods tend to terminate the employee without covering any tail costs or clarifying that the employer will not enforce restrictive provisions (even if unlikely to be legally enforceable based on the short relationship).

It is important to understand that the process of a person finding a new position, which includes interviewing, contract negotiation, and credentialing, can take up to 6 months. For this reason, probationary provisions create real job insecurity for a candidate.

Entering into a new affiliation is a leap of faith both for the employer and the employee. If the circumstances do not work out, the employer should fairly compensate the employee for the notice period and ask them not to return to work or otherwise allow them to keep working the notice period while they search for a new position.
 

Acceleration of notice

Another objectionable provision that employers like to include in their contracts is one which allows the employer to accelerate and immediately terminate an employee who has given proper notice.

The contract will contain a standard notice provision, but when the health care professional submits notice, their last date is suddenly accelerated, and they are released without further compensation, notice, or benefits. This type of provision is particularly offensive to health care employees who take the step of giving proper contractual notice and, similar to the probationary language, can create real job insecurity for an employee who suddenly loses their paycheck and has no new job to start.

Medical workers should be paid for the entire notice period whether or not they are allowed to work. Unfortunately, this type of provision is sometimes hidden in contracts and not noticed by employees, who tend to focus on the notice provision itself. I consider this provision to be a red flag about the employer when I review clients’ contracts.
 

Malpractice tail

Although many employers will claim it is not unusual for an employee to pay for their own malpractice tail, in the current marketplace, the payment of tail can be a deciding factor in whether a candidate accepts a contract.

At a minimum, employers should consider paying for the tail under circumstances where they non-renew a contract, terminate without cause, or the contract is terminated for the employer’s breach. Similarly, I like to seek out payment of the tail by the employer where the contract is terminated owing to a change in the law, use of a force majeure provision, loss of the employer’s hospital contract, or similar provisions where termination is outside the control of the employee.

Employers should also consider a provision where they share the cost of a tail or cover the entire cost on the basis of years of service in order to stand out to a potential candidate.
 

Noncompete provisions

I do not find noncompete provisions to be generally unacceptable when properly written; however, employers should reevaluate the reasonableness of their noncompete language frequently, because such language can make the difference in whether a candidate accepts a contract.

A reasonable noncompete that only protects the employer as necessary and does not restrict the reasonable practice of medicine is always preferable and can be the deciding factor for a candidate. Tying enforcement of a noncompete to reasons for termination (similar to the tail) can also make a positive difference in a candidate’s review of a contract.

Egregious noncompetes, where the candidate is simply informed that the language is “not negotiable,” are unlikely to be compelling to a candidate with other options.
 

Specifics on location, call, schedule

One item potential employees find extremely frustrating about contracts is when it fails to include promises made regarding location, call, and schedule.

These particular items affect a physician’s expectations about a job, including commute time, family life, and lifestyle. An employer or recruiter that makes a lot of promises on these points but won’t commit to the details in writing (or at least offer mutual agreement on these issues) can cause an uncertain candidate to choose the job that offers greater certainty.

There are many provisions of a contract that can make a difference to a particular job applicant. A savvy employer seeking to capture a particular health care professional should find out what the specific goals and needs of the candidate might be and consider adjusting the contract to best satisfy the candidate.

At the end of the day, however, at least for those physicians and others reviewing contracts that are fairly equivalent, it may be the fairness of the contract provisions that end up being the deciding factor.

Ms. Adler is Health Law Group Practice Leader for the law firm Roetzel in Chicago. She reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Case

Ms. F. is a 68-year-old woman who presented to the hospital with sepsis, developed delirium, and stopped eating. Her clinicians recommended a PEG tube. Although she was inconsistently oriented to self, time, and place, she reiterated the same decision across multiple discussions: She did not want the PEG tube. Her replies to what would happen if she didn’t have the procedure and continued not to eat were consistent, too: “I’ll wither away.”

Ms. F. had impaired cognition. Do these impairments mean her clinicians should over-rule her choice? What evidence indicates whether she lacks decision-making capacity? This case of a patient refusing a potentially life-saving procedure amplifies the importance of asking these questions and integrating capacity assessments into clinical care. In this article, we will describe what capacity is, when and how to assess it, and the alternatives when a patient does not have capacity.
 

The ethical background

Before starting a medical treatment or procedure, a physician must obtain the patient’s informed consent. This is a core ethic of medicine. Informed consent describes the voluntary decision made by a competent patient following the disclosure of necessary information. Informed consent is key to achieving a balance between promoting patient self-determination and protecting vulnerable patients from harm. In most clinical encounters, informed consent unfolds effortlessly. However, in the care of patients who are acutely ill, particularly those in hospitals, fulfilling the ethic can be challenging.

It is important to have skills to recognize and address these challenges. One of the most common challenges to practicing the ethic of informed consent is the impact of illness on a person’s decision-making capacity. A patient who retains capacity ought to make his or her decisions and does not need someone else (a friend or a family member) to help with the decision.

Incapacity is unfortunately common among the acutely ill medical inpatient population, which typically skews older with more comorbidities.¹ Impairments frequently are overlooked for a variety of reasons,^2-6 including that many hospitalized patients do not challenge their doctors’ decisions. Doctors may be reluctant to assess capacity because the assessment may medically, legally, or ethically complicate the patient’s care.

Two common terms describe the outcome of an assessment of a patient’s decision-making abilities: competency and capacity. Competency describes a legal principle. It is granted or withdrawn by judicial review. The consequences of a judge rescinding competency are severe: A patient would need a guardian to make choices on his or her behalf.

Capacity, on the other hand, is a clinical concept. A physician assesses whether the patient can make a specific decision in a specific context. The difference between the two terms – competency and capacity – delineates what are the consequences of the assessment and which authority, a judge or a physician, has the right to withdraw a person’s decision-making authority.

The judge offers a global assessment that can lead to a guardianship. The physician’s decision is temporal and situational. Patients can lack capacity when they are ill and recover it when they are healed. Capacity is specific to each medical decision that the patient makes and so a person can lack capacity to make some decisions but not others.
 

Ethical framework to make assessment

Capacity is described by four decisional abilities: 1) communicate a choice, 2) understand relevant information, 3) appreciation, and 4) reasoning.⁷

Communication of a choice may be verbal or nonverbal, but the patient must be able to indicate the treatment choice clearly and consistently. Understanding describes knowing essential information a physician has conveyed. This is assessed by having the patients say back what they were told, such as: “Can you tell me in your own words what is a PEG tube?”

The components of appreciation are: the diagnosis or disorder and the benefits and risks of the proposed intervention as it relates to the diagnosis or disorder. Patients who appreciate their disorder have insight into their condition: “I’m not eating because I have an infection.” This can be assessed with a question such as: “Can you tell me in your own words what are the risks or downsides to you?” This prompt assesses the patient’s appreciation of risk. Reframing the question to ask, “Can you tell me about the upsides of this intervention?” will assess the patient’s appreciation of benefit.

Reasoning assesses the thought process and rationale for a person’s decision. It has two components – comparative and consequential reasoning. The first compares the different choices presented about the proposed intervention: “How does having a PEG tube compare to not having it?” The second asks about the consequences of each choice: “What might happen to a person who has the PEG tube?”

The capacity assessment evaluates a patient's performance on these decision-making abilities. This informs the clinician’s judgment of whether the patient has the capacity to make a decision. A patient who has capacity makes the choice, regardless of the physician’s preference or recommendation.

The physician’s duty is to decide which decision-making abilities to assess. Choice and understanding are essential. In riskier or more consequential decisions, a physician may raise the rigor of the assessment to include appreciation and reasoning.⁸ It is common practice for physicians to raise the standard for when to evaluate and how extensive their evaluation is when the decision is life-altering, as with a PEG tube versus a more routine, non–life-altering decision such as drawing blood for a routine wellness visit.

A simple scoring rubric determines the patient’s ability to answer each question along a range from adequate = 2, marginal = 1, to inadequate = 0. The extremes or adequate or inadequate are straightforward. Judgment is needed when performance is marginal. In the case of repeated marginal answers, a physician must strongly consider whether the patient lacks capacity to make the decision in question.⁹

Who receives a capacity assessment and when?

A good doctor is a good teacher. A doctor should therefore check that patients understand what is happening with their health. Assessing understanding is simply good medicine; for example, a good teacher ought to be asking an unimpaired patient without impaired cognition, “Can you say back to me the key points of what I explained?” With this approach, every patient is effectively “screened” for a capacity impairment.

Certain patients ought to trigger a more thorough examination of decisional abilities. Across multiple articles, the strongest factors associated with incapacity are older age and diminished cognitive function (often detected by MMSE scores below the low 20s).^1,7,10 Other factors that may amplify these deficits and thus should raise clinician concern would be patients with brain diseases such as Alzheimer’s or Parkinson’s, persons with lower education levels, or those who already have someone who helps them make decisions. To be sure, many older adults, even those with cognitive impairments, retain capacity, but extra protection should be in place to ensure their well-being.
 

Consequences of incapacity

If a careful assessment shows a patient has sound decision-making abilities, the patient is free to make the choice. On the other hand, a person does not have the capacity to make the decision at hand if he or she cannot communicate a choice or understand relevant information. Whether appreciation or reasoning ought to be assessed depends on the complexity and the significance of the decision. An assessment of decisional ability is not the end of the decision-making process. The goal is to maximize the patient’s autonomy.

Capacity can change over time. Factors that may inhibit capacity, such as medications, time of day, and even illness acuity, need to be accounted for and, if possible, addressed. The decision ought to be delayed, if possible, to a time when the patient has better chances of having capacity. If it is unlikely that patients’ status will change in the time frame needed to make the choice and they are found to not have capacity, then the decision making can be aided by advance directives or substitute decision makers such as family members or legal guardians.
 

Revisiting the case

Ms. F., who was delirious, retained notable decisional abilities. She understood the procedure of receiving the PEG tube and how the risk of continuing to not eat and not receive the PEG would result in dying by starvation. She appreciated her own diagnosis and how the proposed intervention could alter her condition. She appreciated how not having a PEG would lead to her death. Her choice to refuse the procedure was consistent. Ms. F. showed she retained capacity to make this decision. It was the physician’s duty to respect her autonomy and so to respect her refusal of the PEG.

Dr. Ney is a physician resident, department of psychiatry and human behavior, Thomas Jefferson University Hospital, Philadelphia. He has no conflicts to disclose. Dr. Karlawish is a professor in the departments of medicine, medical ethics and health policy, and neurology, University of Pennsylvania, Philadelphia. He is a site investigator for clinical trials sponsored by Biogen, Eisai, and Lilly.

References

1. Raymont V et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: Cross-sectional study. Lancet. 2004;364(9443):1421-7. doi: 10.1016/S0140-6736(04)17224-3.

2. Hanson M and Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69-70. doi: 10.1503/cjs.004816.

3. Dahlberg J et al. Lack of informed consent for surgical procedures by elderly patients with inability to consent: A retrospective chart review from an academic medical center in Norway. Patient Saf Surg. 2019;13:24. doi: 10.1186/s13037-019-0205-5.

4. Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011;306(4):420-7. doi: 10.1001/jama.2011.1023.

5. Terranova C et al. Ethical and medicolegal implications of capacity of patients in geriatric surgery. Med Sci Law. 2013;53(3):166-71. doi: 10.1177/0025802412473963.

6. John S et al. Assessing patients decision-making capacity in the hospital setting: A literature review. Aust J Rural Health. 2020;28(2):141-8. doi: 10.1111/ajr.12592.

7. Kim SYH et al. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics. 2006;47(4):325-9. doi: 10.1176/appi.psy.47.4.325.

8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-40. doi: 10.1056/NEJMcp074045.

9. Karlawish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16(1):91-8. doi: 10.1159/000109763.

10. Christensen K et al. Decision-making capacity for informed consent in the older population. Bull Am Acad Psychiatry Law. 1995;23(3):353-65.

Case

Ms. F. is a 68-year-old woman who presented to the hospital with sepsis, developed delirium, and stopped eating. Her clinicians recommended a PEG tube. Although she was inconsistently oriented to self, time, and place, she reiterated the same decision across multiple discussions: She did not want the PEG tube. Her replies to what would happen if she didn’t have the procedure and continued not to eat were consistent, too: “I’ll wither away.”

Ms. F. had impaired cognition. Do these impairments mean her clinicians should over-rule her choice? What evidence indicates whether she lacks decision-making capacity? This case of a patient refusing a potentially life-saving procedure amplifies the importance of asking these questions and integrating capacity assessments into clinical care. In this article, we will describe what capacity is, when and how to assess it, and the alternatives when a patient does not have capacity.
 

The ethical background

Before starting a medical treatment or procedure, a physician must obtain the patient’s informed consent. This is a core ethic of medicine. Informed consent describes the voluntary decision made by a competent patient following the disclosure of necessary information. Informed consent is key to achieving a balance between promoting patient self-determination and protecting vulnerable patients from harm. In most clinical encounters, informed consent unfolds effortlessly. However, in the care of patients who are acutely ill, particularly those in hospitals, fulfilling the ethic can be challenging.

It is important to have skills to recognize and address these challenges. One of the most common challenges to practicing the ethic of informed consent is the impact of illness on a person’s decision-making capacity. A patient who retains capacity ought to make his or her decisions and does not need someone else (a friend or a family member) to help with the decision.

Incapacity is unfortunately common among the acutely ill medical inpatient population, which typically skews older with more comorbidities.¹ Impairments frequently are overlooked for a variety of reasons,^2-6 including that many hospitalized patients do not challenge their doctors’ decisions. Doctors may be reluctant to assess capacity because the assessment may medically, legally, or ethically complicate the patient’s care.

Two common terms describe the outcome of an assessment of a patient’s decision-making abilities: competency and capacity. Competency describes a legal principle. It is granted or withdrawn by judicial review. The consequences of a judge rescinding competency are severe: A patient would need a guardian to make choices on his or her behalf.

Capacity, on the other hand, is a clinical concept. A physician assesses whether the patient can make a specific decision in a specific context. The difference between the two terms – competency and capacity – delineates what are the consequences of the assessment and which authority, a judge or a physician, has the right to withdraw a person’s decision-making authority.

The judge offers a global assessment that can lead to a guardianship. The physician’s decision is temporal and situational. Patients can lack capacity when they are ill and recover it when they are healed. Capacity is specific to each medical decision that the patient makes and so a person can lack capacity to make some decisions but not others.
 

Ethical framework to make assessment

Capacity is described by four decisional abilities: 1) communicate a choice, 2) understand relevant information, 3) appreciation, and 4) reasoning.⁷

Communication of a choice may be verbal or nonverbal, but the patient must be able to indicate the treatment choice clearly and consistently. Understanding describes knowing essential information a physician has conveyed. This is assessed by having the patients say back what they were told, such as: “Can you tell me in your own words what is a PEG tube?”

The components of appreciation are: the diagnosis or disorder and the benefits and risks of the proposed intervention as it relates to the diagnosis or disorder. Patients who appreciate their disorder have insight into their condition: “I’m not eating because I have an infection.” This can be assessed with a question such as: “Can you tell me in your own words what are the risks or downsides to you?” This prompt assesses the patient’s appreciation of risk. Reframing the question to ask, “Can you tell me about the upsides of this intervention?” will assess the patient’s appreciation of benefit.

Reasoning assesses the thought process and rationale for a person’s decision. It has two components – comparative and consequential reasoning. The first compares the different choices presented about the proposed intervention: “How does having a PEG tube compare to not having it?” The second asks about the consequences of each choice: “What might happen to a person who has the PEG tube?”

The capacity assessment evaluates a patient's performance on these decision-making abilities. This informs the clinician’s judgment of whether the patient has the capacity to make a decision. A patient who has capacity makes the choice, regardless of the physician’s preference or recommendation.

The physician’s duty is to decide which decision-making abilities to assess. Choice and understanding are essential. In riskier or more consequential decisions, a physician may raise the rigor of the assessment to include appreciation and reasoning.⁸ It is common practice for physicians to raise the standard for when to evaluate and how extensive their evaluation is when the decision is life-altering, as with a PEG tube versus a more routine, non–life-altering decision such as drawing blood for a routine wellness visit.

A simple scoring rubric determines the patient’s ability to answer each question along a range from adequate = 2, marginal = 1, to inadequate = 0. The extremes or adequate or inadequate are straightforward. Judgment is needed when performance is marginal. In the case of repeated marginal answers, a physician must strongly consider whether the patient lacks capacity to make the decision in question.⁹

Who receives a capacity assessment and when?

A good doctor is a good teacher. A doctor should therefore check that patients understand what is happening with their health. Assessing understanding is simply good medicine; for example, a good teacher ought to be asking an unimpaired patient without impaired cognition, “Can you say back to me the key points of what I explained?” With this approach, every patient is effectively “screened” for a capacity impairment.

Certain patients ought to trigger a more thorough examination of decisional abilities. Across multiple articles, the strongest factors associated with incapacity are older age and diminished cognitive function (often detected by MMSE scores below the low 20s).^1,7,10 Other factors that may amplify these deficits and thus should raise clinician concern would be patients with brain diseases such as Alzheimer’s or Parkinson’s, persons with lower education levels, or those who already have someone who helps them make decisions. To be sure, many older adults, even those with cognitive impairments, retain capacity, but extra protection should be in place to ensure their well-being.
 

Consequences of incapacity

If a careful assessment shows a patient has sound decision-making abilities, the patient is free to make the choice. On the other hand, a person does not have the capacity to make the decision at hand if he or she cannot communicate a choice or understand relevant information. Whether appreciation or reasoning ought to be assessed depends on the complexity and the significance of the decision. An assessment of decisional ability is not the end of the decision-making process. The goal is to maximize the patient’s autonomy.

Capacity can change over time. Factors that may inhibit capacity, such as medications, time of day, and even illness acuity, need to be accounted for and, if possible, addressed. The decision ought to be delayed, if possible, to a time when the patient has better chances of having capacity. If it is unlikely that patients’ status will change in the time frame needed to make the choice and they are found to not have capacity, then the decision making can be aided by advance directives or substitute decision makers such as family members or legal guardians.
 

Revisiting the case

Ms. F., who was delirious, retained notable decisional abilities. She understood the procedure of receiving the PEG tube and how the risk of continuing to not eat and not receive the PEG would result in dying by starvation. She appreciated her own diagnosis and how the proposed intervention could alter her condition. She appreciated how not having a PEG would lead to her death. Her choice to refuse the procedure was consistent. Ms. F. showed she retained capacity to make this decision. It was the physician’s duty to respect her autonomy and so to respect her refusal of the PEG.

Dr. Ney is a physician resident, department of psychiatry and human behavior, Thomas Jefferson University Hospital, Philadelphia. He has no conflicts to disclose. Dr. Karlawish is a professor in the departments of medicine, medical ethics and health policy, and neurology, University of Pennsylvania, Philadelphia. He is a site investigator for clinical trials sponsored by Biogen, Eisai, and Lilly.

References

1. Raymont V et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: Cross-sectional study. Lancet. 2004;364(9443):1421-7. doi: 10.1016/S0140-6736(04)17224-3.

2. Hanson M and Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69-70. doi: 10.1503/cjs.004816.

3. Dahlberg J et al. Lack of informed consent for surgical procedures by elderly patients with inability to consent: A retrospective chart review from an academic medical center in Norway. Patient Saf Surg. 2019;13:24. doi: 10.1186/s13037-019-0205-5.

4. Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011;306(4):420-7. doi: 10.1001/jama.2011.1023.

5. Terranova C et al. Ethical and medicolegal implications of capacity of patients in geriatric surgery. Med Sci Law. 2013;53(3):166-71. doi: 10.1177/0025802412473963.

6. John S et al. Assessing patients decision-making capacity in the hospital setting: A literature review. Aust J Rural Health. 2020;28(2):141-8. doi: 10.1111/ajr.12592.

7. Kim SYH et al. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics. 2006;47(4):325-9. doi: 10.1176/appi.psy.47.4.325.

8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-40. doi: 10.1056/NEJMcp074045.

9. Karlawish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16(1):91-8. doi: 10.1159/000109763.

10. Christensen K et al. Decision-making capacity for informed consent in the older population. Bull Am Acad Psychiatry Law. 1995;23(3):353-65.

Case

Ms. F. is a 68-year-old woman who presented to the hospital with sepsis, developed delirium, and stopped eating. Her clinicians recommended a PEG tube. Although she was inconsistently oriented to self, time, and place, she reiterated the same decision across multiple discussions: She did not want the PEG tube. Her replies to what would happen if she didn’t have the procedure and continued not to eat were consistent, too: “I’ll wither away.”

Ms. F. had impaired cognition. Do these impairments mean her clinicians should over-rule her choice? What evidence indicates whether she lacks decision-making capacity? This case of a patient refusing a potentially life-saving procedure amplifies the importance of asking these questions and integrating capacity assessments into clinical care. In this article, we will describe what capacity is, when and how to assess it, and the alternatives when a patient does not have capacity.
 

The ethical background

Before starting a medical treatment or procedure, a physician must obtain the patient’s informed consent. This is a core ethic of medicine. Informed consent describes the voluntary decision made by a competent patient following the disclosure of necessary information. Informed consent is key to achieving a balance between promoting patient self-determination and protecting vulnerable patients from harm. In most clinical encounters, informed consent unfolds effortlessly. However, in the care of patients who are acutely ill, particularly those in hospitals, fulfilling the ethic can be challenging.

It is important to have skills to recognize and address these challenges. One of the most common challenges to practicing the ethic of informed consent is the impact of illness on a person’s decision-making capacity. A patient who retains capacity ought to make his or her decisions and does not need someone else (a friend or a family member) to help with the decision.

Incapacity is unfortunately common among the acutely ill medical inpatient population, which typically skews older with more comorbidities.¹ Impairments frequently are overlooked for a variety of reasons,^2-6 including that many hospitalized patients do not challenge their doctors’ decisions. Doctors may be reluctant to assess capacity because the assessment may medically, legally, or ethically complicate the patient’s care.

Two common terms describe the outcome of an assessment of a patient’s decision-making abilities: competency and capacity. Competency describes a legal principle. It is granted or withdrawn by judicial review. The consequences of a judge rescinding competency are severe: A patient would need a guardian to make choices on his or her behalf.

Capacity, on the other hand, is a clinical concept. A physician assesses whether the patient can make a specific decision in a specific context. The difference between the two terms – competency and capacity – delineates what are the consequences of the assessment and which authority, a judge or a physician, has the right to withdraw a person’s decision-making authority.

The judge offers a global assessment that can lead to a guardianship. The physician’s decision is temporal and situational. Patients can lack capacity when they are ill and recover it when they are healed. Capacity is specific to each medical decision that the patient makes and so a person can lack capacity to make some decisions but not others.
 

Ethical framework to make assessment

Capacity is described by four decisional abilities: 1) communicate a choice, 2) understand relevant information, 3) appreciation, and 4) reasoning.⁷

Communication of a choice may be verbal or nonverbal, but the patient must be able to indicate the treatment choice clearly and consistently. Understanding describes knowing essential information a physician has conveyed. This is assessed by having the patients say back what they were told, such as: “Can you tell me in your own words what is a PEG tube?”

The components of appreciation are: the diagnosis or disorder and the benefits and risks of the proposed intervention as it relates to the diagnosis or disorder. Patients who appreciate their disorder have insight into their condition: “I’m not eating because I have an infection.” This can be assessed with a question such as: “Can you tell me in your own words what are the risks or downsides to you?” This prompt assesses the patient’s appreciation of risk. Reframing the question to ask, “Can you tell me about the upsides of this intervention?” will assess the patient’s appreciation of benefit.

Reasoning assesses the thought process and rationale for a person’s decision. It has two components – comparative and consequential reasoning. The first compares the different choices presented about the proposed intervention: “How does having a PEG tube compare to not having it?” The second asks about the consequences of each choice: “What might happen to a person who has the PEG tube?”

The capacity assessment evaluates a patient's performance on these decision-making abilities. This informs the clinician’s judgment of whether the patient has the capacity to make a decision. A patient who has capacity makes the choice, regardless of the physician’s preference or recommendation.

The physician’s duty is to decide which decision-making abilities to assess. Choice and understanding are essential. In riskier or more consequential decisions, a physician may raise the rigor of the assessment to include appreciation and reasoning.⁸ It is common practice for physicians to raise the standard for when to evaluate and how extensive their evaluation is when the decision is life-altering, as with a PEG tube versus a more routine, non–life-altering decision such as drawing blood for a routine wellness visit.

A simple scoring rubric determines the patient’s ability to answer each question along a range from adequate = 2, marginal = 1, to inadequate = 0. The extremes or adequate or inadequate are straightforward. Judgment is needed when performance is marginal. In the case of repeated marginal answers, a physician must strongly consider whether the patient lacks capacity to make the decision in question.⁹

Who receives a capacity assessment and when?

A good doctor is a good teacher. A doctor should therefore check that patients understand what is happening with their health. Assessing understanding is simply good medicine; for example, a good teacher ought to be asking an unimpaired patient without impaired cognition, “Can you say back to me the key points of what I explained?” With this approach, every patient is effectively “screened” for a capacity impairment.

Certain patients ought to trigger a more thorough examination of decisional abilities. Across multiple articles, the strongest factors associated with incapacity are older age and diminished cognitive function (often detected by MMSE scores below the low 20s).^1,7,10 Other factors that may amplify these deficits and thus should raise clinician concern would be patients with brain diseases such as Alzheimer’s or Parkinson’s, persons with lower education levels, or those who already have someone who helps them make decisions. To be sure, many older adults, even those with cognitive impairments, retain capacity, but extra protection should be in place to ensure their well-being.
 

Consequences of incapacity

If a careful assessment shows a patient has sound decision-making abilities, the patient is free to make the choice. On the other hand, a person does not have the capacity to make the decision at hand if he or she cannot communicate a choice or understand relevant information. Whether appreciation or reasoning ought to be assessed depends on the complexity and the significance of the decision. An assessment of decisional ability is not the end of the decision-making process. The goal is to maximize the patient’s autonomy.

Capacity can change over time. Factors that may inhibit capacity, such as medications, time of day, and even illness acuity, need to be accounted for and, if possible, addressed. The decision ought to be delayed, if possible, to a time when the patient has better chances of having capacity. If it is unlikely that patients’ status will change in the time frame needed to make the choice and they are found to not have capacity, then the decision making can be aided by advance directives or substitute decision makers such as family members or legal guardians.
 

Revisiting the case

Ms. F., who was delirious, retained notable decisional abilities. She understood the procedure of receiving the PEG tube and how the risk of continuing to not eat and not receive the PEG would result in dying by starvation. She appreciated her own diagnosis and how the proposed intervention could alter her condition. She appreciated how not having a PEG would lead to her death. Her choice to refuse the procedure was consistent. Ms. F. showed she retained capacity to make this decision. It was the physician’s duty to respect her autonomy and so to respect her refusal of the PEG.

Dr. Ney is a physician resident, department of psychiatry and human behavior, Thomas Jefferson University Hospital, Philadelphia. He has no conflicts to disclose. Dr. Karlawish is a professor in the departments of medicine, medical ethics and health policy, and neurology, University of Pennsylvania, Philadelphia. He is a site investigator for clinical trials sponsored by Biogen, Eisai, and Lilly.

References

1. Raymont V et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: Cross-sectional study. Lancet. 2004;364(9443):1421-7. doi: 10.1016/S0140-6736(04)17224-3.

2. Hanson M and Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69-70. doi: 10.1503/cjs.004816.

3. Dahlberg J et al. Lack of informed consent for surgical procedures by elderly patients with inability to consent: A retrospective chart review from an academic medical center in Norway. Patient Saf Surg. 2019;13:24. doi: 10.1186/s13037-019-0205-5.

4. Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011;306(4):420-7. doi: 10.1001/jama.2011.1023.

5. Terranova C et al. Ethical and medicolegal implications of capacity of patients in geriatric surgery. Med Sci Law. 2013;53(3):166-71. doi: 10.1177/0025802412473963.

6. John S et al. Assessing patients decision-making capacity in the hospital setting: A literature review. Aust J Rural Health. 2020;28(2):141-8. doi: 10.1111/ajr.12592.

7. Kim SYH et al. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics. 2006;47(4):325-9. doi: 10.1176/appi.psy.47.4.325.

8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-40. doi: 10.1056/NEJMcp074045.

9. Karlawish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16(1):91-8. doi: 10.1159/000109763.

10. Christensen K et al. Decision-making capacity for informed consent in the older population. Bull Am Acad Psychiatry Law. 1995;23(3):353-65.

Dear colleagues,

Most of us engage with social media, whether actively tweeting, following friends on Facebook, or discussing TikTok videos with family. Many gastroenterologists leverage social media to build their professional brand and to reach a wider audience. Others remain wary of committing a social media faux paux or worry about patient confidentiality. In this Perspectives column, Dr. Stephen Chris Pappas and Dr. Mohammad Bilal discuss the risks and benefits of social media for the practicing gastroenterologist. Dr. Pappas has a unique perspective as a gastroenterologist who is also trained as a lawyer, and Dr. Bilal speaks from a wealth of experience leading educational activities on social media. We look forward to hearing your thoughts on Twitter @AGA_GIHN and by email at ginews@gastro.org.

Gyanprakash A. Ketwaroo, MD, MSc, an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.

Carefully consider the plentiful risks, concerns

BY STEPHEN CHRIS PAPPAS, MD, JD, FAASLD, FACLM

Social media for gastroenterologists comes with benefits accompanied by pesky risks. The risks are pesky like a mosquito bite: An itching bite is annoying, but getting malaria is serious. Managing your unprofessional tweet to salvage your reputation is going to be annoying. Disclosing a patient's identity on social media is going to be serious; you could find yourself fired, fined, reprimanded, and without hospital privileges, as happened recently to a Rhode Island physician. I divide the risks of social media into legal risks (for example, disclosing patient identity or inadvertently creating a doctor-patient relationship), risks of compromising ethical standards (for example, impairing the doctor-patient relationship), and mixed legal/ethics risks (for example, inappropriate Twitter banter disparaging individuals, promotion of “fake news”). Fortunately, these risks are intuitive and can be mitigated by attention to some simple principles.

Disclosing a patient’s identity on social media is clearly in violation of privacy laws and other regulations. Since privacy compliance is drummed into us ad nauseum via annual compliance training, we could ask “how on earth could an inadvertent disclosure of identity occur?” We must remember that sites that are nominally termed “secure” may not be. As a general suggestion, I would regard social media of all types as open public forums with permanent postings. Even limited descriptions of a patient on social media may allow identification of the actual patient. The risk may be highest in smaller communities; in the past I assisted a small-town practitioner manage the fallout from inadvertently identifying a patient on his professional Facebook page by simply saying “I recently managed a 38-year-old pregnant woman with Crohn’s disease ...” That small amount of information allowed some members of his community to identify the specific patient. My suggestion would be to never talk about individual patients on social media. Phrase comments or questions generically; for example, “Crohn’s disease in pregnancy is managed with attention to ...”.

Another legal risk of social media engagement is to unknowingly create a patient-doctor relationship with a duty to treat, opening the door for exposure to malpractice litigation if something goes awry. A patient may interpret a social media interaction as establishing a patient-doctor relationship. While we think we know what defines a doctor-patient relationship, it’s not always clear and varies between jurisdictions. Indeed, a physician-patient relationship may not even be a necessary element of a claim for professional negligence (an issue shared with “curbside” consults). A recent court case in Minnesota ruled that a duty to care is established if “... it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That case involved a telephone call, but you could see the standard easily morphing to apply to social media posts. Gastroenterologists should always talk about disease and treatment on social media in generic terms, preferably with appropriate caveats (for example, “Patients with cholestasis and intense itching may be treated with naloxone in selected cases after detailed assessment by a hepatologist”).

Impairing an established doctor-patient relationship by “friending” a patient on your personal Facebook risks a potential compromise of professional ethics, breaking the boundaries between profession and person for the gastroenterologist. The approach by most professional societies is that a “friend” on social media is equal to a friend in the real world; the same legal and ethical standards apply. Doctor-patient friendships may compromise objectivity, lead to preferential but not optimal therapy, and increase the risk of skirting around informed consent among other issues. Being friends on social media is discouraged, but not prohibited, by most professional societies and licensing bodies. In my opinion, that is sound advice. Over a career of more than 40 years, I have had patients who became friends, but only after I had transferred their care to another hepatologist.

More recently with escalating, aggressive, tones for social media communications, GI/hepatology practitioners must be aware of the serious risk of blurring their personal and professional online lives, particularly where Twitter is involved. The rapidity which people seem to want to reply to a tweet, the public and durable natures of a tweet, and the ability to significantly retweet and repost all spell potential disasters for the physician tweeting an inappropriate communication. Separation of personal and professional social media accounts is strongly encouraged but alone is not enough; you are never totally anonymous online. The reality is that a physician will be judged for an inappropriate communication whether it’s found on their professional or personal site. Either posting could result in reputation damage, reprimands, medical license restrictions or revocations, and litigation. Nationally, medical boards now regularly deal with disciplinary actions for inappropriate social media activity. The best preventive measures include pausing before you post, check the veracity of what you are posting, place your post in context, and assess the tone of your post and the tone of the site that you are posting to. A perfect storm for disaster is that the material is not clearly evidence based and could be construed as “fake,” you are personally emotionally charged, and the site you are posting to is a known cauldron of emotion and fake news.

In summary, social media affords benefits in a health care setting but it comes with some baggage. However, the risks of a social media presence are largely instinctive. An initial starting point is pausing to consider, “Would I say/do this in a public venue where everybody could hear/see me?” If there is any concern, don’t post. Subsequently, conduct yourself on social media with meticulous attention to protecting confidentiality, avoiding any impression of creating a doctor-patient relationship, avoiding doctor-friend relationships, being aware of key legal, institutional, and professional society guidance, separating personal and professional activities, and maintaining professionalism.

Dr. Pappas is in the GI and hepatology section of the department of medicine at Baylor College of Medicine, Houston. He has no relevant conflicts of interest to disclose.

References

Attai DJ et al. Semin Hematol. 2017 Oct; 54(4): 198-204.

Bal BS et al. Clin Orthop Relat Res. 2019 Oct; 477(10): 2204-6.

Ekrem, D et al. 20111 Jun 6. https://www.kevinmd.com/2011/06/7-tips-avoid-hipaa-violations-social-media.html

Hallenbeck J. Doctor and Friend. 2005 Jun. https://journalofethics.ama-assn.org/article/doctor-and-friend/2005-06

Moses RE et al. Am J Gastroenterol. 2014 Aug;109(8):1128-32.

Understand its multifaceted importance

BY MOHAMMAD BILAL, MD, FACP

Merriam-Webster’s dictionary defines social media as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content.” Over the last few years, there has been an increase in use of social media by medical professionals. Whether we like it or not, social media is here to stay. Patients use social media to look up information regarding their doctors, medical practices use it to promote the services they offer, institutions share their programs and initiatives, and doctors use it for education, to engage with like-minded colleagues, collaborate, spread awareness, network, and combat medical misinformation. Social media is now rapidly being used by gastroenterologists and hepatologists, as well as majority of professional GI organizations, and hashtags such as “#MedTwitter”, “#GITwitter,” and “#LiverTwitter” have developed into popular academic forums.¹ Therefore, the impact of social media in GI is multifaceted and includes its role in medical education, promoting your practice or division, finding collaborations, building your network and establishing mentors and peer-mentors, disseminating your work, and building your brand.²

What is your goal?

Gastroenterologists could have one or more of the goals mentioned above for using social media. Determining the goals for social media use a priori will allow for determining which social media platform will be appropriate for you. Therefore, it is important to understand the users of various social media platforms. In 2017, Facebook was the highest used social media platform in all age groups, whereas Instagram was most popular amongst ages 18-29 years, while Twitter was used more commonly in ages 30-59 years as compared with Instagram. If your goal is to share scientific knowledge and literature with like-minded physicians and interact with leaders in the field, then Twitter may be ideal. If you want to connect with a younger, more diverse audience, Instagram might be a good option. While many physicians may have a Facebook account, this is often reserved for personal use. Many have separated of personal and professional social media use, although they do not need to exist in silos. Defining your goal with social media use will direct you to the best platform to reach your audience.

Medical education

The use of social media especially Twitter for medical education is continuously increasing. Several leaders in the field use “Tweetorials” as a means to educate others. Tweetorials are a collective set of tweets that systematically cover a specialized topic.³ Other educational forums such as @ScopingSundays, @MondayNightIBD, @IBDClub and @GIJournal provide structured platforms for GI focused discussion.⁴ @MondayNightIBD is also a source for official continued medical education. Other social media educational platforms include “Liver Fellow Network” which has wide variety of educational materials pertaining to hepatology. In addition, there is continuous opportunity to engage with leaders in the field and authors of published studies and guidelines. Several endoscopy educators have dedicated YouTube channels which have endless supply of educational videos.

Networking

As mentioned above, platforms such as #GITwitter and #LiverTwitter have become popular forums for engaging and connecting with like minded colleagues. Social media provides a space to share ideas and build collaborations with colleagues working on similar projects. The concept “#Twitter2Paper” has been proposed which signifies an idea that generated on Twitter and was eventually converted to a manuscript.⁵

Institutional, divisional, and practice promotion

Social media is a great tool to showcase the clinical, educational and scholarship services and efforts by programs, practices or divisions. During the COVID-19 pandemic, recruitment efforts at all stages were mainly shifted to virtual platforms, and social media was an instrumental way for programs to highlight their culture and initiatives. Prospective applicants can often refer to social media to get a better understanding of what the program offers. Similarly, if a new clinical service is being provided, targeted efforts can be made to ensure that patients are aware of the available services.

Patient education and combating misinformation

Several gastroenterologists also use social media to spread awareness regarding GI diseases. Instagram, Facebook, and TikTok are effective mediums where one can reach a wider audience. It is important for gastroenterologists to provide accurate information since there is a sea of misinformation available on the internet as well. Posts regarding colonoscopy and colon cancer awareness can help alleviate myths regarding role of colonoscopy. In addition, patient advocates use social media to provide peer support to others who deal with challenges related to chronic illnesses such as inflammatory bowel disease.

Sharing your work

Sharing your work on social media can help your work reach a broader audience. Studies have shown that work shared on social media has higher altmetric scores and can also lead to increased citations.

Diversity, equity, and inclusion

Social media offers a platform where one can promote or showcase their support for causes they believe in. The hashtag “#DiversityinGI” has been instrumental in promoting causes pertaining to diversity and inclusion in GI.

Pitfalls

As gastroenterologists continue to use social media, it is important to be mindful of potential pitfalls. The most critical aspect is to always remember that no post should intentionally or unintentionally violate HIPAA. It is advisable to know your institutional and state social media policies.

Social media is beaming with knowledge, education, science and inspiration. There are endless opportunities for professional and personal growth with effective and responsible use of social media. Its never to late to join the conversation.

Dr. Bilal is an assistant professor of medicine at the University of Minnesota, Minneapolis and an advanced endoscopist in the division of gastroenterology at Minneapolis VA Medical Center. He has no relevant conflicts of interest to disclose.

References

1. Mikolajczyk AE et al. Hepatol Commun. 2020 Jul 5;4(8):1229-33.

2. Bilal M and Oxentenko AS. Am J Gastroenterol. 2020 Oct;115(10):1549-52.

3. Breu AC. N Engl J Med. 2019 Sep 19;381(12):1097-8.

4. Bilal M et al. Nat Rev Gastroenterol Hepatol. 2021 Aug;18(8):519-20.

5. Pawlak KM et al. United European Gastroenterol J. 2021 Feb;9(1):129-32.




 

Dear colleagues,

Most of us engage with social media, whether actively tweeting, following friends on Facebook, or discussing TikTok videos with family. Many gastroenterologists leverage social media to build their professional brand and to reach a wider audience. Others remain wary of committing a social media faux paux or worry about patient confidentiality. In this Perspectives column, Dr. Stephen Chris Pappas and Dr. Mohammad Bilal discuss the risks and benefits of social media for the practicing gastroenterologist. Dr. Pappas has a unique perspective as a gastroenterologist who is also trained as a lawyer, and Dr. Bilal speaks from a wealth of experience leading educational activities on social media. We look forward to hearing your thoughts on Twitter @AGA_GIHN and by email at ginews@gastro.org.

Gyanprakash A. Ketwaroo, MD, MSc, an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.

Carefully consider the plentiful risks, concerns

BY STEPHEN CHRIS PAPPAS, MD, JD, FAASLD, FACLM

Social media for gastroenterologists comes with benefits accompanied by pesky risks. The risks are pesky like a mosquito bite: An itching bite is annoying, but getting malaria is serious. Managing your unprofessional tweet to salvage your reputation is going to be annoying. Disclosing a patient's identity on social media is going to be serious; you could find yourself fired, fined, reprimanded, and without hospital privileges, as happened recently to a Rhode Island physician. I divide the risks of social media into legal risks (for example, disclosing patient identity or inadvertently creating a doctor-patient relationship), risks of compromising ethical standards (for example, impairing the doctor-patient relationship), and mixed legal/ethics risks (for example, inappropriate Twitter banter disparaging individuals, promotion of “fake news”). Fortunately, these risks are intuitive and can be mitigated by attention to some simple principles.

Disclosing a patient’s identity on social media is clearly in violation of privacy laws and other regulations. Since privacy compliance is drummed into us ad nauseum via annual compliance training, we could ask “how on earth could an inadvertent disclosure of identity occur?” We must remember that sites that are nominally termed “secure” may not be. As a general suggestion, I would regard social media of all types as open public forums with permanent postings. Even limited descriptions of a patient on social media may allow identification of the actual patient. The risk may be highest in smaller communities; in the past I assisted a small-town practitioner manage the fallout from inadvertently identifying a patient on his professional Facebook page by simply saying “I recently managed a 38-year-old pregnant woman with Crohn’s disease ...” That small amount of information allowed some members of his community to identify the specific patient. My suggestion would be to never talk about individual patients on social media. Phrase comments or questions generically; for example, “Crohn’s disease in pregnancy is managed with attention to ...”.

Another legal risk of social media engagement is to unknowingly create a patient-doctor relationship with a duty to treat, opening the door for exposure to malpractice litigation if something goes awry. A patient may interpret a social media interaction as establishing a patient-doctor relationship. While we think we know what defines a doctor-patient relationship, it’s not always clear and varies between jurisdictions. Indeed, a physician-patient relationship may not even be a necessary element of a claim for professional negligence (an issue shared with “curbside” consults). A recent court case in Minnesota ruled that a duty to care is established if “... it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That case involved a telephone call, but you could see the standard easily morphing to apply to social media posts. Gastroenterologists should always talk about disease and treatment on social media in generic terms, preferably with appropriate caveats (for example, “Patients with cholestasis and intense itching may be treated with naloxone in selected cases after detailed assessment by a hepatologist”).

Impairing an established doctor-patient relationship by “friending” a patient on your personal Facebook risks a potential compromise of professional ethics, breaking the boundaries between profession and person for the gastroenterologist. The approach by most professional societies is that a “friend” on social media is equal to a friend in the real world; the same legal and ethical standards apply. Doctor-patient friendships may compromise objectivity, lead to preferential but not optimal therapy, and increase the risk of skirting around informed consent among other issues. Being friends on social media is discouraged, but not prohibited, by most professional societies and licensing bodies. In my opinion, that is sound advice. Over a career of more than 40 years, I have had patients who became friends, but only after I had transferred their care to another hepatologist.

More recently with escalating, aggressive, tones for social media communications, GI/hepatology practitioners must be aware of the serious risk of blurring their personal and professional online lives, particularly where Twitter is involved. The rapidity which people seem to want to reply to a tweet, the public and durable natures of a tweet, and the ability to significantly retweet and repost all spell potential disasters for the physician tweeting an inappropriate communication. Separation of personal and professional social media accounts is strongly encouraged but alone is not enough; you are never totally anonymous online. The reality is that a physician will be judged for an inappropriate communication whether it’s found on their professional or personal site. Either posting could result in reputation damage, reprimands, medical license restrictions or revocations, and litigation. Nationally, medical boards now regularly deal with disciplinary actions for inappropriate social media activity. The best preventive measures include pausing before you post, check the veracity of what you are posting, place your post in context, and assess the tone of your post and the tone of the site that you are posting to. A perfect storm for disaster is that the material is not clearly evidence based and could be construed as “fake,” you are personally emotionally charged, and the site you are posting to is a known cauldron of emotion and fake news.

In summary, social media affords benefits in a health care setting but it comes with some baggage. However, the risks of a social media presence are largely instinctive. An initial starting point is pausing to consider, “Would I say/do this in a public venue where everybody could hear/see me?” If there is any concern, don’t post. Subsequently, conduct yourself on social media with meticulous attention to protecting confidentiality, avoiding any impression of creating a doctor-patient relationship, avoiding doctor-friend relationships, being aware of key legal, institutional, and professional society guidance, separating personal and professional activities, and maintaining professionalism.

Dr. Pappas is in the GI and hepatology section of the department of medicine at Baylor College of Medicine, Houston. He has no relevant conflicts of interest to disclose.

References

Attai DJ et al. Semin Hematol. 2017 Oct; 54(4): 198-204.

Bal BS et al. Clin Orthop Relat Res. 2019 Oct; 477(10): 2204-6.

Ekrem, D et al. 20111 Jun 6. https://www.kevinmd.com/2011/06/7-tips-avoid-hipaa-violations-social-media.html

Hallenbeck J. Doctor and Friend. 2005 Jun. https://journalofethics.ama-assn.org/article/doctor-and-friend/2005-06

Moses RE et al. Am J Gastroenterol. 2014 Aug;109(8):1128-32.

Understand its multifaceted importance

BY MOHAMMAD BILAL, MD, FACP

Merriam-Webster’s dictionary defines social media as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content.” Over the last few years, there has been an increase in use of social media by medical professionals. Whether we like it or not, social media is here to stay. Patients use social media to look up information regarding their doctors, medical practices use it to promote the services they offer, institutions share their programs and initiatives, and doctors use it for education, to engage with like-minded colleagues, collaborate, spread awareness, network, and combat medical misinformation. Social media is now rapidly being used by gastroenterologists and hepatologists, as well as majority of professional GI organizations, and hashtags such as “#MedTwitter”, “#GITwitter,” and “#LiverTwitter” have developed into popular academic forums.¹ Therefore, the impact of social media in GI is multifaceted and includes its role in medical education, promoting your practice or division, finding collaborations, building your network and establishing mentors and peer-mentors, disseminating your work, and building your brand.²

What is your goal?

Gastroenterologists could have one or more of the goals mentioned above for using social media. Determining the goals for social media use a priori will allow for determining which social media platform will be appropriate for you. Therefore, it is important to understand the users of various social media platforms. In 2017, Facebook was the highest used social media platform in all age groups, whereas Instagram was most popular amongst ages 18-29 years, while Twitter was used more commonly in ages 30-59 years as compared with Instagram. If your goal is to share scientific knowledge and literature with like-minded physicians and interact with leaders in the field, then Twitter may be ideal. If you want to connect with a younger, more diverse audience, Instagram might be a good option. While many physicians may have a Facebook account, this is often reserved for personal use. Many have separated of personal and professional social media use, although they do not need to exist in silos. Defining your goal with social media use will direct you to the best platform to reach your audience.

Medical education

The use of social media especially Twitter for medical education is continuously increasing. Several leaders in the field use “Tweetorials” as a means to educate others. Tweetorials are a collective set of tweets that systematically cover a specialized topic.³ Other educational forums such as @ScopingSundays, @MondayNightIBD, @IBDClub and @GIJournal provide structured platforms for GI focused discussion.⁴ @MondayNightIBD is also a source for official continued medical education. Other social media educational platforms include “Liver Fellow Network” which has wide variety of educational materials pertaining to hepatology. In addition, there is continuous opportunity to engage with leaders in the field and authors of published studies and guidelines. Several endoscopy educators have dedicated YouTube channels which have endless supply of educational videos.

Networking

As mentioned above, platforms such as #GITwitter and #LiverTwitter have become popular forums for engaging and connecting with like minded colleagues. Social media provides a space to share ideas and build collaborations with colleagues working on similar projects. The concept “#Twitter2Paper” has been proposed which signifies an idea that generated on Twitter and was eventually converted to a manuscript.⁵

Institutional, divisional, and practice promotion

Social media is a great tool to showcase the clinical, educational and scholarship services and efforts by programs, practices or divisions. During the COVID-19 pandemic, recruitment efforts at all stages were mainly shifted to virtual platforms, and social media was an instrumental way for programs to highlight their culture and initiatives. Prospective applicants can often refer to social media to get a better understanding of what the program offers. Similarly, if a new clinical service is being provided, targeted efforts can be made to ensure that patients are aware of the available services.

Patient education and combating misinformation

Several gastroenterologists also use social media to spread awareness regarding GI diseases. Instagram, Facebook, and TikTok are effective mediums where one can reach a wider audience. It is important for gastroenterologists to provide accurate information since there is a sea of misinformation available on the internet as well. Posts regarding colonoscopy and colon cancer awareness can help alleviate myths regarding role of colonoscopy. In addition, patient advocates use social media to provide peer support to others who deal with challenges related to chronic illnesses such as inflammatory bowel disease.

Sharing your work

Sharing your work on social media can help your work reach a broader audience. Studies have shown that work shared on social media has higher altmetric scores and can also lead to increased citations.

Diversity, equity, and inclusion

Social media offers a platform where one can promote or showcase their support for causes they believe in. The hashtag “#DiversityinGI” has been instrumental in promoting causes pertaining to diversity and inclusion in GI.

Pitfalls

As gastroenterologists continue to use social media, it is important to be mindful of potential pitfalls. The most critical aspect is to always remember that no post should intentionally or unintentionally violate HIPAA. It is advisable to know your institutional and state social media policies.

Social media is beaming with knowledge, education, science and inspiration. There are endless opportunities for professional and personal growth with effective and responsible use of social media. Its never to late to join the conversation.

Dr. Bilal is an assistant professor of medicine at the University of Minnesota, Minneapolis and an advanced endoscopist in the division of gastroenterology at Minneapolis VA Medical Center. He has no relevant conflicts of interest to disclose.

References

1. Mikolajczyk AE et al. Hepatol Commun. 2020 Jul 5;4(8):1229-33.

2. Bilal M and Oxentenko AS. Am J Gastroenterol. 2020 Oct;115(10):1549-52.

3. Breu AC. N Engl J Med. 2019 Sep 19;381(12):1097-8.

4. Bilal M et al. Nat Rev Gastroenterol Hepatol. 2021 Aug;18(8):519-20.

5. Pawlak KM et al. United European Gastroenterol J. 2021 Feb;9(1):129-32.




 

Dear colleagues,

Most of us engage with social media, whether actively tweeting, following friends on Facebook, or discussing TikTok videos with family. Many gastroenterologists leverage social media to build their professional brand and to reach a wider audience. Others remain wary of committing a social media faux paux or worry about patient confidentiality. In this Perspectives column, Dr. Stephen Chris Pappas and Dr. Mohammad Bilal discuss the risks and benefits of social media for the practicing gastroenterologist. Dr. Pappas has a unique perspective as a gastroenterologist who is also trained as a lawyer, and Dr. Bilal speaks from a wealth of experience leading educational activities on social media. We look forward to hearing your thoughts on Twitter @AGA_GIHN and by email at ginews@gastro.org.

Gyanprakash A. Ketwaroo, MD, MSc, an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.

Carefully consider the plentiful risks, concerns

BY STEPHEN CHRIS PAPPAS, MD, JD, FAASLD, FACLM

Social media for gastroenterologists comes with benefits accompanied by pesky risks. The risks are pesky like a mosquito bite: An itching bite is annoying, but getting malaria is serious. Managing your unprofessional tweet to salvage your reputation is going to be annoying. Disclosing a patient's identity on social media is going to be serious; you could find yourself fired, fined, reprimanded, and without hospital privileges, as happened recently to a Rhode Island physician. I divide the risks of social media into legal risks (for example, disclosing patient identity or inadvertently creating a doctor-patient relationship), risks of compromising ethical standards (for example, impairing the doctor-patient relationship), and mixed legal/ethics risks (for example, inappropriate Twitter banter disparaging individuals, promotion of “fake news”). Fortunately, these risks are intuitive and can be mitigated by attention to some simple principles.

Disclosing a patient’s identity on social media is clearly in violation of privacy laws and other regulations. Since privacy compliance is drummed into us ad nauseum via annual compliance training, we could ask “how on earth could an inadvertent disclosure of identity occur?” We must remember that sites that are nominally termed “secure” may not be. As a general suggestion, I would regard social media of all types as open public forums with permanent postings. Even limited descriptions of a patient on social media may allow identification of the actual patient. The risk may be highest in smaller communities; in the past I assisted a small-town practitioner manage the fallout from inadvertently identifying a patient on his professional Facebook page by simply saying “I recently managed a 38-year-old pregnant woman with Crohn’s disease ...” That small amount of information allowed some members of his community to identify the specific patient. My suggestion would be to never talk about individual patients on social media. Phrase comments or questions generically; for example, “Crohn’s disease in pregnancy is managed with attention to ...”.

Another legal risk of social media engagement is to unknowingly create a patient-doctor relationship with a duty to treat, opening the door for exposure to malpractice litigation if something goes awry. A patient may interpret a social media interaction as establishing a patient-doctor relationship. While we think we know what defines a doctor-patient relationship, it’s not always clear and varies between jurisdictions. Indeed, a physician-patient relationship may not even be a necessary element of a claim for professional negligence (an issue shared with “curbside” consults). A recent court case in Minnesota ruled that a duty to care is established if “... it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That case involved a telephone call, but you could see the standard easily morphing to apply to social media posts. Gastroenterologists should always talk about disease and treatment on social media in generic terms, preferably with appropriate caveats (for example, “Patients with cholestasis and intense itching may be treated with naloxone in selected cases after detailed assessment by a hepatologist”).

Impairing an established doctor-patient relationship by “friending” a patient on your personal Facebook risks a potential compromise of professional ethics, breaking the boundaries between profession and person for the gastroenterologist. The approach by most professional societies is that a “friend” on social media is equal to a friend in the real world; the same legal and ethical standards apply. Doctor-patient friendships may compromise objectivity, lead to preferential but not optimal therapy, and increase the risk of skirting around informed consent among other issues. Being friends on social media is discouraged, but not prohibited, by most professional societies and licensing bodies. In my opinion, that is sound advice. Over a career of more than 40 years, I have had patients who became friends, but only after I had transferred their care to another hepatologist.

More recently with escalating, aggressive, tones for social media communications, GI/hepatology practitioners must be aware of the serious risk of blurring their personal and professional online lives, particularly where Twitter is involved. The rapidity which people seem to want to reply to a tweet, the public and durable natures of a tweet, and the ability to significantly retweet and repost all spell potential disasters for the physician tweeting an inappropriate communication. Separation of personal and professional social media accounts is strongly encouraged but alone is not enough; you are never totally anonymous online. The reality is that a physician will be judged for an inappropriate communication whether it’s found on their professional or personal site. Either posting could result in reputation damage, reprimands, medical license restrictions or revocations, and litigation. Nationally, medical boards now regularly deal with disciplinary actions for inappropriate social media activity. The best preventive measures include pausing before you post, check the veracity of what you are posting, place your post in context, and assess the tone of your post and the tone of the site that you are posting to. A perfect storm for disaster is that the material is not clearly evidence based and could be construed as “fake,” you are personally emotionally charged, and the site you are posting to is a known cauldron of emotion and fake news.

In summary, social media affords benefits in a health care setting but it comes with some baggage. However, the risks of a social media presence are largely instinctive. An initial starting point is pausing to consider, “Would I say/do this in a public venue where everybody could hear/see me?” If there is any concern, don’t post. Subsequently, conduct yourself on social media with meticulous attention to protecting confidentiality, avoiding any impression of creating a doctor-patient relationship, avoiding doctor-friend relationships, being aware of key legal, institutional, and professional society guidance, separating personal and professional activities, and maintaining professionalism.

Dr. Pappas is in the GI and hepatology section of the department of medicine at Baylor College of Medicine, Houston. He has no relevant conflicts of interest to disclose.

References

Attai DJ et al. Semin Hematol. 2017 Oct; 54(4): 198-204.

Bal BS et al. Clin Orthop Relat Res. 2019 Oct; 477(10): 2204-6.

Ekrem, D et al. 20111 Jun 6. https://www.kevinmd.com/2011/06/7-tips-avoid-hipaa-violations-social-media.html

Hallenbeck J. Doctor and Friend. 2005 Jun. https://journalofethics.ama-assn.org/article/doctor-and-friend/2005-06

Moses RE et al. Am J Gastroenterol. 2014 Aug;109(8):1128-32.

Understand its multifaceted importance

BY MOHAMMAD BILAL, MD, FACP

Merriam-Webster’s dictionary defines social media as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content.” Over the last few years, there has been an increase in use of social media by medical professionals. Whether we like it or not, social media is here to stay. Patients use social media to look up information regarding their doctors, medical practices use it to promote the services they offer, institutions share their programs and initiatives, and doctors use it for education, to engage with like-minded colleagues, collaborate, spread awareness, network, and combat medical misinformation. Social media is now rapidly being used by gastroenterologists and hepatologists, as well as majority of professional GI organizations, and hashtags such as “#MedTwitter”, “#GITwitter,” and “#LiverTwitter” have developed into popular academic forums.¹ Therefore, the impact of social media in GI is multifaceted and includes its role in medical education, promoting your practice or division, finding collaborations, building your network and establishing mentors and peer-mentors, disseminating your work, and building your brand.²

What is your goal?

Gastroenterologists could have one or more of the goals mentioned above for using social media. Determining the goals for social media use a priori will allow for determining which social media platform will be appropriate for you. Therefore, it is important to understand the users of various social media platforms. In 2017, Facebook was the highest used social media platform in all age groups, whereas Instagram was most popular amongst ages 18-29 years, while Twitter was used more commonly in ages 30-59 years as compared with Instagram. If your goal is to share scientific knowledge and literature with like-minded physicians and interact with leaders in the field, then Twitter may be ideal. If you want to connect with a younger, more diverse audience, Instagram might be a good option. While many physicians may have a Facebook account, this is often reserved for personal use. Many have separated of personal and professional social media use, although they do not need to exist in silos. Defining your goal with social media use will direct you to the best platform to reach your audience.

Medical education

The use of social media especially Twitter for medical education is continuously increasing. Several leaders in the field use “Tweetorials” as a means to educate others. Tweetorials are a collective set of tweets that systematically cover a specialized topic.³ Other educational forums such as @ScopingSundays, @MondayNightIBD, @IBDClub and @GIJournal provide structured platforms for GI focused discussion.⁴ @MondayNightIBD is also a source for official continued medical education. Other social media educational platforms include “Liver Fellow Network” which has wide variety of educational materials pertaining to hepatology. In addition, there is continuous opportunity to engage with leaders in the field and authors of published studies and guidelines. Several endoscopy educators have dedicated YouTube channels which have endless supply of educational videos.

Networking

As mentioned above, platforms such as #GITwitter and #LiverTwitter have become popular forums for engaging and connecting with like minded colleagues. Social media provides a space to share ideas and build collaborations with colleagues working on similar projects. The concept “#Twitter2Paper” has been proposed which signifies an idea that generated on Twitter and was eventually converted to a manuscript.⁵

Institutional, divisional, and practice promotion

Social media is a great tool to showcase the clinical, educational and scholarship services and efforts by programs, practices or divisions. During the COVID-19 pandemic, recruitment efforts at all stages were mainly shifted to virtual platforms, and social media was an instrumental way for programs to highlight their culture and initiatives. Prospective applicants can often refer to social media to get a better understanding of what the program offers. Similarly, if a new clinical service is being provided, targeted efforts can be made to ensure that patients are aware of the available services.

Patient education and combating misinformation

Several gastroenterologists also use social media to spread awareness regarding GI diseases. Instagram, Facebook, and TikTok are effective mediums where one can reach a wider audience. It is important for gastroenterologists to provide accurate information since there is a sea of misinformation available on the internet as well. Posts regarding colonoscopy and colon cancer awareness can help alleviate myths regarding role of colonoscopy. In addition, patient advocates use social media to provide peer support to others who deal with challenges related to chronic illnesses such as inflammatory bowel disease.

Sharing your work

Sharing your work on social media can help your work reach a broader audience. Studies have shown that work shared on social media has higher altmetric scores and can also lead to increased citations.

Diversity, equity, and inclusion

Social media offers a platform where one can promote or showcase their support for causes they believe in. The hashtag “#DiversityinGI” has been instrumental in promoting causes pertaining to diversity and inclusion in GI.

Pitfalls

As gastroenterologists continue to use social media, it is important to be mindful of potential pitfalls. The most critical aspect is to always remember that no post should intentionally or unintentionally violate HIPAA. It is advisable to know your institutional and state social media policies.

Social media is beaming with knowledge, education, science and inspiration. There are endless opportunities for professional and personal growth with effective and responsible use of social media. Its never to late to join the conversation.

Dr. Bilal is an assistant professor of medicine at the University of Minnesota, Minneapolis and an advanced endoscopist in the division of gastroenterology at Minneapolis VA Medical Center. He has no relevant conflicts of interest to disclose.

References

1. Mikolajczyk AE et al. Hepatol Commun. 2020 Jul 5;4(8):1229-33.

2. Bilal M and Oxentenko AS. Am J Gastroenterol. 2020 Oct;115(10):1549-52.

3. Breu AC. N Engl J Med. 2019 Sep 19;381(12):1097-8.

4. Bilal M et al. Nat Rev Gastroenterol Hepatol. 2021 Aug;18(8):519-20.

5. Pawlak KM et al. United European Gastroenterol J. 2021 Feb;9(1):129-32.




 

Residents are confronted daily with situations in clinic that require a foundation in medical ethics to assist in decision-making. Attending physicians require health care services and at times may seek care from resident physicians. If the attending physician has direct oversight over the resident, however, the ethics of the resident treating them need to be addressed. Although patients have autonomy to choose whoever they want as a physician, nonmaleficence dictates that the resident may forego treatment due to concerns for providing suboptimal care; however, this same attending may be treated under specific circumstances. This column explores the ethical implications of both situations.

The Ethical Dilemma of Treating an Attending

Imagine this scenario: You are in your resident general dermatology clinic seeing patients with an attending overseeing your clinical decisions following each encounter. You look on your schedule and see that the next patient is one of your pediatric dermatology attendings for a total-body skin examination (TBSE). You have never treated a physician that oversees you, and you ponder whether you should perform the examination or fetch your attending to perform the encounter alone.

This conundrum then brings other questions to mind: Would changing the reason for the appointment (ie, an acute problem vs a TBSE) alter your decision as to whether or not you would treat this attending? Would the situation be different if this was an attending in a different department?

Ethics Curriculum for Residents

Medical providers face ethical dilemmas daily, and dermatologists and dermatology residents are not excluded. Dermatoethics can provide a framework for the best approach to this hypothetical situation. To equip residents with resources on ethics and a cognitive framework to approach similar situations, the American Board of Dermatology has created an ethics curriculum for residents to learn over their 3 years of training.¹

One study that analyzed the ethical themes portrayed in essays by fourth-year medical students showed that the most common themes included autonomy, social justice, nonmaleficence, beneficence, honesty, and respect.² These themes must be considered in different permutations throughout ethical conundrums.

In the situation of an attending physician who supervises a resident in another clinic voluntarily attending the resident clinic, the physician is aware of the resident’s skills and qualifications and knows that supervision is being provided by an attending physician, which allows informed consent to be made, as a study by Unruh et al³ shows. The patient’s autonomy allows them to choose their treating provider.

However, there are several reasons why the resident may be hesitant to enter the room. One concern may be that during a TBSE the provider usually examines the patient’s genitals, rectum, and breasts.⁴ Because the resident knows the individual personally, the patient and/or the provider may be uncomfortable checking these areas, leaving a portion of the examination unperformed. This neglect may harm the patient (eg, a genital melanoma is missed), violating the tenant of nonmaleficence.

The effect of the medical hierarchy also should be considered. The de facto hierarchy of attendings supervising residents, interns, and medical students, with each group having some oversight over the next, can have positive effects on education and appropriate patient management but also can prove to be detrimental to the patient and provider in some circumstances. Studies have shown that residents may be less willing to disagree with their superior’s opinions for fear of negative reactions and harmful effects on their future careers.^5-7 The hierarchy of medicine also can affect a resident’s moral judgement by intimidating the practitioner to perform tasks or make diagnoses they may not wish to make.^5,6,8,9 For example, the resident may send a prescription for a medication that the attending requested despite no clear indication of need. This mingling of patient and supervisor roles can result in a resident treating their attending physician inconsistently with their standard of care.

Navigating the Ethics of Treating Family Members

The American Medical Association Code of Medical Ethics Opinions on Patient-Physician Relationships highlights treating family members as an important ethical topic. Although most residents and attendings are not biologically related, a familial-style relationship exists in many dermatology programs between attendings and residents due to the close-knit nature of dermatology programs. Diagnostic and treatment accuracy may be diminished by the discomfort or disbelief that a condition could affect someone the resident cares about.¹⁰

The American Medical Association also states that a physician can treat family members in an emergency situation or for short-term minor problems. If these 2 exceptions were to be extrapolated to apply to situations involving residents and attendings in addition to family, there would be situations where a dermatology resident could ethically treat their attending physician.¹⁰ If the attending physician was worried about a problem that was deemed potentially life-threatening, such as a rapidly progressive bullous eruption concerning for Stevens-Johnson syndrome following the initiation of a new medication, and they wanted an urgent evaluation and biopsy, an ethicist could argue that urgent treatment is medically indicated as deferring treatment could have negative consequences on the patient’s health. In addition, if the attending found a splinter in their finger following yardwork and needed assistance in removal, this also could be treated by their resident, as it is minimally invasive and has a finite conclusion.

Treating Nonsupervisory Attendings

In the case of performing a TBSE on an attending from another specialty, it would be acceptable and less ethically ambiguous if no close personal relationship existed between the two practitioners, as this patient would have no direct oversight over the resident physician.

Final Thoughts

Each situation that residents face may carry ethical implications with perspectives from the patient, provider, and bystanders. The above scenarios highlight specific instances that a dermatology resident may face and provide insight into how they may approach the situations. At the same time, it is important to remember that every situation is different and requires a unique approach. Fortunately,physicians—specifically dermatologists—are provided many resources to help navigate challenging scenarios.

Acknowledgments—The author thanks Jane M. Grant-Kels, MD (Farmington, Connecticut), for reviewing this paper and providing feedback to improve its content, as well as Warren R. Heymann, MD (Camden, New Jersey), for assisting in the creation of this topic and article.

Residents are confronted daily with situations in clinic that require a foundation in medical ethics to assist in decision-making. Attending physicians require health care services and at times may seek care from resident physicians. If the attending physician has direct oversight over the resident, however, the ethics of the resident treating them need to be addressed. Although patients have autonomy to choose whoever they want as a physician, nonmaleficence dictates that the resident may forego treatment due to concerns for providing suboptimal care; however, this same attending may be treated under specific circumstances. This column explores the ethical implications of both situations.

The Ethical Dilemma of Treating an Attending

Imagine this scenario: You are in your resident general dermatology clinic seeing patients with an attending overseeing your clinical decisions following each encounter. You look on your schedule and see that the next patient is one of your pediatric dermatology attendings for a total-body skin examination (TBSE). You have never treated a physician that oversees you, and you ponder whether you should perform the examination or fetch your attending to perform the encounter alone.

This conundrum then brings other questions to mind: Would changing the reason for the appointment (ie, an acute problem vs a TBSE) alter your decision as to whether or not you would treat this attending? Would the situation be different if this was an attending in a different department?

Ethics Curriculum for Residents

Medical providers face ethical dilemmas daily, and dermatologists and dermatology residents are not excluded. Dermatoethics can provide a framework for the best approach to this hypothetical situation. To equip residents with resources on ethics and a cognitive framework to approach similar situations, the American Board of Dermatology has created an ethics curriculum for residents to learn over their 3 years of training.¹

One study that analyzed the ethical themes portrayed in essays by fourth-year medical students showed that the most common themes included autonomy, social justice, nonmaleficence, beneficence, honesty, and respect.² These themes must be considered in different permutations throughout ethical conundrums.

In the situation of an attending physician who supervises a resident in another clinic voluntarily attending the resident clinic, the physician is aware of the resident’s skills and qualifications and knows that supervision is being provided by an attending physician, which allows informed consent to be made, as a study by Unruh et al³ shows. The patient’s autonomy allows them to choose their treating provider.

However, there are several reasons why the resident may be hesitant to enter the room. One concern may be that during a TBSE the provider usually examines the patient’s genitals, rectum, and breasts.⁴ Because the resident knows the individual personally, the patient and/or the provider may be uncomfortable checking these areas, leaving a portion of the examination unperformed. This neglect may harm the patient (eg, a genital melanoma is missed), violating the tenant of nonmaleficence.

The effect of the medical hierarchy also should be considered. The de facto hierarchy of attendings supervising residents, interns, and medical students, with each group having some oversight over the next, can have positive effects on education and appropriate patient management but also can prove to be detrimental to the patient and provider in some circumstances. Studies have shown that residents may be less willing to disagree with their superior’s opinions for fear of negative reactions and harmful effects on their future careers.^5-7 The hierarchy of medicine also can affect a resident’s moral judgement by intimidating the practitioner to perform tasks or make diagnoses they may not wish to make.^5,6,8,9 For example, the resident may send a prescription for a medication that the attending requested despite no clear indication of need. This mingling of patient and supervisor roles can result in a resident treating their attending physician inconsistently with their standard of care.

Navigating the Ethics of Treating Family Members

The American Medical Association Code of Medical Ethics Opinions on Patient-Physician Relationships highlights treating family members as an important ethical topic. Although most residents and attendings are not biologically related, a familial-style relationship exists in many dermatology programs between attendings and residents due to the close-knit nature of dermatology programs. Diagnostic and treatment accuracy may be diminished by the discomfort or disbelief that a condition could affect someone the resident cares about.¹⁰

The American Medical Association also states that a physician can treat family members in an emergency situation or for short-term minor problems. If these 2 exceptions were to be extrapolated to apply to situations involving residents and attendings in addition to family, there would be situations where a dermatology resident could ethically treat their attending physician.¹⁰ If the attending physician was worried about a problem that was deemed potentially life-threatening, such as a rapidly progressive bullous eruption concerning for Stevens-Johnson syndrome following the initiation of a new medication, and they wanted an urgent evaluation and biopsy, an ethicist could argue that urgent treatment is medically indicated as deferring treatment could have negative consequences on the patient’s health. In addition, if the attending found a splinter in their finger following yardwork and needed assistance in removal, this also could be treated by their resident, as it is minimally invasive and has a finite conclusion.

Treating Nonsupervisory Attendings

In the case of performing a TBSE on an attending from another specialty, it would be acceptable and less ethically ambiguous if no close personal relationship existed between the two practitioners, as this patient would have no direct oversight over the resident physician.

Final Thoughts

Each situation that residents face may carry ethical implications with perspectives from the patient, provider, and bystanders. The above scenarios highlight specific instances that a dermatology resident may face and provide insight into how they may approach the situations. At the same time, it is important to remember that every situation is different and requires a unique approach. Fortunately,physicians—specifically dermatologists—are provided many resources to help navigate challenging scenarios.

Acknowledgments—The author thanks Jane M. Grant-Kels, MD (Farmington, Connecticut), for reviewing this paper and providing feedback to improve its content, as well as Warren R. Heymann, MD (Camden, New Jersey), for assisting in the creation of this topic and article.

Residents are confronted daily with situations in clinic that require a foundation in medical ethics to assist in decision-making. Attending physicians require health care services and at times may seek care from resident physicians. If the attending physician has direct oversight over the resident, however, the ethics of the resident treating them need to be addressed. Although patients have autonomy to choose whoever they want as a physician, nonmaleficence dictates that the resident may forego treatment due to concerns for providing suboptimal care; however, this same attending may be treated under specific circumstances. This column explores the ethical implications of both situations.

The Ethical Dilemma of Treating an Attending

Imagine this scenario: You are in your resident general dermatology clinic seeing patients with an attending overseeing your clinical decisions following each encounter. You look on your schedule and see that the next patient is one of your pediatric dermatology attendings for a total-body skin examination (TBSE). You have never treated a physician that oversees you, and you ponder whether you should perform the examination or fetch your attending to perform the encounter alone.

This conundrum then brings other questions to mind: Would changing the reason for the appointment (ie, an acute problem vs a TBSE) alter your decision as to whether or not you would treat this attending? Would the situation be different if this was an attending in a different department?

Ethics Curriculum for Residents

Medical providers face ethical dilemmas daily, and dermatologists and dermatology residents are not excluded. Dermatoethics can provide a framework for the best approach to this hypothetical situation. To equip residents with resources on ethics and a cognitive framework to approach similar situations, the American Board of Dermatology has created an ethics curriculum for residents to learn over their 3 years of training.¹

One study that analyzed the ethical themes portrayed in essays by fourth-year medical students showed that the most common themes included autonomy, social justice, nonmaleficence, beneficence, honesty, and respect.² These themes must be considered in different permutations throughout ethical conundrums.

In the situation of an attending physician who supervises a resident in another clinic voluntarily attending the resident clinic, the physician is aware of the resident’s skills and qualifications and knows that supervision is being provided by an attending physician, which allows informed consent to be made, as a study by Unruh et al³ shows. The patient’s autonomy allows them to choose their treating provider.

However, there are several reasons why the resident may be hesitant to enter the room. One concern may be that during a TBSE the provider usually examines the patient’s genitals, rectum, and breasts.⁴ Because the resident knows the individual personally, the patient and/or the provider may be uncomfortable checking these areas, leaving a portion of the examination unperformed. This neglect may harm the patient (eg, a genital melanoma is missed), violating the tenant of nonmaleficence.

The effect of the medical hierarchy also should be considered. The de facto hierarchy of attendings supervising residents, interns, and medical students, with each group having some oversight over the next, can have positive effects on education and appropriate patient management but also can prove to be detrimental to the patient and provider in some circumstances. Studies have shown that residents may be less willing to disagree with their superior’s opinions for fear of negative reactions and harmful effects on their future careers.^5-7 The hierarchy of medicine also can affect a resident’s moral judgement by intimidating the practitioner to perform tasks or make diagnoses they may not wish to make.^5,6,8,9 For example, the resident may send a prescription for a medication that the attending requested despite no clear indication of need. This mingling of patient and supervisor roles can result in a resident treating their attending physician inconsistently with their standard of care.

Navigating the Ethics of Treating Family Members

The American Medical Association Code of Medical Ethics Opinions on Patient-Physician Relationships highlights treating family members as an important ethical topic. Although most residents and attendings are not biologically related, a familial-style relationship exists in many dermatology programs between attendings and residents due to the close-knit nature of dermatology programs. Diagnostic and treatment accuracy may be diminished by the discomfort or disbelief that a condition could affect someone the resident cares about.¹⁰

The American Medical Association also states that a physician can treat family members in an emergency situation or for short-term minor problems. If these 2 exceptions were to be extrapolated to apply to situations involving residents and attendings in addition to family, there would be situations where a dermatology resident could ethically treat their attending physician.¹⁰ If the attending physician was worried about a problem that was deemed potentially life-threatening, such as a rapidly progressive bullous eruption concerning for Stevens-Johnson syndrome following the initiation of a new medication, and they wanted an urgent evaluation and biopsy, an ethicist could argue that urgent treatment is medically indicated as deferring treatment could have negative consequences on the patient’s health. In addition, if the attending found a splinter in their finger following yardwork and needed assistance in removal, this also could be treated by their resident, as it is minimally invasive and has a finite conclusion.

Treating Nonsupervisory Attendings

In the case of performing a TBSE on an attending from another specialty, it would be acceptable and less ethically ambiguous if no close personal relationship existed between the two practitioners, as this patient would have no direct oversight over the resident physician.

Final Thoughts

Each situation that residents face may carry ethical implications with perspectives from the patient, provider, and bystanders. The above scenarios highlight specific instances that a dermatology resident may face and provide insight into how they may approach the situations. At the same time, it is important to remember that every situation is different and requires a unique approach. Fortunately,physicians—specifically dermatologists—are provided many resources to help navigate challenging scenarios.

Acknowledgments—The author thanks Jane M. Grant-Kels, MD (Farmington, Connecticut), for reviewing this paper and providing feedback to improve its content, as well as Warren R. Heymann, MD (Camden, New Jersey), for assisting in the creation of this topic and article.

The years start coming and they don’t stop coming.

Smash Mouth, “All Star”

Dermatologists, similar to everyone else, are subject to the inevitable: aging. More than 80% of the US population develops presbyopia, an age-related reduction in visual acuity, in their lifetime. The most common cause of refractive error in adults, presbyopia can contribute to reduced professional productivity, and individuals with uncorrected presbyopia face an estimated 8-fold increase in difficulty performing demanding near-vision tasks.¹

As specialists who rely heavily on visual assessment, dermatologists likely are aware of presbyopia, seeking care as appropriate; however, visual correction is not one size fits all, and identifying effective job-specific adjustments may require considerable trial and error. To this end, if visual correction may be needed by a large majority of dermatologists at some point, why do we not have specialized recommendations to guide the corrective process according to the individual’s defect and type of practice within the specialty? Do we need resources for dermatologists concerning ophthalmologic wellness and key warning signs of visual acuity deficits and other ocular complications?

These matters are difficult to address, made more so by the lack of data examining correctable visual impairment (CVI) in dermatology. The basis for discussion is clear; however, visual skills are highly relevant to the practice of dermatology, and age-related visual changes often are inevitable. This article will provide an overview of CVI in related disciplines and the importance of understanding CVI and corrective options in dermatology.

CVI Across Medical Disciplines

Other predominantly visual medical specialties such as pathology, radiology, and surgery have initiated research evaluating the impact of CVI on their respective practices, although consistent data still are limited. Much of the work surrounding CVI in medicine can be identified in surgery and its subspecialties. A 2020 study by Tuna et al² found that uncorrected myopia with greater than 1.75 diopter, hyperopia regardless of grade, and presbyopia with greater than 1.25 diopter correlated with reduced surgical performance when using the Da Vinci robotic system. A 2002 report by Wanzel et al³ was among the first of many studies to demonstrate the importance of visuospatial ability in surgical success. In radiology, Krupinski et al⁴ demonstrated reduced accuracy in detecting pulmonary nodules that correlated with increased myopia and decreased accommodation secondary to visual strain.

Most reports examining CVI across medical disciplines are primarily conversational or observational, with some utilizing surveys to assess the prevalence of CVI and the opinions of physicians in the field. For example, in a survey of 93 pathologists in Turkey, 93.5% (87/93) reported at least 1 type of refractive error. Eyeglasses were the most common form of correction (64.5% [60/93]); of those, 33.3% (31/93) reported using eyeglasses during microscopy.⁵

The importance of visual ability in other highly visual specialties suggests that parallels can be drawn to similar practices in dermatology. Detection of cutaneous lesions might be affected by changes in vision, similar to detection of pulmonary lesions in radiology. Likewise, dermatologic surgeons might experience a similar reduction in surgical performance due to impaired visual acuity or visuospatial ability.

The Importance of Visual Performancein Dermatology

With presbyopia often becoming clinically apparent at approximately 40 years of age,^1,6 CVI has the potential to be present for much of a dermatologist’s career. Responsibility falls on the individual practitioner to recognize their visual deficit and seek appropriate optometric or ophthalmologic care. It should be emphasized that there are many effective avenues to correct refractive error, most of which can functionally restore an individual’s vision; however, each option prioritizes different visual attributes (eg, contrast, depth perception, clarity) that have varying degrees of importance in particular areas of dermatologic practice. For example, in addition to visual acuity, dermatologic surgeons might require optimized depth perception, whereas dermatologists performing detailed visual inspection or dermoscopy might instead require optimized contrast sensitivity and acuity. At present, the literature is silent on guiding dermatologists in selecting corrective approaches that enhance the visual characteristics most important for their practice. Lack of research and direction surrounding which visual correction techniques are best suited for individual tasks risks inaccurate and nonspecific conversations with our eye care providers. Focused educated dialogues about visual needs would streamline the process of finding appropriate correction, thereby reducing unnecessary trial and error. As each dermatologic subspecialty might require a unique subset of visual skills, the conceivable benefit of dermatology-specific visual correction resources is evident.

Additionally (although beyond the scope of this commentary), guidance on how a dermatologist should increase their awareness and approach to more serious ophthalmologic conditions—including retinal tear or detachment, age-related macular degeneration, and glaucoma—also would serve as a valuable resource. Overall, prompt identification of visual changes and educated discussions surrounding their correction would allow for optimization based on the required skill set and would improve overall outcomes.

Final Thoughts

Age-related visual changes are a highly prevalent and normal process that carry the potential to impact clinical practice. Fortunately, there are multiple corrective mechanisms that can functionally restore an individual’s eyesight. However, there are no resources to guide dermatologists in seeking specialty-specific correction centered on their daily tasks, which places the responsibility for such correction on the individual. This is a circumstance in which the task at hand is clear, yet we continue to individually reinvent the wheel. We should consider this an opportunity to work together with our optometry and ophthalmology colleagues to create centralized resources that assist dermatologists in navigating age-related visual changes.

Acknowledgments—The authors thank Delaney Stratton, DNP, FNP-BC (Tucson, Arizona); J. Daniel Twelker, OD, PhD (Tucson, Arizona); and Julia Freeman, MD (Pittsburgh, Pennsylvania), for their contributions to the manuscript, as well as Susan M. Swetter, MD (Palo Alto, California) for reviewing and providing feedback.

The years start coming and they don’t stop coming.

Smash Mouth, “All Star”

Dermatologists, similar to everyone else, are subject to the inevitable: aging. More than 80% of the US population develops presbyopia, an age-related reduction in visual acuity, in their lifetime. The most common cause of refractive error in adults, presbyopia can contribute to reduced professional productivity, and individuals with uncorrected presbyopia face an estimated 8-fold increase in difficulty performing demanding near-vision tasks.¹

As specialists who rely heavily on visual assessment, dermatologists likely are aware of presbyopia, seeking care as appropriate; however, visual correction is not one size fits all, and identifying effective job-specific adjustments may require considerable trial and error. To this end, if visual correction may be needed by a large majority of dermatologists at some point, why do we not have specialized recommendations to guide the corrective process according to the individual’s defect and type of practice within the specialty? Do we need resources for dermatologists concerning ophthalmologic wellness and key warning signs of visual acuity deficits and other ocular complications?

These matters are difficult to address, made more so by the lack of data examining correctable visual impairment (CVI) in dermatology. The basis for discussion is clear; however, visual skills are highly relevant to the practice of dermatology, and age-related visual changes often are inevitable. This article will provide an overview of CVI in related disciplines and the importance of understanding CVI and corrective options in dermatology.

CVI Across Medical Disciplines

Other predominantly visual medical specialties such as pathology, radiology, and surgery have initiated research evaluating the impact of CVI on their respective practices, although consistent data still are limited. Much of the work surrounding CVI in medicine can be identified in surgery and its subspecialties. A 2020 study by Tuna et al² found that uncorrected myopia with greater than 1.75 diopter, hyperopia regardless of grade, and presbyopia with greater than 1.25 diopter correlated with reduced surgical performance when using the Da Vinci robotic system. A 2002 report by Wanzel et al³ was among the first of many studies to demonstrate the importance of visuospatial ability in surgical success. In radiology, Krupinski et al⁴ demonstrated reduced accuracy in detecting pulmonary nodules that correlated with increased myopia and decreased accommodation secondary to visual strain.

Most reports examining CVI across medical disciplines are primarily conversational or observational, with some utilizing surveys to assess the prevalence of CVI and the opinions of physicians in the field. For example, in a survey of 93 pathologists in Turkey, 93.5% (87/93) reported at least 1 type of refractive error. Eyeglasses were the most common form of correction (64.5% [60/93]); of those, 33.3% (31/93) reported using eyeglasses during microscopy.⁵

The importance of visual ability in other highly visual specialties suggests that parallels can be drawn to similar practices in dermatology. Detection of cutaneous lesions might be affected by changes in vision, similar to detection of pulmonary lesions in radiology. Likewise, dermatologic surgeons might experience a similar reduction in surgical performance due to impaired visual acuity or visuospatial ability.

The Importance of Visual Performancein Dermatology

With presbyopia often becoming clinically apparent at approximately 40 years of age,^1,6 CVI has the potential to be present for much of a dermatologist’s career. Responsibility falls on the individual practitioner to recognize their visual deficit and seek appropriate optometric or ophthalmologic care. It should be emphasized that there are many effective avenues to correct refractive error, most of which can functionally restore an individual’s vision; however, each option prioritizes different visual attributes (eg, contrast, depth perception, clarity) that have varying degrees of importance in particular areas of dermatologic practice. For example, in addition to visual acuity, dermatologic surgeons might require optimized depth perception, whereas dermatologists performing detailed visual inspection or dermoscopy might instead require optimized contrast sensitivity and acuity. At present, the literature is silent on guiding dermatologists in selecting corrective approaches that enhance the visual characteristics most important for their practice. Lack of research and direction surrounding which visual correction techniques are best suited for individual tasks risks inaccurate and nonspecific conversations with our eye care providers. Focused educated dialogues about visual needs would streamline the process of finding appropriate correction, thereby reducing unnecessary trial and error. As each dermatologic subspecialty might require a unique subset of visual skills, the conceivable benefit of dermatology-specific visual correction resources is evident.

Additionally (although beyond the scope of this commentary), guidance on how a dermatologist should increase their awareness and approach to more serious ophthalmologic conditions—including retinal tear or detachment, age-related macular degeneration, and glaucoma—also would serve as a valuable resource. Overall, prompt identification of visual changes and educated discussions surrounding their correction would allow for optimization based on the required skill set and would improve overall outcomes.

Final Thoughts

Age-related visual changes are a highly prevalent and normal process that carry the potential to impact clinical practice. Fortunately, there are multiple corrective mechanisms that can functionally restore an individual’s eyesight. However, there are no resources to guide dermatologists in seeking specialty-specific correction centered on their daily tasks, which places the responsibility for such correction on the individual. This is a circumstance in which the task at hand is clear, yet we continue to individually reinvent the wheel. We should consider this an opportunity to work together with our optometry and ophthalmology colleagues to create centralized resources that assist dermatologists in navigating age-related visual changes.

Acknowledgments—The authors thank Delaney Stratton, DNP, FNP-BC (Tucson, Arizona); J. Daniel Twelker, OD, PhD (Tucson, Arizona); and Julia Freeman, MD (Pittsburgh, Pennsylvania), for their contributions to the manuscript, as well as Susan M. Swetter, MD (Palo Alto, California) for reviewing and providing feedback.

The years start coming and they don’t stop coming.

Smash Mouth, “All Star”

Dermatologists, similar to everyone else, are subject to the inevitable: aging. More than 80% of the US population develops presbyopia, an age-related reduction in visual acuity, in their lifetime. The most common cause of refractive error in adults, presbyopia can contribute to reduced professional productivity, and individuals with uncorrected presbyopia face an estimated 8-fold increase in difficulty performing demanding near-vision tasks.¹

As specialists who rely heavily on visual assessment, dermatologists likely are aware of presbyopia, seeking care as appropriate; however, visual correction is not one size fits all, and identifying effective job-specific adjustments may require considerable trial and error. To this end, if visual correction may be needed by a large majority of dermatologists at some point, why do we not have specialized recommendations to guide the corrective process according to the individual’s defect and type of practice within the specialty? Do we need resources for dermatologists concerning ophthalmologic wellness and key warning signs of visual acuity deficits and other ocular complications?

These matters are difficult to address, made more so by the lack of data examining correctable visual impairment (CVI) in dermatology. The basis for discussion is clear; however, visual skills are highly relevant to the practice of dermatology, and age-related visual changes often are inevitable. This article will provide an overview of CVI in related disciplines and the importance of understanding CVI and corrective options in dermatology.

CVI Across Medical Disciplines

Other predominantly visual medical specialties such as pathology, radiology, and surgery have initiated research evaluating the impact of CVI on their respective practices, although consistent data still are limited. Much of the work surrounding CVI in medicine can be identified in surgery and its subspecialties. A 2020 study by Tuna et al² found that uncorrected myopia with greater than 1.75 diopter, hyperopia regardless of grade, and presbyopia with greater than 1.25 diopter correlated with reduced surgical performance when using the Da Vinci robotic system. A 2002 report by Wanzel et al³ was among the first of many studies to demonstrate the importance of visuospatial ability in surgical success. In radiology, Krupinski et al⁴ demonstrated reduced accuracy in detecting pulmonary nodules that correlated with increased myopia and decreased accommodation secondary to visual strain.

Most reports examining CVI across medical disciplines are primarily conversational or observational, with some utilizing surveys to assess the prevalence of CVI and the opinions of physicians in the field. For example, in a survey of 93 pathologists in Turkey, 93.5% (87/93) reported at least 1 type of refractive error. Eyeglasses were the most common form of correction (64.5% [60/93]); of those, 33.3% (31/93) reported using eyeglasses during microscopy.⁵

The importance of visual ability in other highly visual specialties suggests that parallels can be drawn to similar practices in dermatology. Detection of cutaneous lesions might be affected by changes in vision, similar to detection of pulmonary lesions in radiology. Likewise, dermatologic surgeons might experience a similar reduction in surgical performance due to impaired visual acuity or visuospatial ability.

The Importance of Visual Performancein Dermatology

With presbyopia often becoming clinically apparent at approximately 40 years of age,^1,6 CVI has the potential to be present for much of a dermatologist’s career. Responsibility falls on the individual practitioner to recognize their visual deficit and seek appropriate optometric or ophthalmologic care. It should be emphasized that there are many effective avenues to correct refractive error, most of which can functionally restore an individual’s vision; however, each option prioritizes different visual attributes (eg, contrast, depth perception, clarity) that have varying degrees of importance in particular areas of dermatologic practice. For example, in addition to visual acuity, dermatologic surgeons might require optimized depth perception, whereas dermatologists performing detailed visual inspection or dermoscopy might instead require optimized contrast sensitivity and acuity. At present, the literature is silent on guiding dermatologists in selecting corrective approaches that enhance the visual characteristics most important for their practice. Lack of research and direction surrounding which visual correction techniques are best suited for individual tasks risks inaccurate and nonspecific conversations with our eye care providers. Focused educated dialogues about visual needs would streamline the process of finding appropriate correction, thereby reducing unnecessary trial and error. As each dermatologic subspecialty might require a unique subset of visual skills, the conceivable benefit of dermatology-specific visual correction resources is evident.

Additionally (although beyond the scope of this commentary), guidance on how a dermatologist should increase their awareness and approach to more serious ophthalmologic conditions—including retinal tear or detachment, age-related macular degeneration, and glaucoma—also would serve as a valuable resource. Overall, prompt identification of visual changes and educated discussions surrounding their correction would allow for optimization based on the required skill set and would improve overall outcomes.

Final Thoughts

Age-related visual changes are a highly prevalent and normal process that carry the potential to impact clinical practice. Fortunately, there are multiple corrective mechanisms that can functionally restore an individual’s eyesight. However, there are no resources to guide dermatologists in seeking specialty-specific correction centered on their daily tasks, which places the responsibility for such correction on the individual. This is a circumstance in which the task at hand is clear, yet we continue to individually reinvent the wheel. We should consider this an opportunity to work together with our optometry and ophthalmology colleagues to create centralized resources that assist dermatologists in navigating age-related visual changes.

Acknowledgments—The authors thank Delaney Stratton, DNP, FNP-BC (Tucson, Arizona); J. Daniel Twelker, OD, PhD (Tucson, Arizona); and Julia Freeman, MD (Pittsburgh, Pennsylvania), for their contributions to the manuscript, as well as Susan M. Swetter, MD (Palo Alto, California) for reviewing and providing feedback.