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SHM Converge: New format, fresh content
While we all long for a traditional in-person meeting “like the good old days”, there are some significant advantages to a virtual meeting like Converge.
The most significant advantage is the ability to review more content than ever before, as we offer a combination of live and recorded “on-demand” sessions. This allows for incredible flexibility in garnering “top-shelf” content from hospital medicine experts around the country, without having to choose from competing sessions. We are especially looking forward to new sessions this year focused on COVID-19; diversity, equity, and inclusion; and resilience.
The Converge conference will still be offering networking sessions throughout – even in the virtual conference environment. We consider networking a vital and endearing part of the value equation for SHM members. For example, we now can participate in several Special Interest Forums, since many of us have several niche interests and want to take advantage of more than one of these networking opportunities. We also carefully preserved the signature “Update in Hospital Medicine” session, as well as the scientific abstract poster reception and the Best of Research and Innovation sessions. These are long-term favorites at the annual conference and lend themselves well to virtual transformation. Some of the workshops and special sessions have exclusive audience engagement and are not offered on demand, so signing up early for these sessions is highly recommended.
SHM remains the professional home for hospitalists, and we rely on the annual conference to keep us all informed on current and forward-thinking clinical practice, practice management, leadership, academics, research, and other topics. This is one of many examples of how SHM has been able to pivot to meet the needs of hospitalists throughout the pandemic. Not only have we successfully converted “traditional” meetings into virtual meetings, but we have been able to curate and deliver content faster and more seamlessly than ever before.
Whether via The Hospitalist, the Journal of Hospital Medicine, the SHM website, or our other educational platforms, SHM has remained committed to being the single “source of truth” for all things hospital medicine. Within the tumultuous political landscape of the past year, the SHM advocacy team has been more active and engaged than ever, in advocating for a myriad of hospitalist-related legislative changes. These are just a few of the ways SHM continues to add value to hospitalist members every day.
Although we will certainly miss seeing each other in person, we are confident that the SHM team will meet and exceed expectations on content delivery and will take advantage of the virtual format to improve content access. We look forward to “seeing” you at SHM Converge this year and hope you take advantage of the enhanced delivery and access to an array of amazing content!
Dr. Scheurer is president of the Society of Hospital Medicine. She is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston.
While we all long for a traditional in-person meeting “like the good old days”, there are some significant advantages to a virtual meeting like Converge.
The most significant advantage is the ability to review more content than ever before, as we offer a combination of live and recorded “on-demand” sessions. This allows for incredible flexibility in garnering “top-shelf” content from hospital medicine experts around the country, without having to choose from competing sessions. We are especially looking forward to new sessions this year focused on COVID-19; diversity, equity, and inclusion; and resilience.
The Converge conference will still be offering networking sessions throughout – even in the virtual conference environment. We consider networking a vital and endearing part of the value equation for SHM members. For example, we now can participate in several Special Interest Forums, since many of us have several niche interests and want to take advantage of more than one of these networking opportunities. We also carefully preserved the signature “Update in Hospital Medicine” session, as well as the scientific abstract poster reception and the Best of Research and Innovation sessions. These are long-term favorites at the annual conference and lend themselves well to virtual transformation. Some of the workshops and special sessions have exclusive audience engagement and are not offered on demand, so signing up early for these sessions is highly recommended.
SHM remains the professional home for hospitalists, and we rely on the annual conference to keep us all informed on current and forward-thinking clinical practice, practice management, leadership, academics, research, and other topics. This is one of many examples of how SHM has been able to pivot to meet the needs of hospitalists throughout the pandemic. Not only have we successfully converted “traditional” meetings into virtual meetings, but we have been able to curate and deliver content faster and more seamlessly than ever before.
Whether via The Hospitalist, the Journal of Hospital Medicine, the SHM website, or our other educational platforms, SHM has remained committed to being the single “source of truth” for all things hospital medicine. Within the tumultuous political landscape of the past year, the SHM advocacy team has been more active and engaged than ever, in advocating for a myriad of hospitalist-related legislative changes. These are just a few of the ways SHM continues to add value to hospitalist members every day.
Although we will certainly miss seeing each other in person, we are confident that the SHM team will meet and exceed expectations on content delivery and will take advantage of the virtual format to improve content access. We look forward to “seeing” you at SHM Converge this year and hope you take advantage of the enhanced delivery and access to an array of amazing content!
Dr. Scheurer is president of the Society of Hospital Medicine. She is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston.
While we all long for a traditional in-person meeting “like the good old days”, there are some significant advantages to a virtual meeting like Converge.
The most significant advantage is the ability to review more content than ever before, as we offer a combination of live and recorded “on-demand” sessions. This allows for incredible flexibility in garnering “top-shelf” content from hospital medicine experts around the country, without having to choose from competing sessions. We are especially looking forward to new sessions this year focused on COVID-19; diversity, equity, and inclusion; and resilience.
The Converge conference will still be offering networking sessions throughout – even in the virtual conference environment. We consider networking a vital and endearing part of the value equation for SHM members. For example, we now can participate in several Special Interest Forums, since many of us have several niche interests and want to take advantage of more than one of these networking opportunities. We also carefully preserved the signature “Update in Hospital Medicine” session, as well as the scientific abstract poster reception and the Best of Research and Innovation sessions. These are long-term favorites at the annual conference and lend themselves well to virtual transformation. Some of the workshops and special sessions have exclusive audience engagement and are not offered on demand, so signing up early for these sessions is highly recommended.
SHM remains the professional home for hospitalists, and we rely on the annual conference to keep us all informed on current and forward-thinking clinical practice, practice management, leadership, academics, research, and other topics. This is one of many examples of how SHM has been able to pivot to meet the needs of hospitalists throughout the pandemic. Not only have we successfully converted “traditional” meetings into virtual meetings, but we have been able to curate and deliver content faster and more seamlessly than ever before.
Whether via The Hospitalist, the Journal of Hospital Medicine, the SHM website, or our other educational platforms, SHM has remained committed to being the single “source of truth” for all things hospital medicine. Within the tumultuous political landscape of the past year, the SHM advocacy team has been more active and engaged than ever, in advocating for a myriad of hospitalist-related legislative changes. These are just a few of the ways SHM continues to add value to hospitalist members every day.
Although we will certainly miss seeing each other in person, we are confident that the SHM team will meet and exceed expectations on content delivery and will take advantage of the virtual format to improve content access. We look forward to “seeing” you at SHM Converge this year and hope you take advantage of the enhanced delivery and access to an array of amazing content!
Dr. Scheurer is president of the Society of Hospital Medicine. She is a hospitalist and chief quality officer, MUSC Health System, Medical University of South Carolina, Charleston.
Endometriosis-associated ovarian cancer
Endometriosis, which affects 1 in 10 women, is one of the most common conditions that gynecologists treat. It is known to cause pain, pelvic adhesive disease, endometriotic cyst formation, and infertility. However, even more sinister, it also increases a woman’s risk for the development of epithelial ovarian cancer (known as endometriosis-associated ovarian cancer or EAOC). A woman with endometriosis has a two- to threefold increased risk of developing epithelial ovarian cancer, compared with nonaffected women.1 This risk appears to be concentrated in the premenopausal age group, particularly the fifth decade of life. After menopause their risk of developing cancer returns to a baseline level.
EAOC classically presents as clear cell or endometrioid adenocarcinomas, rather than high-grade serous carcinomas. However, low-grade serous carcinomas are also frequently observed in this cohort.2,3 Unlike high-grade serous carcinoma, EAOC is more likely to be diagnosed at an early stage, with the majority at stage I or II, and prognosis is better. After matching for age and stage with cases of high-grade serous carcinoma, there is improved disease-free and overall survival observed among cases of EAOC of clear cell and endometrioid histologic cell types.4 The phenomenon of dual primaries (synchronous endometrial and ovarian cancer) occurs more frequently in EAOC than it does in patients with nonendometriosis-related high-grade serous cancer (25% vs. 4%).
The genomics of these endometriosis-associated cancers are quite distinct. Similar to benign endometriosis implants, EAOC is associated with genomic mutations in ARID1A, PIK3CA, and PTEN, as well as progesterone resistance.1,2 Multiple studies have shown that the adjacent eutopic endometrium carries similar gene mutations as those found in both benign endometriotic implants and EAOC.2 This may explain the higher incidence (twofold) of endometrial cancer in patients with endometriosis as well as the increased incidence of dual ovarian and endometrial cancer primaries.
Just as there are multiple theories regarding the mechanism of benign endometriosis, we have theories rather than conclusions regarding the origins of EAOC. One such theory is that it develops from malignant transformation in an existing endometriotic cyst.5 Endometriotic cysts provide an iron-rich environment which promotes reactive oxygen species that promote carcinogenesis by inducing gene mutations and epigenetic alterations. However, if prolonged exposure to oxidative stress within endometriotic cysts were to be the cause for EAOC, we would expect to see a progressively increasing incidence of ovarian cancer over time in patients with expectantly managed cysts. However, in cases of expectant management, an initial, early, increased risk for cancer within the first 5 years is followed by a subsequent decreasing incidence over time.6 This early incidence spike suggests that some endometriotic cysts may have been misclassified as benign, then rapidly declare themselves as malignant during the observation period rather than a transformation into malignancy from a benign endometrioma over time.
An alternative, and favored, theory for the origins of EAOC are that endometrial cells with carcinogenic genomic alterations reflux through the fallopian tubes during menstruation and settle onto the ovarian epithelium which itself is damaged from recent ovulation thus providing an environment that is highly suitable for oncogenesis.2 Genomic analyses of both the eutopic endometrium and malignant cells in patients with EAOC have shown that both tissues contain the same genomic alterations.1 Given that menstruation, including retrograde menstruation, ends after menopause, this mechanism supports the observation that EAOC is predominantly a malignancy of premenopausal women. Additionally, salpingectomy and hysterectomy confers a protective effect on the development of EAOC, theoretically by preventing the retrograde transfer of these mutant progenitor endometrial cells. Furthermore, the factors that increase the number of menstrual cycles (such as an early age of menarche and delayed or nonchildbearing states) increases the risk for EAOC and factors that inhibit menstruation, such as oral contraceptive pill use, appear to decrease its risk.
EAOC most commonly arises in the ovary, and not in the deep endometriosis implants of adjacent pelvic structures (such as the anterior and posterior cul de sac and pelvic peritoneum). It is suggested that the ovary itself provides a uniquely favorable environment for carcinogenesis. As stated above, it is hypothesized that refluxed endometrial cells, carrying important progenitor mutations, may become trapped in the tissues of traumatized ovarian epithelium, ripe with inflammatory changes, post ovulation.2 This microenvironment may promote the development of malignancy.
Given these theories and their supporting evidence, how can we attempt to reduce the incidence of this cancer for our patients with endometriosis? Despite their increased risk for ovarian and endometrial cancers, current recommendations do not support routine cancer screening in women with endometriosis.7 However, risk-mitigation strategies can still be pursued. Hormonal contraceptives to decrease ovulation and menstrual cycling are protective against ovarian cancer and are also helpful in mitigating the symptoms of endometriosis. While removal of endometriotic cysts may not, in and of itself, be a strategy to prevent EAOC, it is still generally recommended because these cysts are commonly a source of pain and infertility. While they do not appear to undergo malignant transformation, it can be difficult to definitively rule out an early ovarian cancer in these complex ovarian cysts, particularly as they are often associated with tumor marker abnormalities such as elevations in CA 125. Therefore, if surgical excision of an endometriotic cyst is not performed, it should be closely followed for at least 5 years to ensure it is a benign structure. If surgery is pursued and ovarian preservation is desired, removal of the fallopian tubes and uterus can help mitigate the risk for EAOC.8
Endometriosis is a morbid condition for many young women. In addition to causing pain and infertility it increases a woman’s risk for ovarian and endometrial cancer, particularly ovarian clear cell, endometrioid, and low-grade serous cancers and synchronous endometrial and ovarian cancers. Endometriotic cysts should be removed or closely monitored, and clinicians should discuss treatment options that minimize frequency of ovulation and menstruation events as a preventative strategy.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Endocrinology. 2019;160(3):626-38.
2. Cancers. 2020;12(6):1676.
3. Lancet Oncol. 2012;13:385-94.
4. Gynecol Oncol. 2014;132(3):760-6.
5. Redox Rep. 2016;21:119-26.
6. Int. J Clin Oncol. 2020;25:51-8.
7. Hum Reprod. 2013;28:1552-68.
8. J Natl Cancer Inst. 2019;111:1097-103.
Endometriosis, which affects 1 in 10 women, is one of the most common conditions that gynecologists treat. It is known to cause pain, pelvic adhesive disease, endometriotic cyst formation, and infertility. However, even more sinister, it also increases a woman’s risk for the development of epithelial ovarian cancer (known as endometriosis-associated ovarian cancer or EAOC). A woman with endometriosis has a two- to threefold increased risk of developing epithelial ovarian cancer, compared with nonaffected women.1 This risk appears to be concentrated in the premenopausal age group, particularly the fifth decade of life. After menopause their risk of developing cancer returns to a baseline level.
EAOC classically presents as clear cell or endometrioid adenocarcinomas, rather than high-grade serous carcinomas. However, low-grade serous carcinomas are also frequently observed in this cohort.2,3 Unlike high-grade serous carcinoma, EAOC is more likely to be diagnosed at an early stage, with the majority at stage I or II, and prognosis is better. After matching for age and stage with cases of high-grade serous carcinoma, there is improved disease-free and overall survival observed among cases of EAOC of clear cell and endometrioid histologic cell types.4 The phenomenon of dual primaries (synchronous endometrial and ovarian cancer) occurs more frequently in EAOC than it does in patients with nonendometriosis-related high-grade serous cancer (25% vs. 4%).
The genomics of these endometriosis-associated cancers are quite distinct. Similar to benign endometriosis implants, EAOC is associated with genomic mutations in ARID1A, PIK3CA, and PTEN, as well as progesterone resistance.1,2 Multiple studies have shown that the adjacent eutopic endometrium carries similar gene mutations as those found in both benign endometriotic implants and EAOC.2 This may explain the higher incidence (twofold) of endometrial cancer in patients with endometriosis as well as the increased incidence of dual ovarian and endometrial cancer primaries.
Just as there are multiple theories regarding the mechanism of benign endometriosis, we have theories rather than conclusions regarding the origins of EAOC. One such theory is that it develops from malignant transformation in an existing endometriotic cyst.5 Endometriotic cysts provide an iron-rich environment which promotes reactive oxygen species that promote carcinogenesis by inducing gene mutations and epigenetic alterations. However, if prolonged exposure to oxidative stress within endometriotic cysts were to be the cause for EAOC, we would expect to see a progressively increasing incidence of ovarian cancer over time in patients with expectantly managed cysts. However, in cases of expectant management, an initial, early, increased risk for cancer within the first 5 years is followed by a subsequent decreasing incidence over time.6 This early incidence spike suggests that some endometriotic cysts may have been misclassified as benign, then rapidly declare themselves as malignant during the observation period rather than a transformation into malignancy from a benign endometrioma over time.
An alternative, and favored, theory for the origins of EAOC are that endometrial cells with carcinogenic genomic alterations reflux through the fallopian tubes during menstruation and settle onto the ovarian epithelium which itself is damaged from recent ovulation thus providing an environment that is highly suitable for oncogenesis.2 Genomic analyses of both the eutopic endometrium and malignant cells in patients with EAOC have shown that both tissues contain the same genomic alterations.1 Given that menstruation, including retrograde menstruation, ends after menopause, this mechanism supports the observation that EAOC is predominantly a malignancy of premenopausal women. Additionally, salpingectomy and hysterectomy confers a protective effect on the development of EAOC, theoretically by preventing the retrograde transfer of these mutant progenitor endometrial cells. Furthermore, the factors that increase the number of menstrual cycles (such as an early age of menarche and delayed or nonchildbearing states) increases the risk for EAOC and factors that inhibit menstruation, such as oral contraceptive pill use, appear to decrease its risk.
EAOC most commonly arises in the ovary, and not in the deep endometriosis implants of adjacent pelvic structures (such as the anterior and posterior cul de sac and pelvic peritoneum). It is suggested that the ovary itself provides a uniquely favorable environment for carcinogenesis. As stated above, it is hypothesized that refluxed endometrial cells, carrying important progenitor mutations, may become trapped in the tissues of traumatized ovarian epithelium, ripe with inflammatory changes, post ovulation.2 This microenvironment may promote the development of malignancy.
Given these theories and their supporting evidence, how can we attempt to reduce the incidence of this cancer for our patients with endometriosis? Despite their increased risk for ovarian and endometrial cancers, current recommendations do not support routine cancer screening in women with endometriosis.7 However, risk-mitigation strategies can still be pursued. Hormonal contraceptives to decrease ovulation and menstrual cycling are protective against ovarian cancer and are also helpful in mitigating the symptoms of endometriosis. While removal of endometriotic cysts may not, in and of itself, be a strategy to prevent EAOC, it is still generally recommended because these cysts are commonly a source of pain and infertility. While they do not appear to undergo malignant transformation, it can be difficult to definitively rule out an early ovarian cancer in these complex ovarian cysts, particularly as they are often associated with tumor marker abnormalities such as elevations in CA 125. Therefore, if surgical excision of an endometriotic cyst is not performed, it should be closely followed for at least 5 years to ensure it is a benign structure. If surgery is pursued and ovarian preservation is desired, removal of the fallopian tubes and uterus can help mitigate the risk for EAOC.8
Endometriosis is a morbid condition for many young women. In addition to causing pain and infertility it increases a woman’s risk for ovarian and endometrial cancer, particularly ovarian clear cell, endometrioid, and low-grade serous cancers and synchronous endometrial and ovarian cancers. Endometriotic cysts should be removed or closely monitored, and clinicians should discuss treatment options that minimize frequency of ovulation and menstruation events as a preventative strategy.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Endocrinology. 2019;160(3):626-38.
2. Cancers. 2020;12(6):1676.
3. Lancet Oncol. 2012;13:385-94.
4. Gynecol Oncol. 2014;132(3):760-6.
5. Redox Rep. 2016;21:119-26.
6. Int. J Clin Oncol. 2020;25:51-8.
7. Hum Reprod. 2013;28:1552-68.
8. J Natl Cancer Inst. 2019;111:1097-103.
Endometriosis, which affects 1 in 10 women, is one of the most common conditions that gynecologists treat. It is known to cause pain, pelvic adhesive disease, endometriotic cyst formation, and infertility. However, even more sinister, it also increases a woman’s risk for the development of epithelial ovarian cancer (known as endometriosis-associated ovarian cancer or EAOC). A woman with endometriosis has a two- to threefold increased risk of developing epithelial ovarian cancer, compared with nonaffected women.1 This risk appears to be concentrated in the premenopausal age group, particularly the fifth decade of life. After menopause their risk of developing cancer returns to a baseline level.
EAOC classically presents as clear cell or endometrioid adenocarcinomas, rather than high-grade serous carcinomas. However, low-grade serous carcinomas are also frequently observed in this cohort.2,3 Unlike high-grade serous carcinoma, EAOC is more likely to be diagnosed at an early stage, with the majority at stage I or II, and prognosis is better. After matching for age and stage with cases of high-grade serous carcinoma, there is improved disease-free and overall survival observed among cases of EAOC of clear cell and endometrioid histologic cell types.4 The phenomenon of dual primaries (synchronous endometrial and ovarian cancer) occurs more frequently in EAOC than it does in patients with nonendometriosis-related high-grade serous cancer (25% vs. 4%).
The genomics of these endometriosis-associated cancers are quite distinct. Similar to benign endometriosis implants, EAOC is associated with genomic mutations in ARID1A, PIK3CA, and PTEN, as well as progesterone resistance.1,2 Multiple studies have shown that the adjacent eutopic endometrium carries similar gene mutations as those found in both benign endometriotic implants and EAOC.2 This may explain the higher incidence (twofold) of endometrial cancer in patients with endometriosis as well as the increased incidence of dual ovarian and endometrial cancer primaries.
Just as there are multiple theories regarding the mechanism of benign endometriosis, we have theories rather than conclusions regarding the origins of EAOC. One such theory is that it develops from malignant transformation in an existing endometriotic cyst.5 Endometriotic cysts provide an iron-rich environment which promotes reactive oxygen species that promote carcinogenesis by inducing gene mutations and epigenetic alterations. However, if prolonged exposure to oxidative stress within endometriotic cysts were to be the cause for EAOC, we would expect to see a progressively increasing incidence of ovarian cancer over time in patients with expectantly managed cysts. However, in cases of expectant management, an initial, early, increased risk for cancer within the first 5 years is followed by a subsequent decreasing incidence over time.6 This early incidence spike suggests that some endometriotic cysts may have been misclassified as benign, then rapidly declare themselves as malignant during the observation period rather than a transformation into malignancy from a benign endometrioma over time.
An alternative, and favored, theory for the origins of EAOC are that endometrial cells with carcinogenic genomic alterations reflux through the fallopian tubes during menstruation and settle onto the ovarian epithelium which itself is damaged from recent ovulation thus providing an environment that is highly suitable for oncogenesis.2 Genomic analyses of both the eutopic endometrium and malignant cells in patients with EAOC have shown that both tissues contain the same genomic alterations.1 Given that menstruation, including retrograde menstruation, ends after menopause, this mechanism supports the observation that EAOC is predominantly a malignancy of premenopausal women. Additionally, salpingectomy and hysterectomy confers a protective effect on the development of EAOC, theoretically by preventing the retrograde transfer of these mutant progenitor endometrial cells. Furthermore, the factors that increase the number of menstrual cycles (such as an early age of menarche and delayed or nonchildbearing states) increases the risk for EAOC and factors that inhibit menstruation, such as oral contraceptive pill use, appear to decrease its risk.
EAOC most commonly arises in the ovary, and not in the deep endometriosis implants of adjacent pelvic structures (such as the anterior and posterior cul de sac and pelvic peritoneum). It is suggested that the ovary itself provides a uniquely favorable environment for carcinogenesis. As stated above, it is hypothesized that refluxed endometrial cells, carrying important progenitor mutations, may become trapped in the tissues of traumatized ovarian epithelium, ripe with inflammatory changes, post ovulation.2 This microenvironment may promote the development of malignancy.
Given these theories and their supporting evidence, how can we attempt to reduce the incidence of this cancer for our patients with endometriosis? Despite their increased risk for ovarian and endometrial cancers, current recommendations do not support routine cancer screening in women with endometriosis.7 However, risk-mitigation strategies can still be pursued. Hormonal contraceptives to decrease ovulation and menstrual cycling are protective against ovarian cancer and are also helpful in mitigating the symptoms of endometriosis. While removal of endometriotic cysts may not, in and of itself, be a strategy to prevent EAOC, it is still generally recommended because these cysts are commonly a source of pain and infertility. While they do not appear to undergo malignant transformation, it can be difficult to definitively rule out an early ovarian cancer in these complex ovarian cysts, particularly as they are often associated with tumor marker abnormalities such as elevations in CA 125. Therefore, if surgical excision of an endometriotic cyst is not performed, it should be closely followed for at least 5 years to ensure it is a benign structure. If surgery is pursued and ovarian preservation is desired, removal of the fallopian tubes and uterus can help mitigate the risk for EAOC.8
Endometriosis is a morbid condition for many young women. In addition to causing pain and infertility it increases a woman’s risk for ovarian and endometrial cancer, particularly ovarian clear cell, endometrioid, and low-grade serous cancers and synchronous endometrial and ovarian cancers. Endometriotic cysts should be removed or closely monitored, and clinicians should discuss treatment options that minimize frequency of ovulation and menstruation events as a preventative strategy.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Endocrinology. 2019;160(3):626-38.
2. Cancers. 2020;12(6):1676.
3. Lancet Oncol. 2012;13:385-94.
4. Gynecol Oncol. 2014;132(3):760-6.
5. Redox Rep. 2016;21:119-26.
6. Int. J Clin Oncol. 2020;25:51-8.
7. Hum Reprod. 2013;28:1552-68.
8. J Natl Cancer Inst. 2019;111:1097-103.
Cellulitis treatment recommendations
He noticed discomfort today and saw that his left lower leg had redness and was warm. He does not recall scratches or injury to his leg. He has not had fever or chills. He has no other symptoms. His diabetes has been well controlled with diet and metformin.
On exam, his blood pressure is 120/70, pulse is 80, temperature is 37 degrees Celsius.
In the left lower extremity, the patient had 1+ edema at the ankle, with a 14-cm x 20-cm warm, erythematous area just above the ankle and extending proximally.
His labs found an HCT of 44 and a WBC of 12,000. What do you recommend?
A) Vascular duplex exam
B) 1st generation cephalosporin
C) 1st generation cephalosporin + TMP/Sulfa
D) Oral clindamycin
E) IV vancomycin
This patient has cellulitis and should receive a beta lactam antibiotic, which will have the best coverage and lowest minimal inhibitory concentration for the likely organism, beta hemolytic streptococci. Clindamycin would likely work, but it has greater side effects. This patient does not need coverage for methicillin-resistant staphylococcus aureus (MRSA). I know many of you, if not most, know this, but I want to go through relevant data and formal recommendations, because of a recent call I received from a patient.
My patient had a full body rash after receiving cephalexin + TMP/sulfa [trimethoprim-sulfamethoxazole] treatment for cellulitis. In recent years the addition of TMP/sulfa to strep treatment to also cover MRSA has become popular, especially in emergency department and urgent care settings.
Moran and colleagues studied cephalexin + TMP/sulfa vs. cephalexin and placebo in patients with uncomplicated cellulitis.1 The outcome measured was clinical cure, and there was no difference between groups; clinical cure occurred in 182 (83.5%) of 218 participants in the cephalexin plus TMP/sulfa group vs. 165 (85.5%) of 193 in the cephalexin group (difference, −2.0%; 95% confidence interval, −9.7% to 5.7%; P = .50).
Jeng and colleagues studied patients admitted for a cellulitis, and evaluated the patients’ response to beta-lactam antibiotics.2 Patients had acute and convalescent serologies for beta hemolytic strep. Almost all evaluable patients with positive strep studies (97%) responded to beta-lactams, and 21 of 23 (91%) with negative studies responded to beta-lactams (overall response rate 95%). This study was done during a time of high MRSA prevalence.
The most recent Infectious Diseases Society of America guidelines for skin and soft tissue infections, recommend oral penicillin, cephalexin, dicloxacillin, or clindamycin for mild cellulitis, and IV equivalent if patients have moderate cellulitis.3 If abscesses are present, then drainage is recommended and MRSA coverage. Kamath and colleagues reported on how closely guidelines for skin and soft tissue infections were followed.4 In patients with mild cellulitis, only 36% received guideline-suggested antibiotics. The most common antibiotic prescribed that was outside the guidelines was trimethoprim-sulfamethoxazole.
Myth: Cellulitis treatment should include MRSA coverage.
My advice: Stick with beta-lactam antibiotics, unless an abscess is present. There is no need to add MRSA coverage for initial treatment of mild to moderate cellulitis.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Moran GJ et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs. cephalexin alone on clinical cure of uncomplicated cellulitis: A randomized clinical trial. JAMA 2017 May 23;317(20):2088-96.
2. Jeng Arthur et al. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis. Medicine. 2010;July;89(4):217-26.
3. Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52.
4. Kamath RS et al. Guidelines vs. actual management of skin and soft tissue infections in the emergency department. Open Forum Infect Dis. 2018 Jan 12;5(1):ofx188.
He noticed discomfort today and saw that his left lower leg had redness and was warm. He does not recall scratches or injury to his leg. He has not had fever or chills. He has no other symptoms. His diabetes has been well controlled with diet and metformin.
On exam, his blood pressure is 120/70, pulse is 80, temperature is 37 degrees Celsius.
In the left lower extremity, the patient had 1+ edema at the ankle, with a 14-cm x 20-cm warm, erythematous area just above the ankle and extending proximally.
His labs found an HCT of 44 and a WBC of 12,000. What do you recommend?
A) Vascular duplex exam
B) 1st generation cephalosporin
C) 1st generation cephalosporin + TMP/Sulfa
D) Oral clindamycin
E) IV vancomycin
This patient has cellulitis and should receive a beta lactam antibiotic, which will have the best coverage and lowest minimal inhibitory concentration for the likely organism, beta hemolytic streptococci. Clindamycin would likely work, but it has greater side effects. This patient does not need coverage for methicillin-resistant staphylococcus aureus (MRSA). I know many of you, if not most, know this, but I want to go through relevant data and formal recommendations, because of a recent call I received from a patient.
My patient had a full body rash after receiving cephalexin + TMP/sulfa [trimethoprim-sulfamethoxazole] treatment for cellulitis. In recent years the addition of TMP/sulfa to strep treatment to also cover MRSA has become popular, especially in emergency department and urgent care settings.
Moran and colleagues studied cephalexin + TMP/sulfa vs. cephalexin and placebo in patients with uncomplicated cellulitis.1 The outcome measured was clinical cure, and there was no difference between groups; clinical cure occurred in 182 (83.5%) of 218 participants in the cephalexin plus TMP/sulfa group vs. 165 (85.5%) of 193 in the cephalexin group (difference, −2.0%; 95% confidence interval, −9.7% to 5.7%; P = .50).
Jeng and colleagues studied patients admitted for a cellulitis, and evaluated the patients’ response to beta-lactam antibiotics.2 Patients had acute and convalescent serologies for beta hemolytic strep. Almost all evaluable patients with positive strep studies (97%) responded to beta-lactams, and 21 of 23 (91%) with negative studies responded to beta-lactams (overall response rate 95%). This study was done during a time of high MRSA prevalence.
The most recent Infectious Diseases Society of America guidelines for skin and soft tissue infections, recommend oral penicillin, cephalexin, dicloxacillin, or clindamycin for mild cellulitis, and IV equivalent if patients have moderate cellulitis.3 If abscesses are present, then drainage is recommended and MRSA coverage. Kamath and colleagues reported on how closely guidelines for skin and soft tissue infections were followed.4 In patients with mild cellulitis, only 36% received guideline-suggested antibiotics. The most common antibiotic prescribed that was outside the guidelines was trimethoprim-sulfamethoxazole.
Myth: Cellulitis treatment should include MRSA coverage.
My advice: Stick with beta-lactam antibiotics, unless an abscess is present. There is no need to add MRSA coverage for initial treatment of mild to moderate cellulitis.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Moran GJ et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs. cephalexin alone on clinical cure of uncomplicated cellulitis: A randomized clinical trial. JAMA 2017 May 23;317(20):2088-96.
2. Jeng Arthur et al. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis. Medicine. 2010;July;89(4):217-26.
3. Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52.
4. Kamath RS et al. Guidelines vs. actual management of skin and soft tissue infections in the emergency department. Open Forum Infect Dis. 2018 Jan 12;5(1):ofx188.
He noticed discomfort today and saw that his left lower leg had redness and was warm. He does not recall scratches or injury to his leg. He has not had fever or chills. He has no other symptoms. His diabetes has been well controlled with diet and metformin.
On exam, his blood pressure is 120/70, pulse is 80, temperature is 37 degrees Celsius.
In the left lower extremity, the patient had 1+ edema at the ankle, with a 14-cm x 20-cm warm, erythematous area just above the ankle and extending proximally.
His labs found an HCT of 44 and a WBC of 12,000. What do you recommend?
A) Vascular duplex exam
B) 1st generation cephalosporin
C) 1st generation cephalosporin + TMP/Sulfa
D) Oral clindamycin
E) IV vancomycin
This patient has cellulitis and should receive a beta lactam antibiotic, which will have the best coverage and lowest minimal inhibitory concentration for the likely organism, beta hemolytic streptococci. Clindamycin would likely work, but it has greater side effects. This patient does not need coverage for methicillin-resistant staphylococcus aureus (MRSA). I know many of you, if not most, know this, but I want to go through relevant data and formal recommendations, because of a recent call I received from a patient.
My patient had a full body rash after receiving cephalexin + TMP/sulfa [trimethoprim-sulfamethoxazole] treatment for cellulitis. In recent years the addition of TMP/sulfa to strep treatment to also cover MRSA has become popular, especially in emergency department and urgent care settings.
Moran and colleagues studied cephalexin + TMP/sulfa vs. cephalexin and placebo in patients with uncomplicated cellulitis.1 The outcome measured was clinical cure, and there was no difference between groups; clinical cure occurred in 182 (83.5%) of 218 participants in the cephalexin plus TMP/sulfa group vs. 165 (85.5%) of 193 in the cephalexin group (difference, −2.0%; 95% confidence interval, −9.7% to 5.7%; P = .50).
Jeng and colleagues studied patients admitted for a cellulitis, and evaluated the patients’ response to beta-lactam antibiotics.2 Patients had acute and convalescent serologies for beta hemolytic strep. Almost all evaluable patients with positive strep studies (97%) responded to beta-lactams, and 21 of 23 (91%) with negative studies responded to beta-lactams (overall response rate 95%). This study was done during a time of high MRSA prevalence.
The most recent Infectious Diseases Society of America guidelines for skin and soft tissue infections, recommend oral penicillin, cephalexin, dicloxacillin, or clindamycin for mild cellulitis, and IV equivalent if patients have moderate cellulitis.3 If abscesses are present, then drainage is recommended and MRSA coverage. Kamath and colleagues reported on how closely guidelines for skin and soft tissue infections were followed.4 In patients with mild cellulitis, only 36% received guideline-suggested antibiotics. The most common antibiotic prescribed that was outside the guidelines was trimethoprim-sulfamethoxazole.
Myth: Cellulitis treatment should include MRSA coverage.
My advice: Stick with beta-lactam antibiotics, unless an abscess is present. There is no need to add MRSA coverage for initial treatment of mild to moderate cellulitis.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Moran GJ et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs. cephalexin alone on clinical cure of uncomplicated cellulitis: A randomized clinical trial. JAMA 2017 May 23;317(20):2088-96.
2. Jeng Arthur et al. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis. Medicine. 2010;July;89(4):217-26.
3. Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52.
4. Kamath RS et al. Guidelines vs. actual management of skin and soft tissue infections in the emergency department. Open Forum Infect Dis. 2018 Jan 12;5(1):ofx188.
Medicaid and access to dermatologists
Recently, an interview titled “Dermatology a bellwether of health inequities during COVID-19,” was published by the AMA. In my opinion, the interview was largely accurate, but I took issue with the following statement in the article: “Dermatology is a lucrative specialty, and many dermatologists do not accept Medicaid.”
To me, this implies that physicians are to blame for poor health care access, which drives me insane. Dermatology is not a particularly lucrative specialty; it ranked 13th in a recent survey from the professional medical network Doximity. Furthermore, if payment for practice expense is removed, dermatology drops much further down, close to primary care.
There is a fundamental misunderstanding by the public and legislators about physician incomes. The reimbursements that are reported by Medicare for example, include the practice expense cost, which for dermatology is about 60% of the total remitted to the doctor, as I wrote in a 2015 column.
That is, the cost of providing the facility, supplies, staff, rent, and utilities are included in “reimbursement,” though this is money that goes out the door to pay the bills as quickly as it comes in. This is for overhead, nothing here for the practitioner’s time and work.
Even when dermatologists perform hospital consults, they usually bring their own supply kit from their office for skin biopsies, or other procedures since these are impossible to find in a hospital.
I also pointed out in my earlier column that most other specialties do not provide the majority of their procedures in the office, but instead, use the hospital, which provides supplies and staff for procedures. These other specialists are to be lauded for providing their services at charity rates, or for no pay at all, but at least they do not have to pay for the building, equipment, supplies, and staff out of pocket. Dermatologists do, since in a sense, they run their own “hospitals” as almost all of their procedures are based out of their offices.
The economics of a patient visit
I do not dispute that it is more difficult for a Medicaid patient to get an appointment with a dermatologist than it is for a patient with private insurance, but this is because Medicaid often pays less than the cost of supplies to see them. It is also easier to get an appointment for a cosmetic procedure than a rash because reimbursements in general are artificially suppressed, even for Medicare (which is also the benchmark for private insurers) by the federal government. Medicare reimbursements have not kept pace with inflation and are about 53% less than they were in 1992.
Let’s look at a skin biopsy. The supplies and equipment to perform a skin biopsy cost over $50. In Ohio, Medicare pays $96.19 for a skin biopsy. Medicaid pays $47.20. That’s correct: less than the cost of supplies and overhead. So, a private practitioner not only provides the service for free, but loses money on every visit that involves a skin biopsy. When I talk to legislators, I liken this to my standing in front of my office and handing out $5 bills. In Ohio, Medicare pays $105.04 for a level 3 office visit. Medicaid pays $57.76. Medicare overhead on a level 3 office visit is again about 50%, so the office visit is about a break-even proposition, if you donate your time.
Academic medical centers can charge additional facility fees, and some receive subsidies from the city and county to treat indigent patients, and are often obligated to see all. Most hospitals with high Medicaid and indigent patient loads pay their surgical specialists to take call at their emergency rooms and often subsidize their emergency room doctors as well.
I agree that dermatology is an important specialty to have access to in the COVID-19 pandemic. I agree that patients of color may be disproportionately impacted because they may be covered by Medicaid more often, or have no insurance at all. The finger of blame, however, should be squarely pointed at politicians who have woefully underfunded Medicaid reimbursement rates, as well as payments for physicians under the Affordable Care Act, while thumping their chests and boasting how they have provided health care to millions. I think this was eloquently demonstrated when as part of the “deal” Congress made with the AMA to get the ACA passed, Congress agreed to pay primary care physicians (but only primary care) Medicare rates for Medicaid patients for 2 years.
Some states have continued to pay enhanced Medicaid rates and have fewer Medicaid patient access issues.
Most convincing, perhaps, are the states that pay Medicare rates or better for their Medicaid enrollees, for example Alaska and Montana. In these states, you will not have access to care issues beyond the actual human shortage of physicians in remote areas.
So, in conclusion, I maintain that dermatology is not a particularly lucrative specialty, once the overhead expense payments are removed, and further argue, that even if it were, why does that obligate us to provide care to insurance plans at a loss? Medicaid access to dermatologists is a government economic issue, not a physician ethical one. Most Americans get to pick the charities they choose to donate to.
The federal government would love to force all physicians into a plan where you must see patients at their chosen rates or see no patients at all. Look no further than our Canadian neighbors, where long wait times to see specialists are legendary. It has been reported that there are only six to seven hundred dermatologists in all of Canada to serve 30 million people.
So, when the topic of poor patient access to care for the Medicaid enrollee or indigent comes up, stand tall and point your finger to your state capital. That is where the blame lies.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Recently, an interview titled “Dermatology a bellwether of health inequities during COVID-19,” was published by the AMA. In my opinion, the interview was largely accurate, but I took issue with the following statement in the article: “Dermatology is a lucrative specialty, and many dermatologists do not accept Medicaid.”
To me, this implies that physicians are to blame for poor health care access, which drives me insane. Dermatology is not a particularly lucrative specialty; it ranked 13th in a recent survey from the professional medical network Doximity. Furthermore, if payment for practice expense is removed, dermatology drops much further down, close to primary care.
There is a fundamental misunderstanding by the public and legislators about physician incomes. The reimbursements that are reported by Medicare for example, include the practice expense cost, which for dermatology is about 60% of the total remitted to the doctor, as I wrote in a 2015 column.
That is, the cost of providing the facility, supplies, staff, rent, and utilities are included in “reimbursement,” though this is money that goes out the door to pay the bills as quickly as it comes in. This is for overhead, nothing here for the practitioner’s time and work.
Even when dermatologists perform hospital consults, they usually bring their own supply kit from their office for skin biopsies, or other procedures since these are impossible to find in a hospital.
I also pointed out in my earlier column that most other specialties do not provide the majority of their procedures in the office, but instead, use the hospital, which provides supplies and staff for procedures. These other specialists are to be lauded for providing their services at charity rates, or for no pay at all, but at least they do not have to pay for the building, equipment, supplies, and staff out of pocket. Dermatologists do, since in a sense, they run their own “hospitals” as almost all of their procedures are based out of their offices.
The economics of a patient visit
I do not dispute that it is more difficult for a Medicaid patient to get an appointment with a dermatologist than it is for a patient with private insurance, but this is because Medicaid often pays less than the cost of supplies to see them. It is also easier to get an appointment for a cosmetic procedure than a rash because reimbursements in general are artificially suppressed, even for Medicare (which is also the benchmark for private insurers) by the federal government. Medicare reimbursements have not kept pace with inflation and are about 53% less than they were in 1992.
Let’s look at a skin biopsy. The supplies and equipment to perform a skin biopsy cost over $50. In Ohio, Medicare pays $96.19 for a skin biopsy. Medicaid pays $47.20. That’s correct: less than the cost of supplies and overhead. So, a private practitioner not only provides the service for free, but loses money on every visit that involves a skin biopsy. When I talk to legislators, I liken this to my standing in front of my office and handing out $5 bills. In Ohio, Medicare pays $105.04 for a level 3 office visit. Medicaid pays $57.76. Medicare overhead on a level 3 office visit is again about 50%, so the office visit is about a break-even proposition, if you donate your time.
Academic medical centers can charge additional facility fees, and some receive subsidies from the city and county to treat indigent patients, and are often obligated to see all. Most hospitals with high Medicaid and indigent patient loads pay their surgical specialists to take call at their emergency rooms and often subsidize their emergency room doctors as well.
I agree that dermatology is an important specialty to have access to in the COVID-19 pandemic. I agree that patients of color may be disproportionately impacted because they may be covered by Medicaid more often, or have no insurance at all. The finger of blame, however, should be squarely pointed at politicians who have woefully underfunded Medicaid reimbursement rates, as well as payments for physicians under the Affordable Care Act, while thumping their chests and boasting how they have provided health care to millions. I think this was eloquently demonstrated when as part of the “deal” Congress made with the AMA to get the ACA passed, Congress agreed to pay primary care physicians (but only primary care) Medicare rates for Medicaid patients for 2 years.
Some states have continued to pay enhanced Medicaid rates and have fewer Medicaid patient access issues.
Most convincing, perhaps, are the states that pay Medicare rates or better for their Medicaid enrollees, for example Alaska and Montana. In these states, you will not have access to care issues beyond the actual human shortage of physicians in remote areas.
So, in conclusion, I maintain that dermatology is not a particularly lucrative specialty, once the overhead expense payments are removed, and further argue, that even if it were, why does that obligate us to provide care to insurance plans at a loss? Medicaid access to dermatologists is a government economic issue, not a physician ethical one. Most Americans get to pick the charities they choose to donate to.
The federal government would love to force all physicians into a plan where you must see patients at their chosen rates or see no patients at all. Look no further than our Canadian neighbors, where long wait times to see specialists are legendary. It has been reported that there are only six to seven hundred dermatologists in all of Canada to serve 30 million people.
So, when the topic of poor patient access to care for the Medicaid enrollee or indigent comes up, stand tall and point your finger to your state capital. That is where the blame lies.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Recently, an interview titled “Dermatology a bellwether of health inequities during COVID-19,” was published by the AMA. In my opinion, the interview was largely accurate, but I took issue with the following statement in the article: “Dermatology is a lucrative specialty, and many dermatologists do not accept Medicaid.”
To me, this implies that physicians are to blame for poor health care access, which drives me insane. Dermatology is not a particularly lucrative specialty; it ranked 13th in a recent survey from the professional medical network Doximity. Furthermore, if payment for practice expense is removed, dermatology drops much further down, close to primary care.
There is a fundamental misunderstanding by the public and legislators about physician incomes. The reimbursements that are reported by Medicare for example, include the practice expense cost, which for dermatology is about 60% of the total remitted to the doctor, as I wrote in a 2015 column.
That is, the cost of providing the facility, supplies, staff, rent, and utilities are included in “reimbursement,” though this is money that goes out the door to pay the bills as quickly as it comes in. This is for overhead, nothing here for the practitioner’s time and work.
Even when dermatologists perform hospital consults, they usually bring their own supply kit from their office for skin biopsies, or other procedures since these are impossible to find in a hospital.
I also pointed out in my earlier column that most other specialties do not provide the majority of their procedures in the office, but instead, use the hospital, which provides supplies and staff for procedures. These other specialists are to be lauded for providing their services at charity rates, or for no pay at all, but at least they do not have to pay for the building, equipment, supplies, and staff out of pocket. Dermatologists do, since in a sense, they run their own “hospitals” as almost all of their procedures are based out of their offices.
The economics of a patient visit
I do not dispute that it is more difficult for a Medicaid patient to get an appointment with a dermatologist than it is for a patient with private insurance, but this is because Medicaid often pays less than the cost of supplies to see them. It is also easier to get an appointment for a cosmetic procedure than a rash because reimbursements in general are artificially suppressed, even for Medicare (which is also the benchmark for private insurers) by the federal government. Medicare reimbursements have not kept pace with inflation and are about 53% less than they were in 1992.
Let’s look at a skin biopsy. The supplies and equipment to perform a skin biopsy cost over $50. In Ohio, Medicare pays $96.19 for a skin biopsy. Medicaid pays $47.20. That’s correct: less than the cost of supplies and overhead. So, a private practitioner not only provides the service for free, but loses money on every visit that involves a skin biopsy. When I talk to legislators, I liken this to my standing in front of my office and handing out $5 bills. In Ohio, Medicare pays $105.04 for a level 3 office visit. Medicaid pays $57.76. Medicare overhead on a level 3 office visit is again about 50%, so the office visit is about a break-even proposition, if you donate your time.
Academic medical centers can charge additional facility fees, and some receive subsidies from the city and county to treat indigent patients, and are often obligated to see all. Most hospitals with high Medicaid and indigent patient loads pay their surgical specialists to take call at their emergency rooms and often subsidize their emergency room doctors as well.
I agree that dermatology is an important specialty to have access to in the COVID-19 pandemic. I agree that patients of color may be disproportionately impacted because they may be covered by Medicaid more often, or have no insurance at all. The finger of blame, however, should be squarely pointed at politicians who have woefully underfunded Medicaid reimbursement rates, as well as payments for physicians under the Affordable Care Act, while thumping their chests and boasting how they have provided health care to millions. I think this was eloquently demonstrated when as part of the “deal” Congress made with the AMA to get the ACA passed, Congress agreed to pay primary care physicians (but only primary care) Medicare rates for Medicaid patients for 2 years.
Some states have continued to pay enhanced Medicaid rates and have fewer Medicaid patient access issues.
Most convincing, perhaps, are the states that pay Medicare rates or better for their Medicaid enrollees, for example Alaska and Montana. In these states, you will not have access to care issues beyond the actual human shortage of physicians in remote areas.
So, in conclusion, I maintain that dermatology is not a particularly lucrative specialty, once the overhead expense payments are removed, and further argue, that even if it were, why does that obligate us to provide care to insurance plans at a loss? Medicaid access to dermatologists is a government economic issue, not a physician ethical one. Most Americans get to pick the charities they choose to donate to.
The federal government would love to force all physicians into a plan where you must see patients at their chosen rates or see no patients at all. Look no further than our Canadian neighbors, where long wait times to see specialists are legendary. It has been reported that there are only six to seven hundred dermatologists in all of Canada to serve 30 million people.
So, when the topic of poor patient access to care for the Medicaid enrollee or indigent comes up, stand tall and point your finger to your state capital. That is where the blame lies.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Victorious endurance: To pass the breaking point and not break
I’ve been thinking a lot about endurance recently.
COVID-19 is surging in the United States. Health care workers exhausted from the first and second waves are quickly reaching the verge of collapse. I’m seeing more and more heartbreaking articles about the bone-deep fatigue, fear, and frustration health care workers are facing, and I weep. As horrible as it is to be fighting this terrifying, little-understood, invisible virus, health care workers are also fighting an equally distressing war against misinformation, recklessness, apathy, and outright denial.
As if that wasn’t enough, we are also dealing with racial and social unrest not seen in decades. The most significant cultural divisions and political animosity perhaps since the Civil War. A contested election. The fraying of our democratic institutions and our standing in the global community. The weakest economy since the Great Depression. Record unemployment. Many individuals and families facing or already experiencing eviction and food insecurity. Record-setting fires, hurricanes, and other natural disasters that are only projected to intensify due to climate change.
That’s a lot to endure. And we don’t have much choice other than to live through it. Some of us will break under the strain; others will disengage by giving up clinical work or even leaving health care altogether. Some of us will pack it in and retire, walk away from relationships with family members or longtime friends, or even emigrate to another country (New Zealand, anyone?). Some of us will passively hunker down, letting the challenges of this time overwhelm us and just hoping we can hang on long enough to emerge, albeit beaten and scarred, on the other side.
But some of us will experience victorious endurance – the kind that doesn’t just accept suffering but finds a way to triumph over it. I came across the concept of victorious endurance in the Bible, but its origin is earlier, from classical Greece. It comes from the ancient Greek word hupomone, which literally means “abiding under” – as in disciplining oneself to bear up under a trial when one would more naturally rebel, or just give up. The ancient Greeks were big on virtues like self-control, long-suffering, and perseverance in the face of seemingly insurmountable difficulties; Odysseus was a poster child for hupomone. I believe the concept of victorious endurance can be applicable for people across many belief systems, philosophies, and ways of life.
The late William Barclay, former professor of divinity and biblical criticism at the University of Glasgow, Scotland, said of hupomone:
It is untranslatable. It does not describe the frame of mind which can sit down with folded hands and bowed head and let a torrent of troubles sweep over it in passive resignation. It describes the ability to bear things in such a triumphant way that it transfigures them. Chrysostom has a great panegyric on this hupomone. He calls it “the root of all goods, the mother of piety, the fruit that never withers, a fortress that is never taken, a harbour that knows no storms” and “the queen of virtues, the foundation of right actions, peace in war, calm in tempest, security in plots.” It is the courageous and triumphant ability to pass the breaking-point and not to break and always to greet the unseen with a cheer. It is the alchemy which transmutes tribulation into strength and glory.
Barclay further noted that “Cicero defines patientia, its Latin equivalent, as: ‘The voluntary and daily suffering of hard and difficult things, for the sake of honour and usefulness.”
In the midst of the most challenging public health emergency of our lifetimes, I am seeing hospitalists – and nurses, respiratory therapists, and countless other health care workers – doing exactly this, every day. I’m so incredibly proud of you all, and thankful beyond words.
I doubt that victorious endurance comes naturally to any of us; it’s something we work at, pursue and nurture. What’s the secret to cultivating victorious endurance in the midst of unimaginable stress? I’m pretty sure there’s no specific formula. I don’t mean to sound like a Pollyanna or to make light of the tumult and turmoil of these times, but here are a few things that, based on my own experiences, may help cultivate this valuable virtue.
Be part of a support network. In the midst of great stress, and especially during this time of social distancing, it’s especially tempting to just hunker down, close in on ourselves, and shut others out – sometimes even our closest friends and loved ones. Maintaining relationships is just too exhausting. But you need people who can come alongside you and offer words of encouragement when you are at your lowest. And there’s nothing that will bring out the best in you like being there to encourage and support someone else. We all need to both receive and to give emotional support at a time like this.
Take the long view. When we’re in the middle of a serious crisis, it seems like the problems we’re facing will last forever. There’s no light at the end of the tunnel, no port in the storm. But even this pandemic won’t last forever. If we can keep in mind the fact that things will eventually get better and that the current situation isn’t permanent, it can help us maintain our perspective and have more patience with the current dysfunction.
Focus on who you want to be in this moment. This is the hardest time most of us have ever lived through, both professionally and personally. But let me throw you a challenge. When you look back on this time from the perspective of five years from now, or maybe ten, how will you want to remember yourself? Who will you want to have been during this time? Looking back, what will make you proud of how you handled this challenge? Be that person.
Look for things to be thankful for. In the midst of the chaos that is our lives and our work right now, I believe we can still occasionally see moments of grace if we keep our eyes open for them. If we aren’t looking for them, we may miss them entirely. And those small moments of love, touches of compassion, displays of selflessness, and even flashes of victorious endurance in yourself or others are gifts to be treasured and held on to – to give thanks for.
Embrace a cause greater than yourself. May I suggest that one thing that might help our efforts to cultivate the virtue of victorious endurance during difficult times might be to embrace a cause that is bigger than yourself; that is, one that lures you to focus beyond your immediate circumstances? What are you passionate about, outside of your life’s normal routine?
If you don’t have a passion, consider what you might become passionate about, with a little effort. For some of us, like me, this will be our faith in God. For others it may be advocating for an end to racism or for broader social justice issues. Maybe it’s working to overcome our cultural and political divisions or to strengthen the institutions of our democracy. Perhaps it’s getting involved with efforts to mitigate climate change. Maybe it’s reaching out to the homeless or hungry in your own community or mentoring a child who is being left behind by the demands of remote learning.
Or perhaps what you embrace is even closer to home: maybe it’s working to eliminate health disparities in your institution or health system, or figuring out how to use technology and resources differently to improve how care is being delivered during or after this pandemic. Maybe it’s as simple as re-committing yourself to personally care for every patient you see today with the very best you have to offer, and with patience, compassion, and grace.
Find something that sets your heart on fire. Something that makes you want to take this difficult time and “transmute tribulation into strength and glory.” Something that, when you look back on these days, will make you thankful that you didn’t just hunker down and subsist through them. Instead, you accomplished great things; you learned; you contributed; and you grew stronger and better.
That’s victorious endurance.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey. This essay was published initially on The Hospital Leader, the official blog of SHM.
I’ve been thinking a lot about endurance recently.
COVID-19 is surging in the United States. Health care workers exhausted from the first and second waves are quickly reaching the verge of collapse. I’m seeing more and more heartbreaking articles about the bone-deep fatigue, fear, and frustration health care workers are facing, and I weep. As horrible as it is to be fighting this terrifying, little-understood, invisible virus, health care workers are also fighting an equally distressing war against misinformation, recklessness, apathy, and outright denial.
As if that wasn’t enough, we are also dealing with racial and social unrest not seen in decades. The most significant cultural divisions and political animosity perhaps since the Civil War. A contested election. The fraying of our democratic institutions and our standing in the global community. The weakest economy since the Great Depression. Record unemployment. Many individuals and families facing or already experiencing eviction and food insecurity. Record-setting fires, hurricanes, and other natural disasters that are only projected to intensify due to climate change.
That’s a lot to endure. And we don’t have much choice other than to live through it. Some of us will break under the strain; others will disengage by giving up clinical work or even leaving health care altogether. Some of us will pack it in and retire, walk away from relationships with family members or longtime friends, or even emigrate to another country (New Zealand, anyone?). Some of us will passively hunker down, letting the challenges of this time overwhelm us and just hoping we can hang on long enough to emerge, albeit beaten and scarred, on the other side.
But some of us will experience victorious endurance – the kind that doesn’t just accept suffering but finds a way to triumph over it. I came across the concept of victorious endurance in the Bible, but its origin is earlier, from classical Greece. It comes from the ancient Greek word hupomone, which literally means “abiding under” – as in disciplining oneself to bear up under a trial when one would more naturally rebel, or just give up. The ancient Greeks were big on virtues like self-control, long-suffering, and perseverance in the face of seemingly insurmountable difficulties; Odysseus was a poster child for hupomone. I believe the concept of victorious endurance can be applicable for people across many belief systems, philosophies, and ways of life.
The late William Barclay, former professor of divinity and biblical criticism at the University of Glasgow, Scotland, said of hupomone:
It is untranslatable. It does not describe the frame of mind which can sit down with folded hands and bowed head and let a torrent of troubles sweep over it in passive resignation. It describes the ability to bear things in such a triumphant way that it transfigures them. Chrysostom has a great panegyric on this hupomone. He calls it “the root of all goods, the mother of piety, the fruit that never withers, a fortress that is never taken, a harbour that knows no storms” and “the queen of virtues, the foundation of right actions, peace in war, calm in tempest, security in plots.” It is the courageous and triumphant ability to pass the breaking-point and not to break and always to greet the unseen with a cheer. It is the alchemy which transmutes tribulation into strength and glory.
Barclay further noted that “Cicero defines patientia, its Latin equivalent, as: ‘The voluntary and daily suffering of hard and difficult things, for the sake of honour and usefulness.”
In the midst of the most challenging public health emergency of our lifetimes, I am seeing hospitalists – and nurses, respiratory therapists, and countless other health care workers – doing exactly this, every day. I’m so incredibly proud of you all, and thankful beyond words.
I doubt that victorious endurance comes naturally to any of us; it’s something we work at, pursue and nurture. What’s the secret to cultivating victorious endurance in the midst of unimaginable stress? I’m pretty sure there’s no specific formula. I don’t mean to sound like a Pollyanna or to make light of the tumult and turmoil of these times, but here are a few things that, based on my own experiences, may help cultivate this valuable virtue.
Be part of a support network. In the midst of great stress, and especially during this time of social distancing, it’s especially tempting to just hunker down, close in on ourselves, and shut others out – sometimes even our closest friends and loved ones. Maintaining relationships is just too exhausting. But you need people who can come alongside you and offer words of encouragement when you are at your lowest. And there’s nothing that will bring out the best in you like being there to encourage and support someone else. We all need to both receive and to give emotional support at a time like this.
Take the long view. When we’re in the middle of a serious crisis, it seems like the problems we’re facing will last forever. There’s no light at the end of the tunnel, no port in the storm. But even this pandemic won’t last forever. If we can keep in mind the fact that things will eventually get better and that the current situation isn’t permanent, it can help us maintain our perspective and have more patience with the current dysfunction.
Focus on who you want to be in this moment. This is the hardest time most of us have ever lived through, both professionally and personally. But let me throw you a challenge. When you look back on this time from the perspective of five years from now, or maybe ten, how will you want to remember yourself? Who will you want to have been during this time? Looking back, what will make you proud of how you handled this challenge? Be that person.
Look for things to be thankful for. In the midst of the chaos that is our lives and our work right now, I believe we can still occasionally see moments of grace if we keep our eyes open for them. If we aren’t looking for them, we may miss them entirely. And those small moments of love, touches of compassion, displays of selflessness, and even flashes of victorious endurance in yourself or others are gifts to be treasured and held on to – to give thanks for.
Embrace a cause greater than yourself. May I suggest that one thing that might help our efforts to cultivate the virtue of victorious endurance during difficult times might be to embrace a cause that is bigger than yourself; that is, one that lures you to focus beyond your immediate circumstances? What are you passionate about, outside of your life’s normal routine?
If you don’t have a passion, consider what you might become passionate about, with a little effort. For some of us, like me, this will be our faith in God. For others it may be advocating for an end to racism or for broader social justice issues. Maybe it’s working to overcome our cultural and political divisions or to strengthen the institutions of our democracy. Perhaps it’s getting involved with efforts to mitigate climate change. Maybe it’s reaching out to the homeless or hungry in your own community or mentoring a child who is being left behind by the demands of remote learning.
Or perhaps what you embrace is even closer to home: maybe it’s working to eliminate health disparities in your institution or health system, or figuring out how to use technology and resources differently to improve how care is being delivered during or after this pandemic. Maybe it’s as simple as re-committing yourself to personally care for every patient you see today with the very best you have to offer, and with patience, compassion, and grace.
Find something that sets your heart on fire. Something that makes you want to take this difficult time and “transmute tribulation into strength and glory.” Something that, when you look back on these days, will make you thankful that you didn’t just hunker down and subsist through them. Instead, you accomplished great things; you learned; you contributed; and you grew stronger and better.
That’s victorious endurance.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey. This essay was published initially on The Hospital Leader, the official blog of SHM.
I’ve been thinking a lot about endurance recently.
COVID-19 is surging in the United States. Health care workers exhausted from the first and second waves are quickly reaching the verge of collapse. I’m seeing more and more heartbreaking articles about the bone-deep fatigue, fear, and frustration health care workers are facing, and I weep. As horrible as it is to be fighting this terrifying, little-understood, invisible virus, health care workers are also fighting an equally distressing war against misinformation, recklessness, apathy, and outright denial.
As if that wasn’t enough, we are also dealing with racial and social unrest not seen in decades. The most significant cultural divisions and political animosity perhaps since the Civil War. A contested election. The fraying of our democratic institutions and our standing in the global community. The weakest economy since the Great Depression. Record unemployment. Many individuals and families facing or already experiencing eviction and food insecurity. Record-setting fires, hurricanes, and other natural disasters that are only projected to intensify due to climate change.
That’s a lot to endure. And we don’t have much choice other than to live through it. Some of us will break under the strain; others will disengage by giving up clinical work or even leaving health care altogether. Some of us will pack it in and retire, walk away from relationships with family members or longtime friends, or even emigrate to another country (New Zealand, anyone?). Some of us will passively hunker down, letting the challenges of this time overwhelm us and just hoping we can hang on long enough to emerge, albeit beaten and scarred, on the other side.
But some of us will experience victorious endurance – the kind that doesn’t just accept suffering but finds a way to triumph over it. I came across the concept of victorious endurance in the Bible, but its origin is earlier, from classical Greece. It comes from the ancient Greek word hupomone, which literally means “abiding under” – as in disciplining oneself to bear up under a trial when one would more naturally rebel, or just give up. The ancient Greeks were big on virtues like self-control, long-suffering, and perseverance in the face of seemingly insurmountable difficulties; Odysseus was a poster child for hupomone. I believe the concept of victorious endurance can be applicable for people across many belief systems, philosophies, and ways of life.
The late William Barclay, former professor of divinity and biblical criticism at the University of Glasgow, Scotland, said of hupomone:
It is untranslatable. It does not describe the frame of mind which can sit down with folded hands and bowed head and let a torrent of troubles sweep over it in passive resignation. It describes the ability to bear things in such a triumphant way that it transfigures them. Chrysostom has a great panegyric on this hupomone. He calls it “the root of all goods, the mother of piety, the fruit that never withers, a fortress that is never taken, a harbour that knows no storms” and “the queen of virtues, the foundation of right actions, peace in war, calm in tempest, security in plots.” It is the courageous and triumphant ability to pass the breaking-point and not to break and always to greet the unseen with a cheer. It is the alchemy which transmutes tribulation into strength and glory.
Barclay further noted that “Cicero defines patientia, its Latin equivalent, as: ‘The voluntary and daily suffering of hard and difficult things, for the sake of honour and usefulness.”
In the midst of the most challenging public health emergency of our lifetimes, I am seeing hospitalists – and nurses, respiratory therapists, and countless other health care workers – doing exactly this, every day. I’m so incredibly proud of you all, and thankful beyond words.
I doubt that victorious endurance comes naturally to any of us; it’s something we work at, pursue and nurture. What’s the secret to cultivating victorious endurance in the midst of unimaginable stress? I’m pretty sure there’s no specific formula. I don’t mean to sound like a Pollyanna or to make light of the tumult and turmoil of these times, but here are a few things that, based on my own experiences, may help cultivate this valuable virtue.
Be part of a support network. In the midst of great stress, and especially during this time of social distancing, it’s especially tempting to just hunker down, close in on ourselves, and shut others out – sometimes even our closest friends and loved ones. Maintaining relationships is just too exhausting. But you need people who can come alongside you and offer words of encouragement when you are at your lowest. And there’s nothing that will bring out the best in you like being there to encourage and support someone else. We all need to both receive and to give emotional support at a time like this.
Take the long view. When we’re in the middle of a serious crisis, it seems like the problems we’re facing will last forever. There’s no light at the end of the tunnel, no port in the storm. But even this pandemic won’t last forever. If we can keep in mind the fact that things will eventually get better and that the current situation isn’t permanent, it can help us maintain our perspective and have more patience with the current dysfunction.
Focus on who you want to be in this moment. This is the hardest time most of us have ever lived through, both professionally and personally. But let me throw you a challenge. When you look back on this time from the perspective of five years from now, or maybe ten, how will you want to remember yourself? Who will you want to have been during this time? Looking back, what will make you proud of how you handled this challenge? Be that person.
Look for things to be thankful for. In the midst of the chaos that is our lives and our work right now, I believe we can still occasionally see moments of grace if we keep our eyes open for them. If we aren’t looking for them, we may miss them entirely. And those small moments of love, touches of compassion, displays of selflessness, and even flashes of victorious endurance in yourself or others are gifts to be treasured and held on to – to give thanks for.
Embrace a cause greater than yourself. May I suggest that one thing that might help our efforts to cultivate the virtue of victorious endurance during difficult times might be to embrace a cause that is bigger than yourself; that is, one that lures you to focus beyond your immediate circumstances? What are you passionate about, outside of your life’s normal routine?
If you don’t have a passion, consider what you might become passionate about, with a little effort. For some of us, like me, this will be our faith in God. For others it may be advocating for an end to racism or for broader social justice issues. Maybe it’s working to overcome our cultural and political divisions or to strengthen the institutions of our democracy. Perhaps it’s getting involved with efforts to mitigate climate change. Maybe it’s reaching out to the homeless or hungry in your own community or mentoring a child who is being left behind by the demands of remote learning.
Or perhaps what you embrace is even closer to home: maybe it’s working to eliminate health disparities in your institution or health system, or figuring out how to use technology and resources differently to improve how care is being delivered during or after this pandemic. Maybe it’s as simple as re-committing yourself to personally care for every patient you see today with the very best you have to offer, and with patience, compassion, and grace.
Find something that sets your heart on fire. Something that makes you want to take this difficult time and “transmute tribulation into strength and glory.” Something that, when you look back on these days, will make you thankful that you didn’t just hunker down and subsist through them. Instead, you accomplished great things; you learned; you contributed; and you grew stronger and better.
That’s victorious endurance.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey. This essay was published initially on The Hospital Leader, the official blog of SHM.
Seen or viewed: A black hematologist’s perspective
After a long day in hematology clinic, I skimmed the inpatient list to see if any of my patients had been admitted. Seeing Ms. Short’s name (changed for privacy), a delightful African American woman I met during my early days of fellowship, had me making the trek to the hospital. She was living with multiple myeloma complicated by extramedullary manifestations that had significantly impacted her quality of life.
During our first encounter, she showed me a growing left subscapular mass the size of an orange that was erythematous, hot, painful, and irritated. As an enthusiastic first-year fellow, I wanted to be aggressive in addressing her concerns in response to her obvious distress about this mass. Ultimately, she left clinic with antibiotics and an appointment with radiation oncology to see if they could use radiation to shrink the subscapular mass.
When I went back in to discuss the plan with her, she grabbed my hand, looked me in my eyes and said: “Thank you, I’ve been mentioning this for a while and you’re the first person to get something done about it.” In that moment I knew that she felt seen.
By the time I made it over to the hospital, she was getting settled in her room to start another cycle of cytoreductive chemotherapy.
“I told them I had a Black doctor!” she exclaimed as I walked into her hospital room. “I was looking for you today in clinic ... I kept telling them I had a Black doctor, but the nurses kept telling me no, that there were only Black nurse practitioners.” She had repeatedly told the staff that I, her “Black doctor,” did indeed exist, and she went on to describe me as “you know, the [heavy-chested] and short Black doctor I saw early this fall.” To this day, her description still makes me chuckle.
Though I laughed at her description, it hurt that I had worked in a clinic for 6 months yet was invisible. Initially disappointed, I left Ms. Short’s room with a smile on my face, energized and encouraged.
My time with Ms. Short prompted me to ruminate on my experience as a Black physician. To put it in perspective, 5% of all physicians are Black, 2% are Black women, and 2.3% are oncologists, even though African Americans make up 13% of the general U.S. population. I reside in a space where I am simultaneously scrutinized because I am one of the few (or the only) Black physicians in the building, and yet I am invisible because my colleagues and coworkers routinely ignore my presence.
Black physicians, let alone hematologists, are so rare that nurses often cannot fathom that a Black woman could be more than a nurse practitioner. Sadly, this is the tip of the iceberg of some of the negative experiences I, and other Black doctors, have had.
How I present myself must be carefully curated to make progress in my career. My peers and superiors seem to hear me better when my hair is straight and not in its naturally curly state. My introversion has been interpreted as being standoffish or disinterested. Any tone other than happy is interpreted as “aggressive” or “angry”. Talking “too much” to Black support staff was reported to my program, as it was viewed as suspicious, disruptive, and “appearances matter”.
I am also expected to be nurturing in ways that White physicians are not required to be. In my presence, White physicians have denigrated an entire patient population that is disproportionately Black by calling them “sicklers.” If there is an interpersonal conflict, I must think about the long-term consequences of voicing my perspective. My non-Black colleagues do not have to think about these things.
Imagine dealing with this at work, then on your commute home being worried about the reality that you may be pulled over and become the next name on the ever-growing list of Black women and men murdered at the hands of police. The cognitive and emotional impact of being invisible is immense and cumulative over the years.
My Blackness creates a bias of inferiority that cannot be overcome by respectability, compliance, professionalism, training, and expertise. This is glaringly apparent on both sides of the physician-patient relationship. Black patients’ concerns are routinely overlooked and dismissed, as seen with Ms. Short, and are reflected in the Black maternal death rate, pain control in Black versus White patients, and personal experience as a patient and an advocate for my family members.
Patients have looked me in the face and said, “all lives matter,” displaying their refusal to recognize that systematic racism and inequality exist. These facts and experiences are the antithesis of “primum non nocere.”
Sadly, my and Ms. Short’s experiences are not singular ones, and racial bias in medicine is a diagnosed, but untreated cancer. Like the malignancies I treat, ignoring the problem has not made it go away; therefore, it continues to fester and spread, causing more destruction. It is of great importance and concern that all physicians recognize, reflect, and correct their implicit biases not only toward their patients, but also colleagues and trainees.
It seems that health care professionals can talk the talk, as many statements have been made against racism and implicit bias in medicine, but can we take true and meaningful action to begin the journey to equity and justice?
I would like to thank Adrienne Glover, MD, MaKenzie Hodge, MD, Maranatha McLean, MD, and Darion Showell, MD, for our stimulating conversations that helped me put pen to paper. I’d also like to thank my family for being my editors.
Daphanie D. Taylor, MD, is a hematology/oncology fellow PGY-6 at Levine Cancer Institute, Charlotte, N.C.
References and further reading
Roy L. “‘It’s My Calling To Change The Statistics’: Why We Need More Black Female Physicians.” Forbes Magazine, 27 Feb. 2020.
“Diversity in Medicine: Facts and Figures 2019.” Association of American Medical Colleges, 2019.
“Facts & Figures: Diversity in Oncology.” American Society of Clinical Oncology. 2020 Jan 16.
After a long day in hematology clinic, I skimmed the inpatient list to see if any of my patients had been admitted. Seeing Ms. Short’s name (changed for privacy), a delightful African American woman I met during my early days of fellowship, had me making the trek to the hospital. She was living with multiple myeloma complicated by extramedullary manifestations that had significantly impacted her quality of life.
During our first encounter, she showed me a growing left subscapular mass the size of an orange that was erythematous, hot, painful, and irritated. As an enthusiastic first-year fellow, I wanted to be aggressive in addressing her concerns in response to her obvious distress about this mass. Ultimately, she left clinic with antibiotics and an appointment with radiation oncology to see if they could use radiation to shrink the subscapular mass.
When I went back in to discuss the plan with her, she grabbed my hand, looked me in my eyes and said: “Thank you, I’ve been mentioning this for a while and you’re the first person to get something done about it.” In that moment I knew that she felt seen.
By the time I made it over to the hospital, she was getting settled in her room to start another cycle of cytoreductive chemotherapy.
“I told them I had a Black doctor!” she exclaimed as I walked into her hospital room. “I was looking for you today in clinic ... I kept telling them I had a Black doctor, but the nurses kept telling me no, that there were only Black nurse practitioners.” She had repeatedly told the staff that I, her “Black doctor,” did indeed exist, and she went on to describe me as “you know, the [heavy-chested] and short Black doctor I saw early this fall.” To this day, her description still makes me chuckle.
Though I laughed at her description, it hurt that I had worked in a clinic for 6 months yet was invisible. Initially disappointed, I left Ms. Short’s room with a smile on my face, energized and encouraged.
My time with Ms. Short prompted me to ruminate on my experience as a Black physician. To put it in perspective, 5% of all physicians are Black, 2% are Black women, and 2.3% are oncologists, even though African Americans make up 13% of the general U.S. population. I reside in a space where I am simultaneously scrutinized because I am one of the few (or the only) Black physicians in the building, and yet I am invisible because my colleagues and coworkers routinely ignore my presence.
Black physicians, let alone hematologists, are so rare that nurses often cannot fathom that a Black woman could be more than a nurse practitioner. Sadly, this is the tip of the iceberg of some of the negative experiences I, and other Black doctors, have had.
How I present myself must be carefully curated to make progress in my career. My peers and superiors seem to hear me better when my hair is straight and not in its naturally curly state. My introversion has been interpreted as being standoffish or disinterested. Any tone other than happy is interpreted as “aggressive” or “angry”. Talking “too much” to Black support staff was reported to my program, as it was viewed as suspicious, disruptive, and “appearances matter”.
I am also expected to be nurturing in ways that White physicians are not required to be. In my presence, White physicians have denigrated an entire patient population that is disproportionately Black by calling them “sicklers.” If there is an interpersonal conflict, I must think about the long-term consequences of voicing my perspective. My non-Black colleagues do not have to think about these things.
Imagine dealing with this at work, then on your commute home being worried about the reality that you may be pulled over and become the next name on the ever-growing list of Black women and men murdered at the hands of police. The cognitive and emotional impact of being invisible is immense and cumulative over the years.
My Blackness creates a bias of inferiority that cannot be overcome by respectability, compliance, professionalism, training, and expertise. This is glaringly apparent on both sides of the physician-patient relationship. Black patients’ concerns are routinely overlooked and dismissed, as seen with Ms. Short, and are reflected in the Black maternal death rate, pain control in Black versus White patients, and personal experience as a patient and an advocate for my family members.
Patients have looked me in the face and said, “all lives matter,” displaying their refusal to recognize that systematic racism and inequality exist. These facts and experiences are the antithesis of “primum non nocere.”
Sadly, my and Ms. Short’s experiences are not singular ones, and racial bias in medicine is a diagnosed, but untreated cancer. Like the malignancies I treat, ignoring the problem has not made it go away; therefore, it continues to fester and spread, causing more destruction. It is of great importance and concern that all physicians recognize, reflect, and correct their implicit biases not only toward their patients, but also colleagues and trainees.
It seems that health care professionals can talk the talk, as many statements have been made against racism and implicit bias in medicine, but can we take true and meaningful action to begin the journey to equity and justice?
I would like to thank Adrienne Glover, MD, MaKenzie Hodge, MD, Maranatha McLean, MD, and Darion Showell, MD, for our stimulating conversations that helped me put pen to paper. I’d also like to thank my family for being my editors.
Daphanie D. Taylor, MD, is a hematology/oncology fellow PGY-6 at Levine Cancer Institute, Charlotte, N.C.
References and further reading
Roy L. “‘It’s My Calling To Change The Statistics’: Why We Need More Black Female Physicians.” Forbes Magazine, 27 Feb. 2020.
“Diversity in Medicine: Facts and Figures 2019.” Association of American Medical Colleges, 2019.
“Facts & Figures: Diversity in Oncology.” American Society of Clinical Oncology. 2020 Jan 16.
After a long day in hematology clinic, I skimmed the inpatient list to see if any of my patients had been admitted. Seeing Ms. Short’s name (changed for privacy), a delightful African American woman I met during my early days of fellowship, had me making the trek to the hospital. She was living with multiple myeloma complicated by extramedullary manifestations that had significantly impacted her quality of life.
During our first encounter, she showed me a growing left subscapular mass the size of an orange that was erythematous, hot, painful, and irritated. As an enthusiastic first-year fellow, I wanted to be aggressive in addressing her concerns in response to her obvious distress about this mass. Ultimately, she left clinic with antibiotics and an appointment with radiation oncology to see if they could use radiation to shrink the subscapular mass.
When I went back in to discuss the plan with her, she grabbed my hand, looked me in my eyes and said: “Thank you, I’ve been mentioning this for a while and you’re the first person to get something done about it.” In that moment I knew that she felt seen.
By the time I made it over to the hospital, she was getting settled in her room to start another cycle of cytoreductive chemotherapy.
“I told them I had a Black doctor!” she exclaimed as I walked into her hospital room. “I was looking for you today in clinic ... I kept telling them I had a Black doctor, but the nurses kept telling me no, that there were only Black nurse practitioners.” She had repeatedly told the staff that I, her “Black doctor,” did indeed exist, and she went on to describe me as “you know, the [heavy-chested] and short Black doctor I saw early this fall.” To this day, her description still makes me chuckle.
Though I laughed at her description, it hurt that I had worked in a clinic for 6 months yet was invisible. Initially disappointed, I left Ms. Short’s room with a smile on my face, energized and encouraged.
My time with Ms. Short prompted me to ruminate on my experience as a Black physician. To put it in perspective, 5% of all physicians are Black, 2% are Black women, and 2.3% are oncologists, even though African Americans make up 13% of the general U.S. population. I reside in a space where I am simultaneously scrutinized because I am one of the few (or the only) Black physicians in the building, and yet I am invisible because my colleagues and coworkers routinely ignore my presence.
Black physicians, let alone hematologists, are so rare that nurses often cannot fathom that a Black woman could be more than a nurse practitioner. Sadly, this is the tip of the iceberg of some of the negative experiences I, and other Black doctors, have had.
How I present myself must be carefully curated to make progress in my career. My peers and superiors seem to hear me better when my hair is straight and not in its naturally curly state. My introversion has been interpreted as being standoffish or disinterested. Any tone other than happy is interpreted as “aggressive” or “angry”. Talking “too much” to Black support staff was reported to my program, as it was viewed as suspicious, disruptive, and “appearances matter”.
I am also expected to be nurturing in ways that White physicians are not required to be. In my presence, White physicians have denigrated an entire patient population that is disproportionately Black by calling them “sicklers.” If there is an interpersonal conflict, I must think about the long-term consequences of voicing my perspective. My non-Black colleagues do not have to think about these things.
Imagine dealing with this at work, then on your commute home being worried about the reality that you may be pulled over and become the next name on the ever-growing list of Black women and men murdered at the hands of police. The cognitive and emotional impact of being invisible is immense and cumulative over the years.
My Blackness creates a bias of inferiority that cannot be overcome by respectability, compliance, professionalism, training, and expertise. This is glaringly apparent on both sides of the physician-patient relationship. Black patients’ concerns are routinely overlooked and dismissed, as seen with Ms. Short, and are reflected in the Black maternal death rate, pain control in Black versus White patients, and personal experience as a patient and an advocate for my family members.
Patients have looked me in the face and said, “all lives matter,” displaying their refusal to recognize that systematic racism and inequality exist. These facts and experiences are the antithesis of “primum non nocere.”
Sadly, my and Ms. Short’s experiences are not singular ones, and racial bias in medicine is a diagnosed, but untreated cancer. Like the malignancies I treat, ignoring the problem has not made it go away; therefore, it continues to fester and spread, causing more destruction. It is of great importance and concern that all physicians recognize, reflect, and correct their implicit biases not only toward their patients, but also colleagues and trainees.
It seems that health care professionals can talk the talk, as many statements have been made against racism and implicit bias in medicine, but can we take true and meaningful action to begin the journey to equity and justice?
I would like to thank Adrienne Glover, MD, MaKenzie Hodge, MD, Maranatha McLean, MD, and Darion Showell, MD, for our stimulating conversations that helped me put pen to paper. I’d also like to thank my family for being my editors.
Daphanie D. Taylor, MD, is a hematology/oncology fellow PGY-6 at Levine Cancer Institute, Charlotte, N.C.
References and further reading
Roy L. “‘It’s My Calling To Change The Statistics’: Why We Need More Black Female Physicians.” Forbes Magazine, 27 Feb. 2020.
“Diversity in Medicine: Facts and Figures 2019.” Association of American Medical Colleges, 2019.
“Facts & Figures: Diversity in Oncology.” American Society of Clinical Oncology. 2020 Jan 16.
What Tom Brady and Patrick Mahomes can teach us about physicians
Warning: This article will be about Tom Brady. If you love Tom Brady, hate Tom Brady, previously loved and now hate Tom Brady, I’m just warning you so you’ll be in the right frame of mind to continue. (If you don’t know who Tom Brady is, he’s Gisele’s husband).
Brady, who plays for the Tampa Bay Buccaneers, has played in the NFL for 21 seasons, an unbelievable number given the average career for a quarterback is 3 years. He’s 43 years old and was the oldest player in a Super Bowl, ever. He faced Patrick Mahomes, the quarterback for the opposing Kansas City Chiefs. Mahomes is one of the most athletic and talented quarterbacks of all time, and Mahomes is nearly 20 years younger than Brady. Yet, in a shot heard around the NFL world, Brady won.
But, was a Brady victory so shocking? Hot-shot residents may have a lot of moxie and talent, but experienced doctors often prevail by simply making sound decisions and avoiding mistakes. In our department, we’ve been discussing this lately: We’re hiring two dermatologists and we’re fortunate to have some amazing candidates apply. Some, like Mahomes, are young all-stars with outstanding ability and potential, right out of residency. Others, Brady-like, have been in practice for years and are ready to move to a new franchise.
Our medical group’s experiences are probably similar to many practices: New physicians out of residency often bring energy, inspiration, and ease with the latest therapies, devices, and surgical techniques. Yet, they sometimes struggle with efficiency and unforced errors. Experienced physicians might not know what’s hot, but they can often see where the best course of action lies, understanding not only the physiology but also the patient in ways that only experience can teach you. Fortunately, for those like me who’ve crossed midlife, there doesn’t seem to be an upper limit to experience – it is possible to keep getting better. Yes, I’m just like Tom Brady. (I wrote this article just to print that line.)
Some of the best doctors I’ve ever seen in action were emeritus physicians. In medical school at Wake Forest University, one of my professors was Dr. Eben Alexander. A retired neurosurgeon, he taught a case-based critical thinking skills class. I recall his brilliant insight and coaching, working through cases that had nothing to do with the brain or with surgery. He used his vast experience and wisdom to teach us how to practice medicine. He was, at that time, nearly 90 years old. Despite having been retired for decades, he was still writing articles and editing journals. He was inspiring. For a minute, he had me thinking I’d like to be a neurosurgeon, so I could be just like Eben Alexander. I did not, but I learned things from him that still impact my practice as a dermatologist today.
I’m sure you’ve had similar experiences of older colleagues or mentors who were the best doctor in the clinic or the O.R. They are the Dr. Anthony Faucis, not just practicing, but leading while in their 8th or 9th decade. We are all so fortunate that they keep playing.
We’ve not made our final choices on whom to hire, but with two positions, I expect we’ll choose both a young doctor and an experienced one to add to our team. It will be fun to watch and learn from them. Just like it will be fun to watch Tom Brady in the Super Bowl again next year.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Warning: This article will be about Tom Brady. If you love Tom Brady, hate Tom Brady, previously loved and now hate Tom Brady, I’m just warning you so you’ll be in the right frame of mind to continue. (If you don’t know who Tom Brady is, he’s Gisele’s husband).
Brady, who plays for the Tampa Bay Buccaneers, has played in the NFL for 21 seasons, an unbelievable number given the average career for a quarterback is 3 years. He’s 43 years old and was the oldest player in a Super Bowl, ever. He faced Patrick Mahomes, the quarterback for the opposing Kansas City Chiefs. Mahomes is one of the most athletic and talented quarterbacks of all time, and Mahomes is nearly 20 years younger than Brady. Yet, in a shot heard around the NFL world, Brady won.
But, was a Brady victory so shocking? Hot-shot residents may have a lot of moxie and talent, but experienced doctors often prevail by simply making sound decisions and avoiding mistakes. In our department, we’ve been discussing this lately: We’re hiring two dermatologists and we’re fortunate to have some amazing candidates apply. Some, like Mahomes, are young all-stars with outstanding ability and potential, right out of residency. Others, Brady-like, have been in practice for years and are ready to move to a new franchise.
Our medical group’s experiences are probably similar to many practices: New physicians out of residency often bring energy, inspiration, and ease with the latest therapies, devices, and surgical techniques. Yet, they sometimes struggle with efficiency and unforced errors. Experienced physicians might not know what’s hot, but they can often see where the best course of action lies, understanding not only the physiology but also the patient in ways that only experience can teach you. Fortunately, for those like me who’ve crossed midlife, there doesn’t seem to be an upper limit to experience – it is possible to keep getting better. Yes, I’m just like Tom Brady. (I wrote this article just to print that line.)
Some of the best doctors I’ve ever seen in action were emeritus physicians. In medical school at Wake Forest University, one of my professors was Dr. Eben Alexander. A retired neurosurgeon, he taught a case-based critical thinking skills class. I recall his brilliant insight and coaching, working through cases that had nothing to do with the brain or with surgery. He used his vast experience and wisdom to teach us how to practice medicine. He was, at that time, nearly 90 years old. Despite having been retired for decades, he was still writing articles and editing journals. He was inspiring. For a minute, he had me thinking I’d like to be a neurosurgeon, so I could be just like Eben Alexander. I did not, but I learned things from him that still impact my practice as a dermatologist today.
I’m sure you’ve had similar experiences of older colleagues or mentors who were the best doctor in the clinic or the O.R. They are the Dr. Anthony Faucis, not just practicing, but leading while in their 8th or 9th decade. We are all so fortunate that they keep playing.
We’ve not made our final choices on whom to hire, but with two positions, I expect we’ll choose both a young doctor and an experienced one to add to our team. It will be fun to watch and learn from them. Just like it will be fun to watch Tom Brady in the Super Bowl again next year.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Warning: This article will be about Tom Brady. If you love Tom Brady, hate Tom Brady, previously loved and now hate Tom Brady, I’m just warning you so you’ll be in the right frame of mind to continue. (If you don’t know who Tom Brady is, he’s Gisele’s husband).
Brady, who plays for the Tampa Bay Buccaneers, has played in the NFL for 21 seasons, an unbelievable number given the average career for a quarterback is 3 years. He’s 43 years old and was the oldest player in a Super Bowl, ever. He faced Patrick Mahomes, the quarterback for the opposing Kansas City Chiefs. Mahomes is one of the most athletic and talented quarterbacks of all time, and Mahomes is nearly 20 years younger than Brady. Yet, in a shot heard around the NFL world, Brady won.
But, was a Brady victory so shocking? Hot-shot residents may have a lot of moxie and talent, but experienced doctors often prevail by simply making sound decisions and avoiding mistakes. In our department, we’ve been discussing this lately: We’re hiring two dermatologists and we’re fortunate to have some amazing candidates apply. Some, like Mahomes, are young all-stars with outstanding ability and potential, right out of residency. Others, Brady-like, have been in practice for years and are ready to move to a new franchise.
Our medical group’s experiences are probably similar to many practices: New physicians out of residency often bring energy, inspiration, and ease with the latest therapies, devices, and surgical techniques. Yet, they sometimes struggle with efficiency and unforced errors. Experienced physicians might not know what’s hot, but they can often see where the best course of action lies, understanding not only the physiology but also the patient in ways that only experience can teach you. Fortunately, for those like me who’ve crossed midlife, there doesn’t seem to be an upper limit to experience – it is possible to keep getting better. Yes, I’m just like Tom Brady. (I wrote this article just to print that line.)
Some of the best doctors I’ve ever seen in action were emeritus physicians. In medical school at Wake Forest University, one of my professors was Dr. Eben Alexander. A retired neurosurgeon, he taught a case-based critical thinking skills class. I recall his brilliant insight and coaching, working through cases that had nothing to do with the brain or with surgery. He used his vast experience and wisdom to teach us how to practice medicine. He was, at that time, nearly 90 years old. Despite having been retired for decades, he was still writing articles and editing journals. He was inspiring. For a minute, he had me thinking I’d like to be a neurosurgeon, so I could be just like Eben Alexander. I did not, but I learned things from him that still impact my practice as a dermatologist today.
I’m sure you’ve had similar experiences of older colleagues or mentors who were the best doctor in the clinic or the O.R. They are the Dr. Anthony Faucis, not just practicing, but leading while in their 8th or 9th decade. We are all so fortunate that they keep playing.
We’ve not made our final choices on whom to hire, but with two positions, I expect we’ll choose both a young doctor and an experienced one to add to our team. It will be fun to watch and learn from them. Just like it will be fun to watch Tom Brady in the Super Bowl again next year.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
When the X-Waiver gets X’ed: Implications for hospitalists
There are two pandemics permeating the United States: COVID-19 and addiction. To date, more than 468,000 people have died from COVID-19 in the U.S. In the 12-month period ending in May 2020, over 80,000 died from a drug related cause – the highest number ever recorded in a year. Many of these deaths involved opioids.
COVID-19 has worsened outcomes for people with addiction. There is less access to treatment, increased isolation, and worsening psychosocial and economic stressors. These factors may drive new, increased, or more risky substance use and return to use for people in recovery. As hospitalists, we have been responders in both COVID-19 and our country’s worsening overdose and addiction crisis.
In December 2020’s Journal of Hospital Medicine article “Converging Crises: Caring for hospitalized adults with substance use disorder in the time of COVID-19”, Dr. Honora Englander and her coauthors called on hospitalists to actively engage patients with substance use disorders during hospitalization. The article highlights the colliding crises of addiction and COVID-19 and provides eight practical approaches for hospitalists to address substance use disorders during the pandemic, including initiating buprenorphine for opioid withdrawal and prescribing it for opioid use disorder (OUD) treatment.
Buprenorphine effectively treats opioid withdrawal, reduces OUD-related mortality, and decreases hospital readmissions related to OUD. To prescribe buprenorphine for OUD in the outpatient setting or on hospital discharge, providers need an X-Waiver. The X-Waiver is a result of the Drug Addiction Treatment Act 2000 (DATA 2000), which was enacted in 2000. It permits physicians to prescribe buprenorphine for OUD treatment after an 8-hour training. In 2016, the Comprehensive Addiction and Recovery Act extended buprenorphine prescribing to physician assistants (PAs) and advanced-practice nurses (APNs). However, PAs and APNs are required to complete a 24-hour training to receive the waiver.
On Jan. 14, 2021, the U.S. Department of Health and Human Services under the Trump administration announced it was removing the X-Waiver training previously required for physicians to prescribe this life-saving medication. However, on Jan. 20, 2021, the Biden administration froze the training requirement removal pending a 60-day review. The excitement about the waiver’s eradication further dampened on Jan. 25, when the plan was halted due to procedural factors coupled with the concern that HHS may not have the authority to void requirements mandated by Congress.
Many of us continue to be hopeful that the X-Waiver will soon be gone. The Substance Abuse and Mental Health Services Administration has committed to working with federal agencies to increase access to buprenorphine. The Biden administration also committed to addressing our country’s addiction crisis, including a plan to “make effective prevention, treatment, and recovery services available to all, including through a $125 billion federal investment.”
Despite the pause on HHS’s recent attempt to “X the X-Waiver,” we now have renewed attention and interest in this critical issue and an opportunity for greater and longer-lasting legislative impact. SHM supports that Congress repeal the legislative requirement for buprenorphine training dictated by DATA 2000 so that it cannot be rolled back by future administrations. To further increase access to buprenorphine treatment, the training requirement should be removed for all providers who care for individuals with OUD.
The X-Waiver has been a barrier to hospitalist adoption of this critical, life-saving medication. HHS’s stance to nix the waiver, though fleeting, should be interpreted as an urgent call to the medical community, including us as hospitalists, to learn about buprenorphine with the many resources available (see table 1). As hospital medicine providers, we can order buprenorphine for patients with OUD during hospitalization. It is discharge prescriptions that have been limited to providers with an X-Waiver.
What can we do now to prepare for the eventual X-Waiver training removal? We can start by educating ourselves with the resources listed in table 1. Those of us who are already buprenorphine champions could lead trainings in our home institutions. In a future without the waiver there will be more flexibility to develop hospitalist-focused buprenorphine trainings, as the previous ones were geared for outpatient providers. Hospitalist organizations could support hospitalist-specific buprenorphine trainings and extend the models to include additional medications for addiction.
There is a large body of evidence regarding buprenorphine’s safety and efficacy in OUD treatment. With a worsening overdose crisis, there have been increasing opioid-related hospitalizations. When new medications for diabetes, hypertension, or DVT treatment become available, as hospitalists we incorporate them into our toolbox. As buprenorphine becomes more accessible, we can be leaders in further adopting it (and other substance use disorder medications while we are at it) as our standard of care for people with OUD.
Dr. Bottner is a physician assistant in the Division of Hospital Medicine at Dell Medical School at The University of Texas at Austin and director of the hospital’s Buprenorphine Team. Dr. Martin is a board-certified addiction medicine physician and hospitalist at University of California, San Francisco, and director of the Addiction Care Team at San Francisco General Hospital. Dr. Bottner and Dr. Martin colead the SHM Substance Use Disorder Special Interest Group.
There are two pandemics permeating the United States: COVID-19 and addiction. To date, more than 468,000 people have died from COVID-19 in the U.S. In the 12-month period ending in May 2020, over 80,000 died from a drug related cause – the highest number ever recorded in a year. Many of these deaths involved opioids.
COVID-19 has worsened outcomes for people with addiction. There is less access to treatment, increased isolation, and worsening psychosocial and economic stressors. These factors may drive new, increased, or more risky substance use and return to use for people in recovery. As hospitalists, we have been responders in both COVID-19 and our country’s worsening overdose and addiction crisis.
In December 2020’s Journal of Hospital Medicine article “Converging Crises: Caring for hospitalized adults with substance use disorder in the time of COVID-19”, Dr. Honora Englander and her coauthors called on hospitalists to actively engage patients with substance use disorders during hospitalization. The article highlights the colliding crises of addiction and COVID-19 and provides eight practical approaches for hospitalists to address substance use disorders during the pandemic, including initiating buprenorphine for opioid withdrawal and prescribing it for opioid use disorder (OUD) treatment.
Buprenorphine effectively treats opioid withdrawal, reduces OUD-related mortality, and decreases hospital readmissions related to OUD. To prescribe buprenorphine for OUD in the outpatient setting or on hospital discharge, providers need an X-Waiver. The X-Waiver is a result of the Drug Addiction Treatment Act 2000 (DATA 2000), which was enacted in 2000. It permits physicians to prescribe buprenorphine for OUD treatment after an 8-hour training. In 2016, the Comprehensive Addiction and Recovery Act extended buprenorphine prescribing to physician assistants (PAs) and advanced-practice nurses (APNs). However, PAs and APNs are required to complete a 24-hour training to receive the waiver.
On Jan. 14, 2021, the U.S. Department of Health and Human Services under the Trump administration announced it was removing the X-Waiver training previously required for physicians to prescribe this life-saving medication. However, on Jan. 20, 2021, the Biden administration froze the training requirement removal pending a 60-day review. The excitement about the waiver’s eradication further dampened on Jan. 25, when the plan was halted due to procedural factors coupled with the concern that HHS may not have the authority to void requirements mandated by Congress.
Many of us continue to be hopeful that the X-Waiver will soon be gone. The Substance Abuse and Mental Health Services Administration has committed to working with federal agencies to increase access to buprenorphine. The Biden administration also committed to addressing our country’s addiction crisis, including a plan to “make effective prevention, treatment, and recovery services available to all, including through a $125 billion federal investment.”
Despite the pause on HHS’s recent attempt to “X the X-Waiver,” we now have renewed attention and interest in this critical issue and an opportunity for greater and longer-lasting legislative impact. SHM supports that Congress repeal the legislative requirement for buprenorphine training dictated by DATA 2000 so that it cannot be rolled back by future administrations. To further increase access to buprenorphine treatment, the training requirement should be removed for all providers who care for individuals with OUD.
The X-Waiver has been a barrier to hospitalist adoption of this critical, life-saving medication. HHS’s stance to nix the waiver, though fleeting, should be interpreted as an urgent call to the medical community, including us as hospitalists, to learn about buprenorphine with the many resources available (see table 1). As hospital medicine providers, we can order buprenorphine for patients with OUD during hospitalization. It is discharge prescriptions that have been limited to providers with an X-Waiver.
What can we do now to prepare for the eventual X-Waiver training removal? We can start by educating ourselves with the resources listed in table 1. Those of us who are already buprenorphine champions could lead trainings in our home institutions. In a future without the waiver there will be more flexibility to develop hospitalist-focused buprenorphine trainings, as the previous ones were geared for outpatient providers. Hospitalist organizations could support hospitalist-specific buprenorphine trainings and extend the models to include additional medications for addiction.
There is a large body of evidence regarding buprenorphine’s safety and efficacy in OUD treatment. With a worsening overdose crisis, there have been increasing opioid-related hospitalizations. When new medications for diabetes, hypertension, or DVT treatment become available, as hospitalists we incorporate them into our toolbox. As buprenorphine becomes more accessible, we can be leaders in further adopting it (and other substance use disorder medications while we are at it) as our standard of care for people with OUD.
Dr. Bottner is a physician assistant in the Division of Hospital Medicine at Dell Medical School at The University of Texas at Austin and director of the hospital’s Buprenorphine Team. Dr. Martin is a board-certified addiction medicine physician and hospitalist at University of California, San Francisco, and director of the Addiction Care Team at San Francisco General Hospital. Dr. Bottner and Dr. Martin colead the SHM Substance Use Disorder Special Interest Group.
There are two pandemics permeating the United States: COVID-19 and addiction. To date, more than 468,000 people have died from COVID-19 in the U.S. In the 12-month period ending in May 2020, over 80,000 died from a drug related cause – the highest number ever recorded in a year. Many of these deaths involved opioids.
COVID-19 has worsened outcomes for people with addiction. There is less access to treatment, increased isolation, and worsening psychosocial and economic stressors. These factors may drive new, increased, or more risky substance use and return to use for people in recovery. As hospitalists, we have been responders in both COVID-19 and our country’s worsening overdose and addiction crisis.
In December 2020’s Journal of Hospital Medicine article “Converging Crises: Caring for hospitalized adults with substance use disorder in the time of COVID-19”, Dr. Honora Englander and her coauthors called on hospitalists to actively engage patients with substance use disorders during hospitalization. The article highlights the colliding crises of addiction and COVID-19 and provides eight practical approaches for hospitalists to address substance use disorders during the pandemic, including initiating buprenorphine for opioid withdrawal and prescribing it for opioid use disorder (OUD) treatment.
Buprenorphine effectively treats opioid withdrawal, reduces OUD-related mortality, and decreases hospital readmissions related to OUD. To prescribe buprenorphine for OUD in the outpatient setting or on hospital discharge, providers need an X-Waiver. The X-Waiver is a result of the Drug Addiction Treatment Act 2000 (DATA 2000), which was enacted in 2000. It permits physicians to prescribe buprenorphine for OUD treatment after an 8-hour training. In 2016, the Comprehensive Addiction and Recovery Act extended buprenorphine prescribing to physician assistants (PAs) and advanced-practice nurses (APNs). However, PAs and APNs are required to complete a 24-hour training to receive the waiver.
On Jan. 14, 2021, the U.S. Department of Health and Human Services under the Trump administration announced it was removing the X-Waiver training previously required for physicians to prescribe this life-saving medication. However, on Jan. 20, 2021, the Biden administration froze the training requirement removal pending a 60-day review. The excitement about the waiver’s eradication further dampened on Jan. 25, when the plan was halted due to procedural factors coupled with the concern that HHS may not have the authority to void requirements mandated by Congress.
Many of us continue to be hopeful that the X-Waiver will soon be gone. The Substance Abuse and Mental Health Services Administration has committed to working with federal agencies to increase access to buprenorphine. The Biden administration also committed to addressing our country’s addiction crisis, including a plan to “make effective prevention, treatment, and recovery services available to all, including through a $125 billion federal investment.”
Despite the pause on HHS’s recent attempt to “X the X-Waiver,” we now have renewed attention and interest in this critical issue and an opportunity for greater and longer-lasting legislative impact. SHM supports that Congress repeal the legislative requirement for buprenorphine training dictated by DATA 2000 so that it cannot be rolled back by future administrations. To further increase access to buprenorphine treatment, the training requirement should be removed for all providers who care for individuals with OUD.
The X-Waiver has been a barrier to hospitalist adoption of this critical, life-saving medication. HHS’s stance to nix the waiver, though fleeting, should be interpreted as an urgent call to the medical community, including us as hospitalists, to learn about buprenorphine with the many resources available (see table 1). As hospital medicine providers, we can order buprenorphine for patients with OUD during hospitalization. It is discharge prescriptions that have been limited to providers with an X-Waiver.
What can we do now to prepare for the eventual X-Waiver training removal? We can start by educating ourselves with the resources listed in table 1. Those of us who are already buprenorphine champions could lead trainings in our home institutions. In a future without the waiver there will be more flexibility to develop hospitalist-focused buprenorphine trainings, as the previous ones were geared for outpatient providers. Hospitalist organizations could support hospitalist-specific buprenorphine trainings and extend the models to include additional medications for addiction.
There is a large body of evidence regarding buprenorphine’s safety and efficacy in OUD treatment. With a worsening overdose crisis, there have been increasing opioid-related hospitalizations. When new medications for diabetes, hypertension, or DVT treatment become available, as hospitalists we incorporate them into our toolbox. As buprenorphine becomes more accessible, we can be leaders in further adopting it (and other substance use disorder medications while we are at it) as our standard of care for people with OUD.
Dr. Bottner is a physician assistant in the Division of Hospital Medicine at Dell Medical School at The University of Texas at Austin and director of the hospital’s Buprenorphine Team. Dr. Martin is a board-certified addiction medicine physician and hospitalist at University of California, San Francisco, and director of the Addiction Care Team at San Francisco General Hospital. Dr. Bottner and Dr. Martin colead the SHM Substance Use Disorder Special Interest Group.
Don’t fear patients reading their clinical notes: Opinion
Doctors are learning about new rules coming this April that encourage open and transparent communication among patients, families, and clinicians. The rules, putting into effect the bipartisan 21st Century Cures Act, mandate offering patients access to notes (“open notes”) written by clinicians in electronic medical records.
A recent article from this news organization noted that for many doctors this represents both a sudden and troubling change in practice. For others, the rules codify what they have been doing as a matter of routine for a decade. Spurred by the OpenNotes movement, at least 55 million Americans are already offered access to their clinical notes, including, since 2013, more than 9 million veterans with access to the Blue Button function in Veterans Affairs practices and hospitals.
The practice is spreading beyond the United States to other countries, including Canada, Sweden, Norway, Estonia, and the United Kingdom.
In this commentary, we review what patients, clinicians, and policymakers have been learning about open notes.
The patient experience
What do patients experience? In a survey of more than 22,000 patients who read notes in three diverse health systems, more than 90% reported having a good grasp of what their doctors and other clinicians had written, and very few (3%) reported being very confused by what they read. About two-thirds described reading their notes as very important for taking care of their health, remembering details of their visits and their care plans, and understanding why a medication was prescribed.
Indeed, in a clinically exciting finding, 14% of survey respondents reported that reading their notes made them more likely to take their medications as their doctors wished. With about half of Americans with chronic illness failing to take their medicines as prescribed, which sometimes leads to compromised outcomes and associated unnecessary costs (estimated at $300 billion annually), these reports of increased adherence should be taken very seriously.
Some doctors anticipate that open notes will erode patient communication. A growing body of research reveals just the opposite. In multiple surveys, patients describe open notes as “extending the visit,” strengthening collaboration and teamwork with their doctor. Quite possibly, the invitation to read notes may in itself increase trust. Such benefits appear especially pronounced among patients who are older, less educated, are persons of color or Hispanic, or who do not speak English at home.
And in several studies, more than a third of patients also report sharing their notes with others, with older and chronically ill patients in particular sharing access with family and friends who are their care partners.
On the other hand, a small minority of patients (5%) do report being more worried by what they read. It’s unknown whether this is because they are better informed about their care or because baseline anxiety levels increase. Doctors expect also that some patients, particularly those with cancer or serious mental illness, will be upset by their notes. So far, evidence does not support that specific concern.
Conversely, withholding, delaying, or blocking notes may be a source of anxiety or even stigmatization. When clinicians find themselves worried about sharing notes, we suggest that they discuss with their patients the benefits and risks. Recall also that transparency facilitates freedom of choice; patients make their own decision, and quite a few choose to leave notes unread.
Finding mistakes early and preventing harm are important goals for health care, and open notes can make care safer. Inevitably, medical records contain errors, omissions, and inaccuracies. In a large patient survey, 21% reported finding an error in their notes, and 42% perceived the error to be serious.
Moreover, 25% of doctors with more than a year’s experience with open notes reported patients finding errors that they (the doctors) considered “serious.” In 2015, the National Academy of Medicine cited open notes as a mechanism for improving diagnostic accuracy. In regard to possible legal action from patients, most attorneys, patients, and doctors agree that more transparent communication will build trust overall and, if anything, diminish litigation. We know of no instances so far of lawsuits deriving from open notes.
The physician experience
Doctors may worry that open notes will impede workflow, that they will be compelled to “dumb down” their documentation to avoid causing offense or anxiety, and that patients will demand changes to what is written. Here, extensive survey research should allay such fears and expectations. In a survey of more than 1,600 clinicians with at least 1 year of experience with open notes, reports of disruption to workflow were uncommon.
Most doctors (84%) reported that patients contacted them with questions about their notes “less than monthly or never.” Approximately two-thirds (62%) reported spending the same amount of time writing visit notes.
After implementing open notes, many doctors do report being more mindful about their documentation. For example, 41% reported changing how they used language such as “patient denies” or “noncompliant,” and 18% reported changing their use of medical jargon or abbreviations. Might these changes undermine the utility of medical notes? A majority of doctors surveyed (78%) said no, reporting that, after implementing open notes, the value of their documentation was the same or better.
Innovations spotlight difficult and often longstanding challenges. Open notes highlight the complex role of medical records in preserving privacy, especially in the spectrum of abuse, whether domestic or involving elders, children or sexual transgressions. For families with adolescents, issues concerning confidentiality can become a two-way street, and federal and state rules at times provide conflicting and idiosyncratic guidance. It is important to emphasize that the new rules permit information blocking if there is clear evidence that doing so “will substantially reduce the risk of harm” to patients or to other third parties.
Perhaps think of open notes as a new medicine designed to help the vast majority of those who use it but with side effects and even contraindications for a few. Doctors can step in to minimize risks to vulnerable individuals, and imaginative and creative solutions to complex issues may emerge. In a growing number of practices serving adolescents, clinicians can now create two notes, with some elements of care visible on a patient portal and others held privately or visible only to the adolescent.
The shared experience
Overall, when it comes to documenting sensitive social information, open notes may act as a useful catalyst prompting deeper discussion about personal details clinically important to record, as opposed to those perhaps best left unwritten.
The implementation of open notes nationwide calls for exciting explorations. How can transparent systems maximize benefits for targeted populations in diverse settings? For patients with mental illness, can notes become part of the therapy? Given that care partners often report more benefit from reading notes than do patients themselves, how can they be mobilized to maximize their contributions to those acutely ill on hospital floors, or to family members with Alzheimer’s or in long-term care facilities?
How can we harness emerging technologies to translate notes and medical records into other languages or support lower literacy levels, while preserving the clinical detail in the notes? Should patients contribute to their own notes, cogenerating them with their clinicians? Experiments for “OurNotes” interventions are underway, and early reports from both patients and doctors hold considerable promise.
Ownership of medical records is evolving. Once firmly held by clinicians, electronic technologies have rapidly led to what may best be viewed currently as joint ownership by clinicians and patients. As apps evolve further and issues with interoperability of records diminish, it is likely that patients will eventually take control. Then it will be up to patients what to carry in their records. Clinicians will advise, but patients will decide.
The new rules herald clear changes in the fabric of care, and after a decade of study we anticipate that the benefits well outweigh the harms. But in the short run, it’s wrong to predict an avalanche. Two decades ago, when patient portals first revealed laboratory test findings to patients, doctors expected cataclysmic change in their practices. It did not occur. The vast majority of patients who registered on portals benefited and few disturbed their doctors.
Similarly, after notes were first unblinded by the OpenNotes research teams, the question we were asked most commonly by the primary care doctors who volunteered was whether the computers were actually displaying their notes. Even though many patients read them carefully, the doctors heard little from them. Clinicians have now reported the same experience in several subsequent studies.
Patients are resourceful, turning quickly to friends or the Internet for answers to their questions. They know how busy doctors are and don’t want to bother them if at all possible. When notes do trigger questions, the time taken to respond is probably offset by silence from other patients finding answers to their own questions in notes they read.
We believe that clinicians should embrace the spirit of the rules and also view them as HIPAA catching up with a computerized universe. As the new practice takes hold, ambiguities will diminish as further experience and research evolve. Warner V. Slack, MD, the first doctor to ask patients to talk to computers, opined that patients are the “largest and least utilized resource in health care.” Open and transparent communication through electronic medical records may mobilize patients (and their families) far more effectively. Patients will almost certainly benefit. Remembering Dr. Slack’s prophecy, we believe that clinicians will too.
A version of this article first appeared on Medscape.com.
Doctors are learning about new rules coming this April that encourage open and transparent communication among patients, families, and clinicians. The rules, putting into effect the bipartisan 21st Century Cures Act, mandate offering patients access to notes (“open notes”) written by clinicians in electronic medical records.
A recent article from this news organization noted that for many doctors this represents both a sudden and troubling change in practice. For others, the rules codify what they have been doing as a matter of routine for a decade. Spurred by the OpenNotes movement, at least 55 million Americans are already offered access to their clinical notes, including, since 2013, more than 9 million veterans with access to the Blue Button function in Veterans Affairs practices and hospitals.
The practice is spreading beyond the United States to other countries, including Canada, Sweden, Norway, Estonia, and the United Kingdom.
In this commentary, we review what patients, clinicians, and policymakers have been learning about open notes.
The patient experience
What do patients experience? In a survey of more than 22,000 patients who read notes in three diverse health systems, more than 90% reported having a good grasp of what their doctors and other clinicians had written, and very few (3%) reported being very confused by what they read. About two-thirds described reading their notes as very important for taking care of their health, remembering details of their visits and their care plans, and understanding why a medication was prescribed.
Indeed, in a clinically exciting finding, 14% of survey respondents reported that reading their notes made them more likely to take their medications as their doctors wished. With about half of Americans with chronic illness failing to take their medicines as prescribed, which sometimes leads to compromised outcomes and associated unnecessary costs (estimated at $300 billion annually), these reports of increased adherence should be taken very seriously.
Some doctors anticipate that open notes will erode patient communication. A growing body of research reveals just the opposite. In multiple surveys, patients describe open notes as “extending the visit,” strengthening collaboration and teamwork with their doctor. Quite possibly, the invitation to read notes may in itself increase trust. Such benefits appear especially pronounced among patients who are older, less educated, are persons of color or Hispanic, or who do not speak English at home.
And in several studies, more than a third of patients also report sharing their notes with others, with older and chronically ill patients in particular sharing access with family and friends who are their care partners.
On the other hand, a small minority of patients (5%) do report being more worried by what they read. It’s unknown whether this is because they are better informed about their care or because baseline anxiety levels increase. Doctors expect also that some patients, particularly those with cancer or serious mental illness, will be upset by their notes. So far, evidence does not support that specific concern.
Conversely, withholding, delaying, or blocking notes may be a source of anxiety or even stigmatization. When clinicians find themselves worried about sharing notes, we suggest that they discuss with their patients the benefits and risks. Recall also that transparency facilitates freedom of choice; patients make their own decision, and quite a few choose to leave notes unread.
Finding mistakes early and preventing harm are important goals for health care, and open notes can make care safer. Inevitably, medical records contain errors, omissions, and inaccuracies. In a large patient survey, 21% reported finding an error in their notes, and 42% perceived the error to be serious.
Moreover, 25% of doctors with more than a year’s experience with open notes reported patients finding errors that they (the doctors) considered “serious.” In 2015, the National Academy of Medicine cited open notes as a mechanism for improving diagnostic accuracy. In regard to possible legal action from patients, most attorneys, patients, and doctors agree that more transparent communication will build trust overall and, if anything, diminish litigation. We know of no instances so far of lawsuits deriving from open notes.
The physician experience
Doctors may worry that open notes will impede workflow, that they will be compelled to “dumb down” their documentation to avoid causing offense or anxiety, and that patients will demand changes to what is written. Here, extensive survey research should allay such fears and expectations. In a survey of more than 1,600 clinicians with at least 1 year of experience with open notes, reports of disruption to workflow were uncommon.
Most doctors (84%) reported that patients contacted them with questions about their notes “less than monthly or never.” Approximately two-thirds (62%) reported spending the same amount of time writing visit notes.
After implementing open notes, many doctors do report being more mindful about their documentation. For example, 41% reported changing how they used language such as “patient denies” or “noncompliant,” and 18% reported changing their use of medical jargon or abbreviations. Might these changes undermine the utility of medical notes? A majority of doctors surveyed (78%) said no, reporting that, after implementing open notes, the value of their documentation was the same or better.
Innovations spotlight difficult and often longstanding challenges. Open notes highlight the complex role of medical records in preserving privacy, especially in the spectrum of abuse, whether domestic or involving elders, children or sexual transgressions. For families with adolescents, issues concerning confidentiality can become a two-way street, and federal and state rules at times provide conflicting and idiosyncratic guidance. It is important to emphasize that the new rules permit information blocking if there is clear evidence that doing so “will substantially reduce the risk of harm” to patients or to other third parties.
Perhaps think of open notes as a new medicine designed to help the vast majority of those who use it but with side effects and even contraindications for a few. Doctors can step in to minimize risks to vulnerable individuals, and imaginative and creative solutions to complex issues may emerge. In a growing number of practices serving adolescents, clinicians can now create two notes, with some elements of care visible on a patient portal and others held privately or visible only to the adolescent.
The shared experience
Overall, when it comes to documenting sensitive social information, open notes may act as a useful catalyst prompting deeper discussion about personal details clinically important to record, as opposed to those perhaps best left unwritten.
The implementation of open notes nationwide calls for exciting explorations. How can transparent systems maximize benefits for targeted populations in diverse settings? For patients with mental illness, can notes become part of the therapy? Given that care partners often report more benefit from reading notes than do patients themselves, how can they be mobilized to maximize their contributions to those acutely ill on hospital floors, or to family members with Alzheimer’s or in long-term care facilities?
How can we harness emerging technologies to translate notes and medical records into other languages or support lower literacy levels, while preserving the clinical detail in the notes? Should patients contribute to their own notes, cogenerating them with their clinicians? Experiments for “OurNotes” interventions are underway, and early reports from both patients and doctors hold considerable promise.
Ownership of medical records is evolving. Once firmly held by clinicians, electronic technologies have rapidly led to what may best be viewed currently as joint ownership by clinicians and patients. As apps evolve further and issues with interoperability of records diminish, it is likely that patients will eventually take control. Then it will be up to patients what to carry in their records. Clinicians will advise, but patients will decide.
The new rules herald clear changes in the fabric of care, and after a decade of study we anticipate that the benefits well outweigh the harms. But in the short run, it’s wrong to predict an avalanche. Two decades ago, when patient portals first revealed laboratory test findings to patients, doctors expected cataclysmic change in their practices. It did not occur. The vast majority of patients who registered on portals benefited and few disturbed their doctors.
Similarly, after notes were first unblinded by the OpenNotes research teams, the question we were asked most commonly by the primary care doctors who volunteered was whether the computers were actually displaying their notes. Even though many patients read them carefully, the doctors heard little from them. Clinicians have now reported the same experience in several subsequent studies.
Patients are resourceful, turning quickly to friends or the Internet for answers to their questions. They know how busy doctors are and don’t want to bother them if at all possible. When notes do trigger questions, the time taken to respond is probably offset by silence from other patients finding answers to their own questions in notes they read.
We believe that clinicians should embrace the spirit of the rules and also view them as HIPAA catching up with a computerized universe. As the new practice takes hold, ambiguities will diminish as further experience and research evolve. Warner V. Slack, MD, the first doctor to ask patients to talk to computers, opined that patients are the “largest and least utilized resource in health care.” Open and transparent communication through electronic medical records may mobilize patients (and their families) far more effectively. Patients will almost certainly benefit. Remembering Dr. Slack’s prophecy, we believe that clinicians will too.
A version of this article first appeared on Medscape.com.
Doctors are learning about new rules coming this April that encourage open and transparent communication among patients, families, and clinicians. The rules, putting into effect the bipartisan 21st Century Cures Act, mandate offering patients access to notes (“open notes”) written by clinicians in electronic medical records.
A recent article from this news organization noted that for many doctors this represents both a sudden and troubling change in practice. For others, the rules codify what they have been doing as a matter of routine for a decade. Spurred by the OpenNotes movement, at least 55 million Americans are already offered access to their clinical notes, including, since 2013, more than 9 million veterans with access to the Blue Button function in Veterans Affairs practices and hospitals.
The practice is spreading beyond the United States to other countries, including Canada, Sweden, Norway, Estonia, and the United Kingdom.
In this commentary, we review what patients, clinicians, and policymakers have been learning about open notes.
The patient experience
What do patients experience? In a survey of more than 22,000 patients who read notes in three diverse health systems, more than 90% reported having a good grasp of what their doctors and other clinicians had written, and very few (3%) reported being very confused by what they read. About two-thirds described reading their notes as very important for taking care of their health, remembering details of their visits and their care plans, and understanding why a medication was prescribed.
Indeed, in a clinically exciting finding, 14% of survey respondents reported that reading their notes made them more likely to take their medications as their doctors wished. With about half of Americans with chronic illness failing to take their medicines as prescribed, which sometimes leads to compromised outcomes and associated unnecessary costs (estimated at $300 billion annually), these reports of increased adherence should be taken very seriously.
Some doctors anticipate that open notes will erode patient communication. A growing body of research reveals just the opposite. In multiple surveys, patients describe open notes as “extending the visit,” strengthening collaboration and teamwork with their doctor. Quite possibly, the invitation to read notes may in itself increase trust. Such benefits appear especially pronounced among patients who are older, less educated, are persons of color or Hispanic, or who do not speak English at home.
And in several studies, more than a third of patients also report sharing their notes with others, with older and chronically ill patients in particular sharing access with family and friends who are their care partners.
On the other hand, a small minority of patients (5%) do report being more worried by what they read. It’s unknown whether this is because they are better informed about their care or because baseline anxiety levels increase. Doctors expect also that some patients, particularly those with cancer or serious mental illness, will be upset by their notes. So far, evidence does not support that specific concern.
Conversely, withholding, delaying, or blocking notes may be a source of anxiety or even stigmatization. When clinicians find themselves worried about sharing notes, we suggest that they discuss with their patients the benefits and risks. Recall also that transparency facilitates freedom of choice; patients make their own decision, and quite a few choose to leave notes unread.
Finding mistakes early and preventing harm are important goals for health care, and open notes can make care safer. Inevitably, medical records contain errors, omissions, and inaccuracies. In a large patient survey, 21% reported finding an error in their notes, and 42% perceived the error to be serious.
Moreover, 25% of doctors with more than a year’s experience with open notes reported patients finding errors that they (the doctors) considered “serious.” In 2015, the National Academy of Medicine cited open notes as a mechanism for improving diagnostic accuracy. In regard to possible legal action from patients, most attorneys, patients, and doctors agree that more transparent communication will build trust overall and, if anything, diminish litigation. We know of no instances so far of lawsuits deriving from open notes.
The physician experience
Doctors may worry that open notes will impede workflow, that they will be compelled to “dumb down” their documentation to avoid causing offense or anxiety, and that patients will demand changes to what is written. Here, extensive survey research should allay such fears and expectations. In a survey of more than 1,600 clinicians with at least 1 year of experience with open notes, reports of disruption to workflow were uncommon.
Most doctors (84%) reported that patients contacted them with questions about their notes “less than monthly or never.” Approximately two-thirds (62%) reported spending the same amount of time writing visit notes.
After implementing open notes, many doctors do report being more mindful about their documentation. For example, 41% reported changing how they used language such as “patient denies” or “noncompliant,” and 18% reported changing their use of medical jargon or abbreviations. Might these changes undermine the utility of medical notes? A majority of doctors surveyed (78%) said no, reporting that, after implementing open notes, the value of their documentation was the same or better.
Innovations spotlight difficult and often longstanding challenges. Open notes highlight the complex role of medical records in preserving privacy, especially in the spectrum of abuse, whether domestic or involving elders, children or sexual transgressions. For families with adolescents, issues concerning confidentiality can become a two-way street, and federal and state rules at times provide conflicting and idiosyncratic guidance. It is important to emphasize that the new rules permit information blocking if there is clear evidence that doing so “will substantially reduce the risk of harm” to patients or to other third parties.
Perhaps think of open notes as a new medicine designed to help the vast majority of those who use it but with side effects and even contraindications for a few. Doctors can step in to minimize risks to vulnerable individuals, and imaginative and creative solutions to complex issues may emerge. In a growing number of practices serving adolescents, clinicians can now create two notes, with some elements of care visible on a patient portal and others held privately or visible only to the adolescent.
The shared experience
Overall, when it comes to documenting sensitive social information, open notes may act as a useful catalyst prompting deeper discussion about personal details clinically important to record, as opposed to those perhaps best left unwritten.
The implementation of open notes nationwide calls for exciting explorations. How can transparent systems maximize benefits for targeted populations in diverse settings? For patients with mental illness, can notes become part of the therapy? Given that care partners often report more benefit from reading notes than do patients themselves, how can they be mobilized to maximize their contributions to those acutely ill on hospital floors, or to family members with Alzheimer’s or in long-term care facilities?
How can we harness emerging technologies to translate notes and medical records into other languages or support lower literacy levels, while preserving the clinical detail in the notes? Should patients contribute to their own notes, cogenerating them with their clinicians? Experiments for “OurNotes” interventions are underway, and early reports from both patients and doctors hold considerable promise.
Ownership of medical records is evolving. Once firmly held by clinicians, electronic technologies have rapidly led to what may best be viewed currently as joint ownership by clinicians and patients. As apps evolve further and issues with interoperability of records diminish, it is likely that patients will eventually take control. Then it will be up to patients what to carry in their records. Clinicians will advise, but patients will decide.
The new rules herald clear changes in the fabric of care, and after a decade of study we anticipate that the benefits well outweigh the harms. But in the short run, it’s wrong to predict an avalanche. Two decades ago, when patient portals first revealed laboratory test findings to patients, doctors expected cataclysmic change in their practices. It did not occur. The vast majority of patients who registered on portals benefited and few disturbed their doctors.
Similarly, after notes were first unblinded by the OpenNotes research teams, the question we were asked most commonly by the primary care doctors who volunteered was whether the computers were actually displaying their notes. Even though many patients read them carefully, the doctors heard little from them. Clinicians have now reported the same experience in several subsequent studies.
Patients are resourceful, turning quickly to friends or the Internet for answers to their questions. They know how busy doctors are and don’t want to bother them if at all possible. When notes do trigger questions, the time taken to respond is probably offset by silence from other patients finding answers to their own questions in notes they read.
We believe that clinicians should embrace the spirit of the rules and also view them as HIPAA catching up with a computerized universe. As the new practice takes hold, ambiguities will diminish as further experience and research evolve. Warner V. Slack, MD, the first doctor to ask patients to talk to computers, opined that patients are the “largest and least utilized resource in health care.” Open and transparent communication through electronic medical records may mobilize patients (and their families) far more effectively. Patients will almost certainly benefit. Remembering Dr. Slack’s prophecy, we believe that clinicians will too.
A version of this article first appeared on Medscape.com.
What to do if an employee tests positive for COVID-19
An increasingly common question I’m receiving is:
As always, it depends, but here is some general advice: The specifics will vary depending on state/local laws, or your particular situation.
First, you need to determine the level of exposure, and whether it requires action. According to the Centers for Disease Control and Prevention, actionable exposure occurs 2 days prior to the onset of illness, and lasts 10 days after onset.
If action is required, you’ll need to determine who needs to quarantine and who needs to be tested. Vaccinated employees who have been exposed to suspected or confirmed COVID-19 are not required to quarantine or be tested if they are fully vaccinated and have remained asymptomatic since the exposure. Those employees should, however, follow all the usual precautions (masks, social distancing, handwashing, etc.) with increased diligence. Remind them that no vaccine is 100% effective, and suggest they self-monitor for symptoms (fever, cough, shortness of breath, etc.)
All other exposed employees should be tested. A negative test means an individual was not infected at the time the sample was collected, but that does not mean an individual will not get sick later. Some providers are retesting on days 5 and 7 post exposure.
Some experts advise that you monitor exposed employees (vaccinated or not) yourself, with daily temperature readings and inquiries regarding symptoms, and perhaps a daily pulse oximetry check, for 14 days following exposure. Document these screenings in writing. Anyone testing positive or developing a fever or other symptoms should, of course, be sent home and seek medical treatment as necessary.
Employees who develop symptoms or test positive for COVID-19 should remain out of work until all CDC “return-to-work” criteria are met. At this writing, the basic criteria include:
- At least 10 days pass after symptoms first appeared
- At least 24 hours pass after last fever without the use of fever-reducing medications
- Cough, shortness of breath, and any other symptoms improve
Anyone who is significantly immunocompromised may need more time at home, and probably consultation with an infectious disease specialist.
Your facility should be thoroughly cleaned after the exposure. Close off all areas used by the sick individual, and clean and disinfect all areas such as offices, doorknobs, bathrooms, common areas, and shared electronic equipment. Of course, the cleaners should wear gowns, gloves, masks, and goggles. Some practices are hiring cleaning crews to professionally disinfect their offices. Once the area has been disinfected, it can be reopened for use. Workers without close contact with the person who is sick can return to work immediately after disinfection.
If the potential infected area is widespread and cannot be isolated to a room or rooms where doors can be shut, it may be prudent to temporarily close your office, send staff home, and divert patients to other locations if they cannot be rescheduled. Once your facility is cleaned and disinfected and staff have been cleared, your office may reopen.
Use enhanced precautions for any staff or patients who are immunocompromised, or otherwise fall into the high-risk category, to keep them out of the path of potential exposure areas and allow them to self-quarantine if they desire.
You should continue following existing leave policies (paid time off, vacation, sick, short-term disability, leave of absence, Family and Medical Leave Act, and Americans with Disabilities Act). If the employee was exposed at work, contact your workers’ compensation carrier regarding lost wages. Unless your state laws specify otherwise, you are under no obligation to pay beyond your policies, but you may do so if you choose.
Of course, you can take proactive steps to prevent unnecessary exposure and avoid closures in the first place; for example:
- Call patients prior to their visit, or question them upon arrival, regarding fever, shortness of breath, and other COVID-19 symptoms.
- Check employees’ temperatures every morning.
- Check patients’ temperatures as they enter the office.
- Require everyone, patients and employees alike, to wear face coverings.
- Ask patients to leave friends and family members at home.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].
An increasingly common question I’m receiving is:
As always, it depends, but here is some general advice: The specifics will vary depending on state/local laws, or your particular situation.
First, you need to determine the level of exposure, and whether it requires action. According to the Centers for Disease Control and Prevention, actionable exposure occurs 2 days prior to the onset of illness, and lasts 10 days after onset.
If action is required, you’ll need to determine who needs to quarantine and who needs to be tested. Vaccinated employees who have been exposed to suspected or confirmed COVID-19 are not required to quarantine or be tested if they are fully vaccinated and have remained asymptomatic since the exposure. Those employees should, however, follow all the usual precautions (masks, social distancing, handwashing, etc.) with increased diligence. Remind them that no vaccine is 100% effective, and suggest they self-monitor for symptoms (fever, cough, shortness of breath, etc.)
All other exposed employees should be tested. A negative test means an individual was not infected at the time the sample was collected, but that does not mean an individual will not get sick later. Some providers are retesting on days 5 and 7 post exposure.
Some experts advise that you monitor exposed employees (vaccinated or not) yourself, with daily temperature readings and inquiries regarding symptoms, and perhaps a daily pulse oximetry check, for 14 days following exposure. Document these screenings in writing. Anyone testing positive or developing a fever or other symptoms should, of course, be sent home and seek medical treatment as necessary.
Employees who develop symptoms or test positive for COVID-19 should remain out of work until all CDC “return-to-work” criteria are met. At this writing, the basic criteria include:
- At least 10 days pass after symptoms first appeared
- At least 24 hours pass after last fever without the use of fever-reducing medications
- Cough, shortness of breath, and any other symptoms improve
Anyone who is significantly immunocompromised may need more time at home, and probably consultation with an infectious disease specialist.
Your facility should be thoroughly cleaned after the exposure. Close off all areas used by the sick individual, and clean and disinfect all areas such as offices, doorknobs, bathrooms, common areas, and shared electronic equipment. Of course, the cleaners should wear gowns, gloves, masks, and goggles. Some practices are hiring cleaning crews to professionally disinfect their offices. Once the area has been disinfected, it can be reopened for use. Workers without close contact with the person who is sick can return to work immediately after disinfection.
If the potential infected area is widespread and cannot be isolated to a room or rooms where doors can be shut, it may be prudent to temporarily close your office, send staff home, and divert patients to other locations if they cannot be rescheduled. Once your facility is cleaned and disinfected and staff have been cleared, your office may reopen.
Use enhanced precautions for any staff or patients who are immunocompromised, or otherwise fall into the high-risk category, to keep them out of the path of potential exposure areas and allow them to self-quarantine if they desire.
You should continue following existing leave policies (paid time off, vacation, sick, short-term disability, leave of absence, Family and Medical Leave Act, and Americans with Disabilities Act). If the employee was exposed at work, contact your workers’ compensation carrier regarding lost wages. Unless your state laws specify otherwise, you are under no obligation to pay beyond your policies, but you may do so if you choose.
Of course, you can take proactive steps to prevent unnecessary exposure and avoid closures in the first place; for example:
- Call patients prior to their visit, or question them upon arrival, regarding fever, shortness of breath, and other COVID-19 symptoms.
- Check employees’ temperatures every morning.
- Check patients’ temperatures as they enter the office.
- Require everyone, patients and employees alike, to wear face coverings.
- Ask patients to leave friends and family members at home.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].
An increasingly common question I’m receiving is:
As always, it depends, but here is some general advice: The specifics will vary depending on state/local laws, or your particular situation.
First, you need to determine the level of exposure, and whether it requires action. According to the Centers for Disease Control and Prevention, actionable exposure occurs 2 days prior to the onset of illness, and lasts 10 days after onset.
If action is required, you’ll need to determine who needs to quarantine and who needs to be tested. Vaccinated employees who have been exposed to suspected or confirmed COVID-19 are not required to quarantine or be tested if they are fully vaccinated and have remained asymptomatic since the exposure. Those employees should, however, follow all the usual precautions (masks, social distancing, handwashing, etc.) with increased diligence. Remind them that no vaccine is 100% effective, and suggest they self-monitor for symptoms (fever, cough, shortness of breath, etc.)
All other exposed employees should be tested. A negative test means an individual was not infected at the time the sample was collected, but that does not mean an individual will not get sick later. Some providers are retesting on days 5 and 7 post exposure.
Some experts advise that you monitor exposed employees (vaccinated or not) yourself, with daily temperature readings and inquiries regarding symptoms, and perhaps a daily pulse oximetry check, for 14 days following exposure. Document these screenings in writing. Anyone testing positive or developing a fever or other symptoms should, of course, be sent home and seek medical treatment as necessary.
Employees who develop symptoms or test positive for COVID-19 should remain out of work until all CDC “return-to-work” criteria are met. At this writing, the basic criteria include:
- At least 10 days pass after symptoms first appeared
- At least 24 hours pass after last fever without the use of fever-reducing medications
- Cough, shortness of breath, and any other symptoms improve
Anyone who is significantly immunocompromised may need more time at home, and probably consultation with an infectious disease specialist.
Your facility should be thoroughly cleaned after the exposure. Close off all areas used by the sick individual, and clean and disinfect all areas such as offices, doorknobs, bathrooms, common areas, and shared electronic equipment. Of course, the cleaners should wear gowns, gloves, masks, and goggles. Some practices are hiring cleaning crews to professionally disinfect their offices. Once the area has been disinfected, it can be reopened for use. Workers without close contact with the person who is sick can return to work immediately after disinfection.
If the potential infected area is widespread and cannot be isolated to a room or rooms where doors can be shut, it may be prudent to temporarily close your office, send staff home, and divert patients to other locations if they cannot be rescheduled. Once your facility is cleaned and disinfected and staff have been cleared, your office may reopen.
Use enhanced precautions for any staff or patients who are immunocompromised, or otherwise fall into the high-risk category, to keep them out of the path of potential exposure areas and allow them to self-quarantine if they desire.
You should continue following existing leave policies (paid time off, vacation, sick, short-term disability, leave of absence, Family and Medical Leave Act, and Americans with Disabilities Act). If the employee was exposed at work, contact your workers’ compensation carrier regarding lost wages. Unless your state laws specify otherwise, you are under no obligation to pay beyond your policies, but you may do so if you choose.
Of course, you can take proactive steps to prevent unnecessary exposure and avoid closures in the first place; for example:
- Call patients prior to their visit, or question them upon arrival, regarding fever, shortness of breath, and other COVID-19 symptoms.
- Check employees’ temperatures every morning.
- Check patients’ temperatures as they enter the office.
- Require everyone, patients and employees alike, to wear face coverings.
- Ask patients to leave friends and family members at home.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].
