Opinion

It has been almost 15 years since the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy established the Task Force on Quality Endoscopy and published the first set of quality indicators for GI endoscopic procedures.

This work was motivated by two seminal reports on patient safety that fostered a demand by the public, policy makers, and payers to accurately define and measure the quality of health care services.

While the Centers for Medicare & Medicaid Services initially designated and required reporting on several basic outcome measures, leaders within the field of gastroenterology recognized the importance of developing evidence-based quality measures for our field, and specifically for endoscopic procedures.

Integrating safety measures into our daily operations has always been important, and over the years, policies have been implemented to incentivize health care providers to meet standards in everything from patient safety to patient satisfaction. With our health care system moving from fee-for-service to value-based care, increased emphasis will continue to be placed on meeting these quality measures.
 

Defining quality and how to measure it

The goals of implementing quality measures within private practices include effective patient care and safety, but they also include issues like access and affordability, as well as the professionalism of your physicians and advanced practice providers.

As a larger practice, we have the resources to support a quality coordinator who spends half their time focused on quality measures. Every provider is required to complete annual education on quality parameters.

We have two committees that propose and track quality initiatives in our practice. We have one on the practice side and one for our ambulatory surgery centers (ASCs). The committees are made of physicians who have a particular interest in quality measures. On the ASC side, our ASC center director from our management partner AmSurg is also a member of the committee.

The road to improving quality within a private practice starts by defining the aspects of care that affect the quality of the patient experience.
 

Tracking quality in the office and in the surgery center

In our practices we have about 60 physicians. Start times and coding accuracy are good examples of what we have tracked in the past as areas of quality improvement. For instance, if only one or two providers get started late, it can cause a domino effect. Schedules get cramped, which can increase stress and possibly cause our team members to rush. Even things that seem like patient satisfaction issues can affect patient care, so it is important to make sure they are being measured.

On the ASC side, we track adenoma detection rates, colonoscopy intervals, complication rates, and many other additional criteria. As an example, when a pathology report is issued, we require our physicians to provide results to our patients within 72 hours.

Data on all providers are tabulated quarterly and then distributed to the providers in the form of a scorecard. The scorecard is then used for constructive feedback on improvements that can be made. A cumulative annual report is given to the providers, which is also incorporated into reviews. Not paying attention to quality measures can potentially have financial ramifications for providers in our group.
 

Find the right fit from a quality standpoint

In terms of what we are tracking, we are probably not that different from most groups of our size. Standardization will continue to increase, and it is important as an early career physician to familiarize yourself with quality measures in gastroenterology.

I often interview early career physicians who would like to join Regional GI, and the most impressive are the young men and women who ask about our processes for tracking quality measures and implementing programs geared toward improvement. If you are thinking of joining a practice, bring it up. You will be glad you did.

The interest in quality shows that you are invested in providing the best evidence-based patient care. As an independent group, this is critical because so much of what we do depends on having a track record of measurement. For instance, an ASC might not be credentialed if the quality metrics do not meet a certain threshold.

We are looking for potential partners who are seriously interested in joining us on our mission to provide the highest-quality care to our patients. After all, that is why became gastroenterologists in the first place.

Dr. Lalani serves as treasurer on the executive committee of the Digestive Health Physicians Association and is a practicing gastroenterologist at U.S. Digestive Health.

It has been almost 15 years since the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy established the Task Force on Quality Endoscopy and published the first set of quality indicators for GI endoscopic procedures.

This work was motivated by two seminal reports on patient safety that fostered a demand by the public, policy makers, and payers to accurately define and measure the quality of health care services.

While the Centers for Medicare & Medicaid Services initially designated and required reporting on several basic outcome measures, leaders within the field of gastroenterology recognized the importance of developing evidence-based quality measures for our field, and specifically for endoscopic procedures.

Integrating safety measures into our daily operations has always been important, and over the years, policies have been implemented to incentivize health care providers to meet standards in everything from patient safety to patient satisfaction. With our health care system moving from fee-for-service to value-based care, increased emphasis will continue to be placed on meeting these quality measures.
 

Defining quality and how to measure it

The goals of implementing quality measures within private practices include effective patient care and safety, but they also include issues like access and affordability, as well as the professionalism of your physicians and advanced practice providers.

As a larger practice, we have the resources to support a quality coordinator who spends half their time focused on quality measures. Every provider is required to complete annual education on quality parameters.

We have two committees that propose and track quality initiatives in our practice. We have one on the practice side and one for our ambulatory surgery centers (ASCs). The committees are made of physicians who have a particular interest in quality measures. On the ASC side, our ASC center director from our management partner AmSurg is also a member of the committee.

The road to improving quality within a private practice starts by defining the aspects of care that affect the quality of the patient experience.
 

Tracking quality in the office and in the surgery center

In our practices we have about 60 physicians. Start times and coding accuracy are good examples of what we have tracked in the past as areas of quality improvement. For instance, if only one or two providers get started late, it can cause a domino effect. Schedules get cramped, which can increase stress and possibly cause our team members to rush. Even things that seem like patient satisfaction issues can affect patient care, so it is important to make sure they are being measured.

On the ASC side, we track adenoma detection rates, colonoscopy intervals, complication rates, and many other additional criteria. As an example, when a pathology report is issued, we require our physicians to provide results to our patients within 72 hours.

Data on all providers are tabulated quarterly and then distributed to the providers in the form of a scorecard. The scorecard is then used for constructive feedback on improvements that can be made. A cumulative annual report is given to the providers, which is also incorporated into reviews. Not paying attention to quality measures can potentially have financial ramifications for providers in our group.
 

Find the right fit from a quality standpoint

In terms of what we are tracking, we are probably not that different from most groups of our size. Standardization will continue to increase, and it is important as an early career physician to familiarize yourself with quality measures in gastroenterology.

I often interview early career physicians who would like to join Regional GI, and the most impressive are the young men and women who ask about our processes for tracking quality measures and implementing programs geared toward improvement. If you are thinking of joining a practice, bring it up. You will be glad you did.

The interest in quality shows that you are invested in providing the best evidence-based patient care. As an independent group, this is critical because so much of what we do depends on having a track record of measurement. For instance, an ASC might not be credentialed if the quality metrics do not meet a certain threshold.

We are looking for potential partners who are seriously interested in joining us on our mission to provide the highest-quality care to our patients. After all, that is why became gastroenterologists in the first place.

Dr. Lalani serves as treasurer on the executive committee of the Digestive Health Physicians Association and is a practicing gastroenterologist at U.S. Digestive Health.

It has been almost 15 years since the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy established the Task Force on Quality Endoscopy and published the first set of quality indicators for GI endoscopic procedures.

This work was motivated by two seminal reports on patient safety that fostered a demand by the public, policy makers, and payers to accurately define and measure the quality of health care services.

While the Centers for Medicare & Medicaid Services initially designated and required reporting on several basic outcome measures, leaders within the field of gastroenterology recognized the importance of developing evidence-based quality measures for our field, and specifically for endoscopic procedures.

Integrating safety measures into our daily operations has always been important, and over the years, policies have been implemented to incentivize health care providers to meet standards in everything from patient safety to patient satisfaction. With our health care system moving from fee-for-service to value-based care, increased emphasis will continue to be placed on meeting these quality measures.
 

Defining quality and how to measure it

The goals of implementing quality measures within private practices include effective patient care and safety, but they also include issues like access and affordability, as well as the professionalism of your physicians and advanced practice providers.

As a larger practice, we have the resources to support a quality coordinator who spends half their time focused on quality measures. Every provider is required to complete annual education on quality parameters.

We have two committees that propose and track quality initiatives in our practice. We have one on the practice side and one for our ambulatory surgery centers (ASCs). The committees are made of physicians who have a particular interest in quality measures. On the ASC side, our ASC center director from our management partner AmSurg is also a member of the committee.

The road to improving quality within a private practice starts by defining the aspects of care that affect the quality of the patient experience.
 

Tracking quality in the office and in the surgery center

In our practices we have about 60 physicians. Start times and coding accuracy are good examples of what we have tracked in the past as areas of quality improvement. For instance, if only one or two providers get started late, it can cause a domino effect. Schedules get cramped, which can increase stress and possibly cause our team members to rush. Even things that seem like patient satisfaction issues can affect patient care, so it is important to make sure they are being measured.

On the ASC side, we track adenoma detection rates, colonoscopy intervals, complication rates, and many other additional criteria. As an example, when a pathology report is issued, we require our physicians to provide results to our patients within 72 hours.

Data on all providers are tabulated quarterly and then distributed to the providers in the form of a scorecard. The scorecard is then used for constructive feedback on improvements that can be made. A cumulative annual report is given to the providers, which is also incorporated into reviews. Not paying attention to quality measures can potentially have financial ramifications for providers in our group.
 

Find the right fit from a quality standpoint

In terms of what we are tracking, we are probably not that different from most groups of our size. Standardization will continue to increase, and it is important as an early career physician to familiarize yourself with quality measures in gastroenterology.

I often interview early career physicians who would like to join Regional GI, and the most impressive are the young men and women who ask about our processes for tracking quality measures and implementing programs geared toward improvement. If you are thinking of joining a practice, bring it up. You will be glad you did.

The interest in quality shows that you are invested in providing the best evidence-based patient care. As an independent group, this is critical because so much of what we do depends on having a track record of measurement. For instance, an ASC might not be credentialed if the quality metrics do not meet a certain threshold.

We are looking for potential partners who are seriously interested in joining us on our mission to provide the highest-quality care to our patients. After all, that is why became gastroenterologists in the first place.

Dr. Lalani serves as treasurer on the executive committee of the Digestive Health Physicians Association and is a practicing gastroenterologist at U.S. Digestive Health.

Each year on Oct. 10, the world takes a moment to commemorate the significance of mental health and its impact on an individual’s life. This year, as we continue to reflect beyond World Mental Health Day, we see the world in a different light. Creating awareness for mental health issues and expanding access to psychiatric services has now become more essential than ever before.

The year 2020 will forever be known as the beginning of the “COVID era” as, unfortunately, the whole world as we know it adapts and reconstructs amid the rise of this global pandemic. This era has brought with it a wave of unemployment, social isolation, economic disaster, death, and disability. It is inevitable that such changes have brought forth perpetual fear and uncertainty, which have taken their toll not only on individuals’ physical health but largely on their mental health as well.

Factors that perpetuate deteriorating mental health include unemployment, poverty, isolation, fear and loss of loved ones – all of which have been further exacerbated globally, thanks to the current pandemic. According to the World Health Organization (WHO), 450 million people in the world suffer from mental illness, and one in four individuals are affected by mental illness in some stage of their lives. This means that mental illness accounts for 13% of the total global burden of disease.

The past few months have been particularly challenging for health care workers around the globe. These challenges include providing care in difficult circumstances, going to work afraid of bringing COVID-19 home, and vulnerability toward becoming mentally and physically ill. An immense sense of responsibility toward patients with mental illness, coupled with continuous fear of becoming infected with this novel virus, has made managing the mental health of our patients all the more challenging.

As a psychiatrist (A.A.M.), I have noticed a massive increase in both the incidence and prevalence of mental illness. Emergency departments are full of patients presenting with suicidal attempts/ideation. Substance abuse has increased in greater magnitude, and outpatients are presenting with escalating numbers of depression and anxiety. Relapse of symptoms among stable patients has been another major problem. Incidents of domestic violence, road rage, and impaired driving secondary to alcoholism leading to psychiatric consultations have also risen drastically.

Mental health units in hospitals are tremendously busy with scarce availability of beds. The increase in waiting times for allocation of beds has also become a major concern globally.

Governments have allocated more funds and are actively attempting to mobilize resources in the developed world. However, adapting to the circumstances has proven to be far more challenging in many regions of the developing world. To avoid personal contacts in health settings, governments have allowed virtual consultations, which has proven to be a highly commendable decision. The use of telephone and video consultations has allowed physicians, particularly psychiatrists, to continue to provide health care to their patients while maintaining social distance. Crisis services have also become far more active, which can help in alleviating mental health emergencies to a great extent.

International crisis is possible

According to the director of the World Federation for Mental Health, citing the report of World Economic Forum, mental health problems could cost the global economy up to $16 trillion between 2010 and 2030, and if this matter is not addressed, it could potentially lead to an international mental health crisis. If the pandemic continues to create such a large impact for a prolonged period of time, the state of mental health globally will continue to be a major concern.

Universal effort is imperative to strengthen the mental health service and increase our ability to provide care for vulnerable individuals. This can be achieved through collaboration with other stakeholders, the allied health sector, the WHO, and the World Bank. The efforts should be directed toward the availability of funds, mobilizing and enhancing resources and training health care and crisis workers. This focus should not only be for developed countries but also for developing countries alike because we are all suffering from the impacts of this global crisis together.

It is important to raise awareness and support one another now more than ever before as we strive to improve and strengthen our mental health on this World Mental Health Day.
 

Dr. Muhammad is clinical professor of psychiatry at McMaster University, Hamilton, Ont. Ms. Amin is a 5th-year MBBS student at St. George’s University Hospital in London.

Each year on Oct. 10, the world takes a moment to commemorate the significance of mental health and its impact on an individual’s life. This year, as we continue to reflect beyond World Mental Health Day, we see the world in a different light. Creating awareness for mental health issues and expanding access to psychiatric services has now become more essential than ever before.

The year 2020 will forever be known as the beginning of the “COVID era” as, unfortunately, the whole world as we know it adapts and reconstructs amid the rise of this global pandemic. This era has brought with it a wave of unemployment, social isolation, economic disaster, death, and disability. It is inevitable that such changes have brought forth perpetual fear and uncertainty, which have taken their toll not only on individuals’ physical health but largely on their mental health as well.

Factors that perpetuate deteriorating mental health include unemployment, poverty, isolation, fear and loss of loved ones – all of which have been further exacerbated globally, thanks to the current pandemic. According to the World Health Organization (WHO), 450 million people in the world suffer from mental illness, and one in four individuals are affected by mental illness in some stage of their lives. This means that mental illness accounts for 13% of the total global burden of disease.

The past few months have been particularly challenging for health care workers around the globe. These challenges include providing care in difficult circumstances, going to work afraid of bringing COVID-19 home, and vulnerability toward becoming mentally and physically ill. An immense sense of responsibility toward patients with mental illness, coupled with continuous fear of becoming infected with this novel virus, has made managing the mental health of our patients all the more challenging.

As a psychiatrist (A.A.M.), I have noticed a massive increase in both the incidence and prevalence of mental illness. Emergency departments are full of patients presenting with suicidal attempts/ideation. Substance abuse has increased in greater magnitude, and outpatients are presenting with escalating numbers of depression and anxiety. Relapse of symptoms among stable patients has been another major problem. Incidents of domestic violence, road rage, and impaired driving secondary to alcoholism leading to psychiatric consultations have also risen drastically.

Mental health units in hospitals are tremendously busy with scarce availability of beds. The increase in waiting times for allocation of beds has also become a major concern globally.

Governments have allocated more funds and are actively attempting to mobilize resources in the developed world. However, adapting to the circumstances has proven to be far more challenging in many regions of the developing world. To avoid personal contacts in health settings, governments have allowed virtual consultations, which has proven to be a highly commendable decision. The use of telephone and video consultations has allowed physicians, particularly psychiatrists, to continue to provide health care to their patients while maintaining social distance. Crisis services have also become far more active, which can help in alleviating mental health emergencies to a great extent.

International crisis is possible

According to the director of the World Federation for Mental Health, citing the report of World Economic Forum, mental health problems could cost the global economy up to $16 trillion between 2010 and 2030, and if this matter is not addressed, it could potentially lead to an international mental health crisis. If the pandemic continues to create such a large impact for a prolonged period of time, the state of mental health globally will continue to be a major concern.

Universal effort is imperative to strengthen the mental health service and increase our ability to provide care for vulnerable individuals. This can be achieved through collaboration with other stakeholders, the allied health sector, the WHO, and the World Bank. The efforts should be directed toward the availability of funds, mobilizing and enhancing resources and training health care and crisis workers. This focus should not only be for developed countries but also for developing countries alike because we are all suffering from the impacts of this global crisis together.

It is important to raise awareness and support one another now more than ever before as we strive to improve and strengthen our mental health on this World Mental Health Day.
 

Dr. Muhammad is clinical professor of psychiatry at McMaster University, Hamilton, Ont. Ms. Amin is a 5th-year MBBS student at St. George’s University Hospital in London.

Each year on Oct. 10, the world takes a moment to commemorate the significance of mental health and its impact on an individual’s life. This year, as we continue to reflect beyond World Mental Health Day, we see the world in a different light. Creating awareness for mental health issues and expanding access to psychiatric services has now become more essential than ever before.

The year 2020 will forever be known as the beginning of the “COVID era” as, unfortunately, the whole world as we know it adapts and reconstructs amid the rise of this global pandemic. This era has brought with it a wave of unemployment, social isolation, economic disaster, death, and disability. It is inevitable that such changes have brought forth perpetual fear and uncertainty, which have taken their toll not only on individuals’ physical health but largely on their mental health as well.

Factors that perpetuate deteriorating mental health include unemployment, poverty, isolation, fear and loss of loved ones – all of which have been further exacerbated globally, thanks to the current pandemic. According to the World Health Organization (WHO), 450 million people in the world suffer from mental illness, and one in four individuals are affected by mental illness in some stage of their lives. This means that mental illness accounts for 13% of the total global burden of disease.

The past few months have been particularly challenging for health care workers around the globe. These challenges include providing care in difficult circumstances, going to work afraid of bringing COVID-19 home, and vulnerability toward becoming mentally and physically ill. An immense sense of responsibility toward patients with mental illness, coupled with continuous fear of becoming infected with this novel virus, has made managing the mental health of our patients all the more challenging.

As a psychiatrist (A.A.M.), I have noticed a massive increase in both the incidence and prevalence of mental illness. Emergency departments are full of patients presenting with suicidal attempts/ideation. Substance abuse has increased in greater magnitude, and outpatients are presenting with escalating numbers of depression and anxiety. Relapse of symptoms among stable patients has been another major problem. Incidents of domestic violence, road rage, and impaired driving secondary to alcoholism leading to psychiatric consultations have also risen drastically.

Mental health units in hospitals are tremendously busy with scarce availability of beds. The increase in waiting times for allocation of beds has also become a major concern globally.

Governments have allocated more funds and are actively attempting to mobilize resources in the developed world. However, adapting to the circumstances has proven to be far more challenging in many regions of the developing world. To avoid personal contacts in health settings, governments have allowed virtual consultations, which has proven to be a highly commendable decision. The use of telephone and video consultations has allowed physicians, particularly psychiatrists, to continue to provide health care to their patients while maintaining social distance. Crisis services have also become far more active, which can help in alleviating mental health emergencies to a great extent.

International crisis is possible

According to the director of the World Federation for Mental Health, citing the report of World Economic Forum, mental health problems could cost the global economy up to $16 trillion between 2010 and 2030, and if this matter is not addressed, it could potentially lead to an international mental health crisis. If the pandemic continues to create such a large impact for a prolonged period of time, the state of mental health globally will continue to be a major concern.

Universal effort is imperative to strengthen the mental health service and increase our ability to provide care for vulnerable individuals. This can be achieved through collaboration with other stakeholders, the allied health sector, the WHO, and the World Bank. The efforts should be directed toward the availability of funds, mobilizing and enhancing resources and training health care and crisis workers. This focus should not only be for developed countries but also for developing countries alike because we are all suffering from the impacts of this global crisis together.

It is important to raise awareness and support one another now more than ever before as we strive to improve and strengthen our mental health on this World Mental Health Day.
 

Dr. Muhammad is clinical professor of psychiatry at McMaster University, Hamilton, Ont. Ms. Amin is a 5th-year MBBS student at St. George’s University Hospital in London.

I had the privilege of attending and speaking at the recent MSVirtual2020—the 8^th Joint ACTRIMS-ECTRIMS Meeting. I came away with a wealth of knowledge, much of which can be put to immediate use in practice, and some that shows the promise of eventual clinical utility.

Dr. Helen Tremlett, PhD, kicked off the meeting with a keynote address covering her important work on the MS prodrome.  The Canada research chair in neuroepidemiology and multiple sclerosis at the University of British Columbia summarized her team’s research to date and offered her thoughts on clinical implications.

Dr. Tremlett’s group has observed that in the five years before an MS symptom onset, individuals who would ultimately be diagnosed tended to experience more hospitalizations, visit their provider more, and fill more prescriptions than did those in the general population. The team dug deeper and found that these individuals experienced a range of issues prior to symptom onset, including pain, headache, migraine, fibromyalgia, irritable bowel syndrome, sleep disturbances, depression/anxiety, and dermatologic issues.

Interestingly, females in this group were less likely to become pregnant and more likely than healthy females to fill an oral contraceptive prescription, suggesting that they were trying to delay pregnancy due to these prodromal symptoms.

Dr. Tremlett noted that the more immediate implications of her group’s work are for clinical researchers, who can now use these findings to understand that there is a prodromal stage as they conduct clinical trials. The ultimate aim is to use this work to develop a diagnostic tool, but that will take more time and study.

COVID-19’s Impact on MS

The impact on COVID-19 on individuals with MS was addressed in a number of sessions. I presented data that clearly shows the risk of infection from COVID-19 is similar to that of the population at large.

• A critical evaluation of MS disease modifying therapies (DMTs) and their potential effects on COVID-19 that I published with my colleagues at the University of Pennsylvania suggested that DMTs might not increase the risk of morbidity and mortality associated with COVID-19 as some had feared. We based this conclusion on an evaluation of pathogenesis of COVID, the importance of the innate immune system in control of exposure to a novel pathogen, and the likely effects, both salutary and pernicious, of DMTs on COVID morbidity and mortality.
•  Investigators from Italy looked at 232 patients from 38 centers with MS and confirmed or suspected COVID and found that the vast majority of them (96%) had mild disease consisting of no or mild pneumonia. The remainder had either severe (2%) or critical (3%) disease.  These investigators have since expanded their observations and suggested that anti-CD20 monoclonal antibody treatment may be associated with a higher risk of hospitalization, though there did not appear to be an increase in the risk of death with their use.  Importantly, the anti-CD20 monoclonal antibody therapies are the DMTs routinely used in patients with progressive MS, generally, the MS population at greatest risk of hospitalization with COVID-19 due to their older age, co-morbidities, and level of debility.
• Recently, French researchers evaluated 347 individuals with MS and COVID by COVID disease severity. They found that there was a higher proportion of patients with severe COVID not receiving DMT compared with individuals receiving treatment (46% and 15%, respectively).

The Increasing Importance of sNfL Concentration

Serum neurofilament light chain (sNfL) concentration continues to be a hot topic. Dr. Jens Kuhle, head of the Multiple Sclerosis Centre at the University of Basel, and colleagues have demonstrated that sNfL levels can play a role in monitoring MS treatment in practice. They evaluated more than 1000 individuals who were taking DMTs, measuring sNfL and deriving a score that reflected how participants fared relative to healthy controls of the same age. Among their findings:

• The resulting score predicted clinical events in the following year, with the effect escalating in magnitude in those whose scores were higher.
• This same predictive effect was seen with respect to future new/enlarging T2 lesions and brain volume loss.
• Score change in patients with NEDA-03 status was linked with a 37% increased risk of clinical events in the following year.

New Radiologic Techniques

Encouraging findings on new radiologic techniques were presented. I found three studies extremely informative. The first two have immediate or near-immediate clinical implications, and the third shows promise.

• In a comparison of patients with MS and healthy individuals who underwent brain 3T MRI to assess lesions and atrophy, R. Bonacchi and colleagues from Milan, Italy found that cardiovascular (CV) risk factors are linked with brain atrophy in patients with MS, even those <50 years of age. Specifically, the presence of at least two CV risk factors was linked with reduced normalized grey matter volume, white matter volume, and brain volume.
• Another comparison of individuals with MS and healthy controls—this one from O. Al-Louzi and colleagues at the National Institute of Neurological Disorders and Stroke—looked at the central vein sign (CVS) biomarker and determined that excluding lesions only if all dimensions of 3T MRI results were less than threshold (versus if any dimension was less than threshold) led to the inclusion of more CVS-positive lesions. Investigators suggested this work could lead to modified clinical guidelines.
• In an evaluation of patients with MS using 3T MRI, F. LaRosa and colleagues from Lausanne, Switzerland reported that RimNet, a prototype built upon two convolutional neural networks, was better than two alternative methods at detecting pragmatic rim lesions, which are linked with higher disease burden. Compared with expert raters, RimNet had higher sensitivity (87% vs 76%) but lower specificity (91% vs 99%).

There were many other valuable presentations at MSVirtual2020, but perhaps the most appreciated experience was the ability to hear more experts deliver their important work. Unlike a live meeting, I was able to easily attend parallel sessions and to do so at my leisure. ECTRIMS has become so big that I often left the live meeting feeling as if I missed out on a lot. Not this year. I heard almost all of it and came away with a greater appreciation of the breadth and depth of the meeting.  I hope that in the future, even following the return of in-person meetings, a virtual format coexists to afford attendees and those unable to attend live the opportunity to experience the totality of the meeting.

I had the privilege of attending and speaking at the recent MSVirtual2020—the 8^th Joint ACTRIMS-ECTRIMS Meeting. I came away with a wealth of knowledge, much of which can be put to immediate use in practice, and some that shows the promise of eventual clinical utility.

Dr. Helen Tremlett, PhD, kicked off the meeting with a keynote address covering her important work on the MS prodrome.  The Canada research chair in neuroepidemiology and multiple sclerosis at the University of British Columbia summarized her team’s research to date and offered her thoughts on clinical implications.

Dr. Tremlett’s group has observed that in the five years before an MS symptom onset, individuals who would ultimately be diagnosed tended to experience more hospitalizations, visit their provider more, and fill more prescriptions than did those in the general population. The team dug deeper and found that these individuals experienced a range of issues prior to symptom onset, including pain, headache, migraine, fibromyalgia, irritable bowel syndrome, sleep disturbances, depression/anxiety, and dermatologic issues.

Interestingly, females in this group were less likely to become pregnant and more likely than healthy females to fill an oral contraceptive prescription, suggesting that they were trying to delay pregnancy due to these prodromal symptoms.

Dr. Tremlett noted that the more immediate implications of her group’s work are for clinical researchers, who can now use these findings to understand that there is a prodromal stage as they conduct clinical trials. The ultimate aim is to use this work to develop a diagnostic tool, but that will take more time and study.

COVID-19’s Impact on MS

The impact on COVID-19 on individuals with MS was addressed in a number of sessions. I presented data that clearly shows the risk of infection from COVID-19 is similar to that of the population at large.

• A critical evaluation of MS disease modifying therapies (DMTs) and their potential effects on COVID-19 that I published with my colleagues at the University of Pennsylvania suggested that DMTs might not increase the risk of morbidity and mortality associated with COVID-19 as some had feared. We based this conclusion on an evaluation of pathogenesis of COVID, the importance of the innate immune system in control of exposure to a novel pathogen, and the likely effects, both salutary and pernicious, of DMTs on COVID morbidity and mortality.
•  Investigators from Italy looked at 232 patients from 38 centers with MS and confirmed or suspected COVID and found that the vast majority of them (96%) had mild disease consisting of no or mild pneumonia. The remainder had either severe (2%) or critical (3%) disease.  These investigators have since expanded their observations and suggested that anti-CD20 monoclonal antibody treatment may be associated with a higher risk of hospitalization, though there did not appear to be an increase in the risk of death with their use.  Importantly, the anti-CD20 monoclonal antibody therapies are the DMTs routinely used in patients with progressive MS, generally, the MS population at greatest risk of hospitalization with COVID-19 due to their older age, co-morbidities, and level of debility.
• Recently, French researchers evaluated 347 individuals with MS and COVID by COVID disease severity. They found that there was a higher proportion of patients with severe COVID not receiving DMT compared with individuals receiving treatment (46% and 15%, respectively).

The Increasing Importance of sNfL Concentration

Serum neurofilament light chain (sNfL) concentration continues to be a hot topic. Dr. Jens Kuhle, head of the Multiple Sclerosis Centre at the University of Basel, and colleagues have demonstrated that sNfL levels can play a role in monitoring MS treatment in practice. They evaluated more than 1000 individuals who were taking DMTs, measuring sNfL and deriving a score that reflected how participants fared relative to healthy controls of the same age. Among their findings:

• The resulting score predicted clinical events in the following year, with the effect escalating in magnitude in those whose scores were higher.
• This same predictive effect was seen with respect to future new/enlarging T2 lesions and brain volume loss.
• Score change in patients with NEDA-03 status was linked with a 37% increased risk of clinical events in the following year.

New Radiologic Techniques

Encouraging findings on new radiologic techniques were presented. I found three studies extremely informative. The first two have immediate or near-immediate clinical implications, and the third shows promise.

• In a comparison of patients with MS and healthy individuals who underwent brain 3T MRI to assess lesions and atrophy, R. Bonacchi and colleagues from Milan, Italy found that cardiovascular (CV) risk factors are linked with brain atrophy in patients with MS, even those <50 years of age. Specifically, the presence of at least two CV risk factors was linked with reduced normalized grey matter volume, white matter volume, and brain volume.
• Another comparison of individuals with MS and healthy controls—this one from O. Al-Louzi and colleagues at the National Institute of Neurological Disorders and Stroke—looked at the central vein sign (CVS) biomarker and determined that excluding lesions only if all dimensions of 3T MRI results were less than threshold (versus if any dimension was less than threshold) led to the inclusion of more CVS-positive lesions. Investigators suggested this work could lead to modified clinical guidelines.
• In an evaluation of patients with MS using 3T MRI, F. LaRosa and colleagues from Lausanne, Switzerland reported that RimNet, a prototype built upon two convolutional neural networks, was better than two alternative methods at detecting pragmatic rim lesions, which are linked with higher disease burden. Compared with expert raters, RimNet had higher sensitivity (87% vs 76%) but lower specificity (91% vs 99%).

There were many other valuable presentations at MSVirtual2020, but perhaps the most appreciated experience was the ability to hear more experts deliver their important work. Unlike a live meeting, I was able to easily attend parallel sessions and to do so at my leisure. ECTRIMS has become so big that I often left the live meeting feeling as if I missed out on a lot. Not this year. I heard almost all of it and came away with a greater appreciation of the breadth and depth of the meeting.  I hope that in the future, even following the return of in-person meetings, a virtual format coexists to afford attendees and those unable to attend live the opportunity to experience the totality of the meeting.

I had the privilege of attending and speaking at the recent MSVirtual2020—the 8^th Joint ACTRIMS-ECTRIMS Meeting. I came away with a wealth of knowledge, much of which can be put to immediate use in practice, and some that shows the promise of eventual clinical utility.

Dr. Helen Tremlett, PhD, kicked off the meeting with a keynote address covering her important work on the MS prodrome.  The Canada research chair in neuroepidemiology and multiple sclerosis at the University of British Columbia summarized her team’s research to date and offered her thoughts on clinical implications.

Dr. Tremlett’s group has observed that in the five years before an MS symptom onset, individuals who would ultimately be diagnosed tended to experience more hospitalizations, visit their provider more, and fill more prescriptions than did those in the general population. The team dug deeper and found that these individuals experienced a range of issues prior to symptom onset, including pain, headache, migraine, fibromyalgia, irritable bowel syndrome, sleep disturbances, depression/anxiety, and dermatologic issues.

Interestingly, females in this group were less likely to become pregnant and more likely than healthy females to fill an oral contraceptive prescription, suggesting that they were trying to delay pregnancy due to these prodromal symptoms.

Dr. Tremlett noted that the more immediate implications of her group’s work are for clinical researchers, who can now use these findings to understand that there is a prodromal stage as they conduct clinical trials. The ultimate aim is to use this work to develop a diagnostic tool, but that will take more time and study.

COVID-19’s Impact on MS

The impact on COVID-19 on individuals with MS was addressed in a number of sessions. I presented data that clearly shows the risk of infection from COVID-19 is similar to that of the population at large.

• A critical evaluation of MS disease modifying therapies (DMTs) and their potential effects on COVID-19 that I published with my colleagues at the University of Pennsylvania suggested that DMTs might not increase the risk of morbidity and mortality associated with COVID-19 as some had feared. We based this conclusion on an evaluation of pathogenesis of COVID, the importance of the innate immune system in control of exposure to a novel pathogen, and the likely effects, both salutary and pernicious, of DMTs on COVID morbidity and mortality.
•  Investigators from Italy looked at 232 patients from 38 centers with MS and confirmed or suspected COVID and found that the vast majority of them (96%) had mild disease consisting of no or mild pneumonia. The remainder had either severe (2%) or critical (3%) disease.  These investigators have since expanded their observations and suggested that anti-CD20 monoclonal antibody treatment may be associated with a higher risk of hospitalization, though there did not appear to be an increase in the risk of death with their use.  Importantly, the anti-CD20 monoclonal antibody therapies are the DMTs routinely used in patients with progressive MS, generally, the MS population at greatest risk of hospitalization with COVID-19 due to their older age, co-morbidities, and level of debility.
• Recently, French researchers evaluated 347 individuals with MS and COVID by COVID disease severity. They found that there was a higher proportion of patients with severe COVID not receiving DMT compared with individuals receiving treatment (46% and 15%, respectively).

The Increasing Importance of sNfL Concentration

Serum neurofilament light chain (sNfL) concentration continues to be a hot topic. Dr. Jens Kuhle, head of the Multiple Sclerosis Centre at the University of Basel, and colleagues have demonstrated that sNfL levels can play a role in monitoring MS treatment in practice. They evaluated more than 1000 individuals who were taking DMTs, measuring sNfL and deriving a score that reflected how participants fared relative to healthy controls of the same age. Among their findings:

• The resulting score predicted clinical events in the following year, with the effect escalating in magnitude in those whose scores were higher.
• This same predictive effect was seen with respect to future new/enlarging T2 lesions and brain volume loss.
• Score change in patients with NEDA-03 status was linked with a 37% increased risk of clinical events in the following year.

New Radiologic Techniques

Encouraging findings on new radiologic techniques were presented. I found three studies extremely informative. The first two have immediate or near-immediate clinical implications, and the third shows promise.

• In a comparison of patients with MS and healthy individuals who underwent brain 3T MRI to assess lesions and atrophy, R. Bonacchi and colleagues from Milan, Italy found that cardiovascular (CV) risk factors are linked with brain atrophy in patients with MS, even those <50 years of age. Specifically, the presence of at least two CV risk factors was linked with reduced normalized grey matter volume, white matter volume, and brain volume.
• Another comparison of individuals with MS and healthy controls—this one from O. Al-Louzi and colleagues at the National Institute of Neurological Disorders and Stroke—looked at the central vein sign (CVS) biomarker and determined that excluding lesions only if all dimensions of 3T MRI results were less than threshold (versus if any dimension was less than threshold) led to the inclusion of more CVS-positive lesions. Investigators suggested this work could lead to modified clinical guidelines.
• In an evaluation of patients with MS using 3T MRI, F. LaRosa and colleagues from Lausanne, Switzerland reported that RimNet, a prototype built upon two convolutional neural networks, was better than two alternative methods at detecting pragmatic rim lesions, which are linked with higher disease burden. Compared with expert raters, RimNet had higher sensitivity (87% vs 76%) but lower specificity (91% vs 99%).

There were many other valuable presentations at MSVirtual2020, but perhaps the most appreciated experience was the ability to hear more experts deliver their important work. Unlike a live meeting, I was able to easily attend parallel sessions and to do so at my leisure. ECTRIMS has become so big that I often left the live meeting feeling as if I missed out on a lot. Not this year. I heard almost all of it and came away with a greater appreciation of the breadth and depth of the meeting.  I hope that in the future, even following the return of in-person meetings, a virtual format coexists to afford attendees and those unable to attend live the opportunity to experience the totality of the meeting.

Having been a reader of Pediatric News for years, I want to bring to light access-to-care issues involving COVID-19 medical facility restrictions for pediatric patients and their parents.

On March 27, 2020, I received a phone call from the Department of Human Services pleading with me to take a medically fragile child who was entering the foster care system that day. He had very specific needs, and they had no one available who could medically meet those needs. The week prior was my kids’ scheduled spring break; the week I got the call was the week that I was voluntarily furloughed from my job as a pediatric nurse practitioner so that I could stay home with my kids as their school would not be reopening for the year, and someone had to be with them. I was already home with my 3-year-old and 6-year-old, so why not add another?

Leo (name changed for privacy) came to me with a multitude of diagnoses, to say the least. Not only did he require physical, speech, and occupational therapy twice weekly, but he often had appointments with 10 different specialists at the local children’s hospital. The first few weeks he was in my care, we had almost daily visits to either therapists or specialists. Keeping up with these types of appointments in a normal world is difficult ... I was getting the crash course on how to navigate all of it in the COVID-19 world.

So now, I am the primary caregiver during the day for my two children and our medically fragile foster child who has multiple medical appointments a week. Our local children’s hospital allowed only the caregiver to accompany him to his visits. In theory this sounds great, right? Fewer people in a facility equals less exposure, less risk, and fewer COVID-19 infections.

But what about the negative consequences of these hospital policies? I have two other children I was caring for. I couldn’t take them to their grandparents’ house because people over age 65 years are at risk of having COVID-19 complications. I had been furloughed, so our income was half what it typically was. Regardless, I had to hire a babysitter each time I took our foster child to the hospital for his appointments because they would not allow my children to accompany me.

Now imagine if I were a single mom who had three kids and a lesser paying job. Schools are closed and she’s forced to work from home and homeschool her children. Or worse, she’s been laid off and living on unemployment. Do you think she is going to have the time or finances available to hire a babysitter so that she can take her medically fragile child in for his cardiology follow-up? Because not only does she have to pay the copays and whatever insurance doesn’t cover, but now she has to fork over $50 for child care. If you don’t know the answer already, it’s no, she does not have the time or the finances. So her child misses a cardiology appointment, which means that his meds weren’t increased according to his growth, which means his pulmonary hypertension is not controlled, which worsens his heart failure ... you get my drift.

Fast forward to Sept. 22, 2020. I had a cardiology appointment at our local heart hospital for myself. It’s 2020, people, I’ve been having some palpitations that I needed checked out and was going in to have a heart monitor patch placed. I had my 4-year-old son with me because he is on a hybrid schedule where we homeschool 2 days a week. We entered the building wearing masks, and I was immediately stopped by security and informed that, according to the COVID-19 policy for their hospital, children under 16 are not allowed to enter the building. After some discussion, I was ultimately refused care because my son was with me that day. Refused care because I had a masked 4-year-old with a normal temperature at my side.

These policies are not working. We are in health care. It should not matter what pandemic is on the table, we should not be refusing patients access to care based on who is by their side that day. We knew the risks when we entered our profession, and we know the proper measures to protect ourselves. Our patients also know the risks and can protect themselves accordingly.

So this is my plea to all medical facilities out there: Stop. Stop telling people their loved ones can’t accompany them to appointments. Stop telling caregivers to wait in their cars while their elderly, demented mothers have their annual physicals. Stop telling moms they need to leave their other children at home. This is now a huge access-to-care issue nationwide and it needs to stop. Excess deaths in our nation are soaring, and it’s not just because people don’t want to seek medical attention; it’s because medical facilities are making it almost impossible to seek help for many. People are dying, and it’s not only from COVID-19. This is on us as health care providers, and we need to step up to the plate and do what is right.
 

Ms. Baxendale is a nurse practitioner in Mustang, Okla. Email her at [email protected].

Having been a reader of Pediatric News for years, I want to bring to light access-to-care issues involving COVID-19 medical facility restrictions for pediatric patients and their parents.

On March 27, 2020, I received a phone call from the Department of Human Services pleading with me to take a medically fragile child who was entering the foster care system that day. He had very specific needs, and they had no one available who could medically meet those needs. The week prior was my kids’ scheduled spring break; the week I got the call was the week that I was voluntarily furloughed from my job as a pediatric nurse practitioner so that I could stay home with my kids as their school would not be reopening for the year, and someone had to be with them. I was already home with my 3-year-old and 6-year-old, so why not add another?

Leo (name changed for privacy) came to me with a multitude of diagnoses, to say the least. Not only did he require physical, speech, and occupational therapy twice weekly, but he often had appointments with 10 different specialists at the local children’s hospital. The first few weeks he was in my care, we had almost daily visits to either therapists or specialists. Keeping up with these types of appointments in a normal world is difficult ... I was getting the crash course on how to navigate all of it in the COVID-19 world.

So now, I am the primary caregiver during the day for my two children and our medically fragile foster child who has multiple medical appointments a week. Our local children’s hospital allowed only the caregiver to accompany him to his visits. In theory this sounds great, right? Fewer people in a facility equals less exposure, less risk, and fewer COVID-19 infections.

But what about the negative consequences of these hospital policies? I have two other children I was caring for. I couldn’t take them to their grandparents’ house because people over age 65 years are at risk of having COVID-19 complications. I had been furloughed, so our income was half what it typically was. Regardless, I had to hire a babysitter each time I took our foster child to the hospital for his appointments because they would not allow my children to accompany me.

Now imagine if I were a single mom who had three kids and a lesser paying job. Schools are closed and she’s forced to work from home and homeschool her children. Or worse, she’s been laid off and living on unemployment. Do you think she is going to have the time or finances available to hire a babysitter so that she can take her medically fragile child in for his cardiology follow-up? Because not only does she have to pay the copays and whatever insurance doesn’t cover, but now she has to fork over $50 for child care. If you don’t know the answer already, it’s no, she does not have the time or the finances. So her child misses a cardiology appointment, which means that his meds weren’t increased according to his growth, which means his pulmonary hypertension is not controlled, which worsens his heart failure ... you get my drift.

Fast forward to Sept. 22, 2020. I had a cardiology appointment at our local heart hospital for myself. It’s 2020, people, I’ve been having some palpitations that I needed checked out and was going in to have a heart monitor patch placed. I had my 4-year-old son with me because he is on a hybrid schedule where we homeschool 2 days a week. We entered the building wearing masks, and I was immediately stopped by security and informed that, according to the COVID-19 policy for their hospital, children under 16 are not allowed to enter the building. After some discussion, I was ultimately refused care because my son was with me that day. Refused care because I had a masked 4-year-old with a normal temperature at my side.

These policies are not working. We are in health care. It should not matter what pandemic is on the table, we should not be refusing patients access to care based on who is by their side that day. We knew the risks when we entered our profession, and we know the proper measures to protect ourselves. Our patients also know the risks and can protect themselves accordingly.

So this is my plea to all medical facilities out there: Stop. Stop telling people their loved ones can’t accompany them to appointments. Stop telling caregivers to wait in their cars while their elderly, demented mothers have their annual physicals. Stop telling moms they need to leave their other children at home. This is now a huge access-to-care issue nationwide and it needs to stop. Excess deaths in our nation are soaring, and it’s not just because people don’t want to seek medical attention; it’s because medical facilities are making it almost impossible to seek help for many. People are dying, and it’s not only from COVID-19. This is on us as health care providers, and we need to step up to the plate and do what is right.
 

Ms. Baxendale is a nurse practitioner in Mustang, Okla. Email her at [email protected].

Having been a reader of Pediatric News for years, I want to bring to light access-to-care issues involving COVID-19 medical facility restrictions for pediatric patients and their parents.

On March 27, 2020, I received a phone call from the Department of Human Services pleading with me to take a medically fragile child who was entering the foster care system that day. He had very specific needs, and they had no one available who could medically meet those needs. The week prior was my kids’ scheduled spring break; the week I got the call was the week that I was voluntarily furloughed from my job as a pediatric nurse practitioner so that I could stay home with my kids as their school would not be reopening for the year, and someone had to be with them. I was already home with my 3-year-old and 6-year-old, so why not add another?

Leo (name changed for privacy) came to me with a multitude of diagnoses, to say the least. Not only did he require physical, speech, and occupational therapy twice weekly, but he often had appointments with 10 different specialists at the local children’s hospital. The first few weeks he was in my care, we had almost daily visits to either therapists or specialists. Keeping up with these types of appointments in a normal world is difficult ... I was getting the crash course on how to navigate all of it in the COVID-19 world.

So now, I am the primary caregiver during the day for my two children and our medically fragile foster child who has multiple medical appointments a week. Our local children’s hospital allowed only the caregiver to accompany him to his visits. In theory this sounds great, right? Fewer people in a facility equals less exposure, less risk, and fewer COVID-19 infections.

But what about the negative consequences of these hospital policies? I have two other children I was caring for. I couldn’t take them to their grandparents’ house because people over age 65 years are at risk of having COVID-19 complications. I had been furloughed, so our income was half what it typically was. Regardless, I had to hire a babysitter each time I took our foster child to the hospital for his appointments because they would not allow my children to accompany me.

Now imagine if I were a single mom who had three kids and a lesser paying job. Schools are closed and she’s forced to work from home and homeschool her children. Or worse, she’s been laid off and living on unemployment. Do you think she is going to have the time or finances available to hire a babysitter so that she can take her medically fragile child in for his cardiology follow-up? Because not only does she have to pay the copays and whatever insurance doesn’t cover, but now she has to fork over $50 for child care. If you don’t know the answer already, it’s no, she does not have the time or the finances. So her child misses a cardiology appointment, which means that his meds weren’t increased according to his growth, which means his pulmonary hypertension is not controlled, which worsens his heart failure ... you get my drift.

Fast forward to Sept. 22, 2020. I had a cardiology appointment at our local heart hospital for myself. It’s 2020, people, I’ve been having some palpitations that I needed checked out and was going in to have a heart monitor patch placed. I had my 4-year-old son with me because he is on a hybrid schedule where we homeschool 2 days a week. We entered the building wearing masks, and I was immediately stopped by security and informed that, according to the COVID-19 policy for their hospital, children under 16 are not allowed to enter the building. After some discussion, I was ultimately refused care because my son was with me that day. Refused care because I had a masked 4-year-old with a normal temperature at my side.

These policies are not working. We are in health care. It should not matter what pandemic is on the table, we should not be refusing patients access to care based on who is by their side that day. We knew the risks when we entered our profession, and we know the proper measures to protect ourselves. Our patients also know the risks and can protect themselves accordingly.

So this is my plea to all medical facilities out there: Stop. Stop telling people their loved ones can’t accompany them to appointments. Stop telling caregivers to wait in their cars while their elderly, demented mothers have their annual physicals. Stop telling moms they need to leave their other children at home. This is now a huge access-to-care issue nationwide and it needs to stop. Excess deaths in our nation are soaring, and it’s not just because people don’t want to seek medical attention; it’s because medical facilities are making it almost impossible to seek help for many. People are dying, and it’s not only from COVID-19. This is on us as health care providers, and we need to step up to the plate and do what is right.
 

Ms. Baxendale is a nurse practitioner in Mustang, Okla. Email her at [email protected].

Looking back at the calendar, I realized that the insane year of 2020 will be the first in memory that I never took a vacation. Not a single trip outside the Phoenix metropolitan area. For that matter, there were only a handful of times I even ventured beyond the borders of Scottsdale.

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

Looking back at the calendar, I realized that the insane year of 2020 will be the first in memory that I never took a vacation. Not a single trip outside the Phoenix metropolitan area. For that matter, there were only a handful of times I even ventured beyond the borders of Scottsdale.

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

Looking back at the calendar, I realized that the insane year of 2020 will be the first in memory that I never took a vacation. Not a single trip outside the Phoenix metropolitan area. For that matter, there were only a handful of times I even ventured beyond the borders of Scottsdale.

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

To say that the pandemic has dropped us into uncharted territory is an understatement of unmeasurable proportions. Every day we learn more about it, and every day that new information brings us new challenges. COVID-19 is playing by its own set of rules. To keep pace with it societies have been forced to adapt to them, and members of those societies have had to realize that these new rules must be obeyed or be prepared to suffer the consequences.

BananaStock/Thinkstock

I’m not sure exactly when it happened but gradually over my 7 and a half decades on this planet it appears that following the rules and understanding the value of “No” have become concepts to be ignored and left to gather dust in the attics and basements of our society. The tug of war between well-considered rules and the often misinterpreted concept of freedom has been ebbing and flowing since Eve plucked a forbidden apple off that tree.

In some parts of the world, the twin skills of saying and responding to “No” have become lost arts. I think it is not by chance that, of the four books I have written for parents, the one titled “How to Say No to Your Toddler” has become the most widely distributed, having been translated into Italian, Polish, and Russian. It is only slightly comforting to learn that at least some parents understand that creating rules can be important, but realize they aren’t quite sure how go about it.

As it has become clear that social distancing and mask wearing are associated with curtailing the spread of COVID-19, state and local governments have had to bone up on their long-forgotten No-saying skills. This relearning process has been particularly painful for school administrators who may have been warned that “You’ll never be able to get first and second graders to wear masks” or that “College students just won’t obey the rules.”

Both of these cautions are based on observations by educators with years of experience and certainly have a ring of truth to them. But could it be that these pessimistic predictions reflect a society in which parents and educators have lost the talent for crafting sensible rules and linking them to enforceable and rational consequences?

As colleges throughout the country have reopened using a variety of learning and residential strategies, there have been numerous incidents that validate the gloomy predictions of student misbehavior. Smaller schools seem to be having less difficulty, which is not surprising given their relative ease in fostering a sense of community. Many schools have been forced to rollback their plans for in-person learning because students have failed to follow some very simple but unpopular rules.

In a swift and decisive response to student misbehavior, Northeastern University in Boston dismissed 11 first-year students and will not refund their tuition when officials discovered a prohibited social gathering in one of the resident facilities (“Northeastern Dismisses 11 Students for Gathering in Violation of COVID-19 Policies,” by Ian Thomsen, News at Northwestern). This response seemed to have come as a surprise to many students and parents around the country who have become accustomed a diet of warnings and minor sanctions.

Whether this action by Northeastern will trigger similar responses by other universities remains to be seen. But we can hope that it sets an example of how learning about “No” can be an important part of one’s education.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

To say that the pandemic has dropped us into uncharted territory is an understatement of unmeasurable proportions. Every day we learn more about it, and every day that new information brings us new challenges. COVID-19 is playing by its own set of rules. To keep pace with it societies have been forced to adapt to them, and members of those societies have had to realize that these new rules must be obeyed or be prepared to suffer the consequences.

BananaStock/Thinkstock

I’m not sure exactly when it happened but gradually over my 7 and a half decades on this planet it appears that following the rules and understanding the value of “No” have become concepts to be ignored and left to gather dust in the attics and basements of our society. The tug of war between well-considered rules and the often misinterpreted concept of freedom has been ebbing and flowing since Eve plucked a forbidden apple off that tree.

In some parts of the world, the twin skills of saying and responding to “No” have become lost arts. I think it is not by chance that, of the four books I have written for parents, the one titled “How to Say No to Your Toddler” has become the most widely distributed, having been translated into Italian, Polish, and Russian. It is only slightly comforting to learn that at least some parents understand that creating rules can be important, but realize they aren’t quite sure how go about it.

As it has become clear that social distancing and mask wearing are associated with curtailing the spread of COVID-19, state and local governments have had to bone up on their long-forgotten No-saying skills. This relearning process has been particularly painful for school administrators who may have been warned that “You’ll never be able to get first and second graders to wear masks” or that “College students just won’t obey the rules.”

Both of these cautions are based on observations by educators with years of experience and certainly have a ring of truth to them. But could it be that these pessimistic predictions reflect a society in which parents and educators have lost the talent for crafting sensible rules and linking them to enforceable and rational consequences?

As colleges throughout the country have reopened using a variety of learning and residential strategies, there have been numerous incidents that validate the gloomy predictions of student misbehavior. Smaller schools seem to be having less difficulty, which is not surprising given their relative ease in fostering a sense of community. Many schools have been forced to rollback their plans for in-person learning because students have failed to follow some very simple but unpopular rules.

In a swift and decisive response to student misbehavior, Northeastern University in Boston dismissed 11 first-year students and will not refund their tuition when officials discovered a prohibited social gathering in one of the resident facilities (“Northeastern Dismisses 11 Students for Gathering in Violation of COVID-19 Policies,” by Ian Thomsen, News at Northwestern). This response seemed to have come as a surprise to many students and parents around the country who have become accustomed a diet of warnings and minor sanctions.

Whether this action by Northeastern will trigger similar responses by other universities remains to be seen. But we can hope that it sets an example of how learning about “No” can be an important part of one’s education.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

To say that the pandemic has dropped us into uncharted territory is an understatement of unmeasurable proportions. Every day we learn more about it, and every day that new information brings us new challenges. COVID-19 is playing by its own set of rules. To keep pace with it societies have been forced to adapt to them, and members of those societies have had to realize that these new rules must be obeyed or be prepared to suffer the consequences.

BananaStock/Thinkstock

I’m not sure exactly when it happened but gradually over my 7 and a half decades on this planet it appears that following the rules and understanding the value of “No” have become concepts to be ignored and left to gather dust in the attics and basements of our society. The tug of war between well-considered rules and the often misinterpreted concept of freedom has been ebbing and flowing since Eve plucked a forbidden apple off that tree.

In some parts of the world, the twin skills of saying and responding to “No” have become lost arts. I think it is not by chance that, of the four books I have written for parents, the one titled “How to Say No to Your Toddler” has become the most widely distributed, having been translated into Italian, Polish, and Russian. It is only slightly comforting to learn that at least some parents understand that creating rules can be important, but realize they aren’t quite sure how go about it.

As it has become clear that social distancing and mask wearing are associated with curtailing the spread of COVID-19, state and local governments have had to bone up on their long-forgotten No-saying skills. This relearning process has been particularly painful for school administrators who may have been warned that “You’ll never be able to get first and second graders to wear masks” or that “College students just won’t obey the rules.”

Both of these cautions are based on observations by educators with years of experience and certainly have a ring of truth to them. But could it be that these pessimistic predictions reflect a society in which parents and educators have lost the talent for crafting sensible rules and linking them to enforceable and rational consequences?

As colleges throughout the country have reopened using a variety of learning and residential strategies, there have been numerous incidents that validate the gloomy predictions of student misbehavior. Smaller schools seem to be having less difficulty, which is not surprising given their relative ease in fostering a sense of community. Many schools have been forced to rollback their plans for in-person learning because students have failed to follow some very simple but unpopular rules.

In a swift and decisive response to student misbehavior, Northeastern University in Boston dismissed 11 first-year students and will not refund their tuition when officials discovered a prohibited social gathering in one of the resident facilities (“Northeastern Dismisses 11 Students for Gathering in Violation of COVID-19 Policies,” by Ian Thomsen, News at Northwestern). This response seemed to have come as a surprise to many students and parents around the country who have become accustomed a diet of warnings and minor sanctions.

Whether this action by Northeastern will trigger similar responses by other universities remains to be seen. But we can hope that it sets an example of how learning about “No” can be an important part of one’s education.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As we continue to stumble around trying to find our way out of the COVID-19 pandemic, it has become clear that the journey has been a never-ending continuum of exercises in risk/benefit assessment. The population always has sorted itself into a bell-shaped curve from those who are risk averse to those who revel in risk taking. And, of course, with a paucity of facts on which we can base our assessment of risk, the discussion often shifts to our gut feelings about the benefits.

Greg Pollock - Fotolia.com

When faced with the question of when it is time for children to return to in-person schooling, there seems to be reasonably good agreement about the benefits of face-to-face learning. The level of risk is still to be determined.

When it comes to the issue of when to return to competitive school sports, the risks are equally indeterminate but there is less agreement on the benefits. This lack of uniformity reflects a long-standing dichotomy between those parents and students with a passion for competitive sports and those who see them as nonessential. This existential tug-of-war has gone on in almost every school system I am aware of when the school budget comes up for a vote.

The debate about a return to competitive sports on a collegiate and professional level unfortunately is colored by enormous revenues from media contracts, which means that high school and middle schools can’t look to what are essentially businesses for guidance. Here in Maine, the organizations responsible for making decisions about school sports struggled for months in making their decision. The delay created confusion, fluctuating angst and disappointment, but the end product made some sense. Volleyball (indoor) and football were indefinitely delayed. Heavy breathing between competitors separated by a couple of feet and protected only by a flimsy net or helmet cage seems like a risk not worth taking – at least until we have more information.

Other sports were allowed to start with restrictions based on existing social distancing mandates which include no locker rooms and no fans. Some rules such as no throw-ins for soccer didn’t make sense given what we are learning about the virus. But, for the most part, the compromises should result in a chance to reap the benefits of competition for the students whose families are willing to expose them to the yet to be fully determined risks.

There has been some grumbling from parents who see the no-fans mandate as a step too far. Until we know more about the risk of group gatherings outdoors, having no fans, including parents and grandparents, makes sense. In fact, to me it is a step long overdue and a rare sliver of silver lining to the pandemic. Competitive youth sports are for the kids. They are not meant to be entertainment events. Too often children are exposed to parental pressure (voiced and unvoiced) about their “performance” on the field. Neither my younger sister nor I can remember our parents going to any of my away football games in high school or any of my lacrosse games in college. I never felt the loss.

Will I miss watching my grandchildren compete? Of course I will miss it badly. However, giving kids some space to learn and enjoy the competition for itself in an atmosphere free of parental over-involvement will be a breath of fresh air. Something we need badly during this pandemic.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

As we continue to stumble around trying to find our way out of the COVID-19 pandemic, it has become clear that the journey has been a never-ending continuum of exercises in risk/benefit assessment. The population always has sorted itself into a bell-shaped curve from those who are risk averse to those who revel in risk taking. And, of course, with a paucity of facts on which we can base our assessment of risk, the discussion often shifts to our gut feelings about the benefits.

Greg Pollock - Fotolia.com

When faced with the question of when it is time for children to return to in-person schooling, there seems to be reasonably good agreement about the benefits of face-to-face learning. The level of risk is still to be determined.

When it comes to the issue of when to return to competitive school sports, the risks are equally indeterminate but there is less agreement on the benefits. This lack of uniformity reflects a long-standing dichotomy between those parents and students with a passion for competitive sports and those who see them as nonessential. This existential tug-of-war has gone on in almost every school system I am aware of when the school budget comes up for a vote.

The debate about a return to competitive sports on a collegiate and professional level unfortunately is colored by enormous revenues from media contracts, which means that high school and middle schools can’t look to what are essentially businesses for guidance. Here in Maine, the organizations responsible for making decisions about school sports struggled for months in making their decision. The delay created confusion, fluctuating angst and disappointment, but the end product made some sense. Volleyball (indoor) and football were indefinitely delayed. Heavy breathing between competitors separated by a couple of feet and protected only by a flimsy net or helmet cage seems like a risk not worth taking – at least until we have more information.

Other sports were allowed to start with restrictions based on existing social distancing mandates which include no locker rooms and no fans. Some rules such as no throw-ins for soccer didn’t make sense given what we are learning about the virus. But, for the most part, the compromises should result in a chance to reap the benefits of competition for the students whose families are willing to expose them to the yet to be fully determined risks.

There has been some grumbling from parents who see the no-fans mandate as a step too far. Until we know more about the risk of group gatherings outdoors, having no fans, including parents and grandparents, makes sense. In fact, to me it is a step long overdue and a rare sliver of silver lining to the pandemic. Competitive youth sports are for the kids. They are not meant to be entertainment events. Too often children are exposed to parental pressure (voiced and unvoiced) about their “performance” on the field. Neither my younger sister nor I can remember our parents going to any of my away football games in high school or any of my lacrosse games in college. I never felt the loss.

Will I miss watching my grandchildren compete? Of course I will miss it badly. However, giving kids some space to learn and enjoy the competition for itself in an atmosphere free of parental over-involvement will be a breath of fresh air. Something we need badly during this pandemic.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

As we continue to stumble around trying to find our way out of the COVID-19 pandemic, it has become clear that the journey has been a never-ending continuum of exercises in risk/benefit assessment. The population always has sorted itself into a bell-shaped curve from those who are risk averse to those who revel in risk taking. And, of course, with a paucity of facts on which we can base our assessment of risk, the discussion often shifts to our gut feelings about the benefits.

Greg Pollock - Fotolia.com

When faced with the question of when it is time for children to return to in-person schooling, there seems to be reasonably good agreement about the benefits of face-to-face learning. The level of risk is still to be determined.

When it comes to the issue of when to return to competitive school sports, the risks are equally indeterminate but there is less agreement on the benefits. This lack of uniformity reflects a long-standing dichotomy between those parents and students with a passion for competitive sports and those who see them as nonessential. This existential tug-of-war has gone on in almost every school system I am aware of when the school budget comes up for a vote.

The debate about a return to competitive sports on a collegiate and professional level unfortunately is colored by enormous revenues from media contracts, which means that high school and middle schools can’t look to what are essentially businesses for guidance. Here in Maine, the organizations responsible for making decisions about school sports struggled for months in making their decision. The delay created confusion, fluctuating angst and disappointment, but the end product made some sense. Volleyball (indoor) and football were indefinitely delayed. Heavy breathing between competitors separated by a couple of feet and protected only by a flimsy net or helmet cage seems like a risk not worth taking – at least until we have more information.

Other sports were allowed to start with restrictions based on existing social distancing mandates which include no locker rooms and no fans. Some rules such as no throw-ins for soccer didn’t make sense given what we are learning about the virus. But, for the most part, the compromises should result in a chance to reap the benefits of competition for the students whose families are willing to expose them to the yet to be fully determined risks.

There has been some grumbling from parents who see the no-fans mandate as a step too far. Until we know more about the risk of group gatherings outdoors, having no fans, including parents and grandparents, makes sense. In fact, to me it is a step long overdue and a rare sliver of silver lining to the pandemic. Competitive youth sports are for the kids. They are not meant to be entertainment events. Too often children are exposed to parental pressure (voiced and unvoiced) about their “performance” on the field. Neither my younger sister nor I can remember our parents going to any of my away football games in high school or any of my lacrosse games in college. I never felt the loss.

Will I miss watching my grandchildren compete? Of course I will miss it badly. However, giving kids some space to learn and enjoy the competition for itself in an atmosphere free of parental over-involvement will be a breath of fresh air. Something we need badly during this pandemic.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I previously wrote a column in which I discussed the possible relationship between television viewing and the risk of developing depression. In that column I mentioned that, while there is widespread suspicion that depression may have a genetic component, I was unaware of any strong evidence that this is the case. This week I encountered another study in the American Journal of Psychiatry that suggests that the environment in which a child is raised can play a significant role in whether he or she will develop depression.

Imagesbybarbara/E+

All of the children in the study had been born to families in which at least one biological parent had been diagnosed with major depression. There were nearly 700 full sibships and 2,600 half sibships studied. The researchers found that children who had been adopted away and raised in families that had been selected for having high-quality childrearing standards were significantly less likely to develop depression (23% for full siblings, 19% for half siblings) than their siblings who had remained in the home of their biological parents. It is interesting that this protective effect of the adoptive home “disappeared when an adoptive parent or stepsibling had major depression or the adoptive home was disrupted by parental death or divorce.”

It is unlikely that this study ever will be replicated because of the unique manner in which these Swedish adoptions were managed and recorded. However, the results appear to make a strong statement that, at least when it comes to depression, nurture has at least as strong an effect as nature and probably even more of an influence than genetics.

Are you surprised by the results of this study? Or, like me, have you always suspected that a child growing up in a household with a depressed, missing, or divorced parent was at increased risk of becoming depressed, particularly they had a genetic vulnerability? How will you change your approach to families with a depressed parent or ones that are navigating through the stormy waters of even an amicable divorce? Will you be more diligent about screening children in these families for depression? Should the agencies that are responsible for managing adoption and foster home placement include this new information in their screening criteria?

It would be very interesting to see a similar study performed using families in which a biological parent had been diagnosed with anxiety or an attention-deficit disorder. Could it mean that we should be considering depression and these conditions as contagious disorders? The results from such studies might help provide clarity to why we are seeing more children with mental health complaints. They might explain why pediatricians are seeing an increasing frequency of mental health complaints in our offices. It may not be too far-fetched to use epidemiologic terms when we are talking about depression, anxiety, and ADHD. Should we be considering these conditions to be contagious under certain circumstances?

Since the human genome has been sequenced I sense that our attention has become overfocused on using what we are learning about our DNA to explain what makes us sick. It may be time to swing the pendulum back a few degrees and remind ourselves of the power of the family environment.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I previously wrote a column in which I discussed the possible relationship between television viewing and the risk of developing depression. In that column I mentioned that, while there is widespread suspicion that depression may have a genetic component, I was unaware of any strong evidence that this is the case. This week I encountered another study in the American Journal of Psychiatry that suggests that the environment in which a child is raised can play a significant role in whether he or she will develop depression.

Imagesbybarbara/E+

All of the children in the study had been born to families in which at least one biological parent had been diagnosed with major depression. There were nearly 700 full sibships and 2,600 half sibships studied. The researchers found that children who had been adopted away and raised in families that had been selected for having high-quality childrearing standards were significantly less likely to develop depression (23% for full siblings, 19% for half siblings) than their siblings who had remained in the home of their biological parents. It is interesting that this protective effect of the adoptive home “disappeared when an adoptive parent or stepsibling had major depression or the adoptive home was disrupted by parental death or divorce.”

It is unlikely that this study ever will be replicated because of the unique manner in which these Swedish adoptions were managed and recorded. However, the results appear to make a strong statement that, at least when it comes to depression, nurture has at least as strong an effect as nature and probably even more of an influence than genetics.

Are you surprised by the results of this study? Or, like me, have you always suspected that a child growing up in a household with a depressed, missing, or divorced parent was at increased risk of becoming depressed, particularly they had a genetic vulnerability? How will you change your approach to families with a depressed parent or ones that are navigating through the stormy waters of even an amicable divorce? Will you be more diligent about screening children in these families for depression? Should the agencies that are responsible for managing adoption and foster home placement include this new information in their screening criteria?

It would be very interesting to see a similar study performed using families in which a biological parent had been diagnosed with anxiety or an attention-deficit disorder. Could it mean that we should be considering depression and these conditions as contagious disorders? The results from such studies might help provide clarity to why we are seeing more children with mental health complaints. They might explain why pediatricians are seeing an increasing frequency of mental health complaints in our offices. It may not be too far-fetched to use epidemiologic terms when we are talking about depression, anxiety, and ADHD. Should we be considering these conditions to be contagious under certain circumstances?

Since the human genome has been sequenced I sense that our attention has become overfocused on using what we are learning about our DNA to explain what makes us sick. It may be time to swing the pendulum back a few degrees and remind ourselves of the power of the family environment.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I previously wrote a column in which I discussed the possible relationship between television viewing and the risk of developing depression. In that column I mentioned that, while there is widespread suspicion that depression may have a genetic component, I was unaware of any strong evidence that this is the case. This week I encountered another study in the American Journal of Psychiatry that suggests that the environment in which a child is raised can play a significant role in whether he or she will develop depression.

Imagesbybarbara/E+

All of the children in the study had been born to families in which at least one biological parent had been diagnosed with major depression. There were nearly 700 full sibships and 2,600 half sibships studied. The researchers found that children who had been adopted away and raised in families that had been selected for having high-quality childrearing standards were significantly less likely to develop depression (23% for full siblings, 19% for half siblings) than their siblings who had remained in the home of their biological parents. It is interesting that this protective effect of the adoptive home “disappeared when an adoptive parent or stepsibling had major depression or the adoptive home was disrupted by parental death or divorce.”

It is unlikely that this study ever will be replicated because of the unique manner in which these Swedish adoptions were managed and recorded. However, the results appear to make a strong statement that, at least when it comes to depression, nurture has at least as strong an effect as nature and probably even more of an influence than genetics.

Are you surprised by the results of this study? Or, like me, have you always suspected that a child growing up in a household with a depressed, missing, or divorced parent was at increased risk of becoming depressed, particularly they had a genetic vulnerability? How will you change your approach to families with a depressed parent or ones that are navigating through the stormy waters of even an amicable divorce? Will you be more diligent about screening children in these families for depression? Should the agencies that are responsible for managing adoption and foster home placement include this new information in their screening criteria?

It would be very interesting to see a similar study performed using families in which a biological parent had been diagnosed with anxiety or an attention-deficit disorder. Could it mean that we should be considering depression and these conditions as contagious disorders? The results from such studies might help provide clarity to why we are seeing more children with mental health complaints. They might explain why pediatricians are seeing an increasing frequency of mental health complaints in our offices. It may not be too far-fetched to use epidemiologic terms when we are talking about depression, anxiety, and ADHD. Should we be considering these conditions to be contagious under certain circumstances?

Since the human genome has been sequenced I sense that our attention has become overfocused on using what we are learning about our DNA to explain what makes us sick. It may be time to swing the pendulum back a few degrees and remind ourselves of the power of the family environment.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

The wholesale shuffling of employees triggered by the COVID-19 pandemic has raised many questions about the differences between full-time, part-time, and full-time equivalent employees, and how employment laws apply to them. While rules vary from state to state, some generalizations can be made.

Even the definitions of full-time and part-time vary. For instance, under the Affordable Care Act (ACA), full time means working at least 30 hours per week. Under the Families First Coronavirus Response Act (FFCRA), it is 40 hours.

Full-time equivalent (FTE) is a concept designed to document a part-time workforce in terms of full-time employment, by taking the total hours worked by all part-time employees and dividing by the full-time schedule. Of course, the ACA and the Paycheck Protection Program (PPP) calculate that number differently: The ACA requires you to total all the hours worked by part-time employees per month, and divide by 120. For the PPP, you divide the total part-time hours per week by 40, and round to the nearest tenth. (You can also use a simplified method that assigns a 1.0 for employees who work 40 hours or more per week and 0.5 for those who work fewer; whichever method you choose, you must apply it consistently on all PPP forms.)

FTEs are important for the purposes of the ACA because employers with 50 or more full-timers plus FTEs must offer health coverage to their full-timers and dependents. But most private practitioners need an accurate FTE total to deal with the PPP: If staffing levels weren’t maintained after you received a PPP loan, your loan forgiveness amount may be reduced. Staffing levels are determined by comparing the average number of full-timers plus FTEs during the “covered period” to either the period from Feb. 15 through June 30, 2019, or Jan. 1 through Feb. 28, 2020.

The PPP aside, FTEs have created confusion over when an employee is entitled to overtime pay. Under federal law, overtime is due whenever an employee works more than 40 hours per week; up to 40 hours, the regular wage is paid. (There are exemptions, and a few states use a daily number.) For example, if a part-timer receiving $900 per week for a 30-hour workweek works more than 30 hours, the hours from 30 to 40 would be compensated at their normal wage of $30 per hour ($900 ÷ 30). If the employee worked more than 40 hours, you would pay overtime (in this case $45 per hour, $30 x 1.5) for the hours in excess of 40.

To address a few other employment questions that I am frequently asked:

Under the FFCRA, you must provide both full- and part-time employees with emergency paid sick leave (EPSL) if they’re unable to work from your office or their home because of illness attributable to COVID-19, quarantine, or caring for a sick family member or child whose school is closed. Full-time employees are entitled to up to 80 hours of EPSL, and part-timers an average of what they work every 2 weeks. Some states have their own laws independent from the FFCRA. Check your state or local laws.

• Some states require you to provide meal and rest breaks to both full- and part-time employees. In California, for example, employers must provide a 30-minute meal break after no more than 5 hours of work, unless the total workday is less than 6 hours and both employers and employees consent to waive breaks. California also requires rest breaks after every 4 hours worked. Check the laws in your state.
• You must include part-time employees in a 401(k) retirement plan if they work at least 1,000 hours in a year, which is about 20 hours per week. That rule is changing in 2021 to 500 hours for employees older than 21. There are state-run retirement programs in California, Connecticut, New Jersey, Washington, and Oregon, among other states. Check your state law for details.
• If you offer paid vacations to full-time employees, you do not have to do the same for part-timers. (In fact, there is no requirement in most states to offer vacation time at all.) My office does offer it to part-time employees on a pro rata basis, as do many others in my area. Again, check your state law.

As always, consult with your attorney if it’s not clear which rules apply in your specific situation.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no relevant disclosures related to the topic of this column. Write to him at [email protected].

The wholesale shuffling of employees triggered by the COVID-19 pandemic has raised many questions about the differences between full-time, part-time, and full-time equivalent employees, and how employment laws apply to them. While rules vary from state to state, some generalizations can be made.

Even the definitions of full-time and part-time vary. For instance, under the Affordable Care Act (ACA), full time means working at least 30 hours per week. Under the Families First Coronavirus Response Act (FFCRA), it is 40 hours.

Full-time equivalent (FTE) is a concept designed to document a part-time workforce in terms of full-time employment, by taking the total hours worked by all part-time employees and dividing by the full-time schedule. Of course, the ACA and the Paycheck Protection Program (PPP) calculate that number differently: The ACA requires you to total all the hours worked by part-time employees per month, and divide by 120. For the PPP, you divide the total part-time hours per week by 40, and round to the nearest tenth. (You can also use a simplified method that assigns a 1.0 for employees who work 40 hours or more per week and 0.5 for those who work fewer; whichever method you choose, you must apply it consistently on all PPP forms.)

FTEs are important for the purposes of the ACA because employers with 50 or more full-timers plus FTEs must offer health coverage to their full-timers and dependents. But most private practitioners need an accurate FTE total to deal with the PPP: If staffing levels weren’t maintained after you received a PPP loan, your loan forgiveness amount may be reduced. Staffing levels are determined by comparing the average number of full-timers plus FTEs during the “covered period” to either the period from Feb. 15 through June 30, 2019, or Jan. 1 through Feb. 28, 2020.

The PPP aside, FTEs have created confusion over when an employee is entitled to overtime pay. Under federal law, overtime is due whenever an employee works more than 40 hours per week; up to 40 hours, the regular wage is paid. (There are exemptions, and a few states use a daily number.) For example, if a part-timer receiving $900 per week for a 30-hour workweek works more than 30 hours, the hours from 30 to 40 would be compensated at their normal wage of $30 per hour ($900 ÷ 30). If the employee worked more than 40 hours, you would pay overtime (in this case $45 per hour, $30 x 1.5) for the hours in excess of 40.

To address a few other employment questions that I am frequently asked:

Under the FFCRA, you must provide both full- and part-time employees with emergency paid sick leave (EPSL) if they’re unable to work from your office or their home because of illness attributable to COVID-19, quarantine, or caring for a sick family member or child whose school is closed. Full-time employees are entitled to up to 80 hours of EPSL, and part-timers an average of what they work every 2 weeks. Some states have their own laws independent from the FFCRA. Check your state or local laws.

• Some states require you to provide meal and rest breaks to both full- and part-time employees. In California, for example, employers must provide a 30-minute meal break after no more than 5 hours of work, unless the total workday is less than 6 hours and both employers and employees consent to waive breaks. California also requires rest breaks after every 4 hours worked. Check the laws in your state.
• You must include part-time employees in a 401(k) retirement plan if they work at least 1,000 hours in a year, which is about 20 hours per week. That rule is changing in 2021 to 500 hours for employees older than 21. There are state-run retirement programs in California, Connecticut, New Jersey, Washington, and Oregon, among other states. Check your state law for details.
• If you offer paid vacations to full-time employees, you do not have to do the same for part-timers. (In fact, there is no requirement in most states to offer vacation time at all.) My office does offer it to part-time employees on a pro rata basis, as do many others in my area. Again, check your state law.

As always, consult with your attorney if it’s not clear which rules apply in your specific situation.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no relevant disclosures related to the topic of this column. Write to him at [email protected].

The wholesale shuffling of employees triggered by the COVID-19 pandemic has raised many questions about the differences between full-time, part-time, and full-time equivalent employees, and how employment laws apply to them. While rules vary from state to state, some generalizations can be made.

Even the definitions of full-time and part-time vary. For instance, under the Affordable Care Act (ACA), full time means working at least 30 hours per week. Under the Families First Coronavirus Response Act (FFCRA), it is 40 hours.

Full-time equivalent (FTE) is a concept designed to document a part-time workforce in terms of full-time employment, by taking the total hours worked by all part-time employees and dividing by the full-time schedule. Of course, the ACA and the Paycheck Protection Program (PPP) calculate that number differently: The ACA requires you to total all the hours worked by part-time employees per month, and divide by 120. For the PPP, you divide the total part-time hours per week by 40, and round to the nearest tenth. (You can also use a simplified method that assigns a 1.0 for employees who work 40 hours or more per week and 0.5 for those who work fewer; whichever method you choose, you must apply it consistently on all PPP forms.)

FTEs are important for the purposes of the ACA because employers with 50 or more full-timers plus FTEs must offer health coverage to their full-timers and dependents. But most private practitioners need an accurate FTE total to deal with the PPP: If staffing levels weren’t maintained after you received a PPP loan, your loan forgiveness amount may be reduced. Staffing levels are determined by comparing the average number of full-timers plus FTEs during the “covered period” to either the period from Feb. 15 through June 30, 2019, or Jan. 1 through Feb. 28, 2020.

The PPP aside, FTEs have created confusion over when an employee is entitled to overtime pay. Under federal law, overtime is due whenever an employee works more than 40 hours per week; up to 40 hours, the regular wage is paid. (There are exemptions, and a few states use a daily number.) For example, if a part-timer receiving $900 per week for a 30-hour workweek works more than 30 hours, the hours from 30 to 40 would be compensated at their normal wage of $30 per hour ($900 ÷ 30). If the employee worked more than 40 hours, you would pay overtime (in this case $45 per hour, $30 x 1.5) for the hours in excess of 40.

To address a few other employment questions that I am frequently asked:

Under the FFCRA, you must provide both full- and part-time employees with emergency paid sick leave (EPSL) if they’re unable to work from your office or their home because of illness attributable to COVID-19, quarantine, or caring for a sick family member or child whose school is closed. Full-time employees are entitled to up to 80 hours of EPSL, and part-timers an average of what they work every 2 weeks. Some states have their own laws independent from the FFCRA. Check your state or local laws.

• Some states require you to provide meal and rest breaks to both full- and part-time employees. In California, for example, employers must provide a 30-minute meal break after no more than 5 hours of work, unless the total workday is less than 6 hours and both employers and employees consent to waive breaks. California also requires rest breaks after every 4 hours worked. Check the laws in your state.
• You must include part-time employees in a 401(k) retirement plan if they work at least 1,000 hours in a year, which is about 20 hours per week. That rule is changing in 2021 to 500 hours for employees older than 21. There are state-run retirement programs in California, Connecticut, New Jersey, Washington, and Oregon, among other states. Check your state law for details.
• If you offer paid vacations to full-time employees, you do not have to do the same for part-timers. (In fact, there is no requirement in most states to offer vacation time at all.) My office does offer it to part-time employees on a pro rata basis, as do many others in my area. Again, check your state law.

As always, consult with your attorney if it’s not clear which rules apply in your specific situation.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no relevant disclosures related to the topic of this column. Write to him at [email protected].

Whether physicians or advanced practice practitioners, we are the backbone of our nation’s network of acute care facilities, and on a daily basis, we see just about everything. We have valuable insight into how to improve our nation’s health care system, especially now, as our nation continues to battle COVID-19.

Our role, squarely on the front lines during this pandemic, has given us an important perspective that needs to be heard. We spend our days managing patients with complexity, coordinating with specialists and subspecialists, and advocating – at local, state, and national levels – so that our patients can more easily transition to their lives out of the hospital.

Our current polarized political climate makes it seem that individual voices will not make a difference. It is easy to feel frustrated and powerless. However, those in our specialty are actually in a perfect position to have an educated and influential say in how we move forward, not only about the immediate health crises, but also regarding future health care issues. That voice begins with voting.

Historically, physicians have had surprisingly low rates of voting. For example, a 2007 study found significantly lower rates of voting among physicians, compared with the general public.¹ While physician voter turnout may have improved in the past decade, given the substantial changes in health care and the increasing amount of physician engagement in the public sphere, our participation should be greater still. Elected officials listen to, and follow up with, constituents who make their voices heard. Each of us can ensure that the health care policy priorities of our fast-growing specialty are addressed by mobilizing to the voting booth.

Candidates we elect shape our health care system for the future, directly impacting us and our patients. Cost, coverage, access to health care, the Centers for Medicare & Medicaid Services inpatient fee schedules, the ongoing pandemic response, surprise billing, use of telehealth, observation status, and the three-midnight rule are just a few of the issues most important to hospital medicine.

Therefore, we, the SHM Public Policy Committee, urge all of our colleagues, regardless of political sway, to make your voice heard this and every election henceforth. The first step is to register to vote, if you have not done so already.² Next, exercise that privilege. Given the pandemic, this is not as simple a process as it has been in the past. Take the time to plan your approach to early voting, mail-in voting, or election day voting. Check your County Supervisor of Elections’ website for further information, including how to register, view candidate profiles, check your precinct, and request a mail-in ballot.

In addition to casting your vote, we encourage you to share your opinions and engage in dialogue about health care issues. Clinical fact can dispel rumor and misinformation, and daily experiences can personalize our patients’ health care stories and the impact laws and rules have on our ability to practice. We are part of a trusted profession and have a unique perspective; others need and want to hear it. They can only do that if we are part of the process. Arming yourself with information and voting are the first steps on the path of advocacy. Interpersonal advocacy can also be done on social media. For example, SHM has an active grassroots advocacy network on Twitter. Tag @SHMadvocacy in your tweets to share your thoughts with their network.

Finally, as advocates for our patients in health care, we can also help ensure their safety during this election, in particular regarding COVID-19. Some patients may not wish to engage us in politics, and we must respect their decision. Others may seek our counsel and we should provide it in an unbiased fashion. We can ask our patients if they have considered a safe voting plan, help patients review the alternatives to voting in person if desired, and inform those who wish to physically cast a vote on Election Day of how to mitigate the risk of in-person voting.

Every election is important and health care is front and center for a multitude of reasons. We who practice hospital medicine are integral to our communities and need to be more politically involved. This is our chance to share our voice through our vote, not just this year, but in future elections as well.

Ann Sheehy, MD, SFHM, is division chief of the Division of Hospital Medicine at the University of Wisconsin, Madison, and chair of the SHM Public Policy Committee. Other members of the SHM PPC include Marta Almli, MD; John Biebelhausen, MD; Robert Burke, MD, MS, FHM; George Cheely, MD; Hyung (Harry) Cho, MD, SFHM; Jennifer Cowart, MD, FHM; Suparna Dutta, MD, MS, MPH; Bradley Flansbaum, DO, MPH, MHM; Alain Folefack, MD; Rick Hilger MD SFHM; Melinda Johnson, MD; Sevan Karadolian, MD; Joshua D. Lenchus, DO, FACP, SFHM; Steve Phillipson, MD; Dahlia Rizk, DO; Kendall Rogers, MD, SFHM; Brett Stauffer, MD, MHS; Amit Vashist, MD, SFHM; Robert Zipper, MD, SFHM.

References

1. Grande D et al. Do doctors vote? J Gen Int Med. 2007 May;22(5):585-9.

2. How to register to vote, confirm or change your registration and get a voter registration card. https://www.usa.gov/voter-registration/.

Whether physicians or advanced practice practitioners, we are the backbone of our nation’s network of acute care facilities, and on a daily basis, we see just about everything. We have valuable insight into how to improve our nation’s health care system, especially now, as our nation continues to battle COVID-19.

Our role, squarely on the front lines during this pandemic, has given us an important perspective that needs to be heard. We spend our days managing patients with complexity, coordinating with specialists and subspecialists, and advocating – at local, state, and national levels – so that our patients can more easily transition to their lives out of the hospital.

Our current polarized political climate makes it seem that individual voices will not make a difference. It is easy to feel frustrated and powerless. However, those in our specialty are actually in a perfect position to have an educated and influential say in how we move forward, not only about the immediate health crises, but also regarding future health care issues. That voice begins with voting.

Historically, physicians have had surprisingly low rates of voting. For example, a 2007 study found significantly lower rates of voting among physicians, compared with the general public.¹ While physician voter turnout may have improved in the past decade, given the substantial changes in health care and the increasing amount of physician engagement in the public sphere, our participation should be greater still. Elected officials listen to, and follow up with, constituents who make their voices heard. Each of us can ensure that the health care policy priorities of our fast-growing specialty are addressed by mobilizing to the voting booth.

Candidates we elect shape our health care system for the future, directly impacting us and our patients. Cost, coverage, access to health care, the Centers for Medicare & Medicaid Services inpatient fee schedules, the ongoing pandemic response, surprise billing, use of telehealth, observation status, and the three-midnight rule are just a few of the issues most important to hospital medicine.

Therefore, we, the SHM Public Policy Committee, urge all of our colleagues, regardless of political sway, to make your voice heard this and every election henceforth. The first step is to register to vote, if you have not done so already.² Next, exercise that privilege. Given the pandemic, this is not as simple a process as it has been in the past. Take the time to plan your approach to early voting, mail-in voting, or election day voting. Check your County Supervisor of Elections’ website for further information, including how to register, view candidate profiles, check your precinct, and request a mail-in ballot.

In addition to casting your vote, we encourage you to share your opinions and engage in dialogue about health care issues. Clinical fact can dispel rumor and misinformation, and daily experiences can personalize our patients’ health care stories and the impact laws and rules have on our ability to practice. We are part of a trusted profession and have a unique perspective; others need and want to hear it. They can only do that if we are part of the process. Arming yourself with information and voting are the first steps on the path of advocacy. Interpersonal advocacy can also be done on social media. For example, SHM has an active grassroots advocacy network on Twitter. Tag @SHMadvocacy in your tweets to share your thoughts with their network.

Finally, as advocates for our patients in health care, we can also help ensure their safety during this election, in particular regarding COVID-19. Some patients may not wish to engage us in politics, and we must respect their decision. Others may seek our counsel and we should provide it in an unbiased fashion. We can ask our patients if they have considered a safe voting plan, help patients review the alternatives to voting in person if desired, and inform those who wish to physically cast a vote on Election Day of how to mitigate the risk of in-person voting.

Every election is important and health care is front and center for a multitude of reasons. We who practice hospital medicine are integral to our communities and need to be more politically involved. This is our chance to share our voice through our vote, not just this year, but in future elections as well.

Ann Sheehy, MD, SFHM, is division chief of the Division of Hospital Medicine at the University of Wisconsin, Madison, and chair of the SHM Public Policy Committee. Other members of the SHM PPC include Marta Almli, MD; John Biebelhausen, MD; Robert Burke, MD, MS, FHM; George Cheely, MD; Hyung (Harry) Cho, MD, SFHM; Jennifer Cowart, MD, FHM; Suparna Dutta, MD, MS, MPH; Bradley Flansbaum, DO, MPH, MHM; Alain Folefack, MD; Rick Hilger MD SFHM; Melinda Johnson, MD; Sevan Karadolian, MD; Joshua D. Lenchus, DO, FACP, SFHM; Steve Phillipson, MD; Dahlia Rizk, DO; Kendall Rogers, MD, SFHM; Brett Stauffer, MD, MHS; Amit Vashist, MD, SFHM; Robert Zipper, MD, SFHM.

References

1. Grande D et al. Do doctors vote? J Gen Int Med. 2007 May;22(5):585-9.

2. How to register to vote, confirm or change your registration and get a voter registration card. https://www.usa.gov/voter-registration/.

Whether physicians or advanced practice practitioners, we are the backbone of our nation’s network of acute care facilities, and on a daily basis, we see just about everything. We have valuable insight into how to improve our nation’s health care system, especially now, as our nation continues to battle COVID-19.

Our role, squarely on the front lines during this pandemic, has given us an important perspective that needs to be heard. We spend our days managing patients with complexity, coordinating with specialists and subspecialists, and advocating – at local, state, and national levels – so that our patients can more easily transition to their lives out of the hospital.

Our current polarized political climate makes it seem that individual voices will not make a difference. It is easy to feel frustrated and powerless. However, those in our specialty are actually in a perfect position to have an educated and influential say in how we move forward, not only about the immediate health crises, but also regarding future health care issues. That voice begins with voting.

Historically, physicians have had surprisingly low rates of voting. For example, a 2007 study found significantly lower rates of voting among physicians, compared with the general public.¹ While physician voter turnout may have improved in the past decade, given the substantial changes in health care and the increasing amount of physician engagement in the public sphere, our participation should be greater still. Elected officials listen to, and follow up with, constituents who make their voices heard. Each of us can ensure that the health care policy priorities of our fast-growing specialty are addressed by mobilizing to the voting booth.

Candidates we elect shape our health care system for the future, directly impacting us and our patients. Cost, coverage, access to health care, the Centers for Medicare & Medicaid Services inpatient fee schedules, the ongoing pandemic response, surprise billing, use of telehealth, observation status, and the three-midnight rule are just a few of the issues most important to hospital medicine.

Therefore, we, the SHM Public Policy Committee, urge all of our colleagues, regardless of political sway, to make your voice heard this and every election henceforth. The first step is to register to vote, if you have not done so already.² Next, exercise that privilege. Given the pandemic, this is not as simple a process as it has been in the past. Take the time to plan your approach to early voting, mail-in voting, or election day voting. Check your County Supervisor of Elections’ website for further information, including how to register, view candidate profiles, check your precinct, and request a mail-in ballot.

In addition to casting your vote, we encourage you to share your opinions and engage in dialogue about health care issues. Clinical fact can dispel rumor and misinformation, and daily experiences can personalize our patients’ health care stories and the impact laws and rules have on our ability to practice. We are part of a trusted profession and have a unique perspective; others need and want to hear it. They can only do that if we are part of the process. Arming yourself with information and voting are the first steps on the path of advocacy. Interpersonal advocacy can also be done on social media. For example, SHM has an active grassroots advocacy network on Twitter. Tag @SHMadvocacy in your tweets to share your thoughts with their network.

Finally, as advocates for our patients in health care, we can also help ensure their safety during this election, in particular regarding COVID-19. Some patients may not wish to engage us in politics, and we must respect their decision. Others may seek our counsel and we should provide it in an unbiased fashion. We can ask our patients if they have considered a safe voting plan, help patients review the alternatives to voting in person if desired, and inform those who wish to physically cast a vote on Election Day of how to mitigate the risk of in-person voting.

Every election is important and health care is front and center for a multitude of reasons. We who practice hospital medicine are integral to our communities and need to be more politically involved. This is our chance to share our voice through our vote, not just this year, but in future elections as well.

Ann Sheehy, MD, SFHM, is division chief of the Division of Hospital Medicine at the University of Wisconsin, Madison, and chair of the SHM Public Policy Committee. Other members of the SHM PPC include Marta Almli, MD; John Biebelhausen, MD; Robert Burke, MD, MS, FHM; George Cheely, MD; Hyung (Harry) Cho, MD, SFHM; Jennifer Cowart, MD, FHM; Suparna Dutta, MD, MS, MPH; Bradley Flansbaum, DO, MPH, MHM; Alain Folefack, MD; Rick Hilger MD SFHM; Melinda Johnson, MD; Sevan Karadolian, MD; Joshua D. Lenchus, DO, FACP, SFHM; Steve Phillipson, MD; Dahlia Rizk, DO; Kendall Rogers, MD, SFHM; Brett Stauffer, MD, MHS; Amit Vashist, MD, SFHM; Robert Zipper, MD, SFHM.

References

1. Grande D et al. Do doctors vote? J Gen Int Med. 2007 May;22(5):585-9.

2. How to register to vote, confirm or change your registration and get a voter registration card. https://www.usa.gov/voter-registration/.