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American football and CTE: Is a racial divide inevitable?
Evidence that American football can lead to chronic traumatic encephalopathy (CTE), continues to grow. As a result, some parents are opting to sign their sons up for other sports.
In the 2017-2018 school year, 6.6% fewer high school athletes participated in tackle football than did 8 years before according to the National Federation of State High School Associations.
Many black parents encourage their sons to play football as a way to protect them gang activity. In addition, the sport can be their sole option for securing a college education for their children, an article in the Atlantic said. A recent survey of 50,000 8th-, 10th-, and 12th-grade students found that tackle football is predominantly the domain of black youth.
“This divergence paints a troubling picture of how economic opportunity – or a lack thereof – governs which boys are incentivized to put their body and brain at risk to play. Depending on where families live, and what other options are available to them, they see either a game that is too violent to consider or one that is necessary and important, if risky. Millions of Americans still watch football; NFL ratings were up this season,” Alana Semuels wrote in the article. “That a distinct portion of families won’t let their children play creates a disturbing future for the country’s most popular game.”
“Without a reversal in economic fortunes for poor communities across the country, football could one day become a sport played almost exclusively by black athletes, while still enjoyed by everyone. Black athletes – who already make up the majority of players in the most dangerous on-field positions – would continue to suffer from long-term brain damage, their life cut short by dementia and the scourge of CTE,” she wrote.
Meanwhile, numerous outlets reported that Super Bowl LIII garnered the lowest ratings since 2008.
Psychiatric hospital set to close
In both Kansas and Missouri, a shortage in mental health care has become evident, according to an article in the Kansas City Star. And now the Two Rivers Behavioral Health System, a private psychiatric hospital in southeast Kansas City, Mo., is closing its doors. The result will be a loss of 129 jobs and 105 fewer mental health beds in the city.
Patients currently in the facility will be relocated, and their care will continue. But for those who come after, care will now be tougher to find.
Two Rivers, owned by Pennsylvania-based Universal Health Services, treats children and adults. It had 2,347 discharges in 2017 and almost $28 million in revenue but had a net loss of about $3.4 million. The facility has been under scrutiny in the past two decades over its treatment of patients, with accusations about the bolstering of false memories concerning involvements in satanic cults and the treatment of a convicted sex offender who assaulted another patient. The most recent state inspection showed that Two Rivers had failed to provide a safe environment for six patients who were considered suicide risks. The patients had unsupervised access to the nurses’ station, as well as access to pens that could have been used for stabbing and a charging cord that could have been used for strangulation.
In an interview with the Star, Mark Stringer, director of the Missouri Department of Mental Health, said private psychiatric hospitals like Two Rivers are finding it harder to keep functioning, partly because of nursing shortages. Private facilities are not subsidized like state mental hospitals and are unable to secure staff from other facilities.
“There is a general worry about the availability of psychiatric services for people in crisis; there’s just no doubt about that,” Mr. Stringer said. “The loss of beds certainly hurts.”
New center offers ‘kind patient care’
In Nashville, Tenn., a new mental illness crisis treatment center is open. The center offers a 24/7 option for those with mental health issues who have run afoul of the law. Instead of incarceration, they can receive treatment, the Tennessean reported.
Estimates are that more than 1 million residents of Tennessee aged 18 years and older have a mental health or substance use disorder. About 25% of those residents having a serious mental health illness.
The new facility includes a crisis walk-in center and a unit where those in the throes of a mental health crisis can seek care. A goal is to get people suffering from an urgent mental illness crisis connected to help faster, especially when they come into contact with police.
“It’s very important to come to a place that’s going to get you help,” Bonnie Kelly said in the article. Ms. Kelly, who reportedly has bipolar disorder, has been arrested several times for disorderly conduct tied to her condition. “It means everything. It is good, kind patient care, rather than just getting you out of the way.”
Aside from benefiting those in need of mental health care, the center will ease the strain on Nashville police, who currently spend more than 5,000 hours each year responding to mental health–related calls. The officers must remain with the person until transfer to a jail or mental health facility is done.
“As a city, we are recognizing that there is a need, and we are investing in that,” East Precinct Commander David Imhof said in the article. “We are helping a population that has had no voice in the past.” Right now, fewer than 60% of patients discharged from state mental health facilities receive any sort of coverage. The result can be cycles of release, arrest, and incarceration.
Agency aims to protect patients
The Oregon Health Authority has stepped in to prevent numerous state-funded mental health facilities run by the same contractor from booting out patients with severe mental health problems.
The contractor is Kepro, a Pennsylvania-based company. Since December, the health authority has reversed decisions to release 17 patients, according to an article in the Oregonian. The harder line follows revelations by the newspaper of serious harm to patients who had been released before they were capable of caring for themselves.
Kepro was hired by the health authority and paid $27 million to evaluate the medical needs of mental health patients in Oregon. As part of the evaluation, 215 of 250 patients were deemed unqualified to remain in care.
One was Ruane Oliverio, who has schizophrenia, who was kicked out of a locked facility in Portland last June. Clinicians had warned against her release, insisting that her mental state remained too vulnerable. After being hospitalized multiple times, she was sent to the Oregon State Hospital, the highest and most expensive level of care. She was one of those targeted for release. This decision was reversed, and she continues to receive care.
Coalition seeks mental health care for refugees
A new coalition called Matters Involving Neuro-Disorders, or MIND, is trying to help refugees with mental health conditions. The effort is a response to several mental health-related deaths of refugees during 2014-2016, a video produced by the San Diego Union-Tribune said.
“Refugees are brought to this country to help them rebuild their lives,” said Justin Mudekereza, executive director of New Neighbor Relief, a nonprofit organization dedicated to helping refugees adjust to their new lives in the United States. “They have gone through a lot in their countries, then from there, they went to refugee camps, where they spend 15-20 years or more before they got a chance to come to this country.”
Sheila S. Mitra-Sarkar, PhD, of the Institute of Public Urban Affairs at San Diego State University, described the need for a “comprehensive solution” to help refugees adapt to their new society, learn English, find housing and employment, and thrive.
“When I see a patient or someone who seems to have a psychological issue ... I look at everything that goes around them,” said John C. Kuek, PhD, of La Maestra Community Health Centers in San Diego. “I’m looking at the housing issue, the employment issue, and translational issue – meaning they have some family back home and they have a live family here to care for.”
Evidence that American football can lead to chronic traumatic encephalopathy (CTE), continues to grow. As a result, some parents are opting to sign their sons up for other sports.
In the 2017-2018 school year, 6.6% fewer high school athletes participated in tackle football than did 8 years before according to the National Federation of State High School Associations.
Many black parents encourage their sons to play football as a way to protect them gang activity. In addition, the sport can be their sole option for securing a college education for their children, an article in the Atlantic said. A recent survey of 50,000 8th-, 10th-, and 12th-grade students found that tackle football is predominantly the domain of black youth.
“This divergence paints a troubling picture of how economic opportunity – or a lack thereof – governs which boys are incentivized to put their body and brain at risk to play. Depending on where families live, and what other options are available to them, they see either a game that is too violent to consider or one that is necessary and important, if risky. Millions of Americans still watch football; NFL ratings were up this season,” Alana Semuels wrote in the article. “That a distinct portion of families won’t let their children play creates a disturbing future for the country’s most popular game.”
“Without a reversal in economic fortunes for poor communities across the country, football could one day become a sport played almost exclusively by black athletes, while still enjoyed by everyone. Black athletes – who already make up the majority of players in the most dangerous on-field positions – would continue to suffer from long-term brain damage, their life cut short by dementia and the scourge of CTE,” she wrote.
Meanwhile, numerous outlets reported that Super Bowl LIII garnered the lowest ratings since 2008.
Psychiatric hospital set to close
In both Kansas and Missouri, a shortage in mental health care has become evident, according to an article in the Kansas City Star. And now the Two Rivers Behavioral Health System, a private psychiatric hospital in southeast Kansas City, Mo., is closing its doors. The result will be a loss of 129 jobs and 105 fewer mental health beds in the city.
Patients currently in the facility will be relocated, and their care will continue. But for those who come after, care will now be tougher to find.
Two Rivers, owned by Pennsylvania-based Universal Health Services, treats children and adults. It had 2,347 discharges in 2017 and almost $28 million in revenue but had a net loss of about $3.4 million. The facility has been under scrutiny in the past two decades over its treatment of patients, with accusations about the bolstering of false memories concerning involvements in satanic cults and the treatment of a convicted sex offender who assaulted another patient. The most recent state inspection showed that Two Rivers had failed to provide a safe environment for six patients who were considered suicide risks. The patients had unsupervised access to the nurses’ station, as well as access to pens that could have been used for stabbing and a charging cord that could have been used for strangulation.
In an interview with the Star, Mark Stringer, director of the Missouri Department of Mental Health, said private psychiatric hospitals like Two Rivers are finding it harder to keep functioning, partly because of nursing shortages. Private facilities are not subsidized like state mental hospitals and are unable to secure staff from other facilities.
“There is a general worry about the availability of psychiatric services for people in crisis; there’s just no doubt about that,” Mr. Stringer said. “The loss of beds certainly hurts.”
New center offers ‘kind patient care’
In Nashville, Tenn., a new mental illness crisis treatment center is open. The center offers a 24/7 option for those with mental health issues who have run afoul of the law. Instead of incarceration, they can receive treatment, the Tennessean reported.
Estimates are that more than 1 million residents of Tennessee aged 18 years and older have a mental health or substance use disorder. About 25% of those residents having a serious mental health illness.
The new facility includes a crisis walk-in center and a unit where those in the throes of a mental health crisis can seek care. A goal is to get people suffering from an urgent mental illness crisis connected to help faster, especially when they come into contact with police.
“It’s very important to come to a place that’s going to get you help,” Bonnie Kelly said in the article. Ms. Kelly, who reportedly has bipolar disorder, has been arrested several times for disorderly conduct tied to her condition. “It means everything. It is good, kind patient care, rather than just getting you out of the way.”
Aside from benefiting those in need of mental health care, the center will ease the strain on Nashville police, who currently spend more than 5,000 hours each year responding to mental health–related calls. The officers must remain with the person until transfer to a jail or mental health facility is done.
“As a city, we are recognizing that there is a need, and we are investing in that,” East Precinct Commander David Imhof said in the article. “We are helping a population that has had no voice in the past.” Right now, fewer than 60% of patients discharged from state mental health facilities receive any sort of coverage. The result can be cycles of release, arrest, and incarceration.
Agency aims to protect patients
The Oregon Health Authority has stepped in to prevent numerous state-funded mental health facilities run by the same contractor from booting out patients with severe mental health problems.
The contractor is Kepro, a Pennsylvania-based company. Since December, the health authority has reversed decisions to release 17 patients, according to an article in the Oregonian. The harder line follows revelations by the newspaper of serious harm to patients who had been released before they were capable of caring for themselves.
Kepro was hired by the health authority and paid $27 million to evaluate the medical needs of mental health patients in Oregon. As part of the evaluation, 215 of 250 patients were deemed unqualified to remain in care.
One was Ruane Oliverio, who has schizophrenia, who was kicked out of a locked facility in Portland last June. Clinicians had warned against her release, insisting that her mental state remained too vulnerable. After being hospitalized multiple times, she was sent to the Oregon State Hospital, the highest and most expensive level of care. She was one of those targeted for release. This decision was reversed, and she continues to receive care.
Coalition seeks mental health care for refugees
A new coalition called Matters Involving Neuro-Disorders, or MIND, is trying to help refugees with mental health conditions. The effort is a response to several mental health-related deaths of refugees during 2014-2016, a video produced by the San Diego Union-Tribune said.
“Refugees are brought to this country to help them rebuild their lives,” said Justin Mudekereza, executive director of New Neighbor Relief, a nonprofit organization dedicated to helping refugees adjust to their new lives in the United States. “They have gone through a lot in their countries, then from there, they went to refugee camps, where they spend 15-20 years or more before they got a chance to come to this country.”
Sheila S. Mitra-Sarkar, PhD, of the Institute of Public Urban Affairs at San Diego State University, described the need for a “comprehensive solution” to help refugees adapt to their new society, learn English, find housing and employment, and thrive.
“When I see a patient or someone who seems to have a psychological issue ... I look at everything that goes around them,” said John C. Kuek, PhD, of La Maestra Community Health Centers in San Diego. “I’m looking at the housing issue, the employment issue, and translational issue – meaning they have some family back home and they have a live family here to care for.”
Evidence that American football can lead to chronic traumatic encephalopathy (CTE), continues to grow. As a result, some parents are opting to sign their sons up for other sports.
In the 2017-2018 school year, 6.6% fewer high school athletes participated in tackle football than did 8 years before according to the National Federation of State High School Associations.
Many black parents encourage their sons to play football as a way to protect them gang activity. In addition, the sport can be their sole option for securing a college education for their children, an article in the Atlantic said. A recent survey of 50,000 8th-, 10th-, and 12th-grade students found that tackle football is predominantly the domain of black youth.
“This divergence paints a troubling picture of how economic opportunity – or a lack thereof – governs which boys are incentivized to put their body and brain at risk to play. Depending on where families live, and what other options are available to them, they see either a game that is too violent to consider or one that is necessary and important, if risky. Millions of Americans still watch football; NFL ratings were up this season,” Alana Semuels wrote in the article. “That a distinct portion of families won’t let their children play creates a disturbing future for the country’s most popular game.”
“Without a reversal in economic fortunes for poor communities across the country, football could one day become a sport played almost exclusively by black athletes, while still enjoyed by everyone. Black athletes – who already make up the majority of players in the most dangerous on-field positions – would continue to suffer from long-term brain damage, their life cut short by dementia and the scourge of CTE,” she wrote.
Meanwhile, numerous outlets reported that Super Bowl LIII garnered the lowest ratings since 2008.
Psychiatric hospital set to close
In both Kansas and Missouri, a shortage in mental health care has become evident, according to an article in the Kansas City Star. And now the Two Rivers Behavioral Health System, a private psychiatric hospital in southeast Kansas City, Mo., is closing its doors. The result will be a loss of 129 jobs and 105 fewer mental health beds in the city.
Patients currently in the facility will be relocated, and their care will continue. But for those who come after, care will now be tougher to find.
Two Rivers, owned by Pennsylvania-based Universal Health Services, treats children and adults. It had 2,347 discharges in 2017 and almost $28 million in revenue but had a net loss of about $3.4 million. The facility has been under scrutiny in the past two decades over its treatment of patients, with accusations about the bolstering of false memories concerning involvements in satanic cults and the treatment of a convicted sex offender who assaulted another patient. The most recent state inspection showed that Two Rivers had failed to provide a safe environment for six patients who were considered suicide risks. The patients had unsupervised access to the nurses’ station, as well as access to pens that could have been used for stabbing and a charging cord that could have been used for strangulation.
In an interview with the Star, Mark Stringer, director of the Missouri Department of Mental Health, said private psychiatric hospitals like Two Rivers are finding it harder to keep functioning, partly because of nursing shortages. Private facilities are not subsidized like state mental hospitals and are unable to secure staff from other facilities.
“There is a general worry about the availability of psychiatric services for people in crisis; there’s just no doubt about that,” Mr. Stringer said. “The loss of beds certainly hurts.”
New center offers ‘kind patient care’
In Nashville, Tenn., a new mental illness crisis treatment center is open. The center offers a 24/7 option for those with mental health issues who have run afoul of the law. Instead of incarceration, they can receive treatment, the Tennessean reported.
Estimates are that more than 1 million residents of Tennessee aged 18 years and older have a mental health or substance use disorder. About 25% of those residents having a serious mental health illness.
The new facility includes a crisis walk-in center and a unit where those in the throes of a mental health crisis can seek care. A goal is to get people suffering from an urgent mental illness crisis connected to help faster, especially when they come into contact with police.
“It’s very important to come to a place that’s going to get you help,” Bonnie Kelly said in the article. Ms. Kelly, who reportedly has bipolar disorder, has been arrested several times for disorderly conduct tied to her condition. “It means everything. It is good, kind patient care, rather than just getting you out of the way.”
Aside from benefiting those in need of mental health care, the center will ease the strain on Nashville police, who currently spend more than 5,000 hours each year responding to mental health–related calls. The officers must remain with the person until transfer to a jail or mental health facility is done.
“As a city, we are recognizing that there is a need, and we are investing in that,” East Precinct Commander David Imhof said in the article. “We are helping a population that has had no voice in the past.” Right now, fewer than 60% of patients discharged from state mental health facilities receive any sort of coverage. The result can be cycles of release, arrest, and incarceration.
Agency aims to protect patients
The Oregon Health Authority has stepped in to prevent numerous state-funded mental health facilities run by the same contractor from booting out patients with severe mental health problems.
The contractor is Kepro, a Pennsylvania-based company. Since December, the health authority has reversed decisions to release 17 patients, according to an article in the Oregonian. The harder line follows revelations by the newspaper of serious harm to patients who had been released before they were capable of caring for themselves.
Kepro was hired by the health authority and paid $27 million to evaluate the medical needs of mental health patients in Oregon. As part of the evaluation, 215 of 250 patients were deemed unqualified to remain in care.
One was Ruane Oliverio, who has schizophrenia, who was kicked out of a locked facility in Portland last June. Clinicians had warned against her release, insisting that her mental state remained too vulnerable. After being hospitalized multiple times, she was sent to the Oregon State Hospital, the highest and most expensive level of care. She was one of those targeted for release. This decision was reversed, and she continues to receive care.
Coalition seeks mental health care for refugees
A new coalition called Matters Involving Neuro-Disorders, or MIND, is trying to help refugees with mental health conditions. The effort is a response to several mental health-related deaths of refugees during 2014-2016, a video produced by the San Diego Union-Tribune said.
“Refugees are brought to this country to help them rebuild their lives,” said Justin Mudekereza, executive director of New Neighbor Relief, a nonprofit organization dedicated to helping refugees adjust to their new lives in the United States. “They have gone through a lot in their countries, then from there, they went to refugee camps, where they spend 15-20 years or more before they got a chance to come to this country.”
Sheila S. Mitra-Sarkar, PhD, of the Institute of Public Urban Affairs at San Diego State University, described the need for a “comprehensive solution” to help refugees adapt to their new society, learn English, find housing and employment, and thrive.
“When I see a patient or someone who seems to have a psychological issue ... I look at everything that goes around them,” said John C. Kuek, PhD, of La Maestra Community Health Centers in San Diego. “I’m looking at the housing issue, the employment issue, and translational issue – meaning they have some family back home and they have a live family here to care for.”
One person’s snake oil is another’s improved bottom line
“I’d be a millionaire if I could get rid of my conscience.”
A friend of mine in obstetrics said that yesterday. We were talking about the various quackery products pushed over the Internet and in some stores. These things claim to heal anything from Parkinson’s disease to a broken heart, and are generally sold by someone without real medical training. Generally, they also include some comment about this being a cure that doctors are hiding from you.
Of course, all of this is untrue. If there were actually cure for some horrible neurologic disease, I’d be thrilled to prescribe it. I’m here to reduce suffering, not prolong it.
I get it. People want to believe there’s hope when there is none. Even if it’s just something like forgetting a broken relationship, they want to believe there’s a way to make it happen quickly and painlessly.
It would be nice if it worked that way, but it doesn’t. Worse, people in these unfortunate medical or emotional situations are often vulnerable to these sales pitches, and there’s no shortage of unscrupulous individuals willing to prey on them.
What bothers me most in these cases is when doctors, with training similar to mine, push these “remedies.” Often they’re sold in a case in the waiting room and recommended during the visit. I assume these physicians either have lost their conscience and don’t care, or over time have somehow convinced themselves that what they’re doing is right.
Having a doctor selling or endorsing such a product gives it a credibility that it usually won’t get from an average Internet huckster, even if it’s for the same thing.
I’m sure some doctors have convinced themselves that the product is harmless, and therefore falls under primum non nocere. But being harmless isn’t the same as being effective, which is what the patient wants.
Like my friend said, with the financial pressures modern physicians are under, it’s easy to look at things like this as a way to improve cash flow and the bottom line. But you can’t lose sight of the patients. They’re why we are here, and selling them a product that will do them no good isn’t right.
Hippocrates’ “Do no harm” is a key part of being a doctor, but Jiminy Cricket’s “always let your conscience be your guide” is part of being a good doctor. We should never forget that.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“I’d be a millionaire if I could get rid of my conscience.”
A friend of mine in obstetrics said that yesterday. We were talking about the various quackery products pushed over the Internet and in some stores. These things claim to heal anything from Parkinson’s disease to a broken heart, and are generally sold by someone without real medical training. Generally, they also include some comment about this being a cure that doctors are hiding from you.
Of course, all of this is untrue. If there were actually cure for some horrible neurologic disease, I’d be thrilled to prescribe it. I’m here to reduce suffering, not prolong it.
I get it. People want to believe there’s hope when there is none. Even if it’s just something like forgetting a broken relationship, they want to believe there’s a way to make it happen quickly and painlessly.
It would be nice if it worked that way, but it doesn’t. Worse, people in these unfortunate medical or emotional situations are often vulnerable to these sales pitches, and there’s no shortage of unscrupulous individuals willing to prey on them.
What bothers me most in these cases is when doctors, with training similar to mine, push these “remedies.” Often they’re sold in a case in the waiting room and recommended during the visit. I assume these physicians either have lost their conscience and don’t care, or over time have somehow convinced themselves that what they’re doing is right.
Having a doctor selling or endorsing such a product gives it a credibility that it usually won’t get from an average Internet huckster, even if it’s for the same thing.
I’m sure some doctors have convinced themselves that the product is harmless, and therefore falls under primum non nocere. But being harmless isn’t the same as being effective, which is what the patient wants.
Like my friend said, with the financial pressures modern physicians are under, it’s easy to look at things like this as a way to improve cash flow and the bottom line. But you can’t lose sight of the patients. They’re why we are here, and selling them a product that will do them no good isn’t right.
Hippocrates’ “Do no harm” is a key part of being a doctor, but Jiminy Cricket’s “always let your conscience be your guide” is part of being a good doctor. We should never forget that.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“I’d be a millionaire if I could get rid of my conscience.”
A friend of mine in obstetrics said that yesterday. We were talking about the various quackery products pushed over the Internet and in some stores. These things claim to heal anything from Parkinson’s disease to a broken heart, and are generally sold by someone without real medical training. Generally, they also include some comment about this being a cure that doctors are hiding from you.
Of course, all of this is untrue. If there were actually cure for some horrible neurologic disease, I’d be thrilled to prescribe it. I’m here to reduce suffering, not prolong it.
I get it. People want to believe there’s hope when there is none. Even if it’s just something like forgetting a broken relationship, they want to believe there’s a way to make it happen quickly and painlessly.
It would be nice if it worked that way, but it doesn’t. Worse, people in these unfortunate medical or emotional situations are often vulnerable to these sales pitches, and there’s no shortage of unscrupulous individuals willing to prey on them.
What bothers me most in these cases is when doctors, with training similar to mine, push these “remedies.” Often they’re sold in a case in the waiting room and recommended during the visit. I assume these physicians either have lost their conscience and don’t care, or over time have somehow convinced themselves that what they’re doing is right.
Having a doctor selling or endorsing such a product gives it a credibility that it usually won’t get from an average Internet huckster, even if it’s for the same thing.
I’m sure some doctors have convinced themselves that the product is harmless, and therefore falls under primum non nocere. But being harmless isn’t the same as being effective, which is what the patient wants.
Like my friend said, with the financial pressures modern physicians are under, it’s easy to look at things like this as a way to improve cash flow and the bottom line. But you can’t lose sight of the patients. They’re why we are here, and selling them a product that will do them no good isn’t right.
Hippocrates’ “Do no harm” is a key part of being a doctor, but Jiminy Cricket’s “always let your conscience be your guide” is part of being a good doctor. We should never forget that.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Penicillin allergy
A 75-year-old man presents with fever, chills, and facial pain. He had an upper respiratory infection 3 weeks ago and has had persistent sinus drainage since. He has tried nasal irrigation and nasal steroids without improvement.
Over the past 5 days, he has had thicker postnasal drip, the development of facial pain, and today fevers as high as 102 degrees. He has a history of giant cell arteritis, for which he takes 30 mg of prednisone daily; coronary artery disease; and hypertension. He has a penicillin allergy (rash on chest, back, and arms 25 years ago). Exam reveals temperature of 101.5 and tenderness over left maxillary sinus.
What treatment do you recommend?
A. Amoxicillin/clavulanate.
B. Cefpodoxime.
C. Levofloxacin.
D. Trimethoprim/sulfamethoxazole.
I think cefpodoxime is probably the best of these choices to treat sinusitis in this patient. Choosing amoxicillin /clavulanate is an option only if you could give the patient a test dose in a controlled setting. I think giving this patient levofloxacin poses greater risk than a penicillin rechallenge. This patient is elderly and on prednisone, both of which increase his risk of tendon rupture if given a quinolone. Also, the Food and Drug Administration released a warning recently regarding increased risk of aortic disease in patients with cardiovascular risk factors who receive fluoroquinolones.1
Merin Kuruvilla, MD, and colleagues described oral amoxicillin challenge for patients with a history of low-risk penicillin allergy (described as benign rash, benign somatic symptoms, or unknown history with penicillin exposure more than 12 months prior).2 The study was done in a single allergy practice where 38 of 50 patients with penicillin allergy histories qualified for the study. Of the 38 eligible patients, 20 consented to oral rechallenge in clinic, and none of them developed immediate or delayed hypersensitivity reactions.
Melissa Iammatteo, MD, et al. studied 155 patients with a history of non–life-threatening penicillin reactions.3 Study participants received placebo followed by a two-step graded challenge to amoxicillin. No reaction occurred in 77% of patients, while 20% of patients had nonallergic reactions, which were equal between placebo and amoxicillin. Only 2.6 % had allergic reactions, all of which were classified as mild.
Reported penicillin allergy occurs in about 10% of community patients, but 90% of these patients can tolerate penicillins.4 Patients reporting a penicillin allergy have increased risk for drug resistance and prolonged hospital stays.5
The American Academy of Allergy, Asthma & Immunology recommended more widespread and routine performance of penicillin allergy testing in patients with a history of allergy to penicillin or other beta-lactam antibiotics.6 Patients who have penicillin allergy histories are more likely to receive drugs, such as clindamycin or a fluoroquinolone, that may carry much greater risks than a beta-lactam antibiotic. It also leads to more vancomycin use, which increases risk of vancomycin resistance.
Allergic reactions to cephalosporins are very infrequent in patients with a penicillin allergy. Eric Macy, MD, and colleagues studied all members of Kaiser Permanente Southern California health plan who had received cephalosporins over a 2-year period.7 More than 275,000 courses were given to patients with penicillin allergy, with only about 1% having an allergic reaction and only three cases of anaphylaxis.
Pearl: Most patients with a history of penicillin allergy will tolerate penicillins and cephalosporins. Penicillin allergy testing should be done to assess if they have a penicillin allergy, and in low-risk patients (patients who do not recall the allergy or had a maculopapular rash), consideration for oral rechallenge in a controlled setting may be an option. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Food and Drug Administration. “FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients,” 2018 Dec 20.
2. Ann Allergy Asthma Immunol. 2018 Nov;121(5):627-8.
3. J Allergy Clin Immunol Pract. 2019 Jan;7(1):236-43.
4. Immunol Allergy Clin North Am. 2017 Nov;37(4):643-62.
5. J Allergy Clin Immunol. 2014 Mar;133(3):790-6.
6. J Allergy Clin Immunol Pract. 2017 Mar - Apr;5(2):333-4.
7. J Allergy Clin Immunol. 2015 Mar;135(3):745-52.e5.
A 75-year-old man presents with fever, chills, and facial pain. He had an upper respiratory infection 3 weeks ago and has had persistent sinus drainage since. He has tried nasal irrigation and nasal steroids without improvement.
Over the past 5 days, he has had thicker postnasal drip, the development of facial pain, and today fevers as high as 102 degrees. He has a history of giant cell arteritis, for which he takes 30 mg of prednisone daily; coronary artery disease; and hypertension. He has a penicillin allergy (rash on chest, back, and arms 25 years ago). Exam reveals temperature of 101.5 and tenderness over left maxillary sinus.
What treatment do you recommend?
A. Amoxicillin/clavulanate.
B. Cefpodoxime.
C. Levofloxacin.
D. Trimethoprim/sulfamethoxazole.
I think cefpodoxime is probably the best of these choices to treat sinusitis in this patient. Choosing amoxicillin /clavulanate is an option only if you could give the patient a test dose in a controlled setting. I think giving this patient levofloxacin poses greater risk than a penicillin rechallenge. This patient is elderly and on prednisone, both of which increase his risk of tendon rupture if given a quinolone. Also, the Food and Drug Administration released a warning recently regarding increased risk of aortic disease in patients with cardiovascular risk factors who receive fluoroquinolones.1
Merin Kuruvilla, MD, and colleagues described oral amoxicillin challenge for patients with a history of low-risk penicillin allergy (described as benign rash, benign somatic symptoms, or unknown history with penicillin exposure more than 12 months prior).2 The study was done in a single allergy practice where 38 of 50 patients with penicillin allergy histories qualified for the study. Of the 38 eligible patients, 20 consented to oral rechallenge in clinic, and none of them developed immediate or delayed hypersensitivity reactions.
Melissa Iammatteo, MD, et al. studied 155 patients with a history of non–life-threatening penicillin reactions.3 Study participants received placebo followed by a two-step graded challenge to amoxicillin. No reaction occurred in 77% of patients, while 20% of patients had nonallergic reactions, which were equal between placebo and amoxicillin. Only 2.6 % had allergic reactions, all of which were classified as mild.
Reported penicillin allergy occurs in about 10% of community patients, but 90% of these patients can tolerate penicillins.4 Patients reporting a penicillin allergy have increased risk for drug resistance and prolonged hospital stays.5
The American Academy of Allergy, Asthma & Immunology recommended more widespread and routine performance of penicillin allergy testing in patients with a history of allergy to penicillin or other beta-lactam antibiotics.6 Patients who have penicillin allergy histories are more likely to receive drugs, such as clindamycin or a fluoroquinolone, that may carry much greater risks than a beta-lactam antibiotic. It also leads to more vancomycin use, which increases risk of vancomycin resistance.
Allergic reactions to cephalosporins are very infrequent in patients with a penicillin allergy. Eric Macy, MD, and colleagues studied all members of Kaiser Permanente Southern California health plan who had received cephalosporins over a 2-year period.7 More than 275,000 courses were given to patients with penicillin allergy, with only about 1% having an allergic reaction and only three cases of anaphylaxis.
Pearl: Most patients with a history of penicillin allergy will tolerate penicillins and cephalosporins. Penicillin allergy testing should be done to assess if they have a penicillin allergy, and in low-risk patients (patients who do not recall the allergy or had a maculopapular rash), consideration for oral rechallenge in a controlled setting may be an option. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Food and Drug Administration. “FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients,” 2018 Dec 20.
2. Ann Allergy Asthma Immunol. 2018 Nov;121(5):627-8.
3. J Allergy Clin Immunol Pract. 2019 Jan;7(1):236-43.
4. Immunol Allergy Clin North Am. 2017 Nov;37(4):643-62.
5. J Allergy Clin Immunol. 2014 Mar;133(3):790-6.
6. J Allergy Clin Immunol Pract. 2017 Mar - Apr;5(2):333-4.
7. J Allergy Clin Immunol. 2015 Mar;135(3):745-52.e5.
A 75-year-old man presents with fever, chills, and facial pain. He had an upper respiratory infection 3 weeks ago and has had persistent sinus drainage since. He has tried nasal irrigation and nasal steroids without improvement.
Over the past 5 days, he has had thicker postnasal drip, the development of facial pain, and today fevers as high as 102 degrees. He has a history of giant cell arteritis, for which he takes 30 mg of prednisone daily; coronary artery disease; and hypertension. He has a penicillin allergy (rash on chest, back, and arms 25 years ago). Exam reveals temperature of 101.5 and tenderness over left maxillary sinus.
What treatment do you recommend?
A. Amoxicillin/clavulanate.
B. Cefpodoxime.
C. Levofloxacin.
D. Trimethoprim/sulfamethoxazole.
I think cefpodoxime is probably the best of these choices to treat sinusitis in this patient. Choosing amoxicillin /clavulanate is an option only if you could give the patient a test dose in a controlled setting. I think giving this patient levofloxacin poses greater risk than a penicillin rechallenge. This patient is elderly and on prednisone, both of which increase his risk of tendon rupture if given a quinolone. Also, the Food and Drug Administration released a warning recently regarding increased risk of aortic disease in patients with cardiovascular risk factors who receive fluoroquinolones.1
Merin Kuruvilla, MD, and colleagues described oral amoxicillin challenge for patients with a history of low-risk penicillin allergy (described as benign rash, benign somatic symptoms, or unknown history with penicillin exposure more than 12 months prior).2 The study was done in a single allergy practice where 38 of 50 patients with penicillin allergy histories qualified for the study. Of the 38 eligible patients, 20 consented to oral rechallenge in clinic, and none of them developed immediate or delayed hypersensitivity reactions.
Melissa Iammatteo, MD, et al. studied 155 patients with a history of non–life-threatening penicillin reactions.3 Study participants received placebo followed by a two-step graded challenge to amoxicillin. No reaction occurred in 77% of patients, while 20% of patients had nonallergic reactions, which were equal between placebo and amoxicillin. Only 2.6 % had allergic reactions, all of which were classified as mild.
Reported penicillin allergy occurs in about 10% of community patients, but 90% of these patients can tolerate penicillins.4 Patients reporting a penicillin allergy have increased risk for drug resistance and prolonged hospital stays.5
The American Academy of Allergy, Asthma & Immunology recommended more widespread and routine performance of penicillin allergy testing in patients with a history of allergy to penicillin or other beta-lactam antibiotics.6 Patients who have penicillin allergy histories are more likely to receive drugs, such as clindamycin or a fluoroquinolone, that may carry much greater risks than a beta-lactam antibiotic. It also leads to more vancomycin use, which increases risk of vancomycin resistance.
Allergic reactions to cephalosporins are very infrequent in patients with a penicillin allergy. Eric Macy, MD, and colleagues studied all members of Kaiser Permanente Southern California health plan who had received cephalosporins over a 2-year period.7 More than 275,000 courses were given to patients with penicillin allergy, with only about 1% having an allergic reaction and only three cases of anaphylaxis.
Pearl: Most patients with a history of penicillin allergy will tolerate penicillins and cephalosporins. Penicillin allergy testing should be done to assess if they have a penicillin allergy, and in low-risk patients (patients who do not recall the allergy or had a maculopapular rash), consideration for oral rechallenge in a controlled setting may be an option. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Food and Drug Administration. “FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients,” 2018 Dec 20.
2. Ann Allergy Asthma Immunol. 2018 Nov;121(5):627-8.
3. J Allergy Clin Immunol Pract. 2019 Jan;7(1):236-43.
4. Immunol Allergy Clin North Am. 2017 Nov;37(4):643-62.
5. J Allergy Clin Immunol. 2014 Mar;133(3):790-6.
6. J Allergy Clin Immunol Pract. 2017 Mar - Apr;5(2):333-4.
7. J Allergy Clin Immunol. 2015 Mar;135(3):745-52.e5.
Tyranny by the numbers
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Aftermath
I cared for my first patient with leukemia my first month as a doctor. Actually, he would protest that characterization. Marty didn’t have leukemia anymore. After chemotherapy and a bone marrow transplant, he was a few years out with no evidence of disease. While his hematologist was hesitant to use the word “cured” until more time had passed, he had been in a lasting remission.
Except that was the chart version of Marty’s story, not his own. He was diagnosed as a college sophomore, left school for treatment, and then never went back. He was pulled from his friends and his life.
“I never thought I would be the guy living in my parents’ basement,” he told me. “No job. No friends. No girlfriend.”
And, the graft-versus-host disease was still affecting him. His skin chronically itched. The light bothered his eyes, so he couldn’t drive long distances. Insecure about his skin and his vision, he self-imposed limitations on his activities, which in turn limited his hobbies.
In medical literature, what Marty was going through is chalked up to issues in survivorship. Many patients experience some version of this story. And it’s often not the hematologist or oncologist, but primary care physicians, who are responsible for managing this challenging aftermath.
Primary care physicians are responsible for a lot. After a certain duration of remission, I’ve noticed we tell some of our hematology and oncology patients, “Congratulations! You’ve graduated our clinic. We are happy to see you back if you’d like. But really, your primary care physician can manage your health now.”
In addition to depression, there was anxiety, understandably centered on the tenuousness of his health. I remember how Marty would send urgent emails and call the office after each blood test. If anything came back abnormal, there came a slew of questions. The meaning behind them was clear: The questions were filled with a fear that it could be the leukemia coming back.
What he didn’t know was that I was scared, too. After all, I was an internal medicine resident, not a hematologist. Was I checking the right labs? Was I taking his concerns seriously enough? Behind the scenes, I checked myself by running things by his bone marrow transplant doctor on a regular basis. She guided me on guiding him.
I often thought that I couldn’t imagine what he was feeling. We were the same age, but our day-to-day concerns took a drastically different tone. We both took a deep interest in his blood work, but while I felt angst over taking responsibility for them, he worried about whether they signaled an impending death.
“If the leukemia does come back,” he told me one day, “I don’t think I want to treat it. I can’t deal with all that again.”
There were many times he wanted to give up, he told me, and it was only for his parents that he pushed through. But now, he said, if it came back and the odds of curing it were that much smaller, he couldn’t do it for his parents again. He would take his savings, travel the world, and not look back.
I listened. I felt I understood his values at that point. I could not disagree.
Looking back, I realize some of my best help to Marty was through paperwork. It wasn’t glamorous, but it was what Marty needed. The passport to putting his life back together included many notes from a doctor: One to get him back into school, another to live in a dorm room, another for accommodations for his vision during exams, another to participate in sports.
At the time, I still was in newfound awe of the power of my signature; suddenly, signing MD at the end of documents persuaded schools, employers, and others to provide necessary services for my patients. I couldn’t think of a better use of my signature than to help Marty get his life back.
At the end of my residency, when I broke the news that I wouldn’t be a primary care physician anymore, I tried to soften it by sharing that I would be staying at Stanford for a fellowship in hematology and oncology. I’d be around. When I casually suggested he could come by anytime to say hello, he said no, and I then realized my blunder. He didn’t want to see me in a cancer center. He had done his time there. That was not the place he wanted to be a patient, ever again.
This month Marty turned 30, and so did I. He occasionally sends me updates from school, which I always enjoy receiving. He is on a sports team; he is pursuing a degree in economics; he has friends. And, he remains in remission. It took a long time, but he is happy.
During our last visit together, Marty gave me a stuffed animal with the name of the college I had helped him go back to. It’s sitting on my bookshelf. It reminds me how to be there for patients during the aftermath, a time that can be easily overlooked as the hardest. It reminds me what matters.
Minor details of this story have been changed to protect privacy.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
I cared for my first patient with leukemia my first month as a doctor. Actually, he would protest that characterization. Marty didn’t have leukemia anymore. After chemotherapy and a bone marrow transplant, he was a few years out with no evidence of disease. While his hematologist was hesitant to use the word “cured” until more time had passed, he had been in a lasting remission.
Except that was the chart version of Marty’s story, not his own. He was diagnosed as a college sophomore, left school for treatment, and then never went back. He was pulled from his friends and his life.
“I never thought I would be the guy living in my parents’ basement,” he told me. “No job. No friends. No girlfriend.”
And, the graft-versus-host disease was still affecting him. His skin chronically itched. The light bothered his eyes, so he couldn’t drive long distances. Insecure about his skin and his vision, he self-imposed limitations on his activities, which in turn limited his hobbies.
In medical literature, what Marty was going through is chalked up to issues in survivorship. Many patients experience some version of this story. And it’s often not the hematologist or oncologist, but primary care physicians, who are responsible for managing this challenging aftermath.
Primary care physicians are responsible for a lot. After a certain duration of remission, I’ve noticed we tell some of our hematology and oncology patients, “Congratulations! You’ve graduated our clinic. We are happy to see you back if you’d like. But really, your primary care physician can manage your health now.”
In addition to depression, there was anxiety, understandably centered on the tenuousness of his health. I remember how Marty would send urgent emails and call the office after each blood test. If anything came back abnormal, there came a slew of questions. The meaning behind them was clear: The questions were filled with a fear that it could be the leukemia coming back.
What he didn’t know was that I was scared, too. After all, I was an internal medicine resident, not a hematologist. Was I checking the right labs? Was I taking his concerns seriously enough? Behind the scenes, I checked myself by running things by his bone marrow transplant doctor on a regular basis. She guided me on guiding him.
I often thought that I couldn’t imagine what he was feeling. We were the same age, but our day-to-day concerns took a drastically different tone. We both took a deep interest in his blood work, but while I felt angst over taking responsibility for them, he worried about whether they signaled an impending death.
“If the leukemia does come back,” he told me one day, “I don’t think I want to treat it. I can’t deal with all that again.”
There were many times he wanted to give up, he told me, and it was only for his parents that he pushed through. But now, he said, if it came back and the odds of curing it were that much smaller, he couldn’t do it for his parents again. He would take his savings, travel the world, and not look back.
I listened. I felt I understood his values at that point. I could not disagree.
Looking back, I realize some of my best help to Marty was through paperwork. It wasn’t glamorous, but it was what Marty needed. The passport to putting his life back together included many notes from a doctor: One to get him back into school, another to live in a dorm room, another for accommodations for his vision during exams, another to participate in sports.
At the time, I still was in newfound awe of the power of my signature; suddenly, signing MD at the end of documents persuaded schools, employers, and others to provide necessary services for my patients. I couldn’t think of a better use of my signature than to help Marty get his life back.
At the end of my residency, when I broke the news that I wouldn’t be a primary care physician anymore, I tried to soften it by sharing that I would be staying at Stanford for a fellowship in hematology and oncology. I’d be around. When I casually suggested he could come by anytime to say hello, he said no, and I then realized my blunder. He didn’t want to see me in a cancer center. He had done his time there. That was not the place he wanted to be a patient, ever again.
This month Marty turned 30, and so did I. He occasionally sends me updates from school, which I always enjoy receiving. He is on a sports team; he is pursuing a degree in economics; he has friends. And, he remains in remission. It took a long time, but he is happy.
During our last visit together, Marty gave me a stuffed animal with the name of the college I had helped him go back to. It’s sitting on my bookshelf. It reminds me how to be there for patients during the aftermath, a time that can be easily overlooked as the hardest. It reminds me what matters.
Minor details of this story have been changed to protect privacy.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
I cared for my first patient with leukemia my first month as a doctor. Actually, he would protest that characterization. Marty didn’t have leukemia anymore. After chemotherapy and a bone marrow transplant, he was a few years out with no evidence of disease. While his hematologist was hesitant to use the word “cured” until more time had passed, he had been in a lasting remission.
Except that was the chart version of Marty’s story, not his own. He was diagnosed as a college sophomore, left school for treatment, and then never went back. He was pulled from his friends and his life.
“I never thought I would be the guy living in my parents’ basement,” he told me. “No job. No friends. No girlfriend.”
And, the graft-versus-host disease was still affecting him. His skin chronically itched. The light bothered his eyes, so he couldn’t drive long distances. Insecure about his skin and his vision, he self-imposed limitations on his activities, which in turn limited his hobbies.
In medical literature, what Marty was going through is chalked up to issues in survivorship. Many patients experience some version of this story. And it’s often not the hematologist or oncologist, but primary care physicians, who are responsible for managing this challenging aftermath.
Primary care physicians are responsible for a lot. After a certain duration of remission, I’ve noticed we tell some of our hematology and oncology patients, “Congratulations! You’ve graduated our clinic. We are happy to see you back if you’d like. But really, your primary care physician can manage your health now.”
In addition to depression, there was anxiety, understandably centered on the tenuousness of his health. I remember how Marty would send urgent emails and call the office after each blood test. If anything came back abnormal, there came a slew of questions. The meaning behind them was clear: The questions were filled with a fear that it could be the leukemia coming back.
What he didn’t know was that I was scared, too. After all, I was an internal medicine resident, not a hematologist. Was I checking the right labs? Was I taking his concerns seriously enough? Behind the scenes, I checked myself by running things by his bone marrow transplant doctor on a regular basis. She guided me on guiding him.
I often thought that I couldn’t imagine what he was feeling. We were the same age, but our day-to-day concerns took a drastically different tone. We both took a deep interest in his blood work, but while I felt angst over taking responsibility for them, he worried about whether they signaled an impending death.
“If the leukemia does come back,” he told me one day, “I don’t think I want to treat it. I can’t deal with all that again.”
There were many times he wanted to give up, he told me, and it was only for his parents that he pushed through. But now, he said, if it came back and the odds of curing it were that much smaller, he couldn’t do it for his parents again. He would take his savings, travel the world, and not look back.
I listened. I felt I understood his values at that point. I could not disagree.
Looking back, I realize some of my best help to Marty was through paperwork. It wasn’t glamorous, but it was what Marty needed. The passport to putting his life back together included many notes from a doctor: One to get him back into school, another to live in a dorm room, another for accommodations for his vision during exams, another to participate in sports.
At the time, I still was in newfound awe of the power of my signature; suddenly, signing MD at the end of documents persuaded schools, employers, and others to provide necessary services for my patients. I couldn’t think of a better use of my signature than to help Marty get his life back.
At the end of my residency, when I broke the news that I wouldn’t be a primary care physician anymore, I tried to soften it by sharing that I would be staying at Stanford for a fellowship in hematology and oncology. I’d be around. When I casually suggested he could come by anytime to say hello, he said no, and I then realized my blunder. He didn’t want to see me in a cancer center. He had done his time there. That was not the place he wanted to be a patient, ever again.
This month Marty turned 30, and so did I. He occasionally sends me updates from school, which I always enjoy receiving. He is on a sports team; he is pursuing a degree in economics; he has friends. And, he remains in remission. It took a long time, but he is happy.
During our last visit together, Marty gave me a stuffed animal with the name of the college I had helped him go back to. It’s sitting on my bookshelf. It reminds me how to be there for patients during the aftermath, a time that can be easily overlooked as the hardest. It reminds me what matters.
Minor details of this story have been changed to protect privacy.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
A shutdown, a lawsuit, and drug prices
As I write this editorial, regarding maintenance of certification. Being a doctor, these days, is neither easy nor relaxing.
The government shutdown is cheered by some, but it has real consequences for 800,000 government workers who are not getting paid, and our scientific community, where grant applications, hiring, data collection, and other critical roles of government are needed, is at a standstill. The class action suit against ABIM is the latest action of physicians telling the ABIM that enough is enough. Read more and form your opinion from our page one article. The ACA continues to be attacked in a variety of ways. To those who want to abolish it, please have a reasonable alternative in place so that real people with real diseases are not left in a desperate situation.
Drug prices continue to make news. The most recent example is the enormous increase in the cost of insulin. I read a lot about the inner workings of the pharmaceutical industry and cannot fathom how such prices are justified. Perhaps we physicians and our medical societies should consider raising our voices for our patients.
In this month’s issue there are several articles about polyp detection and the long-term protective effect of colonoscopy. We are doing really important and excellent work to reduce the burden of colon cancer.
As a heads up, Digestive Disease Week® (DDW) returns to San Diego this year. Housing choices are opening up and in San Diego fill rapidly; visit www.DDW.org/registration for more information. This year’s science is ground-breaking and will continue to advance our knowledge about IBD, the microbiome, and other important topics.
John I. Allen, MD, MBA, AGAF
Editor in Chief
As I write this editorial, regarding maintenance of certification. Being a doctor, these days, is neither easy nor relaxing.
The government shutdown is cheered by some, but it has real consequences for 800,000 government workers who are not getting paid, and our scientific community, where grant applications, hiring, data collection, and other critical roles of government are needed, is at a standstill. The class action suit against ABIM is the latest action of physicians telling the ABIM that enough is enough. Read more and form your opinion from our page one article. The ACA continues to be attacked in a variety of ways. To those who want to abolish it, please have a reasonable alternative in place so that real people with real diseases are not left in a desperate situation.
Drug prices continue to make news. The most recent example is the enormous increase in the cost of insulin. I read a lot about the inner workings of the pharmaceutical industry and cannot fathom how such prices are justified. Perhaps we physicians and our medical societies should consider raising our voices for our patients.
In this month’s issue there are several articles about polyp detection and the long-term protective effect of colonoscopy. We are doing really important and excellent work to reduce the burden of colon cancer.
As a heads up, Digestive Disease Week® (DDW) returns to San Diego this year. Housing choices are opening up and in San Diego fill rapidly; visit www.DDW.org/registration for more information. This year’s science is ground-breaking and will continue to advance our knowledge about IBD, the microbiome, and other important topics.
John I. Allen, MD, MBA, AGAF
Editor in Chief
As I write this editorial, regarding maintenance of certification. Being a doctor, these days, is neither easy nor relaxing.
The government shutdown is cheered by some, but it has real consequences for 800,000 government workers who are not getting paid, and our scientific community, where grant applications, hiring, data collection, and other critical roles of government are needed, is at a standstill. The class action suit against ABIM is the latest action of physicians telling the ABIM that enough is enough. Read more and form your opinion from our page one article. The ACA continues to be attacked in a variety of ways. To those who want to abolish it, please have a reasonable alternative in place so that real people with real diseases are not left in a desperate situation.
Drug prices continue to make news. The most recent example is the enormous increase in the cost of insulin. I read a lot about the inner workings of the pharmaceutical industry and cannot fathom how such prices are justified. Perhaps we physicians and our medical societies should consider raising our voices for our patients.
In this month’s issue there are several articles about polyp detection and the long-term protective effect of colonoscopy. We are doing really important and excellent work to reduce the burden of colon cancer.
As a heads up, Digestive Disease Week® (DDW) returns to San Diego this year. Housing choices are opening up and in San Diego fill rapidly; visit www.DDW.org/registration for more information. This year’s science is ground-breaking and will continue to advance our knowledge about IBD, the microbiome, and other important topics.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Understanding the terminology of gender identity
Use vocabulary to reduce barriers
TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.
We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.
To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.1 It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.1 A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).
A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).
While cisgender persons feel that their experience of gender – their gender identity – agrees with the cultural norms surrounding their sex assigned at birth, transgender/gender-nonconforming (GNC) persons feel that their experience of gender is incongruent with their sex assigned at birth.1 Specifically, a transgender man is a person born with a vagina and therefore assigned female at birth who experiences himself as a man. A transgender woman is a person born with a penis and therefore assigned male at birth who experiences herself as a woman. A gender nonbinary person is someone with any sexual assignment at birth whose gender experience cannot be described using a binary that includes only male and female concepts, and a gender fluid person is someone whose internal experience of gender can oscillate.1 While these examples represent only a few of the many facets of gender diversity, the general terms trans and gender nonconforming (GNC) are widely accepted as inclusive, umbrella terms to describe all persons whose experience of gender is not congruent with their sex assigned at birth.
It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.2 For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.
As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.3 We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.
There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.4 to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.
1. Lancet. 2016 Jul 23;388(10042):390-400.
2. www.genderbread.org/resource/genderbread-person-v4-0.
3. Obstet Gynecol. 2011 Dec;118(6):1454-8.
4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.
Use vocabulary to reduce barriers
Use vocabulary to reduce barriers
TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.
We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.
To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.1 It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.1 A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).
A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).
While cisgender persons feel that their experience of gender – their gender identity – agrees with the cultural norms surrounding their sex assigned at birth, transgender/gender-nonconforming (GNC) persons feel that their experience of gender is incongruent with their sex assigned at birth.1 Specifically, a transgender man is a person born with a vagina and therefore assigned female at birth who experiences himself as a man. A transgender woman is a person born with a penis and therefore assigned male at birth who experiences herself as a woman. A gender nonbinary person is someone with any sexual assignment at birth whose gender experience cannot be described using a binary that includes only male and female concepts, and a gender fluid person is someone whose internal experience of gender can oscillate.1 While these examples represent only a few of the many facets of gender diversity, the general terms trans and gender nonconforming (GNC) are widely accepted as inclusive, umbrella terms to describe all persons whose experience of gender is not congruent with their sex assigned at birth.
It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.2 For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.
As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.3 We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.
There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.4 to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.
1. Lancet. 2016 Jul 23;388(10042):390-400.
2. www.genderbread.org/resource/genderbread-person-v4-0.
3. Obstet Gynecol. 2011 Dec;118(6):1454-8.
4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.
TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.
We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.
To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.1 It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.1 A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).
A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).
While cisgender persons feel that their experience of gender – their gender identity – agrees with the cultural norms surrounding their sex assigned at birth, transgender/gender-nonconforming (GNC) persons feel that their experience of gender is incongruent with their sex assigned at birth.1 Specifically, a transgender man is a person born with a vagina and therefore assigned female at birth who experiences himself as a man. A transgender woman is a person born with a penis and therefore assigned male at birth who experiences herself as a woman. A gender nonbinary person is someone with any sexual assignment at birth whose gender experience cannot be described using a binary that includes only male and female concepts, and a gender fluid person is someone whose internal experience of gender can oscillate.1 While these examples represent only a few of the many facets of gender diversity, the general terms trans and gender nonconforming (GNC) are widely accepted as inclusive, umbrella terms to describe all persons whose experience of gender is not congruent with their sex assigned at birth.
It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.2 For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.
As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.3 We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.
There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.4 to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.
1. Lancet. 2016 Jul 23;388(10042):390-400.
2. www.genderbread.org/resource/genderbread-person-v4-0.
3. Obstet Gynecol. 2011 Dec;118(6):1454-8.
4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.
Speaking in code
If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.
Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.
Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.
However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.
But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
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].
If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.
Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.
Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.
However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.
But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
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].
If you live in Spokane, Wash., 99213 and 99214 are important numbers. Interchanging the last two digits can send your mail into the Twilight Zone. Otherwise those five digit sequences have little significance to most Americans ... unless of course you are a physician. You have been told multiple times by practice administrators and business consultants that the failure to attach the proper sequence to your bill for services can threaten the sustainability of your practice’s bottom line or put you at risk for a costly fine.
Numerical codes for office visits were not handed down on stone tablets. There was a time when a physician simply charged for something he called an “office visit” and about half that for a “short” office visit that took less time and probably nothing for a “quick recheck.” He chose the fees based on what he felt was reasonable. I remember reading of one physician who pegged his charges at a dollar per penny of the cost of a regular postage stamp. For a variety of obvious and some unfortunate reasons, these loosely structured fee structures have disappeared.
Now a physician is asked to justify his or her charges by documenting what transpired during the office visit. The patient always has been the best witness, and at least has some sense of how much work the physician has had to do to arrive at diagnosis and suggest a treatment plan. Because the patient usually was paying the bill and had a personal stake in the value of the services provided, this system seemed to make sense.
However, now some large corporate entity or government agency probably is paying the bill and would like some idea of what it is being billed for. Justifying the service provided now falls on the physician. When the billing codes were first introduced and before the payers became more curious, it was easy. I simply applied 99213 to all my office visits and once or twice a day I would code out a visit that seemed more complex as a 99214. I wasn’t keeping track of how many minutes I spent in each visit, how many questions I asked, or how many body parts I examined. Except for patients with injured extremities, everyone was pretty much getting the same exam. My coding was based on my perception of value and effort. If it took more time than usual to remove a bit of cerumen or reassure an unusually concerned parent I chalked that up as my misfortune, not a reason to code the visit as a 99214. If I felt I needed more money, I assumed that my best option was to see more patients. Neither the patients nor the payers seemed to be complaining.
But obviously somewhere someone felt that there were too many providers gaming the system and there needed to be a better way to assign value to what a physician was doing in his or her examining room. I don’t have a workable alternative. However, I always have felt that if the folks who were paying the bills would come visit my office (unannounced if they wish) and spend a morning watching me see patients, they could more accurately assign a value to my work. I’m not sure how many of you would be comfortable with that degree of transparency. But for me it would be worth it if it freed me from the burden of coding to justify my effort.
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].
Breaking down blockchain: How this novel technology will unfetter health care
One evening in 2016, my 9-year-old son suggested we use Bitcoin to purchase something on the Microsoft Xbox store. Surprised by his suggestion, I was suddenly struck with two thoughts: 1) Microsoft, by accepting Bitcoin, was validating cryptocurrency as a credible form of payment, and 2) I was getting old. My 9-year-old seemed to have a better understanding of a new technology than I did, hardly the first time – or the last time – that happened. In spite of my initial feelings of defeat, I resolved not to cede victory to my son without a fight. I immediately set out to understand cryptocurrencies and, more importantly, the technology underpinning them known as blockchain.
Even just a few years ago, my ignorance of how blockchains work may have been acceptable, but it hardly seems acceptable now. Much more than just cryptocurrency, blockchain technology is beginning to affect every industry that values information sharing and security, and it is about to usher in a revolution in health care. But what are blockchains, and why are they so important?
Explaining blockchains
Blockchains were first conceptualized almost 3 decades ago, but the invention of the first blockchain as we know it today occurred in 2008 by Satoshi Nakomoto, creator of Bitcoin. Blockchains can be thought of as a way to store and communicate information while ensuring its integrity and security. Admittedly, the technology can be a bit confusing, but we’ll attempt to simplify it by focusing on a few fundamental elements.
As the name indicates, the blockchain model relies on a chain of connected blocks. Each block contains some data (which can be financial, medical, legal, or anything else) and bears a unique fingerprint known as a “hash.” Each hash is different and depends entirely on the data stored in the block. In other words, if the contents of the block change, the hash changes, creating an entirely new fingerprint. Each block on the chain also keeps a record of the hash of the previous block. This “links” the chain together, and is the first key to its robust security: If any block is tampered with, its fingerprint will change and it will no longer be linked, thus invalidating all following blocks on the chain.
Ensuring the integrity of the blockchain doesn’t stop there. Just as actual fingerprints can be spoofed by enterprising criminals, hash technology isn’t enough to provide complete security. Thus, several other security features are built into blockchains, with the most noteworthy and important being “decentralization.” This means that blockchains are not stored on any single computer. On the contrary, duplicate copies of every blockchain exist on thousands of computers around the world, creating redundancy and minimizing the vulnerability that any single chain could be tampered with. Before any change in the blockchain can be made and accepted, it must be validated by a majority of the computers storing the chain.
If this all seems perplexing, that’s because it is. Blockchains are complex and difficult to visualize. (But if you’d like a deeper understanding, there are many great YouTube videos that do a great job explaining them.) For now, just remember this: Blockchains are very secure yet highly accessible, and will be essential to how data – especially health data – are stored and communicated in the future.
Blockchains in health care
On Jan. 24, 2019, five major companies (Aetna, Anthem, Health Care Services, IBM, and PNC Bank) “announced a new collaboration to design and create a network using blockchain technology to improve transparency and interoperability in the health care industry.”1 This team of industry leaders is hoping to build the engine that will power the future and impact how health records are created, maintained, and communicated. They’ll achieve this by taking advantage of blockchain’s inclusiveness and decentralization, storing records in a manner that is safe and accessible anywhere a patient seeks care. Because of the redundancy built into blockchains, they can also ensure data integrity. Physicians will benefit from information that is easy to obtain and always accurate; patients will benefit by gaining greater access and ownership of their personal medical records.
The collaboration mentioned above is the latest, but certainly not the first, attempt to exploit the benefits of blockchain for health care. Other major players have already entered the game, and the field is growing quickly. While it’s easy to find their efforts admirable, corporate involvement also means there is money to be saved or made in the space. Chris Ward, head of product for PNC Treasury Management, alluded to this as he commented publicly in the press release: “This collaboration will enable health care–related data and business transactions to occur in way that addresses market demands for transparency and security, while making it easier for the patient, payer, and provider to handle payments. Using this technology, we can remove friction, duplication, and administrative costs that continue to plague the industry.”
Industry executives recognize that interoperability is still the greatest challenge facing the future of health care and are particularly sensitive to the costs of not facing the challenge successfully. Clearly, they see an investment in blockchains as an opportunity to be part of a financially beneficial solution.
Why we should care
As we’ve now covered, there are many advantages of blockchain technology. In fact, we see it as the natural evolution of the patient-centered EHR. Instead of siloed and proprietary information spread across disparate EHRs that can’t communicate, the future of data exchange will be more transparent, yet more secure. Blockchain represents a unique opportunity to democratize the availability of health care information while increasing information quality and lowering costs. It is also shaping up to be the way we’ll exchange sensitive data in the future.
Don’t believe us? Just ask any 9-year-old.
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter, @doctornotte. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
Reference
1. https://newsroom.ibm.com/2019-01-24-Aetna-Anthem-Health-Care-Service-Corporation-PNC-Bank-and-IBM-announce-collaboration-to-establish-blockchain-based-ecosystem-for-the-healthcare-industry
One evening in 2016, my 9-year-old son suggested we use Bitcoin to purchase something on the Microsoft Xbox store. Surprised by his suggestion, I was suddenly struck with two thoughts: 1) Microsoft, by accepting Bitcoin, was validating cryptocurrency as a credible form of payment, and 2) I was getting old. My 9-year-old seemed to have a better understanding of a new technology than I did, hardly the first time – or the last time – that happened. In spite of my initial feelings of defeat, I resolved not to cede victory to my son without a fight. I immediately set out to understand cryptocurrencies and, more importantly, the technology underpinning them known as blockchain.
Even just a few years ago, my ignorance of how blockchains work may have been acceptable, but it hardly seems acceptable now. Much more than just cryptocurrency, blockchain technology is beginning to affect every industry that values information sharing and security, and it is about to usher in a revolution in health care. But what are blockchains, and why are they so important?
Explaining blockchains
Blockchains were first conceptualized almost 3 decades ago, but the invention of the first blockchain as we know it today occurred in 2008 by Satoshi Nakomoto, creator of Bitcoin. Blockchains can be thought of as a way to store and communicate information while ensuring its integrity and security. Admittedly, the technology can be a bit confusing, but we’ll attempt to simplify it by focusing on a few fundamental elements.
As the name indicates, the blockchain model relies on a chain of connected blocks. Each block contains some data (which can be financial, medical, legal, or anything else) and bears a unique fingerprint known as a “hash.” Each hash is different and depends entirely on the data stored in the block. In other words, if the contents of the block change, the hash changes, creating an entirely new fingerprint. Each block on the chain also keeps a record of the hash of the previous block. This “links” the chain together, and is the first key to its robust security: If any block is tampered with, its fingerprint will change and it will no longer be linked, thus invalidating all following blocks on the chain.
Ensuring the integrity of the blockchain doesn’t stop there. Just as actual fingerprints can be spoofed by enterprising criminals, hash technology isn’t enough to provide complete security. Thus, several other security features are built into blockchains, with the most noteworthy and important being “decentralization.” This means that blockchains are not stored on any single computer. On the contrary, duplicate copies of every blockchain exist on thousands of computers around the world, creating redundancy and minimizing the vulnerability that any single chain could be tampered with. Before any change in the blockchain can be made and accepted, it must be validated by a majority of the computers storing the chain.
If this all seems perplexing, that’s because it is. Blockchains are complex and difficult to visualize. (But if you’d like a deeper understanding, there are many great YouTube videos that do a great job explaining them.) For now, just remember this: Blockchains are very secure yet highly accessible, and will be essential to how data – especially health data – are stored and communicated in the future.
Blockchains in health care
On Jan. 24, 2019, five major companies (Aetna, Anthem, Health Care Services, IBM, and PNC Bank) “announced a new collaboration to design and create a network using blockchain technology to improve transparency and interoperability in the health care industry.”1 This team of industry leaders is hoping to build the engine that will power the future and impact how health records are created, maintained, and communicated. They’ll achieve this by taking advantage of blockchain’s inclusiveness and decentralization, storing records in a manner that is safe and accessible anywhere a patient seeks care. Because of the redundancy built into blockchains, they can also ensure data integrity. Physicians will benefit from information that is easy to obtain and always accurate; patients will benefit by gaining greater access and ownership of their personal medical records.
The collaboration mentioned above is the latest, but certainly not the first, attempt to exploit the benefits of blockchain for health care. Other major players have already entered the game, and the field is growing quickly. While it’s easy to find their efforts admirable, corporate involvement also means there is money to be saved or made in the space. Chris Ward, head of product for PNC Treasury Management, alluded to this as he commented publicly in the press release: “This collaboration will enable health care–related data and business transactions to occur in way that addresses market demands for transparency and security, while making it easier for the patient, payer, and provider to handle payments. Using this technology, we can remove friction, duplication, and administrative costs that continue to plague the industry.”
Industry executives recognize that interoperability is still the greatest challenge facing the future of health care and are particularly sensitive to the costs of not facing the challenge successfully. Clearly, they see an investment in blockchains as an opportunity to be part of a financially beneficial solution.
Why we should care
As we’ve now covered, there are many advantages of blockchain technology. In fact, we see it as the natural evolution of the patient-centered EHR. Instead of siloed and proprietary information spread across disparate EHRs that can’t communicate, the future of data exchange will be more transparent, yet more secure. Blockchain represents a unique opportunity to democratize the availability of health care information while increasing information quality and lowering costs. It is also shaping up to be the way we’ll exchange sensitive data in the future.
Don’t believe us? Just ask any 9-year-old.
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter, @doctornotte. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
Reference
1. https://newsroom.ibm.com/2019-01-24-Aetna-Anthem-Health-Care-Service-Corporation-PNC-Bank-and-IBM-announce-collaboration-to-establish-blockchain-based-ecosystem-for-the-healthcare-industry
One evening in 2016, my 9-year-old son suggested we use Bitcoin to purchase something on the Microsoft Xbox store. Surprised by his suggestion, I was suddenly struck with two thoughts: 1) Microsoft, by accepting Bitcoin, was validating cryptocurrency as a credible form of payment, and 2) I was getting old. My 9-year-old seemed to have a better understanding of a new technology than I did, hardly the first time – or the last time – that happened. In spite of my initial feelings of defeat, I resolved not to cede victory to my son without a fight. I immediately set out to understand cryptocurrencies and, more importantly, the technology underpinning them known as blockchain.
Even just a few years ago, my ignorance of how blockchains work may have been acceptable, but it hardly seems acceptable now. Much more than just cryptocurrency, blockchain technology is beginning to affect every industry that values information sharing and security, and it is about to usher in a revolution in health care. But what are blockchains, and why are they so important?
Explaining blockchains
Blockchains were first conceptualized almost 3 decades ago, but the invention of the first blockchain as we know it today occurred in 2008 by Satoshi Nakomoto, creator of Bitcoin. Blockchains can be thought of as a way to store and communicate information while ensuring its integrity and security. Admittedly, the technology can be a bit confusing, but we’ll attempt to simplify it by focusing on a few fundamental elements.
As the name indicates, the blockchain model relies on a chain of connected blocks. Each block contains some data (which can be financial, medical, legal, or anything else) and bears a unique fingerprint known as a “hash.” Each hash is different and depends entirely on the data stored in the block. In other words, if the contents of the block change, the hash changes, creating an entirely new fingerprint. Each block on the chain also keeps a record of the hash of the previous block. This “links” the chain together, and is the first key to its robust security: If any block is tampered with, its fingerprint will change and it will no longer be linked, thus invalidating all following blocks on the chain.
Ensuring the integrity of the blockchain doesn’t stop there. Just as actual fingerprints can be spoofed by enterprising criminals, hash technology isn’t enough to provide complete security. Thus, several other security features are built into blockchains, with the most noteworthy and important being “decentralization.” This means that blockchains are not stored on any single computer. On the contrary, duplicate copies of every blockchain exist on thousands of computers around the world, creating redundancy and minimizing the vulnerability that any single chain could be tampered with. Before any change in the blockchain can be made and accepted, it must be validated by a majority of the computers storing the chain.
If this all seems perplexing, that’s because it is. Blockchains are complex and difficult to visualize. (But if you’d like a deeper understanding, there are many great YouTube videos that do a great job explaining them.) For now, just remember this: Blockchains are very secure yet highly accessible, and will be essential to how data – especially health data – are stored and communicated in the future.
Blockchains in health care
On Jan. 24, 2019, five major companies (Aetna, Anthem, Health Care Services, IBM, and PNC Bank) “announced a new collaboration to design and create a network using blockchain technology to improve transparency and interoperability in the health care industry.”1 This team of industry leaders is hoping to build the engine that will power the future and impact how health records are created, maintained, and communicated. They’ll achieve this by taking advantage of blockchain’s inclusiveness and decentralization, storing records in a manner that is safe and accessible anywhere a patient seeks care. Because of the redundancy built into blockchains, they can also ensure data integrity. Physicians will benefit from information that is easy to obtain and always accurate; patients will benefit by gaining greater access and ownership of their personal medical records.
The collaboration mentioned above is the latest, but certainly not the first, attempt to exploit the benefits of blockchain for health care. Other major players have already entered the game, and the field is growing quickly. While it’s easy to find their efforts admirable, corporate involvement also means there is money to be saved or made in the space. Chris Ward, head of product for PNC Treasury Management, alluded to this as he commented publicly in the press release: “This collaboration will enable health care–related data and business transactions to occur in way that addresses market demands for transparency and security, while making it easier for the patient, payer, and provider to handle payments. Using this technology, we can remove friction, duplication, and administrative costs that continue to plague the industry.”
Industry executives recognize that interoperability is still the greatest challenge facing the future of health care and are particularly sensitive to the costs of not facing the challenge successfully. Clearly, they see an investment in blockchains as an opportunity to be part of a financially beneficial solution.
Why we should care
As we’ve now covered, there are many advantages of blockchain technology. In fact, we see it as the natural evolution of the patient-centered EHR. Instead of siloed and proprietary information spread across disparate EHRs that can’t communicate, the future of data exchange will be more transparent, yet more secure. Blockchain represents a unique opportunity to democratize the availability of health care information while increasing information quality and lowering costs. It is also shaping up to be the way we’ll exchange sensitive data in the future.
Don’t believe us? Just ask any 9-year-old.
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter, @doctornotte. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
Reference
1. https://newsroom.ibm.com/2019-01-24-Aetna-Anthem-Health-Care-Service-Corporation-PNC-Bank-and-IBM-announce-collaboration-to-establish-blockchain-based-ecosystem-for-the-healthcare-industry
American Heart Association guideline on the management of blood cholesterol
The purpose of this guideline is to provide direction for the management of patients with high blood cholesterol to decrease the incidence of atherosclerotic vascular disease. The update was undertaken because new evidence has emerged since the publication of the 2013 ACC/AHA cholesterol guideline about additional cholesterol-lowering agents including ezetimibe and PCSK9 inhibitors.
Measurement and therapeutic modalities
In adults aged 20 years and older who are not on lipid-lowering therapy, measurement of a lipid profile is recommended and is an effective way to estimate atherosclerotic cardiovascular disease (ASCVD) risk and documenting baseline LDL-C.
Statin therapy is divided into three categories: High-intensity statin therapy aims for lowering LDL-C levels by more than 50%, moderate-intensity therapy by 30%-49%, and low-intensity therapy by less than 30%.
Cholesterol management groups
In all individuals at all ages, emphasizing a heart-healthy lifestyle, meaning appropriate diet and exercise, to decrease the risk of developing ASCVD should be advised.
Individuals fall into groups with distinct risk of ASCVD or recurrence of ASCVD and the recommendations are organized according to these risk groups.
Secondary ASCVD prevention: Patients who already have ASCVD by virtue of having had an event or established diagnosis (MI, angina, cerebrovascular accident, or peripheral vascular disease) fall into the secondary prevention category:
- Patients aged 75 years and younger with clinical ASCVD: High-intensity statin therapy should be initiated with aim to reduce LDL-C levels by 50%. In patients who experience statin-related side effects, a moderate-intensity statin should be initiated with the aim to reduce LDL-C by 30%-49%.
- In very high-risk patients with an LDL-C above 70 mg/dL on maximally tolerated statin therapy, it is reasonable to consider the use of a non–statin cholesterol-lowering agent with an LDL-C goal under 70 mg/dL. Ezetimibe (Zetia) can be used initially and if LDL-C remains above 70 mg/dL, then consideration can be given to the addition of a PCSK9-inhibitor therapy (strength of recommendation: ezetimibe – moderate; PCSK9 – strong). The guideline discusses that, even though the evidence supports the efficacy of PCSK9s in reducing the incidence of ASCVD events, the expense of PCSK9 inhibitors give them a high cost, compared with value.
- For patients more than age 75 years with established ASCVD, it is reasonable to continue high-intensity statin therapy if patient is tolerating treatment.
Severe hypercholesterolemia:
- Patients with LDL-C above 190 mg/dL do not need a 10-year risk score calculated. These individuals should receive maximally tolerated statin therapy.
- If patient is unable to achieve 50% reduction in LDL-C and/or have an LDL-C level of 100 mg/dL, the addition of ezetimibe therapy is reasonable.
- If LDL-C is still greater than 100mg/dL on a statin plus ezetimibe, the addition of a PCSK9 inhibitor may be considered. It should be recognized that the addition of a PCSK9 in this circumstance is classified as a weak recommendation.
Diabetes mellitus in adults:
- In patients aged 40-75 years with diabetes, regardless of 10-year ASCVD risk, should be prescribed a moderate-intensity statin (strong recommendation).
- In adults with diabetes mellitus and multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with goal to reduce LDL-C by more than 50%.
- In adults with diabetes mellitus and 10-year ASCVD risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL-C levels by 50% or more.
- In patients aged 20-39 years with diabetes that is either of long duration (at least 10 years, type 2 diabetes mellitus; at least 20 years, type 1 diabetes mellitus), or with end-organ damage including albuminuria, chronic renal insufficiency, retinopathy, neuropathy, or ankle-brachial index below 0.9, it may be reasonable to initiate statin therapy (weak recommendation).
Primary prevention in adults: Adults with LDL 70-189 mg/dL and a 10-year risk of a first ASCVD event (fatal and nonfatal MI or stroke) should be estimated by using the pooled cohort equation. Adults should be categorized according to calculated risk of developing ASCVD: low risk (less than 5%), borderline risk (5% to less than 7.5%), intermediate risk (7.5% and higher to less than 20%), and high risk (20% and higher) (strong recommendation:
- Individualized risk and treatment discussion should be done with clinician and patient.
- Adults in the intermediate-risk group (7.5% and higher to less than 20%), should be placed on moderate-intensity statin with LDL-C goal reduction of more than 30%; for optimal risk reduction, especially in high-risk patients, an LDL-C reduction of more than 50% (strong recommendation).
- Risk-enhancing factors can favor initiation of intensification of statin therapy.
- If a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC) levels. If CAC is zero, statin therapy may be withheld or delayed, except those with diabetes as above, smokers, and strong familial hypercholesterolemia with premature ASCVD. If CAC score is 1-99, it is reasonable to initiate statin therapy for patients older than age 55 years; If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate a statin.
Statin safety: Prior to initiation of a statin, a clinician-patient discussion is recommended detailing ASCVD risk reduction and the potential for side effects/drug interactions. In patients with statin-associated muscle symptoms (SAMS), a detailed account for secondary causes is recommended. In patients with true SAMS, it is recommended to check a creatine kinase level and hepatic function panel; however, routine measurements are not useful. In patients with statin-associated side effects that are not severe, reassess and rechallenge patient to achieve maximal lowering of LDL-C with a modified dosing regimen.
The bottom line
Lifestyle modification is important at all ages, with specific population-guided strategies for lowering cholesterol in subgroups as discussed above. Major changes to the AHA/ACC Cholesterol Clinical Practice Guidelines now mention new agents for lowering cholesterol and using CAC levels as predictability scoring.
Reference
Grundy SM et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018 Nov 10.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Palko is a second-year resident in the family medicine residency program at Abington Jefferson Hospital.
The purpose of this guideline is to provide direction for the management of patients with high blood cholesterol to decrease the incidence of atherosclerotic vascular disease. The update was undertaken because new evidence has emerged since the publication of the 2013 ACC/AHA cholesterol guideline about additional cholesterol-lowering agents including ezetimibe and PCSK9 inhibitors.
Measurement and therapeutic modalities
In adults aged 20 years and older who are not on lipid-lowering therapy, measurement of a lipid profile is recommended and is an effective way to estimate atherosclerotic cardiovascular disease (ASCVD) risk and documenting baseline LDL-C.
Statin therapy is divided into three categories: High-intensity statin therapy aims for lowering LDL-C levels by more than 50%, moderate-intensity therapy by 30%-49%, and low-intensity therapy by less than 30%.
Cholesterol management groups
In all individuals at all ages, emphasizing a heart-healthy lifestyle, meaning appropriate diet and exercise, to decrease the risk of developing ASCVD should be advised.
Individuals fall into groups with distinct risk of ASCVD or recurrence of ASCVD and the recommendations are organized according to these risk groups.
Secondary ASCVD prevention: Patients who already have ASCVD by virtue of having had an event or established diagnosis (MI, angina, cerebrovascular accident, or peripheral vascular disease) fall into the secondary prevention category:
- Patients aged 75 years and younger with clinical ASCVD: High-intensity statin therapy should be initiated with aim to reduce LDL-C levels by 50%. In patients who experience statin-related side effects, a moderate-intensity statin should be initiated with the aim to reduce LDL-C by 30%-49%.
- In very high-risk patients with an LDL-C above 70 mg/dL on maximally tolerated statin therapy, it is reasonable to consider the use of a non–statin cholesterol-lowering agent with an LDL-C goal under 70 mg/dL. Ezetimibe (Zetia) can be used initially and if LDL-C remains above 70 mg/dL, then consideration can be given to the addition of a PCSK9-inhibitor therapy (strength of recommendation: ezetimibe – moderate; PCSK9 – strong). The guideline discusses that, even though the evidence supports the efficacy of PCSK9s in reducing the incidence of ASCVD events, the expense of PCSK9 inhibitors give them a high cost, compared with value.
- For patients more than age 75 years with established ASCVD, it is reasonable to continue high-intensity statin therapy if patient is tolerating treatment.
Severe hypercholesterolemia:
- Patients with LDL-C above 190 mg/dL do not need a 10-year risk score calculated. These individuals should receive maximally tolerated statin therapy.
- If patient is unable to achieve 50% reduction in LDL-C and/or have an LDL-C level of 100 mg/dL, the addition of ezetimibe therapy is reasonable.
- If LDL-C is still greater than 100mg/dL on a statin plus ezetimibe, the addition of a PCSK9 inhibitor may be considered. It should be recognized that the addition of a PCSK9 in this circumstance is classified as a weak recommendation.
Diabetes mellitus in adults:
- In patients aged 40-75 years with diabetes, regardless of 10-year ASCVD risk, should be prescribed a moderate-intensity statin (strong recommendation).
- In adults with diabetes mellitus and multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with goal to reduce LDL-C by more than 50%.
- In adults with diabetes mellitus and 10-year ASCVD risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL-C levels by 50% or more.
- In patients aged 20-39 years with diabetes that is either of long duration (at least 10 years, type 2 diabetes mellitus; at least 20 years, type 1 diabetes mellitus), or with end-organ damage including albuminuria, chronic renal insufficiency, retinopathy, neuropathy, or ankle-brachial index below 0.9, it may be reasonable to initiate statin therapy (weak recommendation).
Primary prevention in adults: Adults with LDL 70-189 mg/dL and a 10-year risk of a first ASCVD event (fatal and nonfatal MI or stroke) should be estimated by using the pooled cohort equation. Adults should be categorized according to calculated risk of developing ASCVD: low risk (less than 5%), borderline risk (5% to less than 7.5%), intermediate risk (7.5% and higher to less than 20%), and high risk (20% and higher) (strong recommendation:
- Individualized risk and treatment discussion should be done with clinician and patient.
- Adults in the intermediate-risk group (7.5% and higher to less than 20%), should be placed on moderate-intensity statin with LDL-C goal reduction of more than 30%; for optimal risk reduction, especially in high-risk patients, an LDL-C reduction of more than 50% (strong recommendation).
- Risk-enhancing factors can favor initiation of intensification of statin therapy.
- If a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC) levels. If CAC is zero, statin therapy may be withheld or delayed, except those with diabetes as above, smokers, and strong familial hypercholesterolemia with premature ASCVD. If CAC score is 1-99, it is reasonable to initiate statin therapy for patients older than age 55 years; If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate a statin.
Statin safety: Prior to initiation of a statin, a clinician-patient discussion is recommended detailing ASCVD risk reduction and the potential for side effects/drug interactions. In patients with statin-associated muscle symptoms (SAMS), a detailed account for secondary causes is recommended. In patients with true SAMS, it is recommended to check a creatine kinase level and hepatic function panel; however, routine measurements are not useful. In patients with statin-associated side effects that are not severe, reassess and rechallenge patient to achieve maximal lowering of LDL-C with a modified dosing regimen.
The bottom line
Lifestyle modification is important at all ages, with specific population-guided strategies for lowering cholesterol in subgroups as discussed above. Major changes to the AHA/ACC Cholesterol Clinical Practice Guidelines now mention new agents for lowering cholesterol and using CAC levels as predictability scoring.
Reference
Grundy SM et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018 Nov 10.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Palko is a second-year resident in the family medicine residency program at Abington Jefferson Hospital.
The purpose of this guideline is to provide direction for the management of patients with high blood cholesterol to decrease the incidence of atherosclerotic vascular disease. The update was undertaken because new evidence has emerged since the publication of the 2013 ACC/AHA cholesterol guideline about additional cholesterol-lowering agents including ezetimibe and PCSK9 inhibitors.
Measurement and therapeutic modalities
In adults aged 20 years and older who are not on lipid-lowering therapy, measurement of a lipid profile is recommended and is an effective way to estimate atherosclerotic cardiovascular disease (ASCVD) risk and documenting baseline LDL-C.
Statin therapy is divided into three categories: High-intensity statin therapy aims for lowering LDL-C levels by more than 50%, moderate-intensity therapy by 30%-49%, and low-intensity therapy by less than 30%.
Cholesterol management groups
In all individuals at all ages, emphasizing a heart-healthy lifestyle, meaning appropriate diet and exercise, to decrease the risk of developing ASCVD should be advised.
Individuals fall into groups with distinct risk of ASCVD or recurrence of ASCVD and the recommendations are organized according to these risk groups.
Secondary ASCVD prevention: Patients who already have ASCVD by virtue of having had an event or established diagnosis (MI, angina, cerebrovascular accident, or peripheral vascular disease) fall into the secondary prevention category:
- Patients aged 75 years and younger with clinical ASCVD: High-intensity statin therapy should be initiated with aim to reduce LDL-C levels by 50%. In patients who experience statin-related side effects, a moderate-intensity statin should be initiated with the aim to reduce LDL-C by 30%-49%.
- In very high-risk patients with an LDL-C above 70 mg/dL on maximally tolerated statin therapy, it is reasonable to consider the use of a non–statin cholesterol-lowering agent with an LDL-C goal under 70 mg/dL. Ezetimibe (Zetia) can be used initially and if LDL-C remains above 70 mg/dL, then consideration can be given to the addition of a PCSK9-inhibitor therapy (strength of recommendation: ezetimibe – moderate; PCSK9 – strong). The guideline discusses that, even though the evidence supports the efficacy of PCSK9s in reducing the incidence of ASCVD events, the expense of PCSK9 inhibitors give them a high cost, compared with value.
- For patients more than age 75 years with established ASCVD, it is reasonable to continue high-intensity statin therapy if patient is tolerating treatment.
Severe hypercholesterolemia:
- Patients with LDL-C above 190 mg/dL do not need a 10-year risk score calculated. These individuals should receive maximally tolerated statin therapy.
- If patient is unable to achieve 50% reduction in LDL-C and/or have an LDL-C level of 100 mg/dL, the addition of ezetimibe therapy is reasonable.
- If LDL-C is still greater than 100mg/dL on a statin plus ezetimibe, the addition of a PCSK9 inhibitor may be considered. It should be recognized that the addition of a PCSK9 in this circumstance is classified as a weak recommendation.
Diabetes mellitus in adults:
- In patients aged 40-75 years with diabetes, regardless of 10-year ASCVD risk, should be prescribed a moderate-intensity statin (strong recommendation).
- In adults with diabetes mellitus and multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with goal to reduce LDL-C by more than 50%.
- In adults with diabetes mellitus and 10-year ASCVD risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL-C levels by 50% or more.
- In patients aged 20-39 years with diabetes that is either of long duration (at least 10 years, type 2 diabetes mellitus; at least 20 years, type 1 diabetes mellitus), or with end-organ damage including albuminuria, chronic renal insufficiency, retinopathy, neuropathy, or ankle-brachial index below 0.9, it may be reasonable to initiate statin therapy (weak recommendation).
Primary prevention in adults: Adults with LDL 70-189 mg/dL and a 10-year risk of a first ASCVD event (fatal and nonfatal MI or stroke) should be estimated by using the pooled cohort equation. Adults should be categorized according to calculated risk of developing ASCVD: low risk (less than 5%), borderline risk (5% to less than 7.5%), intermediate risk (7.5% and higher to less than 20%), and high risk (20% and higher) (strong recommendation:
- Individualized risk and treatment discussion should be done with clinician and patient.
- Adults in the intermediate-risk group (7.5% and higher to less than 20%), should be placed on moderate-intensity statin with LDL-C goal reduction of more than 30%; for optimal risk reduction, especially in high-risk patients, an LDL-C reduction of more than 50% (strong recommendation).
- Risk-enhancing factors can favor initiation of intensification of statin therapy.
- If a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC) levels. If CAC is zero, statin therapy may be withheld or delayed, except those with diabetes as above, smokers, and strong familial hypercholesterolemia with premature ASCVD. If CAC score is 1-99, it is reasonable to initiate statin therapy for patients older than age 55 years; If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate a statin.
Statin safety: Prior to initiation of a statin, a clinician-patient discussion is recommended detailing ASCVD risk reduction and the potential for side effects/drug interactions. In patients with statin-associated muscle symptoms (SAMS), a detailed account for secondary causes is recommended. In patients with true SAMS, it is recommended to check a creatine kinase level and hepatic function panel; however, routine measurements are not useful. In patients with statin-associated side effects that are not severe, reassess and rechallenge patient to achieve maximal lowering of LDL-C with a modified dosing regimen.
The bottom line
Lifestyle modification is important at all ages, with specific population-guided strategies for lowering cholesterol in subgroups as discussed above. Major changes to the AHA/ACC Cholesterol Clinical Practice Guidelines now mention new agents for lowering cholesterol and using CAC levels as predictability scoring.
Reference
Grundy SM et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018 Nov 10.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Palko is a second-year resident in the family medicine residency program at Abington Jefferson Hospital.