Opinion

The Hospitalist recently sat down with Nancy J. Rennert, MD, FACE, FACP, CPHQ, chief of endocrinology and diabetes at Norwalk (Conn.) Hospital, Western Connecticut Health Network, to discuss her institution’s glycemic control initiatives.

Tell us a bit about your program:

Norwalk Hospital is a 366-bed community teaching hospital founded 125 years ago, now part of the growing Western Connecticut Health Network. Our residency and fellowship training programs are affiliated with Yale University, New Haven, Conn., and we are a branch campus of the University of Vermont, Burlington.

With leadership support, we created our Glycemic Care Team (GCT) 4 years ago to focus on improving the quality of care for persons with diabetes who were admitted to our hospital (often for another primary medical reason). Our hospitalists – 8 on the teaching service and 11 on the nonteaching service – are key players in our efforts as they care for the majority of medical inpatients. GCT is interdisciplinary and includes stakeholders at all levels, including quality, pharmacy, nutrition, hospital medicine, diabetes education, administrative leadership, endocrinology, information technology, point-of-care testing/pathology, surgery and more. We meet monthly with an agenda that includes safety events, glucometrics, and discussion of policies and protocols. Subgroups complete tasks in between the monthly meetings, and we bring in other clinical specialties as indicated based on the issues at hand.
 

What prior challenges did you encounter that led you to enroll in the Glycemic Control (GC) eQUIPS Program?

In order to know if our GCT was making a positive difference, we needed to first measure our baseline metrics and then identify our goals and develop our processes. We wanted actionable data analysis and the ability to differentiate areas of our hospital such as individual clinical units. After researching the options, we chose SHM’s GC eQUIPS Program, which we found to be user friendly. The national benchmarking was an important aspect for us as well. As a kick-off event, I invited Greg Maynard, MD, MHM, a hospitalist and the chief quality officer, UC Davis Medical Center, to speak on inpatient diabetes and was thrilled when he accepted my invitation. This provided an exciting start to our journey with SHM’s eQUIPS data management program.

As we began to obtain baseline measurements of glucose control, we needed a standardized, validated tool. The point-of-care glucose meters generated an enormous amount of data, but we were unable to sort this and analyze it in a meaningful and potentially actionable way. We were especially concerned about hypoglycemia. Our first task was to develop a prescriber ordered and nurse driven hypoglycemia protocol. How would we measure the overall effectiveness and success of the stepwise components of the protocol? The eQUIPS hypoglycemia management report was ideal in that it detailed metrics in stepwise fashion as it related to our protocol. For example, we were able to see the time from detection of hypoglycemia to the next point-of-care glucose check and to resolution of the event.

In addition, we wanted some comparative benchmarking data. The GC eQUIPS Program has a robust database of U.S. hospitals, which helped us define our ultimate goal – to be in the upper quartile of all measures. And we did it! Because of the amazing teamwork and leadership support, we were able to achieve national distinction from SHM as a “Top Performer” hospital for glycemic care.
 

How did the program help you and the team design your initiatives?

Data are powerful and convincing. We post and report our eQUIPS Glucometrics to our clinical staff monthly by unit, and through this process, we obtain the necessary “buy-ins” as well as participation to design clinical protocols and order sets. For example, we noted that many patients would be placed on “sliding scale”/coverage insulin alone at the time of hospital admission. This often would not be adjusted during the hospital stay. Our data showed that this practice was associated with more glucose fluctuations and hypoglycemia. When we reviewed this with our hospitalists, we achieved consensus and developed basal/bolus correction insulin protocols, which are embedded in the admission care sets. Following use of these order sets, we noted less hypoglycemia (decreased from 5.9% and remains less than 3.6%) and lower glucose variability. With the help of the eQUIPS metrics and benchmarking, we now have more than 20 protocols and safety rules built into our EHR system.

What were the key benefits that the GC eQUIPS Program provided that you were unable to find elsewhere?

The unique features we found most useful are the national benchmarking and “real-world” data presentation. National benchmarking allows us to compare ourselves with other hospitals (we can sort for like hospitals or all hospitals) and to periodically evaluate our processes and reexamine our goals. As part of this program, we can communicate with leaders of other high-performing hospitals and share strategies and challenges as well as discuss successes and failures. The quarterly benchmark webinar is another opportunity to be part of this professional community and we often pick up helpful information.

We particularly like the hyperglycemia/hypoglycemia scatter plots, which demonstrate the practical and important impact of glycemic control. Often there is a see-saw effect in which, if one parameter goes up, the other goes down; finding the sweet spot between hyperglycemia and hypoglycemia is key and clinically important.
 

Do you have any other comments to share related to your institution’s participation in the program?

We are fortunate to have many successes driven by our participation with the GC eQUIPS Program:

• Coordination of capillary blood glucose (CBG) testing, insulin administration and meal delivery: Use of rapid-acting insulin premeal is standard of care and requires that CBG testing, insulin, and meal delivery be precisely coordinated for optimal insulin action. We developed a process in which the catering associate calls the nurse using a voice-activated pager when the meal tray leaves the kitchen. Then, the nurse checks the CBG and gives insulin when the tray arrives. The tray contains a card to empower the patient to wait for the nurse to administer insulin prior to eating. This also provides an opportunity for nutritional education and carbohydrate awareness. Implementation of this process increased the percentage of patients who had a CBG and insulin administration within 15 minutes before a meal from less than 10% to more than 60%.
• Patient education regarding insulin use: In many cases, hospital patients may be started on insulin and their oral agents may be discontinued. This can be confusing and frightening to patients who often do not know if they will need to be on insulin long term. Our GCT created a script for the staff nurse to inform and reassure patients that this is standard practice and does not mean that they will need to remain on insulin after hospital discharge. The clinical team will communicate with the patient and together they will review treatment options. We have received many positive reviews from patients and staff for improving communication around this aspect of insulin therapy.
• Clinician and leader education: When our data revealed an uptick in hypoglycemia in our critical care units, we engaged the physicians, nurses, and staff and reviewed patient charts to identify potential process changes. To keep hypoglycemia in the spotlight, our director of critical care added hypoglycemia to the ICU checklist, which is discussed on all team clinical rounds. We are also developing an electronic metric (24-hour glucose maximum and minimum values) that can be quickly reviewed by the clinical team daily.
• Hypoglycemia and hyperkalemia: Analysis of our hypoglycemia data revealed a higher-than-expected rate in the ED in patients who did not have a diabetes diagnosis. Further review showed that this was associated with insulin treatment of hyperkalemia. Subsequently, we engaged our resident trainees and other team members in a study to characterize this hypoglycemia-hyperkalemia, and we have recently submitted a manuscript for publication detailing our findings and recommendations for glucose monitoring in these patients.
• Guideline for medical consultation on nonmedical services: Based on review of glucometrics on the nonmedical units and discussions with our hospitalist teams, we designed a guideline that includes recommendations for Medical Consultation in Nonmedical Admissions. Comanagement by a medical consultant will be requested earlier, and we will monitor if this influences glucometrics, patient and hospitalist satisfaction, etc.
• Medical student and house staff education: Two of our GCT hospitalists organize a monthly patient safety conference. After the students and trainees are asked to propose actionable solutions, the hospitalists discuss proposals generated at our GCT meetings. The students and trainees have the opportunity to participate in quality improvement, and we get great ideas from them as well.

Perhaps our biggest success is our Glycemic Care Team itself. We now receive questions and items to review from all departments and are seen as the hospital’s expert team on diabetes and hyperglycemia. It is truly a pleasure to lead this group of extremely high functioning and dedicated professionals. It is said that “team work makes the dream work.” Moving forward, I hope to expand our Glycemic Care Team to all the hospitals in our network.

The Hospitalist recently sat down with Nancy J. Rennert, MD, FACE, FACP, CPHQ, chief of endocrinology and diabetes at Norwalk (Conn.) Hospital, Western Connecticut Health Network, to discuss her institution’s glycemic control initiatives.

Tell us a bit about your program:

Norwalk Hospital is a 366-bed community teaching hospital founded 125 years ago, now part of the growing Western Connecticut Health Network. Our residency and fellowship training programs are affiliated with Yale University, New Haven, Conn., and we are a branch campus of the University of Vermont, Burlington.

With leadership support, we created our Glycemic Care Team (GCT) 4 years ago to focus on improving the quality of care for persons with diabetes who were admitted to our hospital (often for another primary medical reason). Our hospitalists – 8 on the teaching service and 11 on the nonteaching service – are key players in our efforts as they care for the majority of medical inpatients. GCT is interdisciplinary and includes stakeholders at all levels, including quality, pharmacy, nutrition, hospital medicine, diabetes education, administrative leadership, endocrinology, information technology, point-of-care testing/pathology, surgery and more. We meet monthly with an agenda that includes safety events, glucometrics, and discussion of policies and protocols. Subgroups complete tasks in between the monthly meetings, and we bring in other clinical specialties as indicated based on the issues at hand.
 

What prior challenges did you encounter that led you to enroll in the Glycemic Control (GC) eQUIPS Program?

In order to know if our GCT was making a positive difference, we needed to first measure our baseline metrics and then identify our goals and develop our processes. We wanted actionable data analysis and the ability to differentiate areas of our hospital such as individual clinical units. After researching the options, we chose SHM’s GC eQUIPS Program, which we found to be user friendly. The national benchmarking was an important aspect for us as well. As a kick-off event, I invited Greg Maynard, MD, MHM, a hospitalist and the chief quality officer, UC Davis Medical Center, to speak on inpatient diabetes and was thrilled when he accepted my invitation. This provided an exciting start to our journey with SHM’s eQUIPS data management program.

As we began to obtain baseline measurements of glucose control, we needed a standardized, validated tool. The point-of-care glucose meters generated an enormous amount of data, but we were unable to sort this and analyze it in a meaningful and potentially actionable way. We were especially concerned about hypoglycemia. Our first task was to develop a prescriber ordered and nurse driven hypoglycemia protocol. How would we measure the overall effectiveness and success of the stepwise components of the protocol? The eQUIPS hypoglycemia management report was ideal in that it detailed metrics in stepwise fashion as it related to our protocol. For example, we were able to see the time from detection of hypoglycemia to the next point-of-care glucose check and to resolution of the event.

In addition, we wanted some comparative benchmarking data. The GC eQUIPS Program has a robust database of U.S. hospitals, which helped us define our ultimate goal – to be in the upper quartile of all measures. And we did it! Because of the amazing teamwork and leadership support, we were able to achieve national distinction from SHM as a “Top Performer” hospital for glycemic care.
 

How did the program help you and the team design your initiatives?

Data are powerful and convincing. We post and report our eQUIPS Glucometrics to our clinical staff monthly by unit, and through this process, we obtain the necessary “buy-ins” as well as participation to design clinical protocols and order sets. For example, we noted that many patients would be placed on “sliding scale”/coverage insulin alone at the time of hospital admission. This often would not be adjusted during the hospital stay. Our data showed that this practice was associated with more glucose fluctuations and hypoglycemia. When we reviewed this with our hospitalists, we achieved consensus and developed basal/bolus correction insulin protocols, which are embedded in the admission care sets. Following use of these order sets, we noted less hypoglycemia (decreased from 5.9% and remains less than 3.6%) and lower glucose variability. With the help of the eQUIPS metrics and benchmarking, we now have more than 20 protocols and safety rules built into our EHR system.

What were the key benefits that the GC eQUIPS Program provided that you were unable to find elsewhere?

The unique features we found most useful are the national benchmarking and “real-world” data presentation. National benchmarking allows us to compare ourselves with other hospitals (we can sort for like hospitals or all hospitals) and to periodically evaluate our processes and reexamine our goals. As part of this program, we can communicate with leaders of other high-performing hospitals and share strategies and challenges as well as discuss successes and failures. The quarterly benchmark webinar is another opportunity to be part of this professional community and we often pick up helpful information.

We particularly like the hyperglycemia/hypoglycemia scatter plots, which demonstrate the practical and important impact of glycemic control. Often there is a see-saw effect in which, if one parameter goes up, the other goes down; finding the sweet spot between hyperglycemia and hypoglycemia is key and clinically important.
 

Do you have any other comments to share related to your institution’s participation in the program?

We are fortunate to have many successes driven by our participation with the GC eQUIPS Program:

• Coordination of capillary blood glucose (CBG) testing, insulin administration and meal delivery: Use of rapid-acting insulin premeal is standard of care and requires that CBG testing, insulin, and meal delivery be precisely coordinated for optimal insulin action. We developed a process in which the catering associate calls the nurse using a voice-activated pager when the meal tray leaves the kitchen. Then, the nurse checks the CBG and gives insulin when the tray arrives. The tray contains a card to empower the patient to wait for the nurse to administer insulin prior to eating. This also provides an opportunity for nutritional education and carbohydrate awareness. Implementation of this process increased the percentage of patients who had a CBG and insulin administration within 15 minutes before a meal from less than 10% to more than 60%.
• Patient education regarding insulin use: In many cases, hospital patients may be started on insulin and their oral agents may be discontinued. This can be confusing and frightening to patients who often do not know if they will need to be on insulin long term. Our GCT created a script for the staff nurse to inform and reassure patients that this is standard practice and does not mean that they will need to remain on insulin after hospital discharge. The clinical team will communicate with the patient and together they will review treatment options. We have received many positive reviews from patients and staff for improving communication around this aspect of insulin therapy.
• Clinician and leader education: When our data revealed an uptick in hypoglycemia in our critical care units, we engaged the physicians, nurses, and staff and reviewed patient charts to identify potential process changes. To keep hypoglycemia in the spotlight, our director of critical care added hypoglycemia to the ICU checklist, which is discussed on all team clinical rounds. We are also developing an electronic metric (24-hour glucose maximum and minimum values) that can be quickly reviewed by the clinical team daily.
• Hypoglycemia and hyperkalemia: Analysis of our hypoglycemia data revealed a higher-than-expected rate in the ED in patients who did not have a diabetes diagnosis. Further review showed that this was associated with insulin treatment of hyperkalemia. Subsequently, we engaged our resident trainees and other team members in a study to characterize this hypoglycemia-hyperkalemia, and we have recently submitted a manuscript for publication detailing our findings and recommendations for glucose monitoring in these patients.
• Guideline for medical consultation on nonmedical services: Based on review of glucometrics on the nonmedical units and discussions with our hospitalist teams, we designed a guideline that includes recommendations for Medical Consultation in Nonmedical Admissions. Comanagement by a medical consultant will be requested earlier, and we will monitor if this influences glucometrics, patient and hospitalist satisfaction, etc.
• Medical student and house staff education: Two of our GCT hospitalists organize a monthly patient safety conference. After the students and trainees are asked to propose actionable solutions, the hospitalists discuss proposals generated at our GCT meetings. The students and trainees have the opportunity to participate in quality improvement, and we get great ideas from them as well.

Perhaps our biggest success is our Glycemic Care Team itself. We now receive questions and items to review from all departments and are seen as the hospital’s expert team on diabetes and hyperglycemia. It is truly a pleasure to lead this group of extremely high functioning and dedicated professionals. It is said that “team work makes the dream work.” Moving forward, I hope to expand our Glycemic Care Team to all the hospitals in our network.

The Hospitalist recently sat down with Nancy J. Rennert, MD, FACE, FACP, CPHQ, chief of endocrinology and diabetes at Norwalk (Conn.) Hospital, Western Connecticut Health Network, to discuss her institution’s glycemic control initiatives.

Tell us a bit about your program:

Norwalk Hospital is a 366-bed community teaching hospital founded 125 years ago, now part of the growing Western Connecticut Health Network. Our residency and fellowship training programs are affiliated with Yale University, New Haven, Conn., and we are a branch campus of the University of Vermont, Burlington.

With leadership support, we created our Glycemic Care Team (GCT) 4 years ago to focus on improving the quality of care for persons with diabetes who were admitted to our hospital (often for another primary medical reason). Our hospitalists – 8 on the teaching service and 11 on the nonteaching service – are key players in our efforts as they care for the majority of medical inpatients. GCT is interdisciplinary and includes stakeholders at all levels, including quality, pharmacy, nutrition, hospital medicine, diabetes education, administrative leadership, endocrinology, information technology, point-of-care testing/pathology, surgery and more. We meet monthly with an agenda that includes safety events, glucometrics, and discussion of policies and protocols. Subgroups complete tasks in between the monthly meetings, and we bring in other clinical specialties as indicated based on the issues at hand.
 

What prior challenges did you encounter that led you to enroll in the Glycemic Control (GC) eQUIPS Program?

In order to know if our GCT was making a positive difference, we needed to first measure our baseline metrics and then identify our goals and develop our processes. We wanted actionable data analysis and the ability to differentiate areas of our hospital such as individual clinical units. After researching the options, we chose SHM’s GC eQUIPS Program, which we found to be user friendly. The national benchmarking was an important aspect for us as well. As a kick-off event, I invited Greg Maynard, MD, MHM, a hospitalist and the chief quality officer, UC Davis Medical Center, to speak on inpatient diabetes and was thrilled when he accepted my invitation. This provided an exciting start to our journey with SHM’s eQUIPS data management program.

As we began to obtain baseline measurements of glucose control, we needed a standardized, validated tool. The point-of-care glucose meters generated an enormous amount of data, but we were unable to sort this and analyze it in a meaningful and potentially actionable way. We were especially concerned about hypoglycemia. Our first task was to develop a prescriber ordered and nurse driven hypoglycemia protocol. How would we measure the overall effectiveness and success of the stepwise components of the protocol? The eQUIPS hypoglycemia management report was ideal in that it detailed metrics in stepwise fashion as it related to our protocol. For example, we were able to see the time from detection of hypoglycemia to the next point-of-care glucose check and to resolution of the event.

In addition, we wanted some comparative benchmarking data. The GC eQUIPS Program has a robust database of U.S. hospitals, which helped us define our ultimate goal – to be in the upper quartile of all measures. And we did it! Because of the amazing teamwork and leadership support, we were able to achieve national distinction from SHM as a “Top Performer” hospital for glycemic care.
 

How did the program help you and the team design your initiatives?

Data are powerful and convincing. We post and report our eQUIPS Glucometrics to our clinical staff monthly by unit, and through this process, we obtain the necessary “buy-ins” as well as participation to design clinical protocols and order sets. For example, we noted that many patients would be placed on “sliding scale”/coverage insulin alone at the time of hospital admission. This often would not be adjusted during the hospital stay. Our data showed that this practice was associated with more glucose fluctuations and hypoglycemia. When we reviewed this with our hospitalists, we achieved consensus and developed basal/bolus correction insulin protocols, which are embedded in the admission care sets. Following use of these order sets, we noted less hypoglycemia (decreased from 5.9% and remains less than 3.6%) and lower glucose variability. With the help of the eQUIPS metrics and benchmarking, we now have more than 20 protocols and safety rules built into our EHR system.

What were the key benefits that the GC eQUIPS Program provided that you were unable to find elsewhere?

The unique features we found most useful are the national benchmarking and “real-world” data presentation. National benchmarking allows us to compare ourselves with other hospitals (we can sort for like hospitals or all hospitals) and to periodically evaluate our processes and reexamine our goals. As part of this program, we can communicate with leaders of other high-performing hospitals and share strategies and challenges as well as discuss successes and failures. The quarterly benchmark webinar is another opportunity to be part of this professional community and we often pick up helpful information.

We particularly like the hyperglycemia/hypoglycemia scatter plots, which demonstrate the practical and important impact of glycemic control. Often there is a see-saw effect in which, if one parameter goes up, the other goes down; finding the sweet spot between hyperglycemia and hypoglycemia is key and clinically important.
 

Do you have any other comments to share related to your institution’s participation in the program?

We are fortunate to have many successes driven by our participation with the GC eQUIPS Program:

• Coordination of capillary blood glucose (CBG) testing, insulin administration and meal delivery: Use of rapid-acting insulin premeal is standard of care and requires that CBG testing, insulin, and meal delivery be precisely coordinated for optimal insulin action. We developed a process in which the catering associate calls the nurse using a voice-activated pager when the meal tray leaves the kitchen. Then, the nurse checks the CBG and gives insulin when the tray arrives. The tray contains a card to empower the patient to wait for the nurse to administer insulin prior to eating. This also provides an opportunity for nutritional education and carbohydrate awareness. Implementation of this process increased the percentage of patients who had a CBG and insulin administration within 15 minutes before a meal from less than 10% to more than 60%.
• Patient education regarding insulin use: In many cases, hospital patients may be started on insulin and their oral agents may be discontinued. This can be confusing and frightening to patients who often do not know if they will need to be on insulin long term. Our GCT created a script for the staff nurse to inform and reassure patients that this is standard practice and does not mean that they will need to remain on insulin after hospital discharge. The clinical team will communicate with the patient and together they will review treatment options. We have received many positive reviews from patients and staff for improving communication around this aspect of insulin therapy.
• Clinician and leader education: When our data revealed an uptick in hypoglycemia in our critical care units, we engaged the physicians, nurses, and staff and reviewed patient charts to identify potential process changes. To keep hypoglycemia in the spotlight, our director of critical care added hypoglycemia to the ICU checklist, which is discussed on all team clinical rounds. We are also developing an electronic metric (24-hour glucose maximum and minimum values) that can be quickly reviewed by the clinical team daily.
• Hypoglycemia and hyperkalemia: Analysis of our hypoglycemia data revealed a higher-than-expected rate in the ED in patients who did not have a diabetes diagnosis. Further review showed that this was associated with insulin treatment of hyperkalemia. Subsequently, we engaged our resident trainees and other team members in a study to characterize this hypoglycemia-hyperkalemia, and we have recently submitted a manuscript for publication detailing our findings and recommendations for glucose monitoring in these patients.
• Guideline for medical consultation on nonmedical services: Based on review of glucometrics on the nonmedical units and discussions with our hospitalist teams, we designed a guideline that includes recommendations for Medical Consultation in Nonmedical Admissions. Comanagement by a medical consultant will be requested earlier, and we will monitor if this influences glucometrics, patient and hospitalist satisfaction, etc.
• Medical student and house staff education: Two of our GCT hospitalists organize a monthly patient safety conference. After the students and trainees are asked to propose actionable solutions, the hospitalists discuss proposals generated at our GCT meetings. The students and trainees have the opportunity to participate in quality improvement, and we get great ideas from them as well.

Perhaps our biggest success is our Glycemic Care Team itself. We now receive questions and items to review from all departments and are seen as the hospital’s expert team on diabetes and hyperglycemia. It is truly a pleasure to lead this group of extremely high functioning and dedicated professionals. It is said that “team work makes the dream work.” Moving forward, I hope to expand our Glycemic Care Team to all the hospitals in our network.

As an adolescent, says James R. Doty, MD, he was heading down a road toward delinquency. He says his family was poor, and he was often hungry.

copyright/Jupiterimages

His father was an alcoholic, his mother had debilitating depression, and he was so reflexive that, after a nun at his Roman Catholic school slapped him, he slapped her back. But a random decision to browse a magic shop changed the way Dr. Doty was able to imagine his life.

The magic shop owner’s mother, Ruth, taught him about focusing on the present moment – rather than dwelling on past traumas. “What she taught me truly rewired my brain,” he says in an interview with Krista Tippett. “When I met her, I had little to no possibilities. Yet, my own personal circumstances did not change at all.”

“There was a study that was done that showed that the average person, almost 80% of the time, they’re not focused on the present, they’re focused on exactly that: regret about the past or anxiety about the future. When your attention is in those places, you can’t give your full attention to even what’s happening to you at that moment,” Dr. Doty says in the interview with Ms. Tippett for “On Being,” a radio conversation and podcast available online and in some NPR markets. [Distracted attention] “limits what you can accomplish in that moment. Unfortunately, it’s a horrible distraction, and it, again, limits us to the connections we are able to make and actually even who we are.”

Dr. Doty’s life so far has taught him that pain can be harnessed to enrich life.

“Most of us have a tendency to desire pleasure rather than pain. ... I think anyone who has lived a life, which means you have had pain and suffering – is that you realize that there is a gift in the pain and suffering because what it allows you to do is to see the reality that this is part of life. And it’s part of a meaningful life. When you’re able to take that pain and suffering and use it to not hide from the world, to use it not to be afraid of every interaction, but to use it to say, yes, it is hard sometimes, but I have learned so many lessons and have become more appreciative and have more gratitude and see in so many examples how in the face of the greatest adversity, people have shown their greatest humanity,” he says.

An important part of his journey of discovery has been the beneficial role that meditation can have on the body.

“In fact, even after brief periods of meditation, we actually can study the epigenetic effect of how our genes are changing their expression, even with brief periods of meditation, in the context of inflammation markers,” says Dr. Doty, a clinical professor of neurosurgery at Stanford (Calif.) University, and the founder and director of the Center for Compassion and Altruism Research and Education. “It’s extraordinary, because even with people who have meditated in this manner for as little as 2 weeks, you can see effects in regard to their blood pressure, in regard to the release of stress hormones and effects on the immune system.”

Dr. Doty is author of “Into the Magic Shop: A Neurosurgeon’s Quest to Discover the Mysteries of the Brain and the Secrets of the Heart,” (New York: Penguin, 2016), and senior editor of the Oxford Handbook of Compassion Science.

Rx: Go visit an art exhibit

An innovative medical initiative has some Montreal physicians writing prescriptions for patients that, instead of leading them to the pharmacy, takes them to a local art museum.

Médecins francophones du Canada, a doctors’ organization based mainly in the province of Quebec, has partnered with the Montreal Museum of Fine Arts (MMFA) in providing free museum passes to patients.

Physician members of Médecins francophones du Canada can be approved to issue up to 50 prescriptions for a visit to MMFA collections and exhibitions. This is meant to complement existing and more traditional treatment.

The intent, according to the museum’s chief curator and director general, Nathalie Bondil, is to provide a “relaxing, revitalizing experience, a moment of respite” for those burdened physically or mentally by illness. “We can open new doors, not just for the patients, but also for the doctors,” she remarks in an interview with BBC News.

Patients also can avail themselves of the museum’s art therapy programs. “The neutral, beautiful, inspiring space” of museums like MMFA helps improve a patient’s mood and well-being,” Ms. Bondil says. Contemplating a painting or other artwork can, at least temporarily, take the patient to a mental space not dominated by illness-related worry, fear, anger, and sadness.

The idea of art as medicine is echoed elsewhere. A 2017 report in the United Kingdom recognized the vital contribution of the arts to health and well-being.
 

Lady Gaga describes health crisis

From a distance, the life of Lady Gaga might seem exotic and desirable. But the musician and actress recently revealed her own “mental health crisis” – and urged Hollywood to make better mental health care available to those in the entertainment business.

Her work also features multiple deadlines, and the pressure can prove overwhelming. “I began to notice that I would stare off into space and black out for seconds or minutes. I would see flashes of things I was tormented by, experiences that were filed away in my brain with ‘I’ll deal with you later’ for many years because my brain was protecting me, as science teaches us. These were also symptoms of disassociation and PTSD and I did not have a team that included mental health support,” according to an article in Variety reporting a speech by the entertainer, whose birth name is Stefani Joanne Angelina Germanotta.

The anguish she felt morphed into physical chronic pain, fibromyalgia, panic attacks, acute trauma responses, and debilitating declines in her mental health – including thoughts of suicide. One root of the trauma might have been a sexual assault that she says she experienced during childhood.

“I wish there had been a system in place to protect and guide me, a system in place to empower me to say no to things I felt I had to do, a system in place to empower me to stay away from toxic work environments or working with people who were of seriously questionable character,” she says. “There were days that I struggled or couldn’t make it to work, and I don’t want that for other artists or anyone.”
 

Fostering engagement over the phone

After retirement, some people find it difficult to get out into the community and engage with other people. But, for 94-year-old Frances Utpadel, human connection has proven to be a phone call away.

In a service that is provided by the acting industry in Hollywood, the retired film lab technician from Los Angeles has availed herself of the Daily Call Sheet program. The program, run by the Motion Picture and Television Fund and the AARP Foundation, pairs up folks like Ms. Utpadel with a fellow film industry member for phone chats several times each week.

“I was having the downtime because all my friends were moving away and dying,” Ms. Utpadel explains in an interview with People magazine. Now, she and her chat-buddy Norma talk two or three times a week. Conversations range from things going on in their daily lives to world issues.

The content of the conversations can be stimulating, as is sharing her thoughts with a kind voice. “This is something I’m very much for – don’t isolate yourself. I don’t have any friends to be texting or emailing,” she says. “I hear so many people are doing texting and email, and one of the big stores now, they won’t have any cashiers. And, I say, ‘What are they doing to the people? You’re isolating people. And the world is made of people.’”

The connection is even more important for Ms. Utpadel, who for decades, has taken care of her son, Terry – who suffered debilitating injuries in a car crash. She is the sole caregiver for Terry, who is aged 75 years.

Ms. Utpadel is adamant about the value of human interaction in a digital world in which life can be lived in isolation. “I’m used to the generation where you took pictures and had them developed. You don’t have those now. Everybody’s got them on their cell phone. It’s just a whole different world. But, I think, in a way, my world is richer than the other one. I don’t feel deprived about it or anything. I feel I’m better off.”
 

Communication ‘central’ in palliative care

Being a palliative care surgeon means delivering really bad news. It also means helping a patients deal with the realities of impending death. In this emotionally charged atmosphere, the surgeons’ words can be comforting or devastating.

“One of my mentors once told me that words are somewhat like a palliative care physician’s scalpel,” Toronto palliative care physician Evan Schneider, MD, says in an interview with the Canadian Broadcasting Corporation.

“We’re dealing with very intense, emotionally charged conversations. I think communication is probably the most central tenet of what we do. … There’s no one-size-fits-all approach to sharing bad news,” said Dr. Schneider says. The bad news may be anticipated or can come as total blind-side to the patient. In some cases, other treatment options may be available. In other cases, palliative care is the only option.

Clarity in communication is an absolute must. That means providing the information in a form that is understandable and relevant to the patients, and not to the physician. Dr. Schneider says his approach involves “trying to use as little overly jargony or medicalized words as necessary.”

Compounding the challenge, Dr. Schneider’s patients exemplify the linguistic stew that is Toronto, where some 140 different languages are spoken. As an English speaker, Dr. Schneider relies on medical interpreters to talk with patients and for their sensitivity to cultural nuances concerning death and dying that escape him.

“Sometimes there are family members who may [want] to protect their loved one from receiving bad news about their diagnosis or prognosis,” he says. “When we bring an interpreter into those scenarios, it can be very hard for family members, because information can be shared through interpretation that were trying to shield their loved one. That’s always a risk or a possibility when we are dealing with information that has to be translated to someone else.”

As an adolescent, says James R. Doty, MD, he was heading down a road toward delinquency. He says his family was poor, and he was often hungry.

copyright/Jupiterimages

His father was an alcoholic, his mother had debilitating depression, and he was so reflexive that, after a nun at his Roman Catholic school slapped him, he slapped her back. But a random decision to browse a magic shop changed the way Dr. Doty was able to imagine his life.

The magic shop owner’s mother, Ruth, taught him about focusing on the present moment – rather than dwelling on past traumas. “What she taught me truly rewired my brain,” he says in an interview with Krista Tippett. “When I met her, I had little to no possibilities. Yet, my own personal circumstances did not change at all.”

“There was a study that was done that showed that the average person, almost 80% of the time, they’re not focused on the present, they’re focused on exactly that: regret about the past or anxiety about the future. When your attention is in those places, you can’t give your full attention to even what’s happening to you at that moment,” Dr. Doty says in the interview with Ms. Tippett for “On Being,” a radio conversation and podcast available online and in some NPR markets. [Distracted attention] “limits what you can accomplish in that moment. Unfortunately, it’s a horrible distraction, and it, again, limits us to the connections we are able to make and actually even who we are.”

Dr. Doty’s life so far has taught him that pain can be harnessed to enrich life.

“Most of us have a tendency to desire pleasure rather than pain. ... I think anyone who has lived a life, which means you have had pain and suffering – is that you realize that there is a gift in the pain and suffering because what it allows you to do is to see the reality that this is part of life. And it’s part of a meaningful life. When you’re able to take that pain and suffering and use it to not hide from the world, to use it not to be afraid of every interaction, but to use it to say, yes, it is hard sometimes, but I have learned so many lessons and have become more appreciative and have more gratitude and see in so many examples how in the face of the greatest adversity, people have shown their greatest humanity,” he says.

An important part of his journey of discovery has been the beneficial role that meditation can have on the body.

“In fact, even after brief periods of meditation, we actually can study the epigenetic effect of how our genes are changing their expression, even with brief periods of meditation, in the context of inflammation markers,” says Dr. Doty, a clinical professor of neurosurgery at Stanford (Calif.) University, and the founder and director of the Center for Compassion and Altruism Research and Education. “It’s extraordinary, because even with people who have meditated in this manner for as little as 2 weeks, you can see effects in regard to their blood pressure, in regard to the release of stress hormones and effects on the immune system.”

Dr. Doty is author of “Into the Magic Shop: A Neurosurgeon’s Quest to Discover the Mysteries of the Brain and the Secrets of the Heart,” (New York: Penguin, 2016), and senior editor of the Oxford Handbook of Compassion Science.

Rx: Go visit an art exhibit

An innovative medical initiative has some Montreal physicians writing prescriptions for patients that, instead of leading them to the pharmacy, takes them to a local art museum.

Médecins francophones du Canada, a doctors’ organization based mainly in the province of Quebec, has partnered with the Montreal Museum of Fine Arts (MMFA) in providing free museum passes to patients.

Physician members of Médecins francophones du Canada can be approved to issue up to 50 prescriptions for a visit to MMFA collections and exhibitions. This is meant to complement existing and more traditional treatment.

The intent, according to the museum’s chief curator and director general, Nathalie Bondil, is to provide a “relaxing, revitalizing experience, a moment of respite” for those burdened physically or mentally by illness. “We can open new doors, not just for the patients, but also for the doctors,” she remarks in an interview with BBC News.

Patients also can avail themselves of the museum’s art therapy programs. “The neutral, beautiful, inspiring space” of museums like MMFA helps improve a patient’s mood and well-being,” Ms. Bondil says. Contemplating a painting or other artwork can, at least temporarily, take the patient to a mental space not dominated by illness-related worry, fear, anger, and sadness.

The idea of art as medicine is echoed elsewhere. A 2017 report in the United Kingdom recognized the vital contribution of the arts to health and well-being.
 

Lady Gaga describes health crisis

From a distance, the life of Lady Gaga might seem exotic and desirable. But the musician and actress recently revealed her own “mental health crisis” – and urged Hollywood to make better mental health care available to those in the entertainment business.

Her work also features multiple deadlines, and the pressure can prove overwhelming. “I began to notice that I would stare off into space and black out for seconds or minutes. I would see flashes of things I was tormented by, experiences that were filed away in my brain with ‘I’ll deal with you later’ for many years because my brain was protecting me, as science teaches us. These were also symptoms of disassociation and PTSD and I did not have a team that included mental health support,” according to an article in Variety reporting a speech by the entertainer, whose birth name is Stefani Joanne Angelina Germanotta.

The anguish she felt morphed into physical chronic pain, fibromyalgia, panic attacks, acute trauma responses, and debilitating declines in her mental health – including thoughts of suicide. One root of the trauma might have been a sexual assault that she says she experienced during childhood.

“I wish there had been a system in place to protect and guide me, a system in place to empower me to say no to things I felt I had to do, a system in place to empower me to stay away from toxic work environments or working with people who were of seriously questionable character,” she says. “There were days that I struggled or couldn’t make it to work, and I don’t want that for other artists or anyone.”
 

Fostering engagement over the phone

After retirement, some people find it difficult to get out into the community and engage with other people. But, for 94-year-old Frances Utpadel, human connection has proven to be a phone call away.

In a service that is provided by the acting industry in Hollywood, the retired film lab technician from Los Angeles has availed herself of the Daily Call Sheet program. The program, run by the Motion Picture and Television Fund and the AARP Foundation, pairs up folks like Ms. Utpadel with a fellow film industry member for phone chats several times each week.

“I was having the downtime because all my friends were moving away and dying,” Ms. Utpadel explains in an interview with People magazine. Now, she and her chat-buddy Norma talk two or three times a week. Conversations range from things going on in their daily lives to world issues.

The content of the conversations can be stimulating, as is sharing her thoughts with a kind voice. “This is something I’m very much for – don’t isolate yourself. I don’t have any friends to be texting or emailing,” she says. “I hear so many people are doing texting and email, and one of the big stores now, they won’t have any cashiers. And, I say, ‘What are they doing to the people? You’re isolating people. And the world is made of people.’”

The connection is even more important for Ms. Utpadel, who for decades, has taken care of her son, Terry – who suffered debilitating injuries in a car crash. She is the sole caregiver for Terry, who is aged 75 years.

Ms. Utpadel is adamant about the value of human interaction in a digital world in which life can be lived in isolation. “I’m used to the generation where you took pictures and had them developed. You don’t have those now. Everybody’s got them on their cell phone. It’s just a whole different world. But, I think, in a way, my world is richer than the other one. I don’t feel deprived about it or anything. I feel I’m better off.”
 

Communication ‘central’ in palliative care

Being a palliative care surgeon means delivering really bad news. It also means helping a patients deal with the realities of impending death. In this emotionally charged atmosphere, the surgeons’ words can be comforting or devastating.

“One of my mentors once told me that words are somewhat like a palliative care physician’s scalpel,” Toronto palliative care physician Evan Schneider, MD, says in an interview with the Canadian Broadcasting Corporation.

“We’re dealing with very intense, emotionally charged conversations. I think communication is probably the most central tenet of what we do. … There’s no one-size-fits-all approach to sharing bad news,” said Dr. Schneider says. The bad news may be anticipated or can come as total blind-side to the patient. In some cases, other treatment options may be available. In other cases, palliative care is the only option.

Clarity in communication is an absolute must. That means providing the information in a form that is understandable and relevant to the patients, and not to the physician. Dr. Schneider says his approach involves “trying to use as little overly jargony or medicalized words as necessary.”

Compounding the challenge, Dr. Schneider’s patients exemplify the linguistic stew that is Toronto, where some 140 different languages are spoken. As an English speaker, Dr. Schneider relies on medical interpreters to talk with patients and for their sensitivity to cultural nuances concerning death and dying that escape him.

“Sometimes there are family members who may [want] to protect their loved one from receiving bad news about their diagnosis or prognosis,” he says. “When we bring an interpreter into those scenarios, it can be very hard for family members, because information can be shared through interpretation that were trying to shield their loved one. That’s always a risk or a possibility when we are dealing with information that has to be translated to someone else.”

As an adolescent, says James R. Doty, MD, he was heading down a road toward delinquency. He says his family was poor, and he was often hungry.

copyright/Jupiterimages

His father was an alcoholic, his mother had debilitating depression, and he was so reflexive that, after a nun at his Roman Catholic school slapped him, he slapped her back. But a random decision to browse a magic shop changed the way Dr. Doty was able to imagine his life.

The magic shop owner’s mother, Ruth, taught him about focusing on the present moment – rather than dwelling on past traumas. “What she taught me truly rewired my brain,” he says in an interview with Krista Tippett. “When I met her, I had little to no possibilities. Yet, my own personal circumstances did not change at all.”

“There was a study that was done that showed that the average person, almost 80% of the time, they’re not focused on the present, they’re focused on exactly that: regret about the past or anxiety about the future. When your attention is in those places, you can’t give your full attention to even what’s happening to you at that moment,” Dr. Doty says in the interview with Ms. Tippett for “On Being,” a radio conversation and podcast available online and in some NPR markets. [Distracted attention] “limits what you can accomplish in that moment. Unfortunately, it’s a horrible distraction, and it, again, limits us to the connections we are able to make and actually even who we are.”

Dr. Doty’s life so far has taught him that pain can be harnessed to enrich life.

“Most of us have a tendency to desire pleasure rather than pain. ... I think anyone who has lived a life, which means you have had pain and suffering – is that you realize that there is a gift in the pain and suffering because what it allows you to do is to see the reality that this is part of life. And it’s part of a meaningful life. When you’re able to take that pain and suffering and use it to not hide from the world, to use it not to be afraid of every interaction, but to use it to say, yes, it is hard sometimes, but I have learned so many lessons and have become more appreciative and have more gratitude and see in so many examples how in the face of the greatest adversity, people have shown their greatest humanity,” he says.

An important part of his journey of discovery has been the beneficial role that meditation can have on the body.

“In fact, even after brief periods of meditation, we actually can study the epigenetic effect of how our genes are changing their expression, even with brief periods of meditation, in the context of inflammation markers,” says Dr. Doty, a clinical professor of neurosurgery at Stanford (Calif.) University, and the founder and director of the Center for Compassion and Altruism Research and Education. “It’s extraordinary, because even with people who have meditated in this manner for as little as 2 weeks, you can see effects in regard to their blood pressure, in regard to the release of stress hormones and effects on the immune system.”

Dr. Doty is author of “Into the Magic Shop: A Neurosurgeon’s Quest to Discover the Mysteries of the Brain and the Secrets of the Heart,” (New York: Penguin, 2016), and senior editor of the Oxford Handbook of Compassion Science.

Rx: Go visit an art exhibit

An innovative medical initiative has some Montreal physicians writing prescriptions for patients that, instead of leading them to the pharmacy, takes them to a local art museum.

Médecins francophones du Canada, a doctors’ organization based mainly in the province of Quebec, has partnered with the Montreal Museum of Fine Arts (MMFA) in providing free museum passes to patients.

Physician members of Médecins francophones du Canada can be approved to issue up to 50 prescriptions for a visit to MMFA collections and exhibitions. This is meant to complement existing and more traditional treatment.

The intent, according to the museum’s chief curator and director general, Nathalie Bondil, is to provide a “relaxing, revitalizing experience, a moment of respite” for those burdened physically or mentally by illness. “We can open new doors, not just for the patients, but also for the doctors,” she remarks in an interview with BBC News.

Patients also can avail themselves of the museum’s art therapy programs. “The neutral, beautiful, inspiring space” of museums like MMFA helps improve a patient’s mood and well-being,” Ms. Bondil says. Contemplating a painting or other artwork can, at least temporarily, take the patient to a mental space not dominated by illness-related worry, fear, anger, and sadness.

The idea of art as medicine is echoed elsewhere. A 2017 report in the United Kingdom recognized the vital contribution of the arts to health and well-being.
 

Lady Gaga describes health crisis

From a distance, the life of Lady Gaga might seem exotic and desirable. But the musician and actress recently revealed her own “mental health crisis” – and urged Hollywood to make better mental health care available to those in the entertainment business.

Her work also features multiple deadlines, and the pressure can prove overwhelming. “I began to notice that I would stare off into space and black out for seconds or minutes. I would see flashes of things I was tormented by, experiences that were filed away in my brain with ‘I’ll deal with you later’ for many years because my brain was protecting me, as science teaches us. These were also symptoms of disassociation and PTSD and I did not have a team that included mental health support,” according to an article in Variety reporting a speech by the entertainer, whose birth name is Stefani Joanne Angelina Germanotta.

The anguish she felt morphed into physical chronic pain, fibromyalgia, panic attacks, acute trauma responses, and debilitating declines in her mental health – including thoughts of suicide. One root of the trauma might have been a sexual assault that she says she experienced during childhood.

“I wish there had been a system in place to protect and guide me, a system in place to empower me to say no to things I felt I had to do, a system in place to empower me to stay away from toxic work environments or working with people who were of seriously questionable character,” she says. “There were days that I struggled or couldn’t make it to work, and I don’t want that for other artists or anyone.”
 

Fostering engagement over the phone

After retirement, some people find it difficult to get out into the community and engage with other people. But, for 94-year-old Frances Utpadel, human connection has proven to be a phone call away.

In a service that is provided by the acting industry in Hollywood, the retired film lab technician from Los Angeles has availed herself of the Daily Call Sheet program. The program, run by the Motion Picture and Television Fund and the AARP Foundation, pairs up folks like Ms. Utpadel with a fellow film industry member for phone chats several times each week.

“I was having the downtime because all my friends were moving away and dying,” Ms. Utpadel explains in an interview with People magazine. Now, she and her chat-buddy Norma talk two or three times a week. Conversations range from things going on in their daily lives to world issues.

The content of the conversations can be stimulating, as is sharing her thoughts with a kind voice. “This is something I’m very much for – don’t isolate yourself. I don’t have any friends to be texting or emailing,” she says. “I hear so many people are doing texting and email, and one of the big stores now, they won’t have any cashiers. And, I say, ‘What are they doing to the people? You’re isolating people. And the world is made of people.’”

The connection is even more important for Ms. Utpadel, who for decades, has taken care of her son, Terry – who suffered debilitating injuries in a car crash. She is the sole caregiver for Terry, who is aged 75 years.

Ms. Utpadel is adamant about the value of human interaction in a digital world in which life can be lived in isolation. “I’m used to the generation where you took pictures and had them developed. You don’t have those now. Everybody’s got them on their cell phone. It’s just a whole different world. But, I think, in a way, my world is richer than the other one. I don’t feel deprived about it or anything. I feel I’m better off.”
 

Communication ‘central’ in palliative care

Being a palliative care surgeon means delivering really bad news. It also means helping a patients deal with the realities of impending death. In this emotionally charged atmosphere, the surgeons’ words can be comforting or devastating.

“One of my mentors once told me that words are somewhat like a palliative care physician’s scalpel,” Toronto palliative care physician Evan Schneider, MD, says in an interview with the Canadian Broadcasting Corporation.

“We’re dealing with very intense, emotionally charged conversations. I think communication is probably the most central tenet of what we do. … There’s no one-size-fits-all approach to sharing bad news,” said Dr. Schneider says. The bad news may be anticipated or can come as total blind-side to the patient. In some cases, other treatment options may be available. In other cases, palliative care is the only option.

Clarity in communication is an absolute must. That means providing the information in a form that is understandable and relevant to the patients, and not to the physician. Dr. Schneider says his approach involves “trying to use as little overly jargony or medicalized words as necessary.”

Compounding the challenge, Dr. Schneider’s patients exemplify the linguistic stew that is Toronto, where some 140 different languages are spoken. As an English speaker, Dr. Schneider relies on medical interpreters to talk with patients and for their sensitivity to cultural nuances concerning death and dying that escape him.

“Sometimes there are family members who may [want] to protect their loved one from receiving bad news about their diagnosis or prognosis,” he says. “When we bring an interpreter into those scenarios, it can be very hard for family members, because information can be shared through interpretation that were trying to shield their loved one. That’s always a risk or a possibility when we are dealing with information that has to be translated to someone else.”

Medicare just released its 2019 physician fee schedule, which is called the “final rule.” Of course, there is a new final rule every year, so it really isn’t very final. I know this is confusing to many of you, I was dazed for several days by this year’s proposed final rule.

Each year, the Centers for Medicare & Medicaid Services receives input from innumerable sources and formulates its payment for physicians. These responses are often in response to requests by CMS itself, which wants to make sure reimbursements are accurate. Generally, input comes from the American Medical Association’s RVS Update Committee (RUC), which values new and existing CPT codes, as well as Congress, the Health & Human Services Office of Inspector General, lobbyists, specialty society organizations, public advocacy groups, and anyone who can wrangle an appointment at or write a letter to CMS headquarters in Baltimore. This conflicted brew is hashed over, and published in late July as a proposed rule. Public comments are then solicited (all letters and emails are considered, dermatologists sent 1,500 responses to this one!) and a final rule is published in the fall. I have constructed a flowchart of this process.

This year’s proposed rule was particularly disturbing because of major changes in reimbursement proposed by CMS. As you may recall, officials proposed to collapse all the evaluation and management (E/M) codes into two levels and pay bonuses to certain specialists (but not dermatologists). This might have been agreeable, except Medicare reimbursements are a zero-sum game. If someone is paid more, someone else will be paid less. Of course, you could always let the increase come out of the general pool, but that would decrease the conversion factor, and some health care professionals (usually primary care) might not see an overall increase. So, the proposed rule was going to “pay” for this increase by way of eliminating the 25 modifier, the CPT modifier that allows you to be paid for the evaluation and management (E/M) service on the same day as a procedure. This has been averted, at least for two years.

The final rule also makes a real effort to eliminate some meaningless documentation. Effective Jan. 1, 2019, for established patients, practitioners can focus their notes on patient changes. With new and established patients, they need not personally reenter the chief complaint and history already recorded by staff or the patient, other than simply indicate that they reviewed and verified the information in the medical record. In addition, teaching physicians do not have to duplicate notations by residents. CMS also included practice expense for additional skin biopsies.

CMS is also going to pay for services using communication technology. These include:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012). This is provided by a physician or other qualified health care professional who can report E/M services for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. It is important to note that CMS is allowing for this code to include audio-only, real-time telephone interactions, in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010). This is remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment). The code can be reported effective Jan. 1, 2019, for established patients only.

You can use G2012 to decide if an office visit is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow health care professionals to be paid separately for reviewing patient-transmitted photo or video information whether or not a visit is needed. The encounter must be synchronous (real-time), two-way audio interactions enhanced with video or other kinds of data transmission.

It appears that these would only be practical for established patients, and don’t forget, your Internet and text responses to patients’ messages are not secure, unless they are on a secure portal, although their messages to you are HIPAA compliant. However, the telephone, some Internet portals, and your electronic medical record portals are secure. It is intriguing to me that I might get paid for all those bad pictures patients send me, at least if it is not in a global period.

It also appears that Rural Health Clinics and Federally Qualified Health Centers will be able to bill for new and established patient visits via communication technology.

This is all great news to physicians. Kudos to dermatologists Jack Resneck Jr., MD, American Medical Association trustee; and George Hruza, MD, the American Academy of Dermatology president-elect; and Sabra Sullivan, MD, PhD, chair of the AAD’s Council on Government Affairs and Health Policy Government, who organized this lemonade-making effort. And once again, the AAD’s Washington office has shown its great value. This also aptly demonstrates why you write letters to CMS.

In 2021, levels 2-4 will be collapsed into one code (levels 5 will remain, but remember, very few dermatologists use level 5) and you will have to document only at level 2 code levels. Special add-on codes will be added for exceptionally difficult cases for primary care and all specialist physicians, including dermatology. What is not clear is how this new reimbursement schemata will be funded. CMS is still suspicious that there is overlapping work when procedures are performed on the same day as an E/M (evaluation and management code). We may end up fighting this battle all over again.

Currently CMS is conducting a survey, sent to 1,500 dermatologists, on follow-up visits. CMS has stated that they will evaluate the public comments received and consider whether to propose action at a future date. CMS plans to send a letter describing the requirements, once again, to health care professionals in nine affected states, who are required to report the global period encounter. If you are one of these practitioners, please do fill this out and contact Faith McNicholas at AAD ([email protected]) if you have questions. The decision to eliminate global periods (disastrous) will be based on this survey.

This is why you need to stay engaged, write letters, join the AMA, donate to SkinPAC, and attend the legislative fly in, the AAD’s legislative conference held every year in Washington. We are a small specialty. If we do not speak up and stay engaged, we will become the lemons for the next pitcher of lemonade.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

Medicare just released its 2019 physician fee schedule, which is called the “final rule.” Of course, there is a new final rule every year, so it really isn’t very final. I know this is confusing to many of you, I was dazed for several days by this year’s proposed final rule.

Each year, the Centers for Medicare & Medicaid Services receives input from innumerable sources and formulates its payment for physicians. These responses are often in response to requests by CMS itself, which wants to make sure reimbursements are accurate. Generally, input comes from the American Medical Association’s RVS Update Committee (RUC), which values new and existing CPT codes, as well as Congress, the Health & Human Services Office of Inspector General, lobbyists, specialty society organizations, public advocacy groups, and anyone who can wrangle an appointment at or write a letter to CMS headquarters in Baltimore. This conflicted brew is hashed over, and published in late July as a proposed rule. Public comments are then solicited (all letters and emails are considered, dermatologists sent 1,500 responses to this one!) and a final rule is published in the fall. I have constructed a flowchart of this process.

This year’s proposed rule was particularly disturbing because of major changes in reimbursement proposed by CMS. As you may recall, officials proposed to collapse all the evaluation and management (E/M) codes into two levels and pay bonuses to certain specialists (but not dermatologists). This might have been agreeable, except Medicare reimbursements are a zero-sum game. If someone is paid more, someone else will be paid less. Of course, you could always let the increase come out of the general pool, but that would decrease the conversion factor, and some health care professionals (usually primary care) might not see an overall increase. So, the proposed rule was going to “pay” for this increase by way of eliminating the 25 modifier, the CPT modifier that allows you to be paid for the evaluation and management (E/M) service on the same day as a procedure. This has been averted, at least for two years.

The final rule also makes a real effort to eliminate some meaningless documentation. Effective Jan. 1, 2019, for established patients, practitioners can focus their notes on patient changes. With new and established patients, they need not personally reenter the chief complaint and history already recorded by staff or the patient, other than simply indicate that they reviewed and verified the information in the medical record. In addition, teaching physicians do not have to duplicate notations by residents. CMS also included practice expense for additional skin biopsies.

CMS is also going to pay for services using communication technology. These include:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012). This is provided by a physician or other qualified health care professional who can report E/M services for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. It is important to note that CMS is allowing for this code to include audio-only, real-time telephone interactions, in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010). This is remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment). The code can be reported effective Jan. 1, 2019, for established patients only.

You can use G2012 to decide if an office visit is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow health care professionals to be paid separately for reviewing patient-transmitted photo or video information whether or not a visit is needed. The encounter must be synchronous (real-time), two-way audio interactions enhanced with video or other kinds of data transmission.

It appears that these would only be practical for established patients, and don’t forget, your Internet and text responses to patients’ messages are not secure, unless they are on a secure portal, although their messages to you are HIPAA compliant. However, the telephone, some Internet portals, and your electronic medical record portals are secure. It is intriguing to me that I might get paid for all those bad pictures patients send me, at least if it is not in a global period.

It also appears that Rural Health Clinics and Federally Qualified Health Centers will be able to bill for new and established patient visits via communication technology.

This is all great news to physicians. Kudos to dermatologists Jack Resneck Jr., MD, American Medical Association trustee; and George Hruza, MD, the American Academy of Dermatology president-elect; and Sabra Sullivan, MD, PhD, chair of the AAD’s Council on Government Affairs and Health Policy Government, who organized this lemonade-making effort. And once again, the AAD’s Washington office has shown its great value. This also aptly demonstrates why you write letters to CMS.

In 2021, levels 2-4 will be collapsed into one code (levels 5 will remain, but remember, very few dermatologists use level 5) and you will have to document only at level 2 code levels. Special add-on codes will be added for exceptionally difficult cases for primary care and all specialist physicians, including dermatology. What is not clear is how this new reimbursement schemata will be funded. CMS is still suspicious that there is overlapping work when procedures are performed on the same day as an E/M (evaluation and management code). We may end up fighting this battle all over again.

Currently CMS is conducting a survey, sent to 1,500 dermatologists, on follow-up visits. CMS has stated that they will evaluate the public comments received and consider whether to propose action at a future date. CMS plans to send a letter describing the requirements, once again, to health care professionals in nine affected states, who are required to report the global period encounter. If you are one of these practitioners, please do fill this out and contact Faith McNicholas at AAD ([email protected]) if you have questions. The decision to eliminate global periods (disastrous) will be based on this survey.

This is why you need to stay engaged, write letters, join the AMA, donate to SkinPAC, and attend the legislative fly in, the AAD’s legislative conference held every year in Washington. We are a small specialty. If we do not speak up and stay engaged, we will become the lemons for the next pitcher of lemonade.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

Medicare just released its 2019 physician fee schedule, which is called the “final rule.” Of course, there is a new final rule every year, so it really isn’t very final. I know this is confusing to many of you, I was dazed for several days by this year’s proposed final rule.

Each year, the Centers for Medicare & Medicaid Services receives input from innumerable sources and formulates its payment for physicians. These responses are often in response to requests by CMS itself, which wants to make sure reimbursements are accurate. Generally, input comes from the American Medical Association’s RVS Update Committee (RUC), which values new and existing CPT codes, as well as Congress, the Health & Human Services Office of Inspector General, lobbyists, specialty society organizations, public advocacy groups, and anyone who can wrangle an appointment at or write a letter to CMS headquarters in Baltimore. This conflicted brew is hashed over, and published in late July as a proposed rule. Public comments are then solicited (all letters and emails are considered, dermatologists sent 1,500 responses to this one!) and a final rule is published in the fall. I have constructed a flowchart of this process.

This year’s proposed rule was particularly disturbing because of major changes in reimbursement proposed by CMS. As you may recall, officials proposed to collapse all the evaluation and management (E/M) codes into two levels and pay bonuses to certain specialists (but not dermatologists). This might have been agreeable, except Medicare reimbursements are a zero-sum game. If someone is paid more, someone else will be paid less. Of course, you could always let the increase come out of the general pool, but that would decrease the conversion factor, and some health care professionals (usually primary care) might not see an overall increase. So, the proposed rule was going to “pay” for this increase by way of eliminating the 25 modifier, the CPT modifier that allows you to be paid for the evaluation and management (E/M) service on the same day as a procedure. This has been averted, at least for two years.

The final rule also makes a real effort to eliminate some meaningless documentation. Effective Jan. 1, 2019, for established patients, practitioners can focus their notes on patient changes. With new and established patients, they need not personally reenter the chief complaint and history already recorded by staff or the patient, other than simply indicate that they reviewed and verified the information in the medical record. In addition, teaching physicians do not have to duplicate notations by residents. CMS also included practice expense for additional skin biopsies.

CMS is also going to pay for services using communication technology. These include:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012). This is provided by a physician or other qualified health care professional who can report E/M services for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. It is important to note that CMS is allowing for this code to include audio-only, real-time telephone interactions, in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010). This is remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment). The code can be reported effective Jan. 1, 2019, for established patients only.

You can use G2012 to decide if an office visit is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow health care professionals to be paid separately for reviewing patient-transmitted photo or video information whether or not a visit is needed. The encounter must be synchronous (real-time), two-way audio interactions enhanced with video or other kinds of data transmission.

It appears that these would only be practical for established patients, and don’t forget, your Internet and text responses to patients’ messages are not secure, unless they are on a secure portal, although their messages to you are HIPAA compliant. However, the telephone, some Internet portals, and your electronic medical record portals are secure. It is intriguing to me that I might get paid for all those bad pictures patients send me, at least if it is not in a global period.

It also appears that Rural Health Clinics and Federally Qualified Health Centers will be able to bill for new and established patient visits via communication technology.

This is all great news to physicians. Kudos to dermatologists Jack Resneck Jr., MD, American Medical Association trustee; and George Hruza, MD, the American Academy of Dermatology president-elect; and Sabra Sullivan, MD, PhD, chair of the AAD’s Council on Government Affairs and Health Policy Government, who organized this lemonade-making effort. And once again, the AAD’s Washington office has shown its great value. This also aptly demonstrates why you write letters to CMS.

In 2021, levels 2-4 will be collapsed into one code (levels 5 will remain, but remember, very few dermatologists use level 5) and you will have to document only at level 2 code levels. Special add-on codes will be added for exceptionally difficult cases for primary care and all specialist physicians, including dermatology. What is not clear is how this new reimbursement schemata will be funded. CMS is still suspicious that there is overlapping work when procedures are performed on the same day as an E/M (evaluation and management code). We may end up fighting this battle all over again.

Currently CMS is conducting a survey, sent to 1,500 dermatologists, on follow-up visits. CMS has stated that they will evaluate the public comments received and consider whether to propose action at a future date. CMS plans to send a letter describing the requirements, once again, to health care professionals in nine affected states, who are required to report the global period encounter. If you are one of these practitioners, please do fill this out and contact Faith McNicholas at AAD ([email protected]) if you have questions. The decision to eliminate global periods (disastrous) will be based on this survey.

This is why you need to stay engaged, write letters, join the AMA, donate to SkinPAC, and attend the legislative fly in, the AAD’s legislative conference held every year in Washington. We are a small specialty. If we do not speak up and stay engaged, we will become the lemons for the next pitcher of lemonade.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

When the Centers for Medicare & Medicaid Services make a significant change to the inpatient hospital rules, hospitalists are among the first to feel the effects.

You probably remember that, starting in October 2013, when a resident, nurse practitioner (NP), or physician assistant (PA) entered an inpatient admission order on your behalf, you were told to cosign that order before discharge or the hospital would forfeit payment for the entire stay. This policy was put in place by an annual piece of governmental policy known as the Inpatient Prospective Payment System (IPPS) Final Rule – the same one, in fact, that established the Two Midnight Rule.

The CMS felt that the decision to admit a Medicare beneficiary to inpatient care is such a significant event that it was appropriate to require the attending physician to complete a series of certification requirements to justify every inpatient stay. If not completed and finalized prior to discharge, the CMS would not pay for the stay. After 15 months of enforcing that policy, the CMS backed off on most of the certification requirements for most stays. However, the requirement for an authenticated inpatient order prior to discharge was kept in place for all stays. (“Authenticated” is CMS-speak for signed, or, in the case of inpatient orders initially placed by a resident/NP/PA without admitting privileges, cosigned, by a practitioner with admitting privileges.)

In the spring of 2018, the CMS proposed a change to “revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A [inpatient hospital] payment.” The CMS also stated that it did not intend for Medicare auditors to deny hospital inpatient claims based solely on a deficiency in the inpatient order, such as a missing order or one signed after discharge, which the CMS found out was happening.

The description sounded great. In comments to the CMS, many providers assumed that they, too, would be provided similar discretion if they discovered the order defect. Are inpatient orders now optional? What rate of inpatient order technical deficiencies is acceptable to still submit inpatient claims for payment? Can 2-day observation stays where medical necessity for hospital care was present, but no inpatient order given, be billed as an inpatient now?

But these providers had not read the fine print. Consider that the annual IPPS Final Rule has a length of about 2,000 pages. Of those, only about 30 pages represent changes to a group of policies known as the Code of Federal Regulations (CFR). The CFR carries the weight of law (as long as it does not contradict law). When you appeal a Medicare denial to a judge, she will ask what portion of the CFR supports your viewpoint. The other 1,970 pages can be thought of as supporting analysis and reasoning to justify the 30 pages of changes. What changes were actually made to the CFR?

Consider the following two sentences.

• “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.”
• “This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”

These are the first two sentences of 42 CFR 412.3(a), the regulation that defines the inpatient order requirement. On Oct. 1, 2018, the second sentence was removed, but the first sentence still remains. That’s the only change for this section. Does removal of the second sentence absolve providers of the requirement to document inpatient admission orders? Does it absolve providers of the requirement to cosign a resident’s admission order prior to discharge? The Medicare Benefit Policy Manual (MBPM) Chapter 1, Section 10(B) still reads “if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.”

Understanding what changed and what did not change in the CFR is key to understanding why, in this year’s IPPS Final Rule, the CMS repeatedly responded to providers that an inpatient order is still a requirement for a Part A stay and that none of the MBPM guidance regarding the inpatient order, such as the excerpt above, is changing.

At this point, we can only be reasonably certain that if a claim a hospital submits for Part A payment happens to get audited and found to have only one deficiency which is related to the inpatient order, per this guidance it probably won’t get denied. That is very different from saying the attending physician no longer has to provide a signed (or cosigned) inpatient admission order prior to discharge, or at all.

Providers actually did ask the CMS if a hospital could still submit a claim the hospital knows has a missing or incomplete inpatient admission order at the time of discharge. The CMS responded that Medicare contractors have the discretion in extremely rare circumstances to approve cases where an order to admit may be missing or defective, and yet the intent, decision, and recommendation of the ordering practitioner to admit as inpatient can be clearly derived from the medical record. However, note that the discretion belongs to the Medicare contractor, not the provider.

The American College of Physician Advisors (ACPA) asked the CMS the following question about the inpatient order policy change during the 2019 IPPS Final Rule Open Door Forum held on Sept. 11, 2018: “Can providers thus submit a claim, that the provider believes meets all other requirements for Part A payment, in the rare circumstance of an inpatient order deficiency, such as an inpatient order that was cosigned shortly after discharge?”

The CMS declined to answer the question on the call, asking us to submit the question to the Open Door Forum electronic mailbox. If the inpatient order was truly no longer being required for the CMS to pay for inpatient hospital stays, the answer would have been an easy “yes,” but it was not. Subsequently, the CMS responded in writing to the ACPA that “the responsibilities of providers regarding inpatient admission orders is unchanged.” In other words, Medicare auditors have been given discretion to overlook an inpatient order flaw, but providers have not.

At this time, our recommendation is to continue your processes to ensure that the inpatient admission order is completed and signed (or cosigned) prior to discharge by the attending physician for every Medicare patient. This will not only help make sure that the decision to make a hospitalized Medicare beneficiary an inpatient remains with the attending physician, but it will also reduce the risk of nonpayment.

Dr. Hu is executive director of physician advisor services of University of North Carolina Health Care System in Chapel Hill, N.C., and president of the ACPA. Dr. Locke is senior physician advisor at Johns Hopkins Hospital in Baltimore, and president-elect of the ACPA.

When the Centers for Medicare & Medicaid Services make a significant change to the inpatient hospital rules, hospitalists are among the first to feel the effects.

You probably remember that, starting in October 2013, when a resident, nurse practitioner (NP), or physician assistant (PA) entered an inpatient admission order on your behalf, you were told to cosign that order before discharge or the hospital would forfeit payment for the entire stay. This policy was put in place by an annual piece of governmental policy known as the Inpatient Prospective Payment System (IPPS) Final Rule – the same one, in fact, that established the Two Midnight Rule.

The CMS felt that the decision to admit a Medicare beneficiary to inpatient care is such a significant event that it was appropriate to require the attending physician to complete a series of certification requirements to justify every inpatient stay. If not completed and finalized prior to discharge, the CMS would not pay for the stay. After 15 months of enforcing that policy, the CMS backed off on most of the certification requirements for most stays. However, the requirement for an authenticated inpatient order prior to discharge was kept in place for all stays. (“Authenticated” is CMS-speak for signed, or, in the case of inpatient orders initially placed by a resident/NP/PA without admitting privileges, cosigned, by a practitioner with admitting privileges.)

In the spring of 2018, the CMS proposed a change to “revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A [inpatient hospital] payment.” The CMS also stated that it did not intend for Medicare auditors to deny hospital inpatient claims based solely on a deficiency in the inpatient order, such as a missing order or one signed after discharge, which the CMS found out was happening.

The description sounded great. In comments to the CMS, many providers assumed that they, too, would be provided similar discretion if they discovered the order defect. Are inpatient orders now optional? What rate of inpatient order technical deficiencies is acceptable to still submit inpatient claims for payment? Can 2-day observation stays where medical necessity for hospital care was present, but no inpatient order given, be billed as an inpatient now?

But these providers had not read the fine print. Consider that the annual IPPS Final Rule has a length of about 2,000 pages. Of those, only about 30 pages represent changes to a group of policies known as the Code of Federal Regulations (CFR). The CFR carries the weight of law (as long as it does not contradict law). When you appeal a Medicare denial to a judge, she will ask what portion of the CFR supports your viewpoint. The other 1,970 pages can be thought of as supporting analysis and reasoning to justify the 30 pages of changes. What changes were actually made to the CFR?

Consider the following two sentences.

• “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.”
• “This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”

These are the first two sentences of 42 CFR 412.3(a), the regulation that defines the inpatient order requirement. On Oct. 1, 2018, the second sentence was removed, but the first sentence still remains. That’s the only change for this section. Does removal of the second sentence absolve providers of the requirement to document inpatient admission orders? Does it absolve providers of the requirement to cosign a resident’s admission order prior to discharge? The Medicare Benefit Policy Manual (MBPM) Chapter 1, Section 10(B) still reads “if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.”

Understanding what changed and what did not change in the CFR is key to understanding why, in this year’s IPPS Final Rule, the CMS repeatedly responded to providers that an inpatient order is still a requirement for a Part A stay and that none of the MBPM guidance regarding the inpatient order, such as the excerpt above, is changing.

At this point, we can only be reasonably certain that if a claim a hospital submits for Part A payment happens to get audited and found to have only one deficiency which is related to the inpatient order, per this guidance it probably won’t get denied. That is very different from saying the attending physician no longer has to provide a signed (or cosigned) inpatient admission order prior to discharge, or at all.

Providers actually did ask the CMS if a hospital could still submit a claim the hospital knows has a missing or incomplete inpatient admission order at the time of discharge. The CMS responded that Medicare contractors have the discretion in extremely rare circumstances to approve cases where an order to admit may be missing or defective, and yet the intent, decision, and recommendation of the ordering practitioner to admit as inpatient can be clearly derived from the medical record. However, note that the discretion belongs to the Medicare contractor, not the provider.

The American College of Physician Advisors (ACPA) asked the CMS the following question about the inpatient order policy change during the 2019 IPPS Final Rule Open Door Forum held on Sept. 11, 2018: “Can providers thus submit a claim, that the provider believes meets all other requirements for Part A payment, in the rare circumstance of an inpatient order deficiency, such as an inpatient order that was cosigned shortly after discharge?”

The CMS declined to answer the question on the call, asking us to submit the question to the Open Door Forum electronic mailbox. If the inpatient order was truly no longer being required for the CMS to pay for inpatient hospital stays, the answer would have been an easy “yes,” but it was not. Subsequently, the CMS responded in writing to the ACPA that “the responsibilities of providers regarding inpatient admission orders is unchanged.” In other words, Medicare auditors have been given discretion to overlook an inpatient order flaw, but providers have not.

At this time, our recommendation is to continue your processes to ensure that the inpatient admission order is completed and signed (or cosigned) prior to discharge by the attending physician for every Medicare patient. This will not only help make sure that the decision to make a hospitalized Medicare beneficiary an inpatient remains with the attending physician, but it will also reduce the risk of nonpayment.

Dr. Hu is executive director of physician advisor services of University of North Carolina Health Care System in Chapel Hill, N.C., and president of the ACPA. Dr. Locke is senior physician advisor at Johns Hopkins Hospital in Baltimore, and president-elect of the ACPA.

When the Centers for Medicare & Medicaid Services make a significant change to the inpatient hospital rules, hospitalists are among the first to feel the effects.

You probably remember that, starting in October 2013, when a resident, nurse practitioner (NP), or physician assistant (PA) entered an inpatient admission order on your behalf, you were told to cosign that order before discharge or the hospital would forfeit payment for the entire stay. This policy was put in place by an annual piece of governmental policy known as the Inpatient Prospective Payment System (IPPS) Final Rule – the same one, in fact, that established the Two Midnight Rule.

The CMS felt that the decision to admit a Medicare beneficiary to inpatient care is such a significant event that it was appropriate to require the attending physician to complete a series of certification requirements to justify every inpatient stay. If not completed and finalized prior to discharge, the CMS would not pay for the stay. After 15 months of enforcing that policy, the CMS backed off on most of the certification requirements for most stays. However, the requirement for an authenticated inpatient order prior to discharge was kept in place for all stays. (“Authenticated” is CMS-speak for signed, or, in the case of inpatient orders initially placed by a resident/NP/PA without admitting privileges, cosigned, by a practitioner with admitting privileges.)

In the spring of 2018, the CMS proposed a change to “revise the admission order documentation requirements by removing the requirement that written inpatient admission orders are a specific requirement for Medicare Part A [inpatient hospital] payment.” The CMS also stated that it did not intend for Medicare auditors to deny hospital inpatient claims based solely on a deficiency in the inpatient order, such as a missing order or one signed after discharge, which the CMS found out was happening.

The description sounded great. In comments to the CMS, many providers assumed that they, too, would be provided similar discretion if they discovered the order defect. Are inpatient orders now optional? What rate of inpatient order technical deficiencies is acceptable to still submit inpatient claims for payment? Can 2-day observation stays where medical necessity for hospital care was present, but no inpatient order given, be billed as an inpatient now?

But these providers had not read the fine print. Consider that the annual IPPS Final Rule has a length of about 2,000 pages. Of those, only about 30 pages represent changes to a group of policies known as the Code of Federal Regulations (CFR). The CFR carries the weight of law (as long as it does not contradict law). When you appeal a Medicare denial to a judge, she will ask what portion of the CFR supports your viewpoint. The other 1,970 pages can be thought of as supporting analysis and reasoning to justify the 30 pages of changes. What changes were actually made to the CFR?

Consider the following two sentences.

• “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.”
• “This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”

These are the first two sentences of 42 CFR 412.3(a), the regulation that defines the inpatient order requirement. On Oct. 1, 2018, the second sentence was removed, but the first sentence still remains. That’s the only change for this section. Does removal of the second sentence absolve providers of the requirement to document inpatient admission orders? Does it absolve providers of the requirement to cosign a resident’s admission order prior to discharge? The Medicare Benefit Policy Manual (MBPM) Chapter 1, Section 10(B) still reads “if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.”

Understanding what changed and what did not change in the CFR is key to understanding why, in this year’s IPPS Final Rule, the CMS repeatedly responded to providers that an inpatient order is still a requirement for a Part A stay and that none of the MBPM guidance regarding the inpatient order, such as the excerpt above, is changing.

At this point, we can only be reasonably certain that if a claim a hospital submits for Part A payment happens to get audited and found to have only one deficiency which is related to the inpatient order, per this guidance it probably won’t get denied. That is very different from saying the attending physician no longer has to provide a signed (or cosigned) inpatient admission order prior to discharge, or at all.

Providers actually did ask the CMS if a hospital could still submit a claim the hospital knows has a missing or incomplete inpatient admission order at the time of discharge. The CMS responded that Medicare contractors have the discretion in extremely rare circumstances to approve cases where an order to admit may be missing or defective, and yet the intent, decision, and recommendation of the ordering practitioner to admit as inpatient can be clearly derived from the medical record. However, note that the discretion belongs to the Medicare contractor, not the provider.

The American College of Physician Advisors (ACPA) asked the CMS the following question about the inpatient order policy change during the 2019 IPPS Final Rule Open Door Forum held on Sept. 11, 2018: “Can providers thus submit a claim, that the provider believes meets all other requirements for Part A payment, in the rare circumstance of an inpatient order deficiency, such as an inpatient order that was cosigned shortly after discharge?”

The CMS declined to answer the question on the call, asking us to submit the question to the Open Door Forum electronic mailbox. If the inpatient order was truly no longer being required for the CMS to pay for inpatient hospital stays, the answer would have been an easy “yes,” but it was not. Subsequently, the CMS responded in writing to the ACPA that “the responsibilities of providers regarding inpatient admission orders is unchanged.” In other words, Medicare auditors have been given discretion to overlook an inpatient order flaw, but providers have not.

At this time, our recommendation is to continue your processes to ensure that the inpatient admission order is completed and signed (or cosigned) prior to discharge by the attending physician for every Medicare patient. This will not only help make sure that the decision to make a hospitalized Medicare beneficiary an inpatient remains with the attending physician, but it will also reduce the risk of nonpayment.

Dr. Hu is executive director of physician advisor services of University of North Carolina Health Care System in Chapel Hill, N.C., and president of the ACPA. Dr. Locke is senior physician advisor at Johns Hopkins Hospital in Baltimore, and president-elect of the ACPA.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.

We have several new, young employees in my front office, and it had been quite awhile since I had followed my own advice of “eavesdropping” on their telephone conversations with patients. You would think that Millennials, with all the time they spend on phones, would have little to learn in that department – until you remember that Instagram and Snapchat do not require interpersonal skills.

monkeybusinessimages/iStock/Getty Images

So I drafted a memo to refresh all of my staffers’ memories regarding proper professional telephone etiquette. If you want to adapt it for your own use, be my guest:

• The first impression a new patient has of our office is usually made by our receptionists. Even now, in the era of texting and e-mail, the telephone remains our primary point of contact with new and long-time patients. The way we answer it determines, to a significant extent, how the community thinks of us, as people and as health care providers.

• Everyone in the office needs to know how to answer the phone professionally. If you notice that a phone is ringing and the receptionists are unable to answer it, please pick up the phone; an incoming call must never go unanswered.

• Answer all incoming calls before the third ring.• Answer warmly, enthusiastically, and professionally. Since the caller cannot see you, your voice is the only impression of our office a first-time caller will get.

• All messages left overnight with the answering service must be returned as early as possible the very next business day. This is a top priority each morning. Few things annoy callers trying to reach their doctors more than unreturned calls. If the office will be closed for a holiday, or a response will be delayed for any other reason, make sure the service knows, and passes it on to patients.

• If the phone rings while you are dealing with a patient in person, that patient is your first priority. Put the caller on hold, but always ask permission before doing so, and wait for an answer. Never leave a caller on hold for more than a minute or two unless absolutely unavoidable.

• Never answer with, “Doctor’s office, please hold.” To a patient, that is even worse than not answering at all. No matter how often your hold message tells callers how important they are, they know they are being ignored. Such encounters never end well: Those who wait will be grumpy and rude when you get back to them; those who hang up will be even more grumpy and rude when they call back. Worst of all are those who don’t call back and seek care elsewhere – often leaving a nasty comment on social media besides.

• Maintaining patient confidentiality is a top priority. It makes patients feel secure about being treated in our office, and it is also the law. Be cautious about all information that is given over the phone. Don’t disclose any personal information unless you are absolutely certain you are talking to the correct patient. If the caller is not the patient, never discuss personal information without the patient’s permission.

Keep in mind that patients and others in the office may be able to overhear your phone conversations. Keep your voice down; never use the phone’s hands-free “speaker” function.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

We have several new, young employees in my front office, and it had been quite awhile since I had followed my own advice of “eavesdropping” on their telephone conversations with patients. You would think that Millennials, with all the time they spend on phones, would have little to learn in that department – until you remember that Instagram and Snapchat do not require interpersonal skills.

monkeybusinessimages/iStock/Getty Images

So I drafted a memo to refresh all of my staffers’ memories regarding proper professional telephone etiquette. If you want to adapt it for your own use, be my guest:

• The first impression a new patient has of our office is usually made by our receptionists. Even now, in the era of texting and e-mail, the telephone remains our primary point of contact with new and long-time patients. The way we answer it determines, to a significant extent, how the community thinks of us, as people and as health care providers.

• Everyone in the office needs to know how to answer the phone professionally. If you notice that a phone is ringing and the receptionists are unable to answer it, please pick up the phone; an incoming call must never go unanswered.

• Answer all incoming calls before the third ring.• Answer warmly, enthusiastically, and professionally. Since the caller cannot see you, your voice is the only impression of our office a first-time caller will get.

• All messages left overnight with the answering service must be returned as early as possible the very next business day. This is a top priority each morning. Few things annoy callers trying to reach their doctors more than unreturned calls. If the office will be closed for a holiday, or a response will be delayed for any other reason, make sure the service knows, and passes it on to patients.

• If the phone rings while you are dealing with a patient in person, that patient is your first priority. Put the caller on hold, but always ask permission before doing so, and wait for an answer. Never leave a caller on hold for more than a minute or two unless absolutely unavoidable.

• Never answer with, “Doctor’s office, please hold.” To a patient, that is even worse than not answering at all. No matter how often your hold message tells callers how important they are, they know they are being ignored. Such encounters never end well: Those who wait will be grumpy and rude when you get back to them; those who hang up will be even more grumpy and rude when they call back. Worst of all are those who don’t call back and seek care elsewhere – often leaving a nasty comment on social media besides.

• Maintaining patient confidentiality is a top priority. It makes patients feel secure about being treated in our office, and it is also the law. Be cautious about all information that is given over the phone. Don’t disclose any personal information unless you are absolutely certain you are talking to the correct patient. If the caller is not the patient, never discuss personal information without the patient’s permission.

Keep in mind that patients and others in the office may be able to overhear your phone conversations. Keep your voice down; never use the phone’s hands-free “speaker” function.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

We have several new, young employees in my front office, and it had been quite awhile since I had followed my own advice of “eavesdropping” on their telephone conversations with patients. You would think that Millennials, with all the time they spend on phones, would have little to learn in that department – until you remember that Instagram and Snapchat do not require interpersonal skills.

monkeybusinessimages/iStock/Getty Images

So I drafted a memo to refresh all of my staffers’ memories regarding proper professional telephone etiquette. If you want to adapt it for your own use, be my guest:

• The first impression a new patient has of our office is usually made by our receptionists. Even now, in the era of texting and e-mail, the telephone remains our primary point of contact with new and long-time patients. The way we answer it determines, to a significant extent, how the community thinks of us, as people and as health care providers.

• Everyone in the office needs to know how to answer the phone professionally. If you notice that a phone is ringing and the receptionists are unable to answer it, please pick up the phone; an incoming call must never go unanswered.

• Answer all incoming calls before the third ring.• Answer warmly, enthusiastically, and professionally. Since the caller cannot see you, your voice is the only impression of our office a first-time caller will get.

• All messages left overnight with the answering service must be returned as early as possible the very next business day. This is a top priority each morning. Few things annoy callers trying to reach their doctors more than unreturned calls. If the office will be closed for a holiday, or a response will be delayed for any other reason, make sure the service knows, and passes it on to patients.

• If the phone rings while you are dealing with a patient in person, that patient is your first priority. Put the caller on hold, but always ask permission before doing so, and wait for an answer. Never leave a caller on hold for more than a minute or two unless absolutely unavoidable.

• Never answer with, “Doctor’s office, please hold.” To a patient, that is even worse than not answering at all. No matter how often your hold message tells callers how important they are, they know they are being ignored. Such encounters never end well: Those who wait will be grumpy and rude when you get back to them; those who hang up will be even more grumpy and rude when they call back. Worst of all are those who don’t call back and seek care elsewhere – often leaving a nasty comment on social media besides.

• Maintaining patient confidentiality is a top priority. It makes patients feel secure about being treated in our office, and it is also the law. Be cautious about all information that is given over the phone. Don’t disclose any personal information unless you are absolutely certain you are talking to the correct patient. If the caller is not the patient, never discuss personal information without the patient’s permission.

Keep in mind that patients and others in the office may be able to overhear your phone conversations. Keep your voice down; never use the phone’s hands-free “speaker” function.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

SAN DIEGO – The wider picture of the patient’s health and prognosis, not just chronologic age, should enter into the clinical decision to initiate dialysis, according to Bjorg Thorsteinsdottir, MD, a palliative care physician at the Mayo Clinic in Rochester, Minn.

“People perceive they have no choice [but treatment], and we perceive we have to do things to them until everything is lost, then we expect them to do a 180 [degree turn],” she said in a presentation at the meeting sponsored by the American Society of Nephrology.

“A 90-year-old fit individual, with minimal comorbidity living independently, would absolutely be a good candidate for dialysis, while a 75-year-old patient with bad peripheral vascular disease and dementia, living in a nursing home, would be unlikely to live longer on dialysis than off dialysis,” she said. “We need to weigh the risks and benefits for each individual patient against their goals and values. We need to be honest about the lack of benefit for certain subgroups of patients and the heavy treatment burdens of dialysis. Age, comorbidity, and frailty all factor into these deliberations and prognosis.”

More than 107,000 people over age 75 in the United States received dialysis in 2015, according to statistics gathered by the National Kidney Foundation. Yet the survival advantage of dialysis is more limited in elderly patients with multiple comorbidities, Dr. Thorsteinsdottir said. “It becomes important to think about the harms of treatment.”

A 2016 study from the Netherlands found no survival advantage to dialysis, compared with conservative management among kidney failure patients aged 80 and older. The survival advantage was limited with dialysis in patients aged 70 and older who also had multiple comorbidities. (Clin J Am Soc Nephrol. 2016 Apr;11(4):633-40)

In an interview, Dr. Thorsteinsdottir acknowledged that “determining who is unlikely to benefit from dialysis is complicated.” However, she said, “we know that the following comorbidities are the worst: dementia and peripheral vascular disease.”

“No one that I know of currently has an age cutoff for dialysis,” Dr. Thorsteinsdottir said in the interview, “and I do not believe the U.S. is ready for any kind of explicit limit setting by the government on dialysis treatment.”

“We must respond to legitimate concerns raised by recent studies that suggest that strong moral imperatives – to treat anyone we can treat – have created a situation where we are not pausing and asking hard questions about whether the patient in front of us is likely to benefit from dialysis,” she said in the interview. “Patients sense this and do not feel that they are given any alternatives to dialysis treatment. This needs to change.”

Dr. Thorsteinsdottir reported no relevant financial disclosures.

SAN DIEGO – The wider picture of the patient’s health and prognosis, not just chronologic age, should enter into the clinical decision to initiate dialysis, according to Bjorg Thorsteinsdottir, MD, a palliative care physician at the Mayo Clinic in Rochester, Minn.

“People perceive they have no choice [but treatment], and we perceive we have to do things to them until everything is lost, then we expect them to do a 180 [degree turn],” she said in a presentation at the meeting sponsored by the American Society of Nephrology.

“A 90-year-old fit individual, with minimal comorbidity living independently, would absolutely be a good candidate for dialysis, while a 75-year-old patient with bad peripheral vascular disease and dementia, living in a nursing home, would be unlikely to live longer on dialysis than off dialysis,” she said. “We need to weigh the risks and benefits for each individual patient against their goals and values. We need to be honest about the lack of benefit for certain subgroups of patients and the heavy treatment burdens of dialysis. Age, comorbidity, and frailty all factor into these deliberations and prognosis.”

More than 107,000 people over age 75 in the United States received dialysis in 2015, according to statistics gathered by the National Kidney Foundation. Yet the survival advantage of dialysis is more limited in elderly patients with multiple comorbidities, Dr. Thorsteinsdottir said. “It becomes important to think about the harms of treatment.”

A 2016 study from the Netherlands found no survival advantage to dialysis, compared with conservative management among kidney failure patients aged 80 and older. The survival advantage was limited with dialysis in patients aged 70 and older who also had multiple comorbidities. (Clin J Am Soc Nephrol. 2016 Apr;11(4):633-40)

In an interview, Dr. Thorsteinsdottir acknowledged that “determining who is unlikely to benefit from dialysis is complicated.” However, she said, “we know that the following comorbidities are the worst: dementia and peripheral vascular disease.”

“No one that I know of currently has an age cutoff for dialysis,” Dr. Thorsteinsdottir said in the interview, “and I do not believe the U.S. is ready for any kind of explicit limit setting by the government on dialysis treatment.”

“We must respond to legitimate concerns raised by recent studies that suggest that strong moral imperatives – to treat anyone we can treat – have created a situation where we are not pausing and asking hard questions about whether the patient in front of us is likely to benefit from dialysis,” she said in the interview. “Patients sense this and do not feel that they are given any alternatives to dialysis treatment. This needs to change.”

Dr. Thorsteinsdottir reported no relevant financial disclosures.

SAN DIEGO – The wider picture of the patient’s health and prognosis, not just chronologic age, should enter into the clinical decision to initiate dialysis, according to Bjorg Thorsteinsdottir, MD, a palliative care physician at the Mayo Clinic in Rochester, Minn.

“People perceive they have no choice [but treatment], and we perceive we have to do things to them until everything is lost, then we expect them to do a 180 [degree turn],” she said in a presentation at the meeting sponsored by the American Society of Nephrology.

“A 90-year-old fit individual, with minimal comorbidity living independently, would absolutely be a good candidate for dialysis, while a 75-year-old patient with bad peripheral vascular disease and dementia, living in a nursing home, would be unlikely to live longer on dialysis than off dialysis,” she said. “We need to weigh the risks and benefits for each individual patient against their goals and values. We need to be honest about the lack of benefit for certain subgroups of patients and the heavy treatment burdens of dialysis. Age, comorbidity, and frailty all factor into these deliberations and prognosis.”

More than 107,000 people over age 75 in the United States received dialysis in 2015, according to statistics gathered by the National Kidney Foundation. Yet the survival advantage of dialysis is more limited in elderly patients with multiple comorbidities, Dr. Thorsteinsdottir said. “It becomes important to think about the harms of treatment.”

A 2016 study from the Netherlands found no survival advantage to dialysis, compared with conservative management among kidney failure patients aged 80 and older. The survival advantage was limited with dialysis in patients aged 70 and older who also had multiple comorbidities. (Clin J Am Soc Nephrol. 2016 Apr;11(4):633-40)

In an interview, Dr. Thorsteinsdottir acknowledged that “determining who is unlikely to benefit from dialysis is complicated.” However, she said, “we know that the following comorbidities are the worst: dementia and peripheral vascular disease.”

“No one that I know of currently has an age cutoff for dialysis,” Dr. Thorsteinsdottir said in the interview, “and I do not believe the U.S. is ready for any kind of explicit limit setting by the government on dialysis treatment.”

“We must respond to legitimate concerns raised by recent studies that suggest that strong moral imperatives – to treat anyone we can treat – have created a situation where we are not pausing and asking hard questions about whether the patient in front of us is likely to benefit from dialysis,” she said in the interview. “Patients sense this and do not feel that they are given any alternatives to dialysis treatment. This needs to change.”

Dr. Thorsteinsdottir reported no relevant financial disclosures.

Shock waves moved through the gynecologic oncology world on Oct. 31, 2018, when the New England Journal of Medicine published two papers on survival outcomes for women undergoing surgery for early stage cervical cancer.

The first was a randomized controlled trial of laparotomy and minimally invasive surgery (MIS) for radical hysterectomy called the LACC trial.¹ In the multicenter, international trial of 631 women, the primary objective was disease-specific survival (cervical cancer–related deaths) and was powered to detect noninferiority of the MIS approach when compared with laparotomy. The trial was closed early when investigators noted a lower than expected rate of 3-year, disease-free survival (91% vs. 97%) from cervical cancer in the MIS group, which was made up of 84% laparoscopic and 16% robotic approaches, versus laparotomy. There were 19 deaths in the MIS group observed versus three in the laparotomy group. The conclusions of the trial were that MIS surgery is associated with inferior cervical cancer survival.

In the second study, authors analyzed data from large U.S. databases – the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Program – to collect all-cause mortality for patients with early-stage cervical cancer who had undergone radical hysterectomy during 2010-2013.² Among 2,461 observed results, 1,225 had undergone MIS surgery with the majority (79.8%) via robotic-assistance. Women undergoing MIS approaches had smaller, lower grade tumors; were more likely to be white, privately insured, and of a higher income; and had surgery later in the cohort and by nonacademic centers. The researchers adjusted for risk factors with an analytic process called propensity-score weighting, which matched the groups more closely in an attempt to minimize confounders. They identified higher all-cause mortality among women who were treated with an MIS approach, compared with those treated with laparotomy (hazard ratio, 1.65). They also observed a significant decline in the survival from cervical cancer annually that corresponded to the uptake of MIS radical hysterectomies.

In the wake of these publications, many concluded that gynecologic oncologists should no longer offer a minimally invasive approach for radical hysterectomy. Certainly level I evidence published in a highly influential journal is compelling, and the consistency in findings over two studies adds further weight to the results. However, was this the correct conclusion to draw from these results? Surgeons who had been performing MIS radical hysterectomies for many years with favorable outcomes are challenging this and are raising questions about external generalizability and whether these findings were driven by the surgery itself or by the surgeon.

The studies’ authors proposed hypotheses for their results that implicate the surgical route rather than the surgeon; however, these seem ad hoc and not well supported by data, including the authors’ own data. The first was the hypothesis that cervical tumors were being disrupted and disseminated through the use of uterine manipulators in MIS approaches. However, cervical cancers are fairly routinely “disrupted” by preoperative cone biopsies, loop electrosurgical excision procedures (LEEP), and sharp biopsies, which are arguably more invasive than placement of a manipulator. Uterine manipulators routinely are used in endometrial cancer surgeries, in which the manipulator is embedded within the tumor, without an associated negative survival effect in randomized trials.³ Additionally, not all surgeons utilize manipulators for radical hysterectomies, and these studies did not measure or report on their use; therefore, it is impossible to know whether, and by what magnitude, manipulators played a role. Finally, if uterine manipulators are the explanation for inferior survival, surely the recommendation should be to discourage their use, rather than abandon the MIS approach all together.

The other explanation offered was exposure of the tumor to CO₂ gas. This seems an even less plausible explanation because CO₂ gas is routinely used in MIS cancer surgeries for endometrial, prostate, gastric, and colorectal surgeries and is used as insufflation for malignant interventional endoscopies without a significant deleterious effect. Additionally, the cervix is not exposed to CO₂ until colpotomy at the procedure’s end – and only briefly. The in vitro studies implicating a negative effect of simulated CO₂ pneumoperitoneum are neither compelling nor consistent.^4,5

I would like to propose another hypothesis for the results: surgical proficiency. Surgery, unlike medical interventions, is not a simple variable that is dichotomous – performed or not. Surgeons do not randomly select operative approaches for patients. We select surgical approaches based on patients’ circumstances and surgeon factors, including our own mastery of the various techniques. Randomized surgical trials rely on the notion that a surgeon is equally skilled in both or all approaches offered, but this is clearly not the case, and any surgeon recognizes this if he or she has observed more than one surgeon or has attempted a procedure via different routes. While some procedures, such as extrafascial hysterectomy for endometrial cancer, are relatively straightforward and surgeon capabilities are more equitable across different approaches, cervical cancer surgery is quite different.

Early-stage cervical cancer primarily exerts radial growth into the cervical stroma and parametria. Curative surgical excision requires broadly negative margins through this tissue, a so called “radical hysterectomy.” The radicality of hysterectomy has been categorized in stages, acknowledging that different sized lesions require different volumes of parametrial resection to achieve adequate clearance from the tumor.⁶ In doing so, the surgeon must skeletonize and mobilize the distal ureters, cardinal ligament webs, and uterosacral ligaments. These structures are in close proximity to major vascular and neural structures. Hence, the radical hysterectomy is, without dispute, a technically challenging procedure.

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no conflicts of interest. Email Dr. Rossi at [email protected].
 

References

1. N Engl J Med. 2018 Oct 31. doi: 10.1056/NEJMoa1806395.

2. N Engl J Med. 2018 Oct 31. doi: 10.1056/NEJMoa1804923.

3. J Clin Oncol. 2012 Mar 1;30(7):695-700.

4. Med Sci Monit. 2014 Dec 1;20:2497-503.

5. Surg Endosc. 2006 Oct;20(10):1556-9.

6. Gynecol Oncol. 2011 Aug;122(2):264-8.

7. Surgery. 2016 Mar;159(3):736-48.

Shock waves moved through the gynecologic oncology world on Oct. 31, 2018, when the New England Journal of Medicine published two papers on survival outcomes for women undergoing surgery for early stage cervical cancer.

The first was a randomized controlled trial of laparotomy and minimally invasive surgery (MIS) for radical hysterectomy called the LACC trial.¹ In the multicenter, international trial of 631 women, the primary objective was disease-specific survival (cervical cancer–related deaths) and was powered to detect noninferiority of the MIS approach when compared with laparotomy. The trial was closed early when investigators noted a lower than expected rate of 3-year, disease-free survival (91% vs. 97%) from cervical cancer in the MIS group, which was made up of 84% laparoscopic and 16% robotic approaches, versus laparotomy. There were 19 deaths in the MIS group observed versus three in the laparotomy group. The conclusions of the trial were that MIS surgery is associated with inferior cervical cancer survival.

In the second study, authors analyzed data from large U.S. databases – the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Program – to collect all-cause mortality for patients with early-stage cervical cancer who had undergone radical hysterectomy during 2010-2013.² Among 2,461 observed results, 1,225 had undergone MIS surgery with the majority (79.8%) via robotic-assistance. Women undergoing MIS approaches had smaller, lower grade tumors; were more likely to be white, privately insured, and of a higher income; and had surgery later in the cohort and by nonacademic centers. The researchers adjusted for risk factors with an analytic process called propensity-score weighting, which matched the groups more closely in an attempt to minimize confounders. They identified higher all-cause mortality among women who were treated with an MIS approach, compared with those treated with laparotomy (hazard ratio, 1.65). They also observed a significant decline in the survival from cervical cancer annually that corresponded to the uptake of MIS radical hysterectomies.

In the wake of these publications, many concluded that gynecologic oncologists should no longer offer a minimally invasive approach for radical hysterectomy. Certainly level I evidence published in a highly influential journal is compelling, and the consistency in findings over two studies adds further weight to the results. However, was this the correct conclusion to draw from these results? Surgeons who had been performing MIS radical hysterectomies for many years with favorable outcomes are challenging this and are raising questions about external generalizability and whether these findings were driven by the surgery itself or by the surgeon.

The studies’ authors proposed hypotheses for their results that implicate the surgical route rather than the surgeon; however, these seem ad hoc and not well supported by data, including the authors’ own data. The first was the hypothesis that cervical tumors were being disrupted and disseminated through the use of uterine manipulators in MIS approaches. However, cervical cancers are fairly routinely “disrupted” by preoperative cone biopsies, loop electrosurgical excision procedures (LEEP), and sharp biopsies, which are arguably more invasive than placement of a manipulator. Uterine manipulators routinely are used in endometrial cancer surgeries, in which the manipulator is embedded within the tumor, without an associated negative survival effect in randomized trials.³ Additionally, not all surgeons utilize manipulators for radical hysterectomies, and these studies did not measure or report on their use; therefore, it is impossible to know whether, and by what magnitude, manipulators played a role. Finally, if uterine manipulators are the explanation for inferior survival, surely the recommendation should be to discourage their use, rather than abandon the MIS approach all together.

The other explanation offered was exposure of the tumor to CO₂ gas. This seems an even less plausible explanation because CO₂ gas is routinely used in MIS cancer surgeries for endometrial, prostate, gastric, and colorectal surgeries and is used as insufflation for malignant interventional endoscopies without a significant deleterious effect. Additionally, the cervix is not exposed to CO₂ until colpotomy at the procedure’s end – and only briefly. The in vitro studies implicating a negative effect of simulated CO₂ pneumoperitoneum are neither compelling nor consistent.^4,5

I would like to propose another hypothesis for the results: surgical proficiency. Surgery, unlike medical interventions, is not a simple variable that is dichotomous – performed or not. Surgeons do not randomly select operative approaches for patients. We select surgical approaches based on patients’ circumstances and surgeon factors, including our own mastery of the various techniques. Randomized surgical trials rely on the notion that a surgeon is equally skilled in both or all approaches offered, but this is clearly not the case, and any surgeon recognizes this if he or she has observed more than one surgeon or has attempted a procedure via different routes. While some procedures, such as extrafascial hysterectomy for endometrial cancer, are relatively straightforward and surgeon capabilities are more equitable across different approaches, cervical cancer surgery is quite different.

Early-stage cervical cancer primarily exerts radial growth into the cervical stroma and parametria. Curative surgical excision requires broadly negative margins through this tissue, a so called “radical hysterectomy.” The radicality of hysterectomy has been categorized in stages, acknowledging that different sized lesions require different volumes of parametrial resection to achieve adequate clearance from the tumor.⁶ In doing so, the surgeon must skeletonize and mobilize the distal ureters, cardinal ligament webs, and uterosacral ligaments. These structures are in close proximity to major vascular and neural structures. Hence, the radical hysterectomy is, without dispute, a technically challenging procedure.

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no conflicts of interest. Email Dr. Rossi at [email protected].
 

References

1. N Engl J Med. 2018 Oct 31. doi: 10.1056/NEJMoa1806395.

2. N Engl J Med. 2018 Oct 31. doi: 10.1056/NEJMoa1804923.

3. J Clin Oncol. 2012 Mar 1;30(7):695-700.

4. Med Sci Monit. 2014 Dec 1;20:2497-503.

5. Surg Endosc. 2006 Oct;20(10):1556-9.

6. Gynecol Oncol. 2011 Aug;122(2):264-8.

7. Surgery. 2016 Mar;159(3):736-48.

Shock waves moved through the gynecologic oncology world on Oct. 31, 2018, when the New England Journal of Medicine published two papers on survival outcomes for women undergoing surgery for early stage cervical cancer.

The first was a randomized controlled trial of laparotomy and minimally invasive surgery (MIS) for radical hysterectomy called the LACC trial.¹ In the multicenter, international trial of 631 women, the primary objective was disease-specific survival (cervical cancer–related deaths) and was powered to detect noninferiority of the MIS approach when compared with laparotomy. The trial was closed early when investigators noted a lower than expected rate of 3-year, disease-free survival (91% vs. 97%) from cervical cancer in the MIS group, which was made up of 84% laparoscopic and 16% robotic approaches, versus laparotomy. There were 19 deaths in the MIS group observed versus three in the laparotomy group. The conclusions of the trial were that MIS surgery is associated with inferior cervical cancer survival.

In the second study, authors analyzed data from large U.S. databases – the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Program – to collect all-cause mortality for patients with early-stage cervical cancer who had undergone radical hysterectomy during 2010-2013.² Among 2,461 observed results, 1,225 had undergone MIS surgery with the majority (79.8%) via robotic-assistance. Women undergoing MIS approaches had smaller, lower grade tumors; were more likely to be white, privately insured, and of a higher income; and had surgery later in the cohort and by nonacademic centers. The researchers adjusted for risk factors with an analytic process called propensity-score weighting, which matched the groups more closely in an attempt to minimize confounders. They identified higher all-cause mortality among women who were treated with an MIS approach, compared with those treated with laparotomy (hazard ratio, 1.65). They also observed a significant decline in the survival from cervical cancer annually that corresponded to the uptake of MIS radical hysterectomies.

In the wake of these publications, many concluded that gynecologic oncologists should no longer offer a minimally invasive approach for radical hysterectomy. Certainly level I evidence published in a highly influential journal is compelling, and the consistency in findings over two studies adds further weight to the results. However, was this the correct conclusion to draw from these results? Surgeons who had been performing MIS radical hysterectomies for many years with favorable outcomes are challenging this and are raising questions about external generalizability and whether these findings were driven by the surgery itself or by the surgeon.

The studies’ authors proposed hypotheses for their results that implicate the surgical route rather than the surgeon; however, these seem ad hoc and not well supported by data, including the authors’ own data. The first was the hypothesis that cervical tumors were being disrupted and disseminated through the use of uterine manipulators in MIS approaches. However, cervical cancers are fairly routinely “disrupted” by preoperative cone biopsies, loop electrosurgical excision procedures (LEEP), and sharp biopsies, which are arguably more invasive than placement of a manipulator. Uterine manipulators routinely are used in endometrial cancer surgeries, in which the manipulator is embedded within the tumor, without an associated negative survival effect in randomized trials.³ Additionally, not all surgeons utilize manipulators for radical hysterectomies, and these studies did not measure or report on their use; therefore, it is impossible to know whether, and by what magnitude, manipulators played a role. Finally, if uterine manipulators are the explanation for inferior survival, surely the recommendation should be to discourage their use, rather than abandon the MIS approach all together.

The other explanation offered was exposure of the tumor to CO₂ gas. This seems an even less plausible explanation because CO₂ gas is routinely used in MIS cancer surgeries for endometrial, prostate, gastric, and colorectal surgeries and is used as insufflation for malignant interventional endoscopies without a significant deleterious effect. Additionally, the cervix is not exposed to CO₂ until colpotomy at the procedure’s end – and only briefly. The in vitro studies implicating a negative effect of simulated CO₂ pneumoperitoneum are neither compelling nor consistent.^4,5

I would like to propose another hypothesis for the results: surgical proficiency. Surgery, unlike medical interventions, is not a simple variable that is dichotomous – performed or not. Surgeons do not randomly select operative approaches for patients. We select surgical approaches based on patients’ circumstances and surgeon factors, including our own mastery of the various techniques. Randomized surgical trials rely on the notion that a surgeon is equally skilled in both or all approaches offered, but this is clearly not the case, and any surgeon recognizes this if he or she has observed more than one surgeon or has attempted a procedure via different routes. While some procedures, such as extrafascial hysterectomy for endometrial cancer, are relatively straightforward and surgeon capabilities are more equitable across different approaches, cervical cancer surgery is quite different.

Early-stage cervical cancer primarily exerts radial growth into the cervical stroma and parametria. Curative surgical excision requires broadly negative margins through this tissue, a so called “radical hysterectomy.” The radicality of hysterectomy has been categorized in stages, acknowledging that different sized lesions require different volumes of parametrial resection to achieve adequate clearance from the tumor.⁶ In doing so, the surgeon must skeletonize and mobilize the distal ureters, cardinal ligament webs, and uterosacral ligaments. These structures are in close proximity to major vascular and neural structures. Hence, the radical hysterectomy is, without dispute, a technically challenging procedure.

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no conflicts of interest. Email Dr. Rossi at [email protected].
 

References

1. N Engl J Med. 2018 Oct 31. doi: 10.1056/NEJMoa1806395.

2. N Engl J Med. 2018 Oct 31. doi: 10.1056/NEJMoa1804923.

3. J Clin Oncol. 2012 Mar 1;30(7):695-700.

4. Med Sci Monit. 2014 Dec 1;20:2497-503.

5. Surg Endosc. 2006 Oct;20(10):1556-9.

6. Gynecol Oncol. 2011 Aug;122(2):264-8.

7. Surgery. 2016 Mar;159(3):736-48.

Like all of us, I was very troubled by the recent mass shooting in Thousand Oaks, Calif. This shooting was on top of the massacre at Pittsburgh’s Tree of Life synagogue, the shootings in a yoga studio ... the sickening list goes on and on.

As both a veteran and a psychiatrist with expertise in posttraumatic stress disorder, I was especially dismayed by the assumption that the Thousand Oaks shooter, who had served in the Marine Corps, had PTSD, and that the PTSD had led to the shooting.

The overall effect of these assumptions is to reinforce the stigma against veterans as “ticking time bombs.”

No question, there are plenty of other stereotypes to go around, especially those of Muslims as terrorists. In reality, as reports from the GAO and independent news sources show, most “terrorist” attacks in the United States have been carried out by right-wing extremists, mainly white, and born in this country.

Back to veterans. It is true that there have been several mass shootings by service members and veterans, including the massacre at Fort Hood, Tex., in 2009 by an Army major, the 2017 shooting up of a church in Texas by someone who had served in the Air Force, and this most recent one by a former Marine.

But there have been many other shootings and acts of political violence by numerous others, including those for whom “life is going down the toilet.” When you look at these situations, the driving factors are usually anger, irritability, and a sense of being wronged. Often, delusions and paranoia emerge.

It is true that there are many barriers to treatment for both veterans and nonveterans, including stigma, lack of insurance, and the dearth of mental health providers.

Those factors have nothing to do with being a veteran, who are normally very proud of both their country and their military service.

Let us celebrate those who have given so much to this country, America’s sons and daughters.
 

Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.

Like all of us, I was very troubled by the recent mass shooting in Thousand Oaks, Calif. This shooting was on top of the massacre at Pittsburgh’s Tree of Life synagogue, the shootings in a yoga studio ... the sickening list goes on and on.

As both a veteran and a psychiatrist with expertise in posttraumatic stress disorder, I was especially dismayed by the assumption that the Thousand Oaks shooter, who had served in the Marine Corps, had PTSD, and that the PTSD had led to the shooting.

The overall effect of these assumptions is to reinforce the stigma against veterans as “ticking time bombs.”

No question, there are plenty of other stereotypes to go around, especially those of Muslims as terrorists. In reality, as reports from the GAO and independent news sources show, most “terrorist” attacks in the United States have been carried out by right-wing extremists, mainly white, and born in this country.

Back to veterans. It is true that there have been several mass shootings by service members and veterans, including the massacre at Fort Hood, Tex., in 2009 by an Army major, the 2017 shooting up of a church in Texas by someone who had served in the Air Force, and this most recent one by a former Marine.

But there have been many other shootings and acts of political violence by numerous others, including those for whom “life is going down the toilet.” When you look at these situations, the driving factors are usually anger, irritability, and a sense of being wronged. Often, delusions and paranoia emerge.

It is true that there are many barriers to treatment for both veterans and nonveterans, including stigma, lack of insurance, and the dearth of mental health providers.

Those factors have nothing to do with being a veteran, who are normally very proud of both their country and their military service.

Let us celebrate those who have given so much to this country, America’s sons and daughters.
 

Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.

Like all of us, I was very troubled by the recent mass shooting in Thousand Oaks, Calif. This shooting was on top of the massacre at Pittsburgh’s Tree of Life synagogue, the shootings in a yoga studio ... the sickening list goes on and on.

As both a veteran and a psychiatrist with expertise in posttraumatic stress disorder, I was especially dismayed by the assumption that the Thousand Oaks shooter, who had served in the Marine Corps, had PTSD, and that the PTSD had led to the shooting.

The overall effect of these assumptions is to reinforce the stigma against veterans as “ticking time bombs.”

No question, there are plenty of other stereotypes to go around, especially those of Muslims as terrorists. In reality, as reports from the GAO and independent news sources show, most “terrorist” attacks in the United States have been carried out by right-wing extremists, mainly white, and born in this country.

Back to veterans. It is true that there have been several mass shootings by service members and veterans, including the massacre at Fort Hood, Tex., in 2009 by an Army major, the 2017 shooting up of a church in Texas by someone who had served in the Air Force, and this most recent one by a former Marine.

But there have been many other shootings and acts of political violence by numerous others, including those for whom “life is going down the toilet.” When you look at these situations, the driving factors are usually anger, irritability, and a sense of being wronged. Often, delusions and paranoia emerge.

It is true that there are many barriers to treatment for both veterans and nonveterans, including stigma, lack of insurance, and the dearth of mental health providers.

Those factors have nothing to do with being a veteran, who are normally very proud of both their country and their military service.

Let us celebrate those who have given so much to this country, America’s sons and daughters.
 

Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.

Nutritious eating need not involve counting calories, carbohydrates, or points, according to food and nutrition editor Paul Kita.

dulezidar/Thinkstock

After talking with experts and studying various diets, Mr. Kita said he found an approach that works for him.

The key is eating “real food,” such as chicken, tomatoes, eggs, and avocados; avoiding processed foods; and not demonizing anything. Approaching food this way for 10 years has allowed Mr. Kita to keep his weight at 155 pounds – give or take 5, – he wrote in Men’s Health.

“I eat cookies. I eat carbs. I even drink coffee supposedly loaded with mycotoxins,” Mr. Kita wrote. “I [eat] fruits and vegetables with every meal and cut back on booze and desserts. I have two clementines or a banana or a split broiled tomato for breakfast. I eat a big salad of mixed greens or a side of coleslaw or a ripe, juicy pear for lunch.”

He said dinner might include sautéed spinach or a carrot salad and roasted sweet potatoes. “And then I either choose to have a beer with or after dinner or a simple dessert. If I’m not craving something sweet, I’ll have a cup of tea.”

He said he tries for about 30 grams of protein at each meal.

“Here’s my main takeaway ... if the plan you have for what you feed yourself causes you more stress and adds more work to your already-busy life, you’re not eating well. The best diet ... doesn’t have celebrity endorsements. The best diet is one that is based on the inclusion of healthful foods – not the exclusion of food groups.”

Students seek to prevent suicides

The beauty of mountains can be breathtaking for someone passing through. For residents, living in the shadow of the giants, however, can be isolating, especially for small mountain communities. Grand Junction, Colo., is located in a valley ringed by tall mountains, desert mesas, and red-rock cliffs. For local residents, and especially teenagers, it can feel like the end of the world.

“I know we can’t really fix this because it’s nature,” 17-year-old Victoria Mendoza said in an NPR interview. “I feel like the people in our valley feel like there’s only life inside of Grand Junction.”

Ms. Mendoza has fought depression, as have other members of her family and others in the community. Seven student suicides occurred in the 2016-2017 school year. “It felt like there was this cloud around our whole valley,” Ms. Mendoza said. “It got to a point where we were just waiting for the next one.”

Rural settings can foster the loneliness that, for some, is only cured by self-inflicted death. Of the top 10 U.S. states with the highest rates of suicide, 8 are located in the rural mountain West. The view of mental illness as a sign of personal weakness remains prevalent, and having ready access to guns is not helpful.

In Grand Junction, students have seized the reins of a suicide prevention in which they act as peer mentors to younger students that either seek help or appear to be floundering. The approach, called the Sources of Strength suicide program, exemplifies a broader shift in public health thinking that is taking place. In Grand Junction, the strategy is to zero in on the mental health and well-being of everyone. That encourages a sense of community, even in a setting of physical isolation.

Cannabidiol and substance-free living

With cannabis use becoming more part of the norm and with its legalization, the idea of altering the way we see the world is, for some, moving from a no-go option to a practice that can help ease the strains of life. For those who struggle with PTSD or other anxieties, cannabis can be a way to alleviate paranoia, anxiety, and mood swings without the use of prescription drugs.

Of course, there will be many who will overenthusiastically embrace the chance to legally alter themselves, such as what occurs with alcohol. Sobriety means different things to different people. Some alcoholics happily live with an occasional drink. They consider themselves on a path of sobriety. Others must go cold turkey forever. This is a different sobriety. Each can be effective and can bring happiness.

“Does using cannabidiol count as a strike against recovery or a substance-free lifestyle? This can lead into particularly tricky terrain as many people turn to cannabis products as a solution for all manner of ailments – from mental health to addiction. As we reckon with cannabis legalization as a country, perhaps what we really should be asking ourselves is how we’re going to redefine the traditional meaning of sobriety,” Amanda Scriver wrote in the Walrus.

“As cannabidiol gains popularity, we must give people the capacity to examine, evaluate, and possibly amend their own health, wellness, or recovery journey in a way that feels right for them. Yes, we need better medical understanding of cannabis and its related products, and yes, we also need training in the harm-reduction model. But we also need compassion and the courage to rethink old definitions,” Ms. Scriver wrote.

Masculinity tied to mental health

As a celebrity, Lenard Larry McKelvey, aka Charlamagne Tha God, makes his living being brash and bold. On his radio show, The Breakfast Club, he asks questions some do not want asked. But, like many, he is also anxious about the world. As a father, he worries about his daughters. As a black man, he worries about police brutality.

But unlike many, he has a forum and an audience. And he is using his forum to speak out about his fears and anxieties in the hope that it helps others deal with their demons. A recent example is his book, “Shook One: Anxiety Playing Tricks On Me” (Touchstone, 2018).

He is a strong advocate of therapy. “I go to therapy just to push those negative thoughts out of my mind. None of us can escape thinking negatively. Negative thoughts are going to pop up in your head. You’re going to have self-doubt sometimes; you’re going to be insecure sometimes. You’re going to worry about your kids; you’re going to worry about your wife, but it’s about pushing that %@C# out and not holding onto it. When you hold onto it, that’s when it grows,” he explained in an interview with the Boston Globe.

He espoused the freedom that comes from self-acceptance. “My whole life, people have said to me, ‘You can’t be soft.’ I don’t care about that anymore. I don’t care about how people perceive me when it comes to masculinity. You know what’s masculine? Masculine is taking care of your mind, your body, and your soul. We spend so much time on our body. We want that six-pack. But what about your mental health? What about your mental well-being? I go to the gym three, four times a week. Why can’t I put that same effort and same energy into getting mentally strong?”

Can extremists’ mindsets change?

The recent massacre at the Pittsburgh synagogue was yet another vile example of hatred and bigotry. But, in the United States and elsewhere, the shooter was one of many. Why?

According to an NPR piece, there are several possible explanations. Those brimming with racist hated might have little opportunity to get off that track. “We haven’t wanted to acknowledge that we have a problem with violent right-wing extremism in this kind of domestic terrorism,” said sociologist Pete Simi, PhD, of Chapman University in Orange, Calif. Dr. Simi has studied violent white nationalists and other hate groups for decades.


“White supremacy is really a problem throughout the United States,” Dr. Simi said. “It doesn’t know any geographic boundaries. It’s not isolated to either urban or rural or suburban – it cuts across all.”

There is little knowledge of how to deal with home-grown hatred. Banning immigrants perceived as being a threat is one attempt to deal with foreign-born terrorism, but that doesn’t work for citizens. For them, rehabilitation is possible, according to Dr. Simi, but it comes with a big price tag of revamped social, education, housing, and employment programs. Governments are loathe to take on those costs, in part because it is an admission that society is broken.

“A big, big problem that we face as a society is abdicating our responsibility in terms of providing this kind of social support and social safety net for individuals that suffer from mental health, as well as drug problems,” Dr. Simi said in the interview.

Small-scale local efforts, such as the Chicago-based Life After Hate, are working for change. How to scale up such efforts is a vexing problem.

Nutritious eating need not involve counting calories, carbohydrates, or points, according to food and nutrition editor Paul Kita.

dulezidar/Thinkstock

After talking with experts and studying various diets, Mr. Kita said he found an approach that works for him.

The key is eating “real food,” such as chicken, tomatoes, eggs, and avocados; avoiding processed foods; and not demonizing anything. Approaching food this way for 10 years has allowed Mr. Kita to keep his weight at 155 pounds – give or take 5, – he wrote in Men’s Health.

“I eat cookies. I eat carbs. I even drink coffee supposedly loaded with mycotoxins,” Mr. Kita wrote. “I [eat] fruits and vegetables with every meal and cut back on booze and desserts. I have two clementines or a banana or a split broiled tomato for breakfast. I eat a big salad of mixed greens or a side of coleslaw or a ripe, juicy pear for lunch.”

He said dinner might include sautéed spinach or a carrot salad and roasted sweet potatoes. “And then I either choose to have a beer with or after dinner or a simple dessert. If I’m not craving something sweet, I’ll have a cup of tea.”

He said he tries for about 30 grams of protein at each meal.

“Here’s my main takeaway ... if the plan you have for what you feed yourself causes you more stress and adds more work to your already-busy life, you’re not eating well. The best diet ... doesn’t have celebrity endorsements. The best diet is one that is based on the inclusion of healthful foods – not the exclusion of food groups.”

Students seek to prevent suicides

The beauty of mountains can be breathtaking for someone passing through. For residents, living in the shadow of the giants, however, can be isolating, especially for small mountain communities. Grand Junction, Colo., is located in a valley ringed by tall mountains, desert mesas, and red-rock cliffs. For local residents, and especially teenagers, it can feel like the end of the world.

“I know we can’t really fix this because it’s nature,” 17-year-old Victoria Mendoza said in an NPR interview. “I feel like the people in our valley feel like there’s only life inside of Grand Junction.”

Ms. Mendoza has fought depression, as have other members of her family and others in the community. Seven student suicides occurred in the 2016-2017 school year. “It felt like there was this cloud around our whole valley,” Ms. Mendoza said. “It got to a point where we were just waiting for the next one.”

Rural settings can foster the loneliness that, for some, is only cured by self-inflicted death. Of the top 10 U.S. states with the highest rates of suicide, 8 are located in the rural mountain West. The view of mental illness as a sign of personal weakness remains prevalent, and having ready access to guns is not helpful.

In Grand Junction, students have seized the reins of a suicide prevention in which they act as peer mentors to younger students that either seek help or appear to be floundering. The approach, called the Sources of Strength suicide program, exemplifies a broader shift in public health thinking that is taking place. In Grand Junction, the strategy is to zero in on the mental health and well-being of everyone. That encourages a sense of community, even in a setting of physical isolation.

Cannabidiol and substance-free living

With cannabis use becoming more part of the norm and with its legalization, the idea of altering the way we see the world is, for some, moving from a no-go option to a practice that can help ease the strains of life. For those who struggle with PTSD or other anxieties, cannabis can be a way to alleviate paranoia, anxiety, and mood swings without the use of prescription drugs.

Of course, there will be many who will overenthusiastically embrace the chance to legally alter themselves, such as what occurs with alcohol. Sobriety means different things to different people. Some alcoholics happily live with an occasional drink. They consider themselves on a path of sobriety. Others must go cold turkey forever. This is a different sobriety. Each can be effective and can bring happiness.

“Does using cannabidiol count as a strike against recovery or a substance-free lifestyle? This can lead into particularly tricky terrain as many people turn to cannabis products as a solution for all manner of ailments – from mental health to addiction. As we reckon with cannabis legalization as a country, perhaps what we really should be asking ourselves is how we’re going to redefine the traditional meaning of sobriety,” Amanda Scriver wrote in the Walrus.

“As cannabidiol gains popularity, we must give people the capacity to examine, evaluate, and possibly amend their own health, wellness, or recovery journey in a way that feels right for them. Yes, we need better medical understanding of cannabis and its related products, and yes, we also need training in the harm-reduction model. But we also need compassion and the courage to rethink old definitions,” Ms. Scriver wrote.

Masculinity tied to mental health

As a celebrity, Lenard Larry McKelvey, aka Charlamagne Tha God, makes his living being brash and bold. On his radio show, The Breakfast Club, he asks questions some do not want asked. But, like many, he is also anxious about the world. As a father, he worries about his daughters. As a black man, he worries about police brutality.

But unlike many, he has a forum and an audience. And he is using his forum to speak out about his fears and anxieties in the hope that it helps others deal with their demons. A recent example is his book, “Shook One: Anxiety Playing Tricks On Me” (Touchstone, 2018).

He is a strong advocate of therapy. “I go to therapy just to push those negative thoughts out of my mind. None of us can escape thinking negatively. Negative thoughts are going to pop up in your head. You’re going to have self-doubt sometimes; you’re going to be insecure sometimes. You’re going to worry about your kids; you’re going to worry about your wife, but it’s about pushing that %@C# out and not holding onto it. When you hold onto it, that’s when it grows,” he explained in an interview with the Boston Globe.

He espoused the freedom that comes from self-acceptance. “My whole life, people have said to me, ‘You can’t be soft.’ I don’t care about that anymore. I don’t care about how people perceive me when it comes to masculinity. You know what’s masculine? Masculine is taking care of your mind, your body, and your soul. We spend so much time on our body. We want that six-pack. But what about your mental health? What about your mental well-being? I go to the gym three, four times a week. Why can’t I put that same effort and same energy into getting mentally strong?”

Can extremists’ mindsets change?

The recent massacre at the Pittsburgh synagogue was yet another vile example of hatred and bigotry. But, in the United States and elsewhere, the shooter was one of many. Why?

According to an NPR piece, there are several possible explanations. Those brimming with racist hated might have little opportunity to get off that track. “We haven’t wanted to acknowledge that we have a problem with violent right-wing extremism in this kind of domestic terrorism,” said sociologist Pete Simi, PhD, of Chapman University in Orange, Calif. Dr. Simi has studied violent white nationalists and other hate groups for decades.


“White supremacy is really a problem throughout the United States,” Dr. Simi said. “It doesn’t know any geographic boundaries. It’s not isolated to either urban or rural or suburban – it cuts across all.”

There is little knowledge of how to deal with home-grown hatred. Banning immigrants perceived as being a threat is one attempt to deal with foreign-born terrorism, but that doesn’t work for citizens. For them, rehabilitation is possible, according to Dr. Simi, but it comes with a big price tag of revamped social, education, housing, and employment programs. Governments are loathe to take on those costs, in part because it is an admission that society is broken.

“A big, big problem that we face as a society is abdicating our responsibility in terms of providing this kind of social support and social safety net for individuals that suffer from mental health, as well as drug problems,” Dr. Simi said in the interview.

Small-scale local efforts, such as the Chicago-based Life After Hate, are working for change. How to scale up such efforts is a vexing problem.

Nutritious eating need not involve counting calories, carbohydrates, or points, according to food and nutrition editor Paul Kita.

dulezidar/Thinkstock

After talking with experts and studying various diets, Mr. Kita said he found an approach that works for him.

The key is eating “real food,” such as chicken, tomatoes, eggs, and avocados; avoiding processed foods; and not demonizing anything. Approaching food this way for 10 years has allowed Mr. Kita to keep his weight at 155 pounds – give or take 5, – he wrote in Men’s Health.

“I eat cookies. I eat carbs. I even drink coffee supposedly loaded with mycotoxins,” Mr. Kita wrote. “I [eat] fruits and vegetables with every meal and cut back on booze and desserts. I have two clementines or a banana or a split broiled tomato for breakfast. I eat a big salad of mixed greens or a side of coleslaw or a ripe, juicy pear for lunch.”

He said dinner might include sautéed spinach or a carrot salad and roasted sweet potatoes. “And then I either choose to have a beer with or after dinner or a simple dessert. If I’m not craving something sweet, I’ll have a cup of tea.”

He said he tries for about 30 grams of protein at each meal.

“Here’s my main takeaway ... if the plan you have for what you feed yourself causes you more stress and adds more work to your already-busy life, you’re not eating well. The best diet ... doesn’t have celebrity endorsements. The best diet is one that is based on the inclusion of healthful foods – not the exclusion of food groups.”

Students seek to prevent suicides

The beauty of mountains can be breathtaking for someone passing through. For residents, living in the shadow of the giants, however, can be isolating, especially for small mountain communities. Grand Junction, Colo., is located in a valley ringed by tall mountains, desert mesas, and red-rock cliffs. For local residents, and especially teenagers, it can feel like the end of the world.

“I know we can’t really fix this because it’s nature,” 17-year-old Victoria Mendoza said in an NPR interview. “I feel like the people in our valley feel like there’s only life inside of Grand Junction.”

Ms. Mendoza has fought depression, as have other members of her family and others in the community. Seven student suicides occurred in the 2016-2017 school year. “It felt like there was this cloud around our whole valley,” Ms. Mendoza said. “It got to a point where we were just waiting for the next one.”

Rural settings can foster the loneliness that, for some, is only cured by self-inflicted death. Of the top 10 U.S. states with the highest rates of suicide, 8 are located in the rural mountain West. The view of mental illness as a sign of personal weakness remains prevalent, and having ready access to guns is not helpful.

In Grand Junction, students have seized the reins of a suicide prevention in which they act as peer mentors to younger students that either seek help or appear to be floundering. The approach, called the Sources of Strength suicide program, exemplifies a broader shift in public health thinking that is taking place. In Grand Junction, the strategy is to zero in on the mental health and well-being of everyone. That encourages a sense of community, even in a setting of physical isolation.

Cannabidiol and substance-free living

With cannabis use becoming more part of the norm and with its legalization, the idea of altering the way we see the world is, for some, moving from a no-go option to a practice that can help ease the strains of life. For those who struggle with PTSD or other anxieties, cannabis can be a way to alleviate paranoia, anxiety, and mood swings without the use of prescription drugs.

Of course, there will be many who will overenthusiastically embrace the chance to legally alter themselves, such as what occurs with alcohol. Sobriety means different things to different people. Some alcoholics happily live with an occasional drink. They consider themselves on a path of sobriety. Others must go cold turkey forever. This is a different sobriety. Each can be effective and can bring happiness.

“Does using cannabidiol count as a strike against recovery or a substance-free lifestyle? This can lead into particularly tricky terrain as many people turn to cannabis products as a solution for all manner of ailments – from mental health to addiction. As we reckon with cannabis legalization as a country, perhaps what we really should be asking ourselves is how we’re going to redefine the traditional meaning of sobriety,” Amanda Scriver wrote in the Walrus.

“As cannabidiol gains popularity, we must give people the capacity to examine, evaluate, and possibly amend their own health, wellness, or recovery journey in a way that feels right for them. Yes, we need better medical understanding of cannabis and its related products, and yes, we also need training in the harm-reduction model. But we also need compassion and the courage to rethink old definitions,” Ms. Scriver wrote.

Masculinity tied to mental health

As a celebrity, Lenard Larry McKelvey, aka Charlamagne Tha God, makes his living being brash and bold. On his radio show, The Breakfast Club, he asks questions some do not want asked. But, like many, he is also anxious about the world. As a father, he worries about his daughters. As a black man, he worries about police brutality.

But unlike many, he has a forum and an audience. And he is using his forum to speak out about his fears and anxieties in the hope that it helps others deal with their demons. A recent example is his book, “Shook One: Anxiety Playing Tricks On Me” (Touchstone, 2018).

He is a strong advocate of therapy. “I go to therapy just to push those negative thoughts out of my mind. None of us can escape thinking negatively. Negative thoughts are going to pop up in your head. You’re going to have self-doubt sometimes; you’re going to be insecure sometimes. You’re going to worry about your kids; you’re going to worry about your wife, but it’s about pushing that %@C# out and not holding onto it. When you hold onto it, that’s when it grows,” he explained in an interview with the Boston Globe.

He espoused the freedom that comes from self-acceptance. “My whole life, people have said to me, ‘You can’t be soft.’ I don’t care about that anymore. I don’t care about how people perceive me when it comes to masculinity. You know what’s masculine? Masculine is taking care of your mind, your body, and your soul. We spend so much time on our body. We want that six-pack. But what about your mental health? What about your mental well-being? I go to the gym three, four times a week. Why can’t I put that same effort and same energy into getting mentally strong?”

Can extremists’ mindsets change?

The recent massacre at the Pittsburgh synagogue was yet another vile example of hatred and bigotry. But, in the United States and elsewhere, the shooter was one of many. Why?

According to an NPR piece, there are several possible explanations. Those brimming with racist hated might have little opportunity to get off that track. “We haven’t wanted to acknowledge that we have a problem with violent right-wing extremism in this kind of domestic terrorism,” said sociologist Pete Simi, PhD, of Chapman University in Orange, Calif. Dr. Simi has studied violent white nationalists and other hate groups for decades.


“White supremacy is really a problem throughout the United States,” Dr. Simi said. “It doesn’t know any geographic boundaries. It’s not isolated to either urban or rural or suburban – it cuts across all.”

There is little knowledge of how to deal with home-grown hatred. Banning immigrants perceived as being a threat is one attempt to deal with foreign-born terrorism, but that doesn’t work for citizens. For them, rehabilitation is possible, according to Dr. Simi, but it comes with a big price tag of revamped social, education, housing, and employment programs. Governments are loathe to take on those costs, in part because it is an admission that society is broken.

“A big, big problem that we face as a society is abdicating our responsibility in terms of providing this kind of social support and social safety net for individuals that suffer from mental health, as well as drug problems,” Dr. Simi said in the interview.

Small-scale local efforts, such as the Chicago-based Life After Hate, are working for change. How to scale up such efforts is a vexing problem.