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Why is loxapine overlooked, underprescribed for psychosis?
I have always tried to practice common sense psychiatry, however, sometimes it seems I am alone in this pursuit. My best example is the minimal prescribing of loxapine (Adasuve) for treating the problem of psychosis, most notably schizophrenia.
Mind you, neither I nor anyone in family own stock in any pharmaceutical companies. I don’t lecture for them, so I have no conflicts in writing about this observation – which I hope will improve patient care, thereby saving lives and making a difference.
Everyone should be familiar with the evolution of atypical antipsychotics and how these medications are touted as “second-generation” classes of medication advertised as superior to the older, first-generation antipsychotics. However, as we get more experience with the second-generation atypical antipsychotics, we are learning that they have problematic side effects of their own. For example, they are associated with metabolic syndrome, so they cause weight gain, hyperglycemia, increased risk of stroke, sudden cardiac death, blood clots, and diabetes. Maybe these problems are so endemic in the low-income, African American population I treat that I am overly sensitive to trying to prevent these medical disorders while treating a patient’s mental illness. However, my public health leanings have long caused me to think that low-income African Americans are the canary in America’s health status coal mine, as it seems that what hits this group first eventually will hit the majority population. Accordingly, it seems to me that it is well advised to pay attention to this group’s well-being, physical health, and mental health challenges.
Everyone also should be aware that clozapine (Clozaril) had been dubbed the first atypical antipsychotic. But, in some regard, that designation might be given to thioridazine – although some maintain that the ratio of serotonergic to dopamine effects is not strong enough to earn that title. Unfortunately, both thioridazine and clozapine have serious side effects. Thioridazine is associated with severe cardiac arrhythmias, and clozapine has been associated with the aforementioned side effects of atypical antipsychotics but also can cause life-threatening agranulocytosis, necessitating regular white blood cell counts to monitor for this possibility.
, which belongs class of medication known as dibenzodiazepines – a class that is extraordinarily similar to dibenzoxazepine. The late William Glazer, MD, a distinguished psychopharmacologist long affiliated with Yale University, New Haven, Conn., even suggested that loxapine might behave as an atypical antipsychotic (J Clin Psychiatry. 1999;60 Suppl 10:42-6). Extensive clinical experience with loxapine suggests the same but with some key differences from the standard atypical antipsychotics regarding its side-effect profile.
First, loxapine, despite being chemically related to clozapine, does not cause agranulocytosis, so the need for white blood cell monitoring is not necessary. Second, I have not seen the problematic metabolic syndrome caused by standard atypical antipsychotic medication. It amazes me when I see patients on aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone who also have diabetes and are on metformin – especially when the development of the patients’ diabetes can be traced back to when they were put on an atypical antipsychotic. I often find myself taking patients off their atypical antipsychotic and putting them on loxapine, resulting in gradual weight loss while maintaining the patients’ stable mental status and absence of psychotic symptoms.
It seems to me that if clozapine and loxapine are so similar (they both bind to serotonin and dopamine receptors), loxapine should be the first drug of choice for the treatment of psychotic symptoms. It acts like an atypical but without the problems of weight gain, hyperglycemia, increased risk of stroke, sudden cardiac death, blood clots, and diabetes that the atypicals may cause. Most of the hundreds of patients with psychotic symptoms I have treated over the past 40 years are on the low dose of loxapine 25 mg at bedtime (although the prescribing information on loxapine says it has to be given at least twice a day, as the half life of the medication is only 4 hours). In some rare instances, I prescribe a total of 50 mg at bedtime.
So, not prescribing loxapine does not make sense to me – other than the medication is generic and so it is not being marketed aggressively by people who make money from prescribing medication and are practicing money, not medicine. The other possibility is that most psychiatrists might not know the connection between clozapine and loxapine, so I thought I should use my influence (what little I have) to inform.
Dr. Bell is staff psychiatrist at Jackson Park Hospital’s surgical-medical/psychiatric inpatient unit in Chicago; and chairman of the department of psychiatry at Windsor University, St. Kitts. He also is clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (the birthplace of child psychiatry), all in Chicago.
I have always tried to practice common sense psychiatry, however, sometimes it seems I am alone in this pursuit. My best example is the minimal prescribing of loxapine (Adasuve) for treating the problem of psychosis, most notably schizophrenia.
Mind you, neither I nor anyone in family own stock in any pharmaceutical companies. I don’t lecture for them, so I have no conflicts in writing about this observation – which I hope will improve patient care, thereby saving lives and making a difference.
Everyone should be familiar with the evolution of atypical antipsychotics and how these medications are touted as “second-generation” classes of medication advertised as superior to the older, first-generation antipsychotics. However, as we get more experience with the second-generation atypical antipsychotics, we are learning that they have problematic side effects of their own. For example, they are associated with metabolic syndrome, so they cause weight gain, hyperglycemia, increased risk of stroke, sudden cardiac death, blood clots, and diabetes. Maybe these problems are so endemic in the low-income, African American population I treat that I am overly sensitive to trying to prevent these medical disorders while treating a patient’s mental illness. However, my public health leanings have long caused me to think that low-income African Americans are the canary in America’s health status coal mine, as it seems that what hits this group first eventually will hit the majority population. Accordingly, it seems to me that it is well advised to pay attention to this group’s well-being, physical health, and mental health challenges.
Everyone also should be aware that clozapine (Clozaril) had been dubbed the first atypical antipsychotic. But, in some regard, that designation might be given to thioridazine – although some maintain that the ratio of serotonergic to dopamine effects is not strong enough to earn that title. Unfortunately, both thioridazine and clozapine have serious side effects. Thioridazine is associated with severe cardiac arrhythmias, and clozapine has been associated with the aforementioned side effects of atypical antipsychotics but also can cause life-threatening agranulocytosis, necessitating regular white blood cell counts to monitor for this possibility.
, which belongs class of medication known as dibenzodiazepines – a class that is extraordinarily similar to dibenzoxazepine. The late William Glazer, MD, a distinguished psychopharmacologist long affiliated with Yale University, New Haven, Conn., even suggested that loxapine might behave as an atypical antipsychotic (J Clin Psychiatry. 1999;60 Suppl 10:42-6). Extensive clinical experience with loxapine suggests the same but with some key differences from the standard atypical antipsychotics regarding its side-effect profile.
First, loxapine, despite being chemically related to clozapine, does not cause agranulocytosis, so the need for white blood cell monitoring is not necessary. Second, I have not seen the problematic metabolic syndrome caused by standard atypical antipsychotic medication. It amazes me when I see patients on aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone who also have diabetes and are on metformin – especially when the development of the patients’ diabetes can be traced back to when they were put on an atypical antipsychotic. I often find myself taking patients off their atypical antipsychotic and putting them on loxapine, resulting in gradual weight loss while maintaining the patients’ stable mental status and absence of psychotic symptoms.
It seems to me that if clozapine and loxapine are so similar (they both bind to serotonin and dopamine receptors), loxapine should be the first drug of choice for the treatment of psychotic symptoms. It acts like an atypical but without the problems of weight gain, hyperglycemia, increased risk of stroke, sudden cardiac death, blood clots, and diabetes that the atypicals may cause. Most of the hundreds of patients with psychotic symptoms I have treated over the past 40 years are on the low dose of loxapine 25 mg at bedtime (although the prescribing information on loxapine says it has to be given at least twice a day, as the half life of the medication is only 4 hours). In some rare instances, I prescribe a total of 50 mg at bedtime.
So, not prescribing loxapine does not make sense to me – other than the medication is generic and so it is not being marketed aggressively by people who make money from prescribing medication and are practicing money, not medicine. The other possibility is that most psychiatrists might not know the connection between clozapine and loxapine, so I thought I should use my influence (what little I have) to inform.
Dr. Bell is staff psychiatrist at Jackson Park Hospital’s surgical-medical/psychiatric inpatient unit in Chicago; and chairman of the department of psychiatry at Windsor University, St. Kitts. He also is clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (the birthplace of child psychiatry), all in Chicago.
I have always tried to practice common sense psychiatry, however, sometimes it seems I am alone in this pursuit. My best example is the minimal prescribing of loxapine (Adasuve) for treating the problem of psychosis, most notably schizophrenia.
Mind you, neither I nor anyone in family own stock in any pharmaceutical companies. I don’t lecture for them, so I have no conflicts in writing about this observation – which I hope will improve patient care, thereby saving lives and making a difference.
Everyone should be familiar with the evolution of atypical antipsychotics and how these medications are touted as “second-generation” classes of medication advertised as superior to the older, first-generation antipsychotics. However, as we get more experience with the second-generation atypical antipsychotics, we are learning that they have problematic side effects of their own. For example, they are associated with metabolic syndrome, so they cause weight gain, hyperglycemia, increased risk of stroke, sudden cardiac death, blood clots, and diabetes. Maybe these problems are so endemic in the low-income, African American population I treat that I am overly sensitive to trying to prevent these medical disorders while treating a patient’s mental illness. However, my public health leanings have long caused me to think that low-income African Americans are the canary in America’s health status coal mine, as it seems that what hits this group first eventually will hit the majority population. Accordingly, it seems to me that it is well advised to pay attention to this group’s well-being, physical health, and mental health challenges.
Everyone also should be aware that clozapine (Clozaril) had been dubbed the first atypical antipsychotic. But, in some regard, that designation might be given to thioridazine – although some maintain that the ratio of serotonergic to dopamine effects is not strong enough to earn that title. Unfortunately, both thioridazine and clozapine have serious side effects. Thioridazine is associated with severe cardiac arrhythmias, and clozapine has been associated with the aforementioned side effects of atypical antipsychotics but also can cause life-threatening agranulocytosis, necessitating regular white blood cell counts to monitor for this possibility.
, which belongs class of medication known as dibenzodiazepines – a class that is extraordinarily similar to dibenzoxazepine. The late William Glazer, MD, a distinguished psychopharmacologist long affiliated with Yale University, New Haven, Conn., even suggested that loxapine might behave as an atypical antipsychotic (J Clin Psychiatry. 1999;60 Suppl 10:42-6). Extensive clinical experience with loxapine suggests the same but with some key differences from the standard atypical antipsychotics regarding its side-effect profile.
First, loxapine, despite being chemically related to clozapine, does not cause agranulocytosis, so the need for white blood cell monitoring is not necessary. Second, I have not seen the problematic metabolic syndrome caused by standard atypical antipsychotic medication. It amazes me when I see patients on aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone who also have diabetes and are on metformin – especially when the development of the patients’ diabetes can be traced back to when they were put on an atypical antipsychotic. I often find myself taking patients off their atypical antipsychotic and putting them on loxapine, resulting in gradual weight loss while maintaining the patients’ stable mental status and absence of psychotic symptoms.
It seems to me that if clozapine and loxapine are so similar (they both bind to serotonin and dopamine receptors), loxapine should be the first drug of choice for the treatment of psychotic symptoms. It acts like an atypical but without the problems of weight gain, hyperglycemia, increased risk of stroke, sudden cardiac death, blood clots, and diabetes that the atypicals may cause. Most of the hundreds of patients with psychotic symptoms I have treated over the past 40 years are on the low dose of loxapine 25 mg at bedtime (although the prescribing information on loxapine says it has to be given at least twice a day, as the half life of the medication is only 4 hours). In some rare instances, I prescribe a total of 50 mg at bedtime.
So, not prescribing loxapine does not make sense to me – other than the medication is generic and so it is not being marketed aggressively by people who make money from prescribing medication and are practicing money, not medicine. The other possibility is that most psychiatrists might not know the connection between clozapine and loxapine, so I thought I should use my influence (what little I have) to inform.
Dr. Bell is staff psychiatrist at Jackson Park Hospital’s surgical-medical/psychiatric inpatient unit in Chicago; and chairman of the department of psychiatry at Windsor University, St. Kitts. He also is clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (the birthplace of child psychiatry), all in Chicago.
FDA approval of powerful opioid tinged with irony
The timing of the Food and Drug Administration’s Nov. 2 approval of the medication Dsuvia, a sublingual formulation of the synthetic opioid sufentanil, is interesting – to say the least. Dsuvia is a powerful pain medication, said to be 10 times more potent than fentanyl and 1,000 times more potent than morphine. The medication, developed by AcelRx Pharmaceuticals for use in medically supervised settings, has an indication for moderate to severe pain, and is packaged in single-dose applicators.
The chairperson of the FDA’s Anesthetic and Analgesics Drug Product Advisory Committee, Raeford E. Brown Jr., MD, a professor of pediatric anesthesia at the University of Kentucky, Lexington, could not be present Oct. 12 at the committee vote recommending approval. With the consumer advocacy group Public Citizen, Dr. Brown wrote a letter to FDA leaders detailing concerns about the new formulation of sufentanil.
“It is my observation,” Dr. Brown wrote, “that once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the postmarketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been postmarketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market.”
Dr. Brown went on to detail his concerns about sufentanil. In the intravenous formulation, the medication has been in use for more than two decades.
“It is so potent that abusers of this intravenous formulation often die when they inject the first dose; I have witnessed this in resuscitating physicians, medical students, technicians, and other health care providers, some successfully, as a part of my duties as a clinician in a major academic medical center. Because it is so potent, the dosing volume, whether in the IV formulation or the sublingual form, can be quite small. It is thus an extremely divertible drug, and I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market.”
The letter finishes by criticizing the fact that the full Drug Safety and Risk Management Advisory Committee was not invited to the Oct. 12 meeting, and finally, about the ease of diversion among health care professionals – and anesthesiologists in particular.
Meanwhile, Scott Gottlieb, MD, commissioner of the FDA, posted a lengthy explanation on the organization’s website on Nov. 2, after the vote. In his statement on the agency’s approval of Dsuvia and the FDA’s future consideration of new opioids, Dr. Gottlieb explains: “To address concerns about the potential risks associated with Dsuvia, this product will have strong limitations on its use. It can’t be dispensed to patients for home use and should not be used for more than 72 hours. And it should only be administered by a health care provider using a single-dose applicator. That means it won’t be available at retail pharmacies for patients to take home. These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse of Dsuvia, as well reduce the potential for diversion. Because of the risks of addiction, abuse, and misuse with opioids, Dsuvia also is to be reserved for use in patients for whom alternative pain treatment options have not been tolerated, or are not expected to be tolerated, where existing treatment options have not provided adequate analgesia, or where these alternatives are not expected to provide adequate analgesia.”
In addition to the statement posted on the FDA’s website, Dr. Gottlieb made the approval of Dsuvia the topic of his weekly #SundayTweetorial on Nov. 4. In this venue, Dr. Gottlieb posts tweets on a single topic. On both Twitter and the FDA website, he noted that a major factor in the approval of Dsuvia was advantages it might convey for pain control to soldiers on the battlefield, where oral medications might take time to work and intravenous access might not be possible.
One tweet read: “Whether there’s a need for another powerful opioid in the throes of a massive crisis of addiction is a critical question. As a public health agency, we have an obligation to address this question for patients with pain, for the addiction crisis, for innovators, for all Americans.”
Another tweet stated, “While Dsuvia brings another highly potent opioid to market it fulfills a limited, unmet medical need in treating our nation’s soldiers on the battlefield. That’s why the Pentagon worked closely with the sponsor on developing Dsuvia. FDA committed to prioritize needs of our troops.”
in possible deaths from misdirected use of a very potent agent. And while the new opioid may have been geared toward unmet military needs, Dsuvia will be available for use in civilian medical facilities as well.
There is some irony to the idea that a pharmaceutical company would continue to develop opioids when there is so much need for nonaddictive agents for pain control and so much pressure on physicians to limit access of opiates to pain patients. We are left to stand by and watch as yet another potent opioid preparation is introduced.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.
The timing of the Food and Drug Administration’s Nov. 2 approval of the medication Dsuvia, a sublingual formulation of the synthetic opioid sufentanil, is interesting – to say the least. Dsuvia is a powerful pain medication, said to be 10 times more potent than fentanyl and 1,000 times more potent than morphine. The medication, developed by AcelRx Pharmaceuticals for use in medically supervised settings, has an indication for moderate to severe pain, and is packaged in single-dose applicators.
The chairperson of the FDA’s Anesthetic and Analgesics Drug Product Advisory Committee, Raeford E. Brown Jr., MD, a professor of pediatric anesthesia at the University of Kentucky, Lexington, could not be present Oct. 12 at the committee vote recommending approval. With the consumer advocacy group Public Citizen, Dr. Brown wrote a letter to FDA leaders detailing concerns about the new formulation of sufentanil.
“It is my observation,” Dr. Brown wrote, “that once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the postmarketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been postmarketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market.”
Dr. Brown went on to detail his concerns about sufentanil. In the intravenous formulation, the medication has been in use for more than two decades.
“It is so potent that abusers of this intravenous formulation often die when they inject the first dose; I have witnessed this in resuscitating physicians, medical students, technicians, and other health care providers, some successfully, as a part of my duties as a clinician in a major academic medical center. Because it is so potent, the dosing volume, whether in the IV formulation or the sublingual form, can be quite small. It is thus an extremely divertible drug, and I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market.”
The letter finishes by criticizing the fact that the full Drug Safety and Risk Management Advisory Committee was not invited to the Oct. 12 meeting, and finally, about the ease of diversion among health care professionals – and anesthesiologists in particular.
Meanwhile, Scott Gottlieb, MD, commissioner of the FDA, posted a lengthy explanation on the organization’s website on Nov. 2, after the vote. In his statement on the agency’s approval of Dsuvia and the FDA’s future consideration of new opioids, Dr. Gottlieb explains: “To address concerns about the potential risks associated with Dsuvia, this product will have strong limitations on its use. It can’t be dispensed to patients for home use and should not be used for more than 72 hours. And it should only be administered by a health care provider using a single-dose applicator. That means it won’t be available at retail pharmacies for patients to take home. These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse of Dsuvia, as well reduce the potential for diversion. Because of the risks of addiction, abuse, and misuse with opioids, Dsuvia also is to be reserved for use in patients for whom alternative pain treatment options have not been tolerated, or are not expected to be tolerated, where existing treatment options have not provided adequate analgesia, or where these alternatives are not expected to provide adequate analgesia.”
In addition to the statement posted on the FDA’s website, Dr. Gottlieb made the approval of Dsuvia the topic of his weekly #SundayTweetorial on Nov. 4. In this venue, Dr. Gottlieb posts tweets on a single topic. On both Twitter and the FDA website, he noted that a major factor in the approval of Dsuvia was advantages it might convey for pain control to soldiers on the battlefield, where oral medications might take time to work and intravenous access might not be possible.
One tweet read: “Whether there’s a need for another powerful opioid in the throes of a massive crisis of addiction is a critical question. As a public health agency, we have an obligation to address this question for patients with pain, for the addiction crisis, for innovators, for all Americans.”
Another tweet stated, “While Dsuvia brings another highly potent opioid to market it fulfills a limited, unmet medical need in treating our nation’s soldiers on the battlefield. That’s why the Pentagon worked closely with the sponsor on developing Dsuvia. FDA committed to prioritize needs of our troops.”
in possible deaths from misdirected use of a very potent agent. And while the new opioid may have been geared toward unmet military needs, Dsuvia will be available for use in civilian medical facilities as well.
There is some irony to the idea that a pharmaceutical company would continue to develop opioids when there is so much need for nonaddictive agents for pain control and so much pressure on physicians to limit access of opiates to pain patients. We are left to stand by and watch as yet another potent opioid preparation is introduced.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.
The timing of the Food and Drug Administration’s Nov. 2 approval of the medication Dsuvia, a sublingual formulation of the synthetic opioid sufentanil, is interesting – to say the least. Dsuvia is a powerful pain medication, said to be 10 times more potent than fentanyl and 1,000 times more potent than morphine. The medication, developed by AcelRx Pharmaceuticals for use in medically supervised settings, has an indication for moderate to severe pain, and is packaged in single-dose applicators.
The chairperson of the FDA’s Anesthetic and Analgesics Drug Product Advisory Committee, Raeford E. Brown Jr., MD, a professor of pediatric anesthesia at the University of Kentucky, Lexington, could not be present Oct. 12 at the committee vote recommending approval. With the consumer advocacy group Public Citizen, Dr. Brown wrote a letter to FDA leaders detailing concerns about the new formulation of sufentanil.
“It is my observation,” Dr. Brown wrote, “that once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the postmarketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been postmarketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market.”
Dr. Brown went on to detail his concerns about sufentanil. In the intravenous formulation, the medication has been in use for more than two decades.
“It is so potent that abusers of this intravenous formulation often die when they inject the first dose; I have witnessed this in resuscitating physicians, medical students, technicians, and other health care providers, some successfully, as a part of my duties as a clinician in a major academic medical center. Because it is so potent, the dosing volume, whether in the IV formulation or the sublingual form, can be quite small. It is thus an extremely divertible drug, and I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market.”
The letter finishes by criticizing the fact that the full Drug Safety and Risk Management Advisory Committee was not invited to the Oct. 12 meeting, and finally, about the ease of diversion among health care professionals – and anesthesiologists in particular.
Meanwhile, Scott Gottlieb, MD, commissioner of the FDA, posted a lengthy explanation on the organization’s website on Nov. 2, after the vote. In his statement on the agency’s approval of Dsuvia and the FDA’s future consideration of new opioids, Dr. Gottlieb explains: “To address concerns about the potential risks associated with Dsuvia, this product will have strong limitations on its use. It can’t be dispensed to patients for home use and should not be used for more than 72 hours. And it should only be administered by a health care provider using a single-dose applicator. That means it won’t be available at retail pharmacies for patients to take home. These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse of Dsuvia, as well reduce the potential for diversion. Because of the risks of addiction, abuse, and misuse with opioids, Dsuvia also is to be reserved for use in patients for whom alternative pain treatment options have not been tolerated, or are not expected to be tolerated, where existing treatment options have not provided adequate analgesia, or where these alternatives are not expected to provide adequate analgesia.”
In addition to the statement posted on the FDA’s website, Dr. Gottlieb made the approval of Dsuvia the topic of his weekly #SundayTweetorial on Nov. 4. In this venue, Dr. Gottlieb posts tweets on a single topic. On both Twitter and the FDA website, he noted that a major factor in the approval of Dsuvia was advantages it might convey for pain control to soldiers on the battlefield, where oral medications might take time to work and intravenous access might not be possible.
One tweet read: “Whether there’s a need for another powerful opioid in the throes of a massive crisis of addiction is a critical question. As a public health agency, we have an obligation to address this question for patients with pain, for the addiction crisis, for innovators, for all Americans.”
Another tweet stated, “While Dsuvia brings another highly potent opioid to market it fulfills a limited, unmet medical need in treating our nation’s soldiers on the battlefield. That’s why the Pentagon worked closely with the sponsor on developing Dsuvia. FDA committed to prioritize needs of our troops.”
in possible deaths from misdirected use of a very potent agent. And while the new opioid may have been geared toward unmet military needs, Dsuvia will be available for use in civilian medical facilities as well.
There is some irony to the idea that a pharmaceutical company would continue to develop opioids when there is so much need for nonaddictive agents for pain control and so much pressure on physicians to limit access of opiates to pain patients. We are left to stand by and watch as yet another potent opioid preparation is introduced.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.
Are you an optimist or pessimist?
“I’m fine. How are your kids?”
“They’re doing great, but we miss you. It hasn’t been the same at that group since you retired.”
I thanked her for her kind words. But the truth is that there were certainly physicians remaining at that practice who were at least as skillful and probably more caring than I had been. However, they were being increasingly challenged by an organization that struggled with how to be customer friendly and patient centered although it claimed to be both.
It must have been 8 years since I first met this young woman. She had just delivered her first child and was finishing her last year of family practice residency. In the nearly a decade since I had last spoken to her, she had worked in a couple primary care practices and was now the administrator of a rehabilitation facility. She described the all too common scenario of spending hours at home trying to complete her charting when she was doing primary care. Now she spends a good chunk of her time on the phone arguing with insurance companies trying to get coverage for her aging patients.
As she told me how frustrated she was with her current job and how pessimistic she was about the future of health care in this country, I realized that it wasn’t me that she really missed. I, and my old practice, are just examples of what primary care used to be.
As I walked home from the grocery store after our encounter, I wondered how deeply I shared her pessimism. We mostly talked about how bad things have gotten now. But we didn’t talk much about where we thought the state of health care in the Unite States was headed.
Are you an optimist or a pessimist? To what degree will your answer to be colored by your career trajectory? Would you tell a young person that you think our health care system is so messed up that you would discourage them from becoming a physician because the work environment is becoming increasingly toxic?
Or would you acknowledge that health care in this country is going through a difficult time, but the potential reward of knowing that every day you have helped, or at least tried to help, someone is worth riding out storm?
For a moment, step back from your narrow focus as a health care provider. What would you tell a 40-something father of two children who is worried about what health care is going to look like when he is as old as his parents are now?
If you have come down on the positive side of this coin, where are the solutions going to come from? Is technology going to come up with the answers? Is a nationwide electronic medical record system that allows all providers to communicate seamlessly with each other a realistic possibility? Will physicians and patients eventually adapt to and accept a new reality in which health care providers are primarily technicians following algorithms generated by a team of scientists and payers?
Or will we continue to muddle along and hope that our system will get over the hiccups and arrive at some political solution? I am eager to hear what you think. ... and feel.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
“I’m fine. How are your kids?”
“They’re doing great, but we miss you. It hasn’t been the same at that group since you retired.”
I thanked her for her kind words. But the truth is that there were certainly physicians remaining at that practice who were at least as skillful and probably more caring than I had been. However, they were being increasingly challenged by an organization that struggled with how to be customer friendly and patient centered although it claimed to be both.
It must have been 8 years since I first met this young woman. She had just delivered her first child and was finishing her last year of family practice residency. In the nearly a decade since I had last spoken to her, she had worked in a couple primary care practices and was now the administrator of a rehabilitation facility. She described the all too common scenario of spending hours at home trying to complete her charting when she was doing primary care. Now she spends a good chunk of her time on the phone arguing with insurance companies trying to get coverage for her aging patients.
As she told me how frustrated she was with her current job and how pessimistic she was about the future of health care in this country, I realized that it wasn’t me that she really missed. I, and my old practice, are just examples of what primary care used to be.
As I walked home from the grocery store after our encounter, I wondered how deeply I shared her pessimism. We mostly talked about how bad things have gotten now. But we didn’t talk much about where we thought the state of health care in the Unite States was headed.
Are you an optimist or a pessimist? To what degree will your answer to be colored by your career trajectory? Would you tell a young person that you think our health care system is so messed up that you would discourage them from becoming a physician because the work environment is becoming increasingly toxic?
Or would you acknowledge that health care in this country is going through a difficult time, but the potential reward of knowing that every day you have helped, or at least tried to help, someone is worth riding out storm?
For a moment, step back from your narrow focus as a health care provider. What would you tell a 40-something father of two children who is worried about what health care is going to look like when he is as old as his parents are now?
If you have come down on the positive side of this coin, where are the solutions going to come from? Is technology going to come up with the answers? Is a nationwide electronic medical record system that allows all providers to communicate seamlessly with each other a realistic possibility? Will physicians and patients eventually adapt to and accept a new reality in which health care providers are primarily technicians following algorithms generated by a team of scientists and payers?
Or will we continue to muddle along and hope that our system will get over the hiccups and arrive at some political solution? I am eager to hear what you think. ... and feel.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
“I’m fine. How are your kids?”
“They’re doing great, but we miss you. It hasn’t been the same at that group since you retired.”
I thanked her for her kind words. But the truth is that there were certainly physicians remaining at that practice who were at least as skillful and probably more caring than I had been. However, they were being increasingly challenged by an organization that struggled with how to be customer friendly and patient centered although it claimed to be both.
It must have been 8 years since I first met this young woman. She had just delivered her first child and was finishing her last year of family practice residency. In the nearly a decade since I had last spoken to her, she had worked in a couple primary care practices and was now the administrator of a rehabilitation facility. She described the all too common scenario of spending hours at home trying to complete her charting when she was doing primary care. Now she spends a good chunk of her time on the phone arguing with insurance companies trying to get coverage for her aging patients.
As she told me how frustrated she was with her current job and how pessimistic she was about the future of health care in this country, I realized that it wasn’t me that she really missed. I, and my old practice, are just examples of what primary care used to be.
As I walked home from the grocery store after our encounter, I wondered how deeply I shared her pessimism. We mostly talked about how bad things have gotten now. But we didn’t talk much about where we thought the state of health care in the Unite States was headed.
Are you an optimist or a pessimist? To what degree will your answer to be colored by your career trajectory? Would you tell a young person that you think our health care system is so messed up that you would discourage them from becoming a physician because the work environment is becoming increasingly toxic?
Or would you acknowledge that health care in this country is going through a difficult time, but the potential reward of knowing that every day you have helped, or at least tried to help, someone is worth riding out storm?
For a moment, step back from your narrow focus as a health care provider. What would you tell a 40-something father of two children who is worried about what health care is going to look like when he is as old as his parents are now?
If you have come down on the positive side of this coin, where are the solutions going to come from? Is technology going to come up with the answers? Is a nationwide electronic medical record system that allows all providers to communicate seamlessly with each other a realistic possibility? Will physicians and patients eventually adapt to and accept a new reality in which health care providers are primarily technicians following algorithms generated by a team of scientists and payers?
Or will we continue to muddle along and hope that our system will get over the hiccups and arrive at some political solution? I am eager to hear what you think. ... and feel.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Did I really say that?
Unless you decide to start a second career as an expert witness, giving a deposition is a challenge you should avoid at all costs. I have given a few depositions myself, as both a defendant and a witness, and I have reviewed a dozen or more as a consultant for a local law firm. It is an unnatural and artificial format for transferring information. You will survive the depositions rigid and arbitrary rules only by listening to and following your lawyer’s coaching both before and during the deposition. Hopefully you never will be deposed. However,
First, in a deposition every word you utter is recorded. There are no second chances to edit or clarify what you have said. Your words must be carefully chosen. Several times each year I encounter the parent of a former patient in the grocery store who quotes to me some advice they claim I gave them 2 or 3 decades ago. Although I can imagine that I might have voiced the message they are remembering, sometimes I have to cringe at the bluntness and the crude choice of words they are attributing to me. Obviously, I got away with my fast and loose handling of the English language most of the time and am flattered that it was memorable. But I wonder how often I offended a family with my shoot-from-the-hip advice.
In a similar vein, I found that one of the benefits of having medical students shadow me around the office was that their presence forced me to listen to myself. Did I really say that? How sloppy had I gotten in my explanations to parents and patients? Having another pair of ears in the office can be like having a court stenographer at your deposition.
The situation can be particularly insidious when a parent asks what you take to be a rhetorical question or more likely makes a statement that is incorrect, but you fail to correct it because it is off topic and you are in a hurry to get to the next exam room. If in a deposition the plaintiff’s lawyer prefaces a question with “We all know that sugar makes children hyper,” before you leap over his preface and give your answer you should respond that you are unaware of any scientific evidence that supports his assertion. But if a parent offhandedly mentions that his child was on a “sugar high” you might not take the time to disagree because the parent’s observation had no significance to the history he was relating. However, the parent could interpret from your silence that you believe sugar causes hyperactivity.
Of course the volume of old wives tales, urban legends, and chat room myths that float by you in the office every day makes it impractical to counter every bit of misinformation we hear. But the rules of deposition should remind us that our failure to disagree might sometimes be interpreted as an agreement.
One of the more difficult concepts challenging the deposed physician is avoiding the too much information trap. Your answers in a deposition should be simple and to the point. Physicians are trained to teach. How often are we clouding the answers the patients want by trying to impress them with our breadth of knowledge and command of scientific language?
Although you may have a scribe helping you craft your electronic medical records, hopefully he or she won’t be a court stenographer. And even more fortunately, most patients and parents aren’t listening to every word you say. But from time to time, it helps to pretend you are being deposed. Or at least take a moment to listen to what you have been saying.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Unless you decide to start a second career as an expert witness, giving a deposition is a challenge you should avoid at all costs. I have given a few depositions myself, as both a defendant and a witness, and I have reviewed a dozen or more as a consultant for a local law firm. It is an unnatural and artificial format for transferring information. You will survive the depositions rigid and arbitrary rules only by listening to and following your lawyer’s coaching both before and during the deposition. Hopefully you never will be deposed. However,
First, in a deposition every word you utter is recorded. There are no second chances to edit or clarify what you have said. Your words must be carefully chosen. Several times each year I encounter the parent of a former patient in the grocery store who quotes to me some advice they claim I gave them 2 or 3 decades ago. Although I can imagine that I might have voiced the message they are remembering, sometimes I have to cringe at the bluntness and the crude choice of words they are attributing to me. Obviously, I got away with my fast and loose handling of the English language most of the time and am flattered that it was memorable. But I wonder how often I offended a family with my shoot-from-the-hip advice.
In a similar vein, I found that one of the benefits of having medical students shadow me around the office was that their presence forced me to listen to myself. Did I really say that? How sloppy had I gotten in my explanations to parents and patients? Having another pair of ears in the office can be like having a court stenographer at your deposition.
The situation can be particularly insidious when a parent asks what you take to be a rhetorical question or more likely makes a statement that is incorrect, but you fail to correct it because it is off topic and you are in a hurry to get to the next exam room. If in a deposition the plaintiff’s lawyer prefaces a question with “We all know that sugar makes children hyper,” before you leap over his preface and give your answer you should respond that you are unaware of any scientific evidence that supports his assertion. But if a parent offhandedly mentions that his child was on a “sugar high” you might not take the time to disagree because the parent’s observation had no significance to the history he was relating. However, the parent could interpret from your silence that you believe sugar causes hyperactivity.
Of course the volume of old wives tales, urban legends, and chat room myths that float by you in the office every day makes it impractical to counter every bit of misinformation we hear. But the rules of deposition should remind us that our failure to disagree might sometimes be interpreted as an agreement.
One of the more difficult concepts challenging the deposed physician is avoiding the too much information trap. Your answers in a deposition should be simple and to the point. Physicians are trained to teach. How often are we clouding the answers the patients want by trying to impress them with our breadth of knowledge and command of scientific language?
Although you may have a scribe helping you craft your electronic medical records, hopefully he or she won’t be a court stenographer. And even more fortunately, most patients and parents aren’t listening to every word you say. But from time to time, it helps to pretend you are being deposed. Or at least take a moment to listen to what you have been saying.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Unless you decide to start a second career as an expert witness, giving a deposition is a challenge you should avoid at all costs. I have given a few depositions myself, as both a defendant and a witness, and I have reviewed a dozen or more as a consultant for a local law firm. It is an unnatural and artificial format for transferring information. You will survive the depositions rigid and arbitrary rules only by listening to and following your lawyer’s coaching both before and during the deposition. Hopefully you never will be deposed. However,
First, in a deposition every word you utter is recorded. There are no second chances to edit or clarify what you have said. Your words must be carefully chosen. Several times each year I encounter the parent of a former patient in the grocery store who quotes to me some advice they claim I gave them 2 or 3 decades ago. Although I can imagine that I might have voiced the message they are remembering, sometimes I have to cringe at the bluntness and the crude choice of words they are attributing to me. Obviously, I got away with my fast and loose handling of the English language most of the time and am flattered that it was memorable. But I wonder how often I offended a family with my shoot-from-the-hip advice.
In a similar vein, I found that one of the benefits of having medical students shadow me around the office was that their presence forced me to listen to myself. Did I really say that? How sloppy had I gotten in my explanations to parents and patients? Having another pair of ears in the office can be like having a court stenographer at your deposition.
The situation can be particularly insidious when a parent asks what you take to be a rhetorical question or more likely makes a statement that is incorrect, but you fail to correct it because it is off topic and you are in a hurry to get to the next exam room. If in a deposition the plaintiff’s lawyer prefaces a question with “We all know that sugar makes children hyper,” before you leap over his preface and give your answer you should respond that you are unaware of any scientific evidence that supports his assertion. But if a parent offhandedly mentions that his child was on a “sugar high” you might not take the time to disagree because the parent’s observation had no significance to the history he was relating. However, the parent could interpret from your silence that you believe sugar causes hyperactivity.
Of course the volume of old wives tales, urban legends, and chat room myths that float by you in the office every day makes it impractical to counter every bit of misinformation we hear. But the rules of deposition should remind us that our failure to disagree might sometimes be interpreted as an agreement.
One of the more difficult concepts challenging the deposed physician is avoiding the too much information trap. Your answers in a deposition should be simple and to the point. Physicians are trained to teach. How often are we clouding the answers the patients want by trying to impress them with our breadth of knowledge and command of scientific language?
Although you may have a scribe helping you craft your electronic medical records, hopefully he or she won’t be a court stenographer. And even more fortunately, most patients and parents aren’t listening to every word you say. But from time to time, it helps to pretend you are being deposed. Or at least take a moment to listen to what you have been saying.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Information overload
The evening James Wu (not his real name) learned he had leukemia, he asked his nurse to please get his doctor. There was something important he had to ask her.
“I have this mole. On my back.” He squirmed anxiously. “Doctor, is it dangerous?”
James did have something dangerous – though it had nothing to do with a skin blemish he’d had his whole life. Earlier that day, I had pulled up a chair and told him we had final results from the bone marrow biopsy I had done the day before. It was unfortunately what we suspected. James had cancer. It was a type of cancer called acute lymphoblastic leukemia, a cancer of the blood.
James had said nothing. He looked down, shocked, and crestfallen. Even though we had planted the seeds early that this was likely cancer, the confirmation is always heartbreaking. It closes the door on optimism, shutting out the slim hope that it could be something else. Anything else.
I could have said more. But I waited.
We could go on, spelling out the next steps and treatment options. But patients usually don’t retain it. The details don’t mean anything right now.
Instead, I usually just hint at what’s to come. Most importantly, I reassure them that we are with them now, every step of the way. This will be a road we’ll walk together.
It was silent for a while. Finally, James spoke.
“OK,” he said. “So … it’s not something in my diet?”
“No. It’s a leukemia.”
“It cannot be related to stress?”
“No. You did nothing to cause this.”
For most, it’s a process. After dropping the diagnostic bomb, treatment is another conversation. Prognosis another. If I have the luxury of continuity, I try to carve the information into chunks, giving patients time to process each piece.
This felt especially salient for James, who was in his mid-30s and had never even been in a hospital before, much less dealt with a serious diagnosis. His grandparents had died of “old age,” and no one in his family had been sick. He had never interacted with the health care system in a meaningful way. Even words like chemotherapy seemed beyond him, existing in a different world from the one he lived in. Cancer was abstract.
“Would I be awake during chemotherapy?”
“Yes. Completely.”
James had a wife, a 2-year-old, and a full-time job. Watching his daughter aimlessly wander around the hospital room, I wondered, were they planning on having more children? We could get the fertility specialist to see him before starting chemotherapy.
I looked at his nightstand, where his laptop was open to data-packed spreadsheets, and I wondered what his work meant for him. Would he want to continue working through his treatment? We could have our social worker write a letter to his employer.
There would be time for all of that. Later.
I said that, for tonight, there would be nothing else. Tomorrow, we would do an ultrasound of his heart and arrange for a special IV to administer chemotherapy. Then, I would come back, and we would talk about the treatment, and what it all means, in a lot more detail.
I asked James if he had any questions right now. As expected, he said no. Until a few hours later, when I was called about his very important question.
That day, looking into the terrified face of a previously healthy 30-something-year-old, I could see the future. I could see the month-long hospital stay. The chemotherapy would kill his immune system, he would get fevers, and bacteria would grow in his bloodstream. He’d get short of breath and we’d find fungus growing in his lungs. He’d take an antifungal and it would make him hallucinate. Maybe he’d spend a few days in the ICU, requiring a large catheter in his neck just to maintain his blood pressure. He would bleed; we would transfuse him with blood. He would get so many bone marrow biopsies and lumbar punctures that his skin would be marked, and he would tell each proceduralist where to go. It would be months of treatment. And then miraculously, it would go into remission. He would celebrate; his wife would cry. Maybe he’d get a bone marrow transplant; we’d find out his brother was a match, and he’d fly in from thousands of miles away. He would get graft-versus-host disease, and his skin would harden. And even after all of that, even if his bone marrow was clear of disease, he would not say he was “cured.” He would live in fear of this because he would know how likely it was to relapse. Maybe in a few months, maybe in a few years. Every cough would be a catastrophe. Every ache a fear of the worst. He would become intimately familiar with words like minimal residual disease and neutropenia, frequent the message boards, and always have a bag packed in case he needed to come back to the hospital. Everything else, from that moment on, would come in second place.
There, then, with his toddler playfully tugging at his hospital gown, I said none of that.
Instead, I examined his back. I told him his mole looked fine.
“Wow,” he breathed a long sigh of relief. “Thank you, doctor. That’s good news.”
Certain details of this story were modified slightly to protect privacy.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
The evening James Wu (not his real name) learned he had leukemia, he asked his nurse to please get his doctor. There was something important he had to ask her.
“I have this mole. On my back.” He squirmed anxiously. “Doctor, is it dangerous?”
James did have something dangerous – though it had nothing to do with a skin blemish he’d had his whole life. Earlier that day, I had pulled up a chair and told him we had final results from the bone marrow biopsy I had done the day before. It was unfortunately what we suspected. James had cancer. It was a type of cancer called acute lymphoblastic leukemia, a cancer of the blood.
James had said nothing. He looked down, shocked, and crestfallen. Even though we had planted the seeds early that this was likely cancer, the confirmation is always heartbreaking. It closes the door on optimism, shutting out the slim hope that it could be something else. Anything else.
I could have said more. But I waited.
We could go on, spelling out the next steps and treatment options. But patients usually don’t retain it. The details don’t mean anything right now.
Instead, I usually just hint at what’s to come. Most importantly, I reassure them that we are with them now, every step of the way. This will be a road we’ll walk together.
It was silent for a while. Finally, James spoke.
“OK,” he said. “So … it’s not something in my diet?”
“No. It’s a leukemia.”
“It cannot be related to stress?”
“No. You did nothing to cause this.”
For most, it’s a process. After dropping the diagnostic bomb, treatment is another conversation. Prognosis another. If I have the luxury of continuity, I try to carve the information into chunks, giving patients time to process each piece.
This felt especially salient for James, who was in his mid-30s and had never even been in a hospital before, much less dealt with a serious diagnosis. His grandparents had died of “old age,” and no one in his family had been sick. He had never interacted with the health care system in a meaningful way. Even words like chemotherapy seemed beyond him, existing in a different world from the one he lived in. Cancer was abstract.
“Would I be awake during chemotherapy?”
“Yes. Completely.”
James had a wife, a 2-year-old, and a full-time job. Watching his daughter aimlessly wander around the hospital room, I wondered, were they planning on having more children? We could get the fertility specialist to see him before starting chemotherapy.
I looked at his nightstand, where his laptop was open to data-packed spreadsheets, and I wondered what his work meant for him. Would he want to continue working through his treatment? We could have our social worker write a letter to his employer.
There would be time for all of that. Later.
I said that, for tonight, there would be nothing else. Tomorrow, we would do an ultrasound of his heart and arrange for a special IV to administer chemotherapy. Then, I would come back, and we would talk about the treatment, and what it all means, in a lot more detail.
I asked James if he had any questions right now. As expected, he said no. Until a few hours later, when I was called about his very important question.
That day, looking into the terrified face of a previously healthy 30-something-year-old, I could see the future. I could see the month-long hospital stay. The chemotherapy would kill his immune system, he would get fevers, and bacteria would grow in his bloodstream. He’d get short of breath and we’d find fungus growing in his lungs. He’d take an antifungal and it would make him hallucinate. Maybe he’d spend a few days in the ICU, requiring a large catheter in his neck just to maintain his blood pressure. He would bleed; we would transfuse him with blood. He would get so many bone marrow biopsies and lumbar punctures that his skin would be marked, and he would tell each proceduralist where to go. It would be months of treatment. And then miraculously, it would go into remission. He would celebrate; his wife would cry. Maybe he’d get a bone marrow transplant; we’d find out his brother was a match, and he’d fly in from thousands of miles away. He would get graft-versus-host disease, and his skin would harden. And even after all of that, even if his bone marrow was clear of disease, he would not say he was “cured.” He would live in fear of this because he would know how likely it was to relapse. Maybe in a few months, maybe in a few years. Every cough would be a catastrophe. Every ache a fear of the worst. He would become intimately familiar with words like minimal residual disease and neutropenia, frequent the message boards, and always have a bag packed in case he needed to come back to the hospital. Everything else, from that moment on, would come in second place.
There, then, with his toddler playfully tugging at his hospital gown, I said none of that.
Instead, I examined his back. I told him his mole looked fine.
“Wow,” he breathed a long sigh of relief. “Thank you, doctor. That’s good news.”
Certain details of this story were modified slightly to protect privacy.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
The evening James Wu (not his real name) learned he had leukemia, he asked his nurse to please get his doctor. There was something important he had to ask her.
“I have this mole. On my back.” He squirmed anxiously. “Doctor, is it dangerous?”
James did have something dangerous – though it had nothing to do with a skin blemish he’d had his whole life. Earlier that day, I had pulled up a chair and told him we had final results from the bone marrow biopsy I had done the day before. It was unfortunately what we suspected. James had cancer. It was a type of cancer called acute lymphoblastic leukemia, a cancer of the blood.
James had said nothing. He looked down, shocked, and crestfallen. Even though we had planted the seeds early that this was likely cancer, the confirmation is always heartbreaking. It closes the door on optimism, shutting out the slim hope that it could be something else. Anything else.
I could have said more. But I waited.
We could go on, spelling out the next steps and treatment options. But patients usually don’t retain it. The details don’t mean anything right now.
Instead, I usually just hint at what’s to come. Most importantly, I reassure them that we are with them now, every step of the way. This will be a road we’ll walk together.
It was silent for a while. Finally, James spoke.
“OK,” he said. “So … it’s not something in my diet?”
“No. It’s a leukemia.”
“It cannot be related to stress?”
“No. You did nothing to cause this.”
For most, it’s a process. After dropping the diagnostic bomb, treatment is another conversation. Prognosis another. If I have the luxury of continuity, I try to carve the information into chunks, giving patients time to process each piece.
This felt especially salient for James, who was in his mid-30s and had never even been in a hospital before, much less dealt with a serious diagnosis. His grandparents had died of “old age,” and no one in his family had been sick. He had never interacted with the health care system in a meaningful way. Even words like chemotherapy seemed beyond him, existing in a different world from the one he lived in. Cancer was abstract.
“Would I be awake during chemotherapy?”
“Yes. Completely.”
James had a wife, a 2-year-old, and a full-time job. Watching his daughter aimlessly wander around the hospital room, I wondered, were they planning on having more children? We could get the fertility specialist to see him before starting chemotherapy.
I looked at his nightstand, where his laptop was open to data-packed spreadsheets, and I wondered what his work meant for him. Would he want to continue working through his treatment? We could have our social worker write a letter to his employer.
There would be time for all of that. Later.
I said that, for tonight, there would be nothing else. Tomorrow, we would do an ultrasound of his heart and arrange for a special IV to administer chemotherapy. Then, I would come back, and we would talk about the treatment, and what it all means, in a lot more detail.
I asked James if he had any questions right now. As expected, he said no. Until a few hours later, when I was called about his very important question.
That day, looking into the terrified face of a previously healthy 30-something-year-old, I could see the future. I could see the month-long hospital stay. The chemotherapy would kill his immune system, he would get fevers, and bacteria would grow in his bloodstream. He’d get short of breath and we’d find fungus growing in his lungs. He’d take an antifungal and it would make him hallucinate. Maybe he’d spend a few days in the ICU, requiring a large catheter in his neck just to maintain his blood pressure. He would bleed; we would transfuse him with blood. He would get so many bone marrow biopsies and lumbar punctures that his skin would be marked, and he would tell each proceduralist where to go. It would be months of treatment. And then miraculously, it would go into remission. He would celebrate; his wife would cry. Maybe he’d get a bone marrow transplant; we’d find out his brother was a match, and he’d fly in from thousands of miles away. He would get graft-versus-host disease, and his skin would harden. And even after all of that, even if his bone marrow was clear of disease, he would not say he was “cured.” He would live in fear of this because he would know how likely it was to relapse. Maybe in a few months, maybe in a few years. Every cough would be a catastrophe. Every ache a fear of the worst. He would become intimately familiar with words like minimal residual disease and neutropenia, frequent the message boards, and always have a bag packed in case he needed to come back to the hospital. Everything else, from that moment on, would come in second place.
There, then, with his toddler playfully tugging at his hospital gown, I said none of that.
Instead, I examined his back. I told him his mole looked fine.
“Wow,” he breathed a long sigh of relief. “Thank you, doctor. That’s good news.”
Certain details of this story were modified slightly to protect privacy.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
Taurine
Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.1
Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.3 And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,1,4 and is noted for conferring antiaging benefits.5
Acne and other inflammatory conditions
The use of .6,7
In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H2O2 production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.3
Wide-ranging protection potential
In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.2
Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.1
Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.8
Penetration enhancement
In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.9
Possible skin whitening and anti-aging roles and other promising lab results
Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.10
In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.5
Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.11
In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.4
Conclusion
Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
References
1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.
2. J Invest Dermatol. 2003 Aug;121(2):354-61.
3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.
4. Adv Biomed Res. 2014 Oct 7;3:204.
5. Adv Exp Med Biol. 2015;803:481-7.
6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.
7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.
8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.
9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.
10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.
11. Adv Exp Med Biol. 2015;803:167-77.
Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.1
Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.3 And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,1,4 and is noted for conferring antiaging benefits.5
Acne and other inflammatory conditions
The use of .6,7
In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H2O2 production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.3
Wide-ranging protection potential
In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.2
Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.1
Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.8
Penetration enhancement
In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.9
Possible skin whitening and anti-aging roles and other promising lab results
Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.10
In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.5
Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.11
In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.4
Conclusion
Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
References
1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.
2. J Invest Dermatol. 2003 Aug;121(2):354-61.
3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.
4. Adv Biomed Res. 2014 Oct 7;3:204.
5. Adv Exp Med Biol. 2015;803:481-7.
6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.
7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.
8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.
9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.
10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.
11. Adv Exp Med Biol. 2015;803:167-77.
Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.1
Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.3 And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,1,4 and is noted for conferring antiaging benefits.5
Acne and other inflammatory conditions
The use of .6,7
In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H2O2 production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.3
Wide-ranging protection potential
In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.2
Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.1
Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.8
Penetration enhancement
In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.9
Possible skin whitening and anti-aging roles and other promising lab results
Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.10
In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.5
Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.11
In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.4
Conclusion
Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
References
1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.
2. J Invest Dermatol. 2003 Aug;121(2):354-61.
3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.
4. Adv Biomed Res. 2014 Oct 7;3:204.
5. Adv Exp Med Biol. 2015;803:481-7.
6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.
7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.
8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.
9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.
10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.
11. Adv Exp Med Biol. 2015;803:167-77.
Where to go with wearables
On Sept. 14 of this year, Apple executives took to the stage to tout the incredible benefits of their new Apple Watch Series 4. While impressively presented in typical Apple fashion, the watch appeared to be only an evolution – not a revolution – in wearable technology. Still, there were a few noteworthy aspects of the new model that seemed to shine a light on the direction of the industry as a whole, and these were all focused on health care.
Like products from FitBit, Garmin, and others, the new Apple Watch can monitor a user’s heart rate and notify if it goes too high or too low. In addition, the watch now includes “fall detection,” and can automatically call for help if its wearer has taken a spill and become unresponsive. Soon it will even be capable of recording a single-lead ECG and detecting atrial fibrillation. While this all sounds fantastic, it also raises an important question in the minds of many physicians (including us): What do we do with all of these new data?
Findings from a Digital Health Study published by the American Medical Association in 20161 reveal that most doctors are aware of growing advances in Mobile Health (mHealth). Interestingly, however, while 85% see potential advantages in mHealth, less than 30% have begun employing it in their practices. This speaks to an adoption divide and highlights the many barriers to overcome before we can bridge it.
First and foremost, providers need confidence in the accuracy of the monitoring equipment, and, thus far, that accuracy has been questionable. Heart rate measurement, for example, is a staple of all currently available fitness wearables, yet is replete with technological pitfalls. This is because most consumer devices rely on optical sensors to measure heart rate. While inexpensive and noninvasive, the accuracy of these sensors can be affected by the interference of sweat, movement, and even the patient’s skin conditions – so much so that FitBit is currently embroiled in a class action lawsuit2 over the issue, in spite of providing disclaimers that a FitBit is “not a medical device.” To improve heart-monitoring capability, Apple has changed to a new sensor technology for this latest generation of Apple Watch. So far its accuracy has yet to be proven, and Apple’s delay in releasing the ECG features until “later this year” suggests there may still be bugs to work out.
Another significant concern raised by the onslaught of wearable health data is how to incorporate it into the electronic health record. Physicians care about efficient data integration, and, when asked in the aforementioned AMA study, physicians named this as their No. 1 functional requirement. EHR vendors have made some strides to allow patients to upload monitoring data directly through an online portal, but the large variety of available consumer devices has made standardizing this process difficult. Doctors have also made it clear that they want it to be straightforward to access and use the information provided by patients, and don’t want it to require special training. These are considerable challenges that will require collaboration between EHR vendors and wearable manufacturers to solve.
The introduction of additional players into the health care space also evokes questions of who owns this new health data set, and who is accountable for its integrity. If history is any indicator, device manufacturers will try their best to eschew any liability, and shift culpability onto patients and physicians. This is causing malpractice insurers to rethink policy coverage and forcing doctors to face a new reality of having “too much information.” While we are excited about the potential for better access to patient monitoring data, we agree that physicians need to understand where their responsibility for these data begins and ends.
Likewise, patients need to understand who has access to their personal health information, and how it’s being used. Privacy concerns will only become more evident as our society becomes ever more connected and as technologies become more invasive. The term “wearable” may soon become antiquated, as more products are coming to market that cross the skin barrier to collect samples directly from the blood or interstitial fluid. Devices such as Abbott’s new FreeStyle Libre continuous blood glucose monitor can be worn for weeks at a time, with its tiny sensor placed just under the skin. It constantly monitors trends in blood sugar and produces enough data points to determine the eating, sleeping, and activity habits of its wearer. This is all uploadable to Abbott’s servers, allowing patients and their providers to review it, thereby further expanding their personal health information footprint.
One encouraging aspect of the expansion mobile health technology is its organic, patient-led adoption. This is quite different from the epoch of electronic health records, which was motivated largely by government financial incentives and resulted in expensive, inefficient software. Patients are expressing a greater desire to take ownership of their health and have a growing interest in personal fitness. Also, the size of the consumer marketplace is forcing vendors to create competitive, high-value, and user-friendly mHealth devices. These products may seem to offer endless possibilities, but patients, vendors, and providers must fully acknowledge existing limitations in order to truly spark a revolution in wearable technology and actually improve patient care.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
References
1. Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools. (2016) American Medical Association.
2. Kate Mclellan et al. v. Fitbit Inc. Fitbit Heart Rate Monitors Fraud & Defects Lawsuit.
On Sept. 14 of this year, Apple executives took to the stage to tout the incredible benefits of their new Apple Watch Series 4. While impressively presented in typical Apple fashion, the watch appeared to be only an evolution – not a revolution – in wearable technology. Still, there were a few noteworthy aspects of the new model that seemed to shine a light on the direction of the industry as a whole, and these were all focused on health care.
Like products from FitBit, Garmin, and others, the new Apple Watch can monitor a user’s heart rate and notify if it goes too high or too low. In addition, the watch now includes “fall detection,” and can automatically call for help if its wearer has taken a spill and become unresponsive. Soon it will even be capable of recording a single-lead ECG and detecting atrial fibrillation. While this all sounds fantastic, it also raises an important question in the minds of many physicians (including us): What do we do with all of these new data?
Findings from a Digital Health Study published by the American Medical Association in 20161 reveal that most doctors are aware of growing advances in Mobile Health (mHealth). Interestingly, however, while 85% see potential advantages in mHealth, less than 30% have begun employing it in their practices. This speaks to an adoption divide and highlights the many barriers to overcome before we can bridge it.
First and foremost, providers need confidence in the accuracy of the monitoring equipment, and, thus far, that accuracy has been questionable. Heart rate measurement, for example, is a staple of all currently available fitness wearables, yet is replete with technological pitfalls. This is because most consumer devices rely on optical sensors to measure heart rate. While inexpensive and noninvasive, the accuracy of these sensors can be affected by the interference of sweat, movement, and even the patient’s skin conditions – so much so that FitBit is currently embroiled in a class action lawsuit2 over the issue, in spite of providing disclaimers that a FitBit is “not a medical device.” To improve heart-monitoring capability, Apple has changed to a new sensor technology for this latest generation of Apple Watch. So far its accuracy has yet to be proven, and Apple’s delay in releasing the ECG features until “later this year” suggests there may still be bugs to work out.
Another significant concern raised by the onslaught of wearable health data is how to incorporate it into the electronic health record. Physicians care about efficient data integration, and, when asked in the aforementioned AMA study, physicians named this as their No. 1 functional requirement. EHR vendors have made some strides to allow patients to upload monitoring data directly through an online portal, but the large variety of available consumer devices has made standardizing this process difficult. Doctors have also made it clear that they want it to be straightforward to access and use the information provided by patients, and don’t want it to require special training. These are considerable challenges that will require collaboration between EHR vendors and wearable manufacturers to solve.
The introduction of additional players into the health care space also evokes questions of who owns this new health data set, and who is accountable for its integrity. If history is any indicator, device manufacturers will try their best to eschew any liability, and shift culpability onto patients and physicians. This is causing malpractice insurers to rethink policy coverage and forcing doctors to face a new reality of having “too much information.” While we are excited about the potential for better access to patient monitoring data, we agree that physicians need to understand where their responsibility for these data begins and ends.
Likewise, patients need to understand who has access to their personal health information, and how it’s being used. Privacy concerns will only become more evident as our society becomes ever more connected and as technologies become more invasive. The term “wearable” may soon become antiquated, as more products are coming to market that cross the skin barrier to collect samples directly from the blood or interstitial fluid. Devices such as Abbott’s new FreeStyle Libre continuous blood glucose monitor can be worn for weeks at a time, with its tiny sensor placed just under the skin. It constantly monitors trends in blood sugar and produces enough data points to determine the eating, sleeping, and activity habits of its wearer. This is all uploadable to Abbott’s servers, allowing patients and their providers to review it, thereby further expanding their personal health information footprint.
One encouraging aspect of the expansion mobile health technology is its organic, patient-led adoption. This is quite different from the epoch of electronic health records, which was motivated largely by government financial incentives and resulted in expensive, inefficient software. Patients are expressing a greater desire to take ownership of their health and have a growing interest in personal fitness. Also, the size of the consumer marketplace is forcing vendors to create competitive, high-value, and user-friendly mHealth devices. These products may seem to offer endless possibilities, but patients, vendors, and providers must fully acknowledge existing limitations in order to truly spark a revolution in wearable technology and actually improve patient care.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
References
1. Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools. (2016) American Medical Association.
2. Kate Mclellan et al. v. Fitbit Inc. Fitbit Heart Rate Monitors Fraud & Defects Lawsuit.
On Sept. 14 of this year, Apple executives took to the stage to tout the incredible benefits of their new Apple Watch Series 4. While impressively presented in typical Apple fashion, the watch appeared to be only an evolution – not a revolution – in wearable technology. Still, there were a few noteworthy aspects of the new model that seemed to shine a light on the direction of the industry as a whole, and these were all focused on health care.
Like products from FitBit, Garmin, and others, the new Apple Watch can monitor a user’s heart rate and notify if it goes too high or too low. In addition, the watch now includes “fall detection,” and can automatically call for help if its wearer has taken a spill and become unresponsive. Soon it will even be capable of recording a single-lead ECG and detecting atrial fibrillation. While this all sounds fantastic, it also raises an important question in the minds of many physicians (including us): What do we do with all of these new data?
Findings from a Digital Health Study published by the American Medical Association in 20161 reveal that most doctors are aware of growing advances in Mobile Health (mHealth). Interestingly, however, while 85% see potential advantages in mHealth, less than 30% have begun employing it in their practices. This speaks to an adoption divide and highlights the many barriers to overcome before we can bridge it.
First and foremost, providers need confidence in the accuracy of the monitoring equipment, and, thus far, that accuracy has been questionable. Heart rate measurement, for example, is a staple of all currently available fitness wearables, yet is replete with technological pitfalls. This is because most consumer devices rely on optical sensors to measure heart rate. While inexpensive and noninvasive, the accuracy of these sensors can be affected by the interference of sweat, movement, and even the patient’s skin conditions – so much so that FitBit is currently embroiled in a class action lawsuit2 over the issue, in spite of providing disclaimers that a FitBit is “not a medical device.” To improve heart-monitoring capability, Apple has changed to a new sensor technology for this latest generation of Apple Watch. So far its accuracy has yet to be proven, and Apple’s delay in releasing the ECG features until “later this year” suggests there may still be bugs to work out.
Another significant concern raised by the onslaught of wearable health data is how to incorporate it into the electronic health record. Physicians care about efficient data integration, and, when asked in the aforementioned AMA study, physicians named this as their No. 1 functional requirement. EHR vendors have made some strides to allow patients to upload monitoring data directly through an online portal, but the large variety of available consumer devices has made standardizing this process difficult. Doctors have also made it clear that they want it to be straightforward to access and use the information provided by patients, and don’t want it to require special training. These are considerable challenges that will require collaboration between EHR vendors and wearable manufacturers to solve.
The introduction of additional players into the health care space also evokes questions of who owns this new health data set, and who is accountable for its integrity. If history is any indicator, device manufacturers will try their best to eschew any liability, and shift culpability onto patients and physicians. This is causing malpractice insurers to rethink policy coverage and forcing doctors to face a new reality of having “too much information.” While we are excited about the potential for better access to patient monitoring data, we agree that physicians need to understand where their responsibility for these data begins and ends.
Likewise, patients need to understand who has access to their personal health information, and how it’s being used. Privacy concerns will only become more evident as our society becomes ever more connected and as technologies become more invasive. The term “wearable” may soon become antiquated, as more products are coming to market that cross the skin barrier to collect samples directly from the blood or interstitial fluid. Devices such as Abbott’s new FreeStyle Libre continuous blood glucose monitor can be worn for weeks at a time, with its tiny sensor placed just under the skin. It constantly monitors trends in blood sugar and produces enough data points to determine the eating, sleeping, and activity habits of its wearer. This is all uploadable to Abbott’s servers, allowing patients and their providers to review it, thereby further expanding their personal health information footprint.
One encouraging aspect of the expansion mobile health technology is its organic, patient-led adoption. This is quite different from the epoch of electronic health records, which was motivated largely by government financial incentives and resulted in expensive, inefficient software. Patients are expressing a greater desire to take ownership of their health and have a growing interest in personal fitness. Also, the size of the consumer marketplace is forcing vendors to create competitive, high-value, and user-friendly mHealth devices. These products may seem to offer endless possibilities, but patients, vendors, and providers must fully acknowledge existing limitations in order to truly spark a revolution in wearable technology and actually improve patient care.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
References
1. Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools. (2016) American Medical Association.
2. Kate Mclellan et al. v. Fitbit Inc. Fitbit Heart Rate Monitors Fraud & Defects Lawsuit.
Death of a sales pitch
The EHR and our troubled health care system, Part 1
In 2000, the Institute of Medicine published “To Err Is Human,” a landmark study that warned that as many as 98,000 people die annually as a result of medical errors. One conclusion of the report stated, “When patients see multiple providers in different settings, none of whom has access to complete information, it becomes easier for things to go wrong.” Government and public reaction to the study resulted in the rushed integration of electronic health records into the U.S. medical system. EHR vendors promised solutions that included a dramatic reduction of preventable errors, a simplified system of physician communication, and the consolidation of a patient’s salient medical information into a single, transferable file. Now, almost 20 years later, these promises remain mostly unfilled. How did we get here?
Systems of medical records have been in place since 1600 B.C. For thousands of years, they consisted mainly of the patient’s diagnosis and the physician’s treatment. In 1968, the New England Journal of Medicine published the special article “Medical Records That Guide and Teach” by Lawrence L. Weed, MD. In the report, Dr. Weed advocated for the organization of medical records by problems rather than by a single diagnosis. This was the birth of our modern system. Medical records would now include lists of symptoms, findings, and problems that would organize the physician’s planning and allow third parties to confirm the initial diagnosis. Nearly concurrent with this publication, the next major innovation was developing in a very unusual location.
In 1999, Fortune magazine labeled Jack Welch “Manager of the Century” for his innovative work as CEO of General Electric. His techniques involved cutting waste and streamlining his workforce. While these methods were somewhat controversial, GE’s market value increased dramatically under his watch. The publishers at Fortune became interested in finding similar innovators in other fields. In this pursuit, they sent journalist Philip Longman to find the “Jack Welch” of health care.
Mr. Longman had recently lost his wife to breast cancer and was becoming obsessed with medical errors and health care quality integration. He set out to discover the best health care system in the United States. After months of research, Mr. Longman reached a startling conclusion. By nearly every metric, the Veterans Affairs system produced the highest quality of care. The key factor in upholding that quality appeared to be the EHR system VistA (Veterans Information Systems and Technology Architecture).
The development of VistA was a grassroots effort begun in the 1970s. Using Tandy computers and Wang processors, the VA “hardhats” sought to develop an electronic system for medical records and communication. This effort was initially opposed and driven underground by the central bureaucracy. Laptops were confiscated, people were fired. Still, development continued, and in 1978, the Decentralized Hospital Computer Program was launched at 20 VA sites. The national rollout occurred in 1994 under the name VistA.
VistA was developed by doctors, for doctors, and routinely enjoys the highest satisfaction rates among all available EHRs. VistA also is an open source model; its code is readily available on the VA website. After seeing the evidence of VistA’s efficacy, Representative Pete Stark (D-CA) introduced HR 6898 on Sept. 15, 2008. The bill would establish a large federal open source health IT system that private hospitals could leverage. The bill also mandated that only open source solutions would receive federal funding. As opposed to proprietary systems, open source models allow for rapid innovation, easy personal configuration, and incorporation of open source apps from unlimited numbers of contributors.
HR 6898 never passed, despite initial bipartisan support. By relying on lobbyists, marketing, and money, the proprietary EHR vendors killed the Stark bill. After a 4-month scramble, the Health Information Technology for Economic and Clinical Health Act (HITECH) passed, with EHR vendor support. HITECH established a certification system for EHRs. While the Stark bill envisioned a single, open source network, there were soon hundreds of certified EHR systems in the United States.
Before the HITECH Act, many EHRs existed, but several barriers blocked full implementation. Early systems were essentially electronic filing cabinets. Their developers had not anticipated the lack of standardization among physicians and hospital systems. The need for custom EHR bases frustrated the vendors. The question of marketing was omnipresent. Who was the actual customer? An economic model developed in which clinicians would bear the time and even financial costs as the benefits would be passed on to insurers, hospitals, and, presumably, the patients.
EHRs needed to become practical, affordable, and interoperable, but who was demanding this? Where was the financial motivation? In the beginning, vendors of EHRs had to convince doctors, the public, and the government of their worth. Now, essentially mandated by the HITECH Act, they only had to sell themselves to hospital administrators, who often had a different motive. Profits.
Many of today’s EHRs are simply modified billing platforms, and doctors are paying the price. The Meaningful Use standards were meant to provide financial incentives for EHR adoption. Stage 2 required EHRs to be able to transport clinical information from one system to another. Looking at our actual practices can provide a master class in the gap between “be able to” and “actually doing.” Again, who does the EHR vendor see as the customer? Certainly not the physician. My patients can list every type of inferior vena cava filter (or at least those with pending legal action), but most of them have never heard of an EHR. Just like “service lines,” EHRs can make it very difficult for patients to seek care outside of their primary system. Who would see this barrier in communication as a perk and not a deficiency? Hospital administrators. The free transfer of medical records is bad for business. Therefore, hospitals don’t prioritize it in their EHRs. The EHR vendors also benefit since an easy transfer of records would simplify a hospital’s transition from one EHR to another. So, as with most deficiencies in the EHR, physicians are left to find ways around these problems. Sometimes, we need to go to comical lengths.
Two months ago, a patient pointed to a large machine behind our check-in desk. “What is that,” he asked incredulously; it was a fax machine. While my competence with this apparatus is marginal (my office staff has taken to yelling “doctor faxing!” to alert one another that I am about to inadvertently copy or scan my documents into oblivion), faxes remain a mainstay of medical care. Abandoned by modern business practices as a relic of the 1980s, why are we constantly faxing medical information? Because we are not the customer.
Disruption is now a favorable term in business. Doctors are busy people. BUSY people. Most of us walk a tightrope, a razor-thin timeline. Will we see the next patient in time, the next surgery? Will we get the medical records done today? Will we get the dictations done before being suspended? Will we make the committee meeting, the conference call, the next clinic across town? Will we have dinner with our spouse or see our kids today? Will we make it to the parent-teacher conference inexplicably scheduled for 10:45 a.m. on a Tuesday??!! When deciding between work commitments and family, we side with work overwhelmingly (and depressingly). Explaining this to a layperson is an impossible feat. I have stopped trying, stopped making excuses. Only we know how catastrophic “disruption” can be. Disruption in a 40-patient clinic. Disruption in the trauma bay. I have seen physicians reduced to tears by this disruption. Some activities need disruption. Typing with your back to the patient. Onerous documentation to facilitate billing. Faxing medical records. Will these be disrupted? Who is the customer?
In 1999, the Institute of Medicine started this process, telling us, “To err is human.” I now respond with another Alexander Pope quote, “The same ambition can destroy or save.” The money and influence of EHR vendors destroyed the chance to nationalize the most successful EHR our country has ever seen. What happens now? EHRs are incontrovertibly associated with burnout. Burnout is incontrovertibly associated with outcomes ranging from early retirement to suicide. EHRs cause physician harm. Major vendors can follow the Big Tobacco play book and deny the obvious, but the burden of proof is shifting to them. With their billions of dollars in profits, what have they done to study this problem? To help?
Who is their customer?
Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, division of vascular and endovascular surgery, Louisiana State University Health Sciences Center, New Orleans.
References
Institute of Medicine (US) Committee on Quality of Health Care in America. 2000. To Err Is Human: Building a Safer Health System. Washington: The National Academies Press.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600.
Longman P. “Best Care Anywhere: Why VA Health Care Is Better Than Yours.” (Oakland: Berrett-Koehler Publishers).
The EHR and our troubled health care system, Part 1
The EHR and our troubled health care system, Part 1
In 2000, the Institute of Medicine published “To Err Is Human,” a landmark study that warned that as many as 98,000 people die annually as a result of medical errors. One conclusion of the report stated, “When patients see multiple providers in different settings, none of whom has access to complete information, it becomes easier for things to go wrong.” Government and public reaction to the study resulted in the rushed integration of electronic health records into the U.S. medical system. EHR vendors promised solutions that included a dramatic reduction of preventable errors, a simplified system of physician communication, and the consolidation of a patient’s salient medical information into a single, transferable file. Now, almost 20 years later, these promises remain mostly unfilled. How did we get here?
Systems of medical records have been in place since 1600 B.C. For thousands of years, they consisted mainly of the patient’s diagnosis and the physician’s treatment. In 1968, the New England Journal of Medicine published the special article “Medical Records That Guide and Teach” by Lawrence L. Weed, MD. In the report, Dr. Weed advocated for the organization of medical records by problems rather than by a single diagnosis. This was the birth of our modern system. Medical records would now include lists of symptoms, findings, and problems that would organize the physician’s planning and allow third parties to confirm the initial diagnosis. Nearly concurrent with this publication, the next major innovation was developing in a very unusual location.
In 1999, Fortune magazine labeled Jack Welch “Manager of the Century” for his innovative work as CEO of General Electric. His techniques involved cutting waste and streamlining his workforce. While these methods were somewhat controversial, GE’s market value increased dramatically under his watch. The publishers at Fortune became interested in finding similar innovators in other fields. In this pursuit, they sent journalist Philip Longman to find the “Jack Welch” of health care.
Mr. Longman had recently lost his wife to breast cancer and was becoming obsessed with medical errors and health care quality integration. He set out to discover the best health care system in the United States. After months of research, Mr. Longman reached a startling conclusion. By nearly every metric, the Veterans Affairs system produced the highest quality of care. The key factor in upholding that quality appeared to be the EHR system VistA (Veterans Information Systems and Technology Architecture).
The development of VistA was a grassroots effort begun in the 1970s. Using Tandy computers and Wang processors, the VA “hardhats” sought to develop an electronic system for medical records and communication. This effort was initially opposed and driven underground by the central bureaucracy. Laptops were confiscated, people were fired. Still, development continued, and in 1978, the Decentralized Hospital Computer Program was launched at 20 VA sites. The national rollout occurred in 1994 under the name VistA.
VistA was developed by doctors, for doctors, and routinely enjoys the highest satisfaction rates among all available EHRs. VistA also is an open source model; its code is readily available on the VA website. After seeing the evidence of VistA’s efficacy, Representative Pete Stark (D-CA) introduced HR 6898 on Sept. 15, 2008. The bill would establish a large federal open source health IT system that private hospitals could leverage. The bill also mandated that only open source solutions would receive federal funding. As opposed to proprietary systems, open source models allow for rapid innovation, easy personal configuration, and incorporation of open source apps from unlimited numbers of contributors.
HR 6898 never passed, despite initial bipartisan support. By relying on lobbyists, marketing, and money, the proprietary EHR vendors killed the Stark bill. After a 4-month scramble, the Health Information Technology for Economic and Clinical Health Act (HITECH) passed, with EHR vendor support. HITECH established a certification system for EHRs. While the Stark bill envisioned a single, open source network, there were soon hundreds of certified EHR systems in the United States.
Before the HITECH Act, many EHRs existed, but several barriers blocked full implementation. Early systems were essentially electronic filing cabinets. Their developers had not anticipated the lack of standardization among physicians and hospital systems. The need for custom EHR bases frustrated the vendors. The question of marketing was omnipresent. Who was the actual customer? An economic model developed in which clinicians would bear the time and even financial costs as the benefits would be passed on to insurers, hospitals, and, presumably, the patients.
EHRs needed to become practical, affordable, and interoperable, but who was demanding this? Where was the financial motivation? In the beginning, vendors of EHRs had to convince doctors, the public, and the government of their worth. Now, essentially mandated by the HITECH Act, they only had to sell themselves to hospital administrators, who often had a different motive. Profits.
Many of today’s EHRs are simply modified billing platforms, and doctors are paying the price. The Meaningful Use standards were meant to provide financial incentives for EHR adoption. Stage 2 required EHRs to be able to transport clinical information from one system to another. Looking at our actual practices can provide a master class in the gap between “be able to” and “actually doing.” Again, who does the EHR vendor see as the customer? Certainly not the physician. My patients can list every type of inferior vena cava filter (or at least those with pending legal action), but most of them have never heard of an EHR. Just like “service lines,” EHRs can make it very difficult for patients to seek care outside of their primary system. Who would see this barrier in communication as a perk and not a deficiency? Hospital administrators. The free transfer of medical records is bad for business. Therefore, hospitals don’t prioritize it in their EHRs. The EHR vendors also benefit since an easy transfer of records would simplify a hospital’s transition from one EHR to another. So, as with most deficiencies in the EHR, physicians are left to find ways around these problems. Sometimes, we need to go to comical lengths.
Two months ago, a patient pointed to a large machine behind our check-in desk. “What is that,” he asked incredulously; it was a fax machine. While my competence with this apparatus is marginal (my office staff has taken to yelling “doctor faxing!” to alert one another that I am about to inadvertently copy or scan my documents into oblivion), faxes remain a mainstay of medical care. Abandoned by modern business practices as a relic of the 1980s, why are we constantly faxing medical information? Because we are not the customer.
Disruption is now a favorable term in business. Doctors are busy people. BUSY people. Most of us walk a tightrope, a razor-thin timeline. Will we see the next patient in time, the next surgery? Will we get the medical records done today? Will we get the dictations done before being suspended? Will we make the committee meeting, the conference call, the next clinic across town? Will we have dinner with our spouse or see our kids today? Will we make it to the parent-teacher conference inexplicably scheduled for 10:45 a.m. on a Tuesday??!! When deciding between work commitments and family, we side with work overwhelmingly (and depressingly). Explaining this to a layperson is an impossible feat. I have stopped trying, stopped making excuses. Only we know how catastrophic “disruption” can be. Disruption in a 40-patient clinic. Disruption in the trauma bay. I have seen physicians reduced to tears by this disruption. Some activities need disruption. Typing with your back to the patient. Onerous documentation to facilitate billing. Faxing medical records. Will these be disrupted? Who is the customer?
In 1999, the Institute of Medicine started this process, telling us, “To err is human.” I now respond with another Alexander Pope quote, “The same ambition can destroy or save.” The money and influence of EHR vendors destroyed the chance to nationalize the most successful EHR our country has ever seen. What happens now? EHRs are incontrovertibly associated with burnout. Burnout is incontrovertibly associated with outcomes ranging from early retirement to suicide. EHRs cause physician harm. Major vendors can follow the Big Tobacco play book and deny the obvious, but the burden of proof is shifting to them. With their billions of dollars in profits, what have they done to study this problem? To help?
Who is their customer?
Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, division of vascular and endovascular surgery, Louisiana State University Health Sciences Center, New Orleans.
References
Institute of Medicine (US) Committee on Quality of Health Care in America. 2000. To Err Is Human: Building a Safer Health System. Washington: The National Academies Press.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600.
Longman P. “Best Care Anywhere: Why VA Health Care Is Better Than Yours.” (Oakland: Berrett-Koehler Publishers).
In 2000, the Institute of Medicine published “To Err Is Human,” a landmark study that warned that as many as 98,000 people die annually as a result of medical errors. One conclusion of the report stated, “When patients see multiple providers in different settings, none of whom has access to complete information, it becomes easier for things to go wrong.” Government and public reaction to the study resulted in the rushed integration of electronic health records into the U.S. medical system. EHR vendors promised solutions that included a dramatic reduction of preventable errors, a simplified system of physician communication, and the consolidation of a patient’s salient medical information into a single, transferable file. Now, almost 20 years later, these promises remain mostly unfilled. How did we get here?
Systems of medical records have been in place since 1600 B.C. For thousands of years, they consisted mainly of the patient’s diagnosis and the physician’s treatment. In 1968, the New England Journal of Medicine published the special article “Medical Records That Guide and Teach” by Lawrence L. Weed, MD. In the report, Dr. Weed advocated for the organization of medical records by problems rather than by a single diagnosis. This was the birth of our modern system. Medical records would now include lists of symptoms, findings, and problems that would organize the physician’s planning and allow third parties to confirm the initial diagnosis. Nearly concurrent with this publication, the next major innovation was developing in a very unusual location.
In 1999, Fortune magazine labeled Jack Welch “Manager of the Century” for his innovative work as CEO of General Electric. His techniques involved cutting waste and streamlining his workforce. While these methods were somewhat controversial, GE’s market value increased dramatically under his watch. The publishers at Fortune became interested in finding similar innovators in other fields. In this pursuit, they sent journalist Philip Longman to find the “Jack Welch” of health care.
Mr. Longman had recently lost his wife to breast cancer and was becoming obsessed with medical errors and health care quality integration. He set out to discover the best health care system in the United States. After months of research, Mr. Longman reached a startling conclusion. By nearly every metric, the Veterans Affairs system produced the highest quality of care. The key factor in upholding that quality appeared to be the EHR system VistA (Veterans Information Systems and Technology Architecture).
The development of VistA was a grassroots effort begun in the 1970s. Using Tandy computers and Wang processors, the VA “hardhats” sought to develop an electronic system for medical records and communication. This effort was initially opposed and driven underground by the central bureaucracy. Laptops were confiscated, people were fired. Still, development continued, and in 1978, the Decentralized Hospital Computer Program was launched at 20 VA sites. The national rollout occurred in 1994 under the name VistA.
VistA was developed by doctors, for doctors, and routinely enjoys the highest satisfaction rates among all available EHRs. VistA also is an open source model; its code is readily available on the VA website. After seeing the evidence of VistA’s efficacy, Representative Pete Stark (D-CA) introduced HR 6898 on Sept. 15, 2008. The bill would establish a large federal open source health IT system that private hospitals could leverage. The bill also mandated that only open source solutions would receive federal funding. As opposed to proprietary systems, open source models allow for rapid innovation, easy personal configuration, and incorporation of open source apps from unlimited numbers of contributors.
HR 6898 never passed, despite initial bipartisan support. By relying on lobbyists, marketing, and money, the proprietary EHR vendors killed the Stark bill. After a 4-month scramble, the Health Information Technology for Economic and Clinical Health Act (HITECH) passed, with EHR vendor support. HITECH established a certification system for EHRs. While the Stark bill envisioned a single, open source network, there were soon hundreds of certified EHR systems in the United States.
Before the HITECH Act, many EHRs existed, but several barriers blocked full implementation. Early systems were essentially electronic filing cabinets. Their developers had not anticipated the lack of standardization among physicians and hospital systems. The need for custom EHR bases frustrated the vendors. The question of marketing was omnipresent. Who was the actual customer? An economic model developed in which clinicians would bear the time and even financial costs as the benefits would be passed on to insurers, hospitals, and, presumably, the patients.
EHRs needed to become practical, affordable, and interoperable, but who was demanding this? Where was the financial motivation? In the beginning, vendors of EHRs had to convince doctors, the public, and the government of their worth. Now, essentially mandated by the HITECH Act, they only had to sell themselves to hospital administrators, who often had a different motive. Profits.
Many of today’s EHRs are simply modified billing platforms, and doctors are paying the price. The Meaningful Use standards were meant to provide financial incentives for EHR adoption. Stage 2 required EHRs to be able to transport clinical information from one system to another. Looking at our actual practices can provide a master class in the gap between “be able to” and “actually doing.” Again, who does the EHR vendor see as the customer? Certainly not the physician. My patients can list every type of inferior vena cava filter (or at least those with pending legal action), but most of them have never heard of an EHR. Just like “service lines,” EHRs can make it very difficult for patients to seek care outside of their primary system. Who would see this barrier in communication as a perk and not a deficiency? Hospital administrators. The free transfer of medical records is bad for business. Therefore, hospitals don’t prioritize it in their EHRs. The EHR vendors also benefit since an easy transfer of records would simplify a hospital’s transition from one EHR to another. So, as with most deficiencies in the EHR, physicians are left to find ways around these problems. Sometimes, we need to go to comical lengths.
Two months ago, a patient pointed to a large machine behind our check-in desk. “What is that,” he asked incredulously; it was a fax machine. While my competence with this apparatus is marginal (my office staff has taken to yelling “doctor faxing!” to alert one another that I am about to inadvertently copy or scan my documents into oblivion), faxes remain a mainstay of medical care. Abandoned by modern business practices as a relic of the 1980s, why are we constantly faxing medical information? Because we are not the customer.
Disruption is now a favorable term in business. Doctors are busy people. BUSY people. Most of us walk a tightrope, a razor-thin timeline. Will we see the next patient in time, the next surgery? Will we get the medical records done today? Will we get the dictations done before being suspended? Will we make the committee meeting, the conference call, the next clinic across town? Will we have dinner with our spouse or see our kids today? Will we make it to the parent-teacher conference inexplicably scheduled for 10:45 a.m. on a Tuesday??!! When deciding between work commitments and family, we side with work overwhelmingly (and depressingly). Explaining this to a layperson is an impossible feat. I have stopped trying, stopped making excuses. Only we know how catastrophic “disruption” can be. Disruption in a 40-patient clinic. Disruption in the trauma bay. I have seen physicians reduced to tears by this disruption. Some activities need disruption. Typing with your back to the patient. Onerous documentation to facilitate billing. Faxing medical records. Will these be disrupted? Who is the customer?
In 1999, the Institute of Medicine started this process, telling us, “To err is human.” I now respond with another Alexander Pope quote, “The same ambition can destroy or save.” The money and influence of EHR vendors destroyed the chance to nationalize the most successful EHR our country has ever seen. What happens now? EHRs are incontrovertibly associated with burnout. Burnout is incontrovertibly associated with outcomes ranging from early retirement to suicide. EHRs cause physician harm. Major vendors can follow the Big Tobacco play book and deny the obvious, but the burden of proof is shifting to them. With their billions of dollars in profits, what have they done to study this problem? To help?
Who is their customer?
Dr. Sheahan is the Claude C. Craighead Jr. Professor and Chair, division of vascular and endovascular surgery, Louisiana State University Health Sciences Center, New Orleans.
References
Institute of Medicine (US) Committee on Quality of Health Care in America. 2000. To Err Is Human: Building a Safer Health System. Washington: The National Academies Press.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600.
Longman P. “Best Care Anywhere: Why VA Health Care Is Better Than Yours.” (Oakland: Berrett-Koehler Publishers).
Constipation because of deportation-related trauma
I recently saw Anaeli (not her real name), an 8-year-old Mexican American girl, in clinic for worsening constipation. Her mother brought her in because of a year’s worth of increasingly irregular bowel movements. Looking through her chart, it was easy to find the starting point of Anaeli’s constipation – it aligned with her father’s deportation. U.S. Immigration and Customs Enforcement had arrested him while he was dropping Anaeli off at school.
Family separation at the border has reignited awareness of the effects of adverse childhood events. As a young pediatrician training in San Diego, I see both the impact of immigration policies on children and the resulting need for trauma-informed care. We need coordinated efforts in homes, schools, and hospitals to effectively treat affected kids.
For the past year, Anaeli’s caregivers have struggled to do so. She has been acting out, frequently crying and throwing fits about going to school. Anaeli has missed about 30 days of school because of behavioral issues.
What does 30 fewer days of first grade look like? Anaeli’s language skills are at a standstill. She cannot follow complex directions like her peers. Because of her academic shortcomings, Anaeli earned an individualized education plan and a teacher’s aide to help her focus. This aide has adopted a “tough love” attitude. Anaeli’s mom reports that she is often disciplined by long time-outs in the classroom bathroom and worries that this discipline is causing Anaeli to withhold stool to a point of loosing control and soiling herself. Since working with the aide, Anaeli has been having daily “accidents,” stooling in her pants, despite being toilet trained for years.
After the appointment, I called the school three times and was finally able to get in touch with Anaeli’s aide. She expressed frustration over Anaeli’s “lack of trying” and “meltdown” reaction to discipline. She said Anaeli’s mom was not enforcing limits at home. She told me she had successfully used time-outs in the bathroom with her own children. When I reviewed the impact of childhood trauma and more appropriate approaches to discipline, the aide grew defensive and challenged me by asking if I have kids of my own.
While I disagreed with the aide’s methods, I understood her frustration. Anaeli is not easy to help. But she is just one of a generation of children affected by the deportation of a family member. Like them, Anaeli’s health is deeply affected by stress in a way that she many not be able to verbalize.
Trauma-informed care should be an essential lens for caregivers of children who have been separated from their family. Resolving Anaeli’s constipation will require a concerted effort by her mom, health providers, teachers, and aides to encourage good behavior, use measured disciplinary tactics, and consume a high-fiber diet. In doing so, we can provide children like her with the appropriate environment to build resilience.
Dr. Parekh is a pediatrician in San Diego. Email her at [email protected].
I recently saw Anaeli (not her real name), an 8-year-old Mexican American girl, in clinic for worsening constipation. Her mother brought her in because of a year’s worth of increasingly irregular bowel movements. Looking through her chart, it was easy to find the starting point of Anaeli’s constipation – it aligned with her father’s deportation. U.S. Immigration and Customs Enforcement had arrested him while he was dropping Anaeli off at school.
Family separation at the border has reignited awareness of the effects of adverse childhood events. As a young pediatrician training in San Diego, I see both the impact of immigration policies on children and the resulting need for trauma-informed care. We need coordinated efforts in homes, schools, and hospitals to effectively treat affected kids.
For the past year, Anaeli’s caregivers have struggled to do so. She has been acting out, frequently crying and throwing fits about going to school. Anaeli has missed about 30 days of school because of behavioral issues.
What does 30 fewer days of first grade look like? Anaeli’s language skills are at a standstill. She cannot follow complex directions like her peers. Because of her academic shortcomings, Anaeli earned an individualized education plan and a teacher’s aide to help her focus. This aide has adopted a “tough love” attitude. Anaeli’s mom reports that she is often disciplined by long time-outs in the classroom bathroom and worries that this discipline is causing Anaeli to withhold stool to a point of loosing control and soiling herself. Since working with the aide, Anaeli has been having daily “accidents,” stooling in her pants, despite being toilet trained for years.
After the appointment, I called the school three times and was finally able to get in touch with Anaeli’s aide. She expressed frustration over Anaeli’s “lack of trying” and “meltdown” reaction to discipline. She said Anaeli’s mom was not enforcing limits at home. She told me she had successfully used time-outs in the bathroom with her own children. When I reviewed the impact of childhood trauma and more appropriate approaches to discipline, the aide grew defensive and challenged me by asking if I have kids of my own.
While I disagreed with the aide’s methods, I understood her frustration. Anaeli is not easy to help. But she is just one of a generation of children affected by the deportation of a family member. Like them, Anaeli’s health is deeply affected by stress in a way that she many not be able to verbalize.
Trauma-informed care should be an essential lens for caregivers of children who have been separated from their family. Resolving Anaeli’s constipation will require a concerted effort by her mom, health providers, teachers, and aides to encourage good behavior, use measured disciplinary tactics, and consume a high-fiber diet. In doing so, we can provide children like her with the appropriate environment to build resilience.
Dr. Parekh is a pediatrician in San Diego. Email her at [email protected].
I recently saw Anaeli (not her real name), an 8-year-old Mexican American girl, in clinic for worsening constipation. Her mother brought her in because of a year’s worth of increasingly irregular bowel movements. Looking through her chart, it was easy to find the starting point of Anaeli’s constipation – it aligned with her father’s deportation. U.S. Immigration and Customs Enforcement had arrested him while he was dropping Anaeli off at school.
Family separation at the border has reignited awareness of the effects of adverse childhood events. As a young pediatrician training in San Diego, I see both the impact of immigration policies on children and the resulting need for trauma-informed care. We need coordinated efforts in homes, schools, and hospitals to effectively treat affected kids.
For the past year, Anaeli’s caregivers have struggled to do so. She has been acting out, frequently crying and throwing fits about going to school. Anaeli has missed about 30 days of school because of behavioral issues.
What does 30 fewer days of first grade look like? Anaeli’s language skills are at a standstill. She cannot follow complex directions like her peers. Because of her academic shortcomings, Anaeli earned an individualized education plan and a teacher’s aide to help her focus. This aide has adopted a “tough love” attitude. Anaeli’s mom reports that she is often disciplined by long time-outs in the classroom bathroom and worries that this discipline is causing Anaeli to withhold stool to a point of loosing control and soiling herself. Since working with the aide, Anaeli has been having daily “accidents,” stooling in her pants, despite being toilet trained for years.
After the appointment, I called the school three times and was finally able to get in touch with Anaeli’s aide. She expressed frustration over Anaeli’s “lack of trying” and “meltdown” reaction to discipline. She said Anaeli’s mom was not enforcing limits at home. She told me she had successfully used time-outs in the bathroom with her own children. When I reviewed the impact of childhood trauma and more appropriate approaches to discipline, the aide grew defensive and challenged me by asking if I have kids of my own.
While I disagreed with the aide’s methods, I understood her frustration. Anaeli is not easy to help. But she is just one of a generation of children affected by the deportation of a family member. Like them, Anaeli’s health is deeply affected by stress in a way that she many not be able to verbalize.
Trauma-informed care should be an essential lens for caregivers of children who have been separated from their family. Resolving Anaeli’s constipation will require a concerted effort by her mom, health providers, teachers, and aides to encourage good behavior, use measured disciplinary tactics, and consume a high-fiber diet. In doing so, we can provide children like her with the appropriate environment to build resilience.
Dr. Parekh is a pediatrician in San Diego. Email her at [email protected].
Pathologic superstition
When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder
I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.
Superstitions like these are familiar to all of us.
One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.
Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.
Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.
For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.
Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).
These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.
Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.
Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.
Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.
In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.
Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.
During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].
When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder
I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.
Superstitions like these are familiar to all of us.
One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.
Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.
Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.
For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.
Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).
These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.
Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.
Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.
Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.
In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.
Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.
During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].
When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder
I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.
Superstitions like these are familiar to all of us.
One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.
Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.
Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.
For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.
Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).
These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.
Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.
Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.
Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.
In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.
Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.
During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].