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Pediatricians doing good globally
Do the images of Syrian refugee children kindle a desire to leave the privileged suburban-dwelling patients in your practice for just a few weeks and donate your clinical skills to help the victims of political conflict? Or, are you looking for a way to give your post-retirement life some meaning by volunteering on a typhoon-ravaged island in Southeast Asia?
Before you ask your partners for a 1-month leave of absence or try to convince your spouse that camping out in a refugee camp would be a better way to spend this year’s travel budget, I urge you to read Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement, published in Pediatrics. This lengthy and thorough report by the American Board of Pediatrics Global Health Task Force will give you pause and should serve as an important reality check before you run off to buy the plane tickets for your personal mission of mercy.
Gitanjli Arora, MD, of the Children’s Hospital of Los Angeles, and her coauthors point out that, just because there appears to be a need for people with clinical expertise does not mean that your little black bag of skills honed in the privileged bubble of a first-world country is going to be of much help. This question is one I have pondered on several occasions when I have been offered what might be called “medical voluntourism” opportunities.
If I have distinguished myself as a clinician, that skill has been based on my ability to listen and communicate. Dropped into a community where I have little or no language facility and cultural awareness, I would need to rely on my observational skills. While I pride myself on my ability to make a visual diagnosis, the truth is that my diagnostic successes based solely on observation are almost exclusively dermatologic ones. And, let me add, my familiarity with tropical skin rashes is severely limited. I’m sure I could learn but not in a stay as short as a month.
Taking a history and communicating a treatment plan would force me to rely on the skills of a translator. In settings dominated by upheaval, many of the presenting complaints are going to be the result of, or at least heavily colored by, the chaos induced by anxiety. The ability to sort out where the mind and body connect is difficult enough in a community in which I have spent 40 years and speak the language. Regardless of how much sympathy I feel for the victims of tragic events, my clinical skills would have little value in the short term. Even worse, I would probably just be in the way. As the Task Force points out, my presence could also be squandering local resources as on-site providers worked to get me up to speed.
The authors also explore the numerous other complicating factors that must be considered by those of us who feel the pull to help the victims of global strife and natural disaster. While the authors discourage physicians like you and me from “dropping in” to help, they offer an abundance of suggestions on how we can act globally and stay locally.
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].
Do the images of Syrian refugee children kindle a desire to leave the privileged suburban-dwelling patients in your practice for just a few weeks and donate your clinical skills to help the victims of political conflict? Or, are you looking for a way to give your post-retirement life some meaning by volunteering on a typhoon-ravaged island in Southeast Asia?
Before you ask your partners for a 1-month leave of absence or try to convince your spouse that camping out in a refugee camp would be a better way to spend this year’s travel budget, I urge you to read Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement, published in Pediatrics. This lengthy and thorough report by the American Board of Pediatrics Global Health Task Force will give you pause and should serve as an important reality check before you run off to buy the plane tickets for your personal mission of mercy.
Gitanjli Arora, MD, of the Children’s Hospital of Los Angeles, and her coauthors point out that, just because there appears to be a need for people with clinical expertise does not mean that your little black bag of skills honed in the privileged bubble of a first-world country is going to be of much help. This question is one I have pondered on several occasions when I have been offered what might be called “medical voluntourism” opportunities.
If I have distinguished myself as a clinician, that skill has been based on my ability to listen and communicate. Dropped into a community where I have little or no language facility and cultural awareness, I would need to rely on my observational skills. While I pride myself on my ability to make a visual diagnosis, the truth is that my diagnostic successes based solely on observation are almost exclusively dermatologic ones. And, let me add, my familiarity with tropical skin rashes is severely limited. I’m sure I could learn but not in a stay as short as a month.
Taking a history and communicating a treatment plan would force me to rely on the skills of a translator. In settings dominated by upheaval, many of the presenting complaints are going to be the result of, or at least heavily colored by, the chaos induced by anxiety. The ability to sort out where the mind and body connect is difficult enough in a community in which I have spent 40 years and speak the language. Regardless of how much sympathy I feel for the victims of tragic events, my clinical skills would have little value in the short term. Even worse, I would probably just be in the way. As the Task Force points out, my presence could also be squandering local resources as on-site providers worked to get me up to speed.
The authors also explore the numerous other complicating factors that must be considered by those of us who feel the pull to help the victims of global strife and natural disaster. While the authors discourage physicians like you and me from “dropping in” to help, they offer an abundance of suggestions on how we can act globally and stay locally.
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].
Do the images of Syrian refugee children kindle a desire to leave the privileged suburban-dwelling patients in your practice for just a few weeks and donate your clinical skills to help the victims of political conflict? Or, are you looking for a way to give your post-retirement life some meaning by volunteering on a typhoon-ravaged island in Southeast Asia?
Before you ask your partners for a 1-month leave of absence or try to convince your spouse that camping out in a refugee camp would be a better way to spend this year’s travel budget, I urge you to read Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement, published in Pediatrics. This lengthy and thorough report by the American Board of Pediatrics Global Health Task Force will give you pause and should serve as an important reality check before you run off to buy the plane tickets for your personal mission of mercy.
Gitanjli Arora, MD, of the Children’s Hospital of Los Angeles, and her coauthors point out that, just because there appears to be a need for people with clinical expertise does not mean that your little black bag of skills honed in the privileged bubble of a first-world country is going to be of much help. This question is one I have pondered on several occasions when I have been offered what might be called “medical voluntourism” opportunities.
If I have distinguished myself as a clinician, that skill has been based on my ability to listen and communicate. Dropped into a community where I have little or no language facility and cultural awareness, I would need to rely on my observational skills. While I pride myself on my ability to make a visual diagnosis, the truth is that my diagnostic successes based solely on observation are almost exclusively dermatologic ones. And, let me add, my familiarity with tropical skin rashes is severely limited. I’m sure I could learn but not in a stay as short as a month.
Taking a history and communicating a treatment plan would force me to rely on the skills of a translator. In settings dominated by upheaval, many of the presenting complaints are going to be the result of, or at least heavily colored by, the chaos induced by anxiety. The ability to sort out where the mind and body connect is difficult enough in a community in which I have spent 40 years and speak the language. Regardless of how much sympathy I feel for the victims of tragic events, my clinical skills would have little value in the short term. Even worse, I would probably just be in the way. As the Task Force points out, my presence could also be squandering local resources as on-site providers worked to get me up to speed.
The authors also explore the numerous other complicating factors that must be considered by those of us who feel the pull to help the victims of global strife and natural disaster. While the authors discourage physicians like you and me from “dropping in” to help, they offer an abundance of suggestions on how we can act globally and stay locally.
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].
Employment practices liability insurance
No matter how complete your insurance portfolio, there is one policy – one you probably have never heard of – that you should definitely consider adding to it.
A while ago, I spoke with a dermatologist in California who experienced every employer’s nightmare: he fired an incompetent employee, who promptly sued him for wrongful termination and accused him of sexual harassment to boot. The charges were completely false, and the employee’s transgressions were well documented; but he was not insured against a suit of that type, and defending it would have been prohibitively expensive. He was forced to settle it for a significant sum of money.
Disasters like that are becoming more common. Plaintiffs’ attorneys know that most small businesses, including medical practices, are not insured against internal liability actions – and that settlements are cheaper than litigation.
Fortunately, there is a relatively inexpensive alternative: not covered by conventional liability insurance. These include wrongful termination, sexual harassment, discrimination, breach of employment contract, negligent hiring or evaluation, failure to promote, wrongful discipline, mismanagement of benefits, and the ever-popular “emotional distress.”
EPLI coverage would have permitted the California dermatologist to mount a proper defense against his employee’s groundless charges. In fact, there is a better than even chance that the lawsuit would have been dropped, or never filed to begin with.
Some liability carriers are beginning to cover some employee-related issues in “umbrella” policies, so before looking into EPLI, check your current coverage. Then, as with all insurance, you should shop around for the best price and carefully read the policies on your short list. All EPLI policies cover litigation against your practice and its owners by employees, but some cover only full-timers. Try to obtain the broadest coverage possible so that claims from part-time, temporary, and seasonal employees, and, if possible, even applicants for employment and former employees, also are covered.
You should also look for the most comprehensive policy in terms of coverage. Almost every EPLI policy covers the allegations mentioned above, but some offer a more comprehensive list of covered acts, such as invasion of privacy and defamation of character.
Also be aware of precisely what each policy does not cover. Most exclude punitive damages and court-imposed fines, as well as criminal acts, fraud, and other clearly illegal conduct. For example, you would not be covered if you fired an employee because he or she refused to falsify insurance claims.
Depending on where you practice, it may be necessary to ask an employment attorney to evaluate your individual EPLI needs. An underwriter cannot anticipate every eventuality for you, particularly if he or she does not live in your area and is not familiar with employment conditions in your community.
As with any liability policy, try to get a clause added that permits you to choose your own defense attorney. Better still, pick a specific attorney or firm that you trust and have that counsel named in an endorsement to the policy. Otherwise, the insurance carrier will select an attorney from its own panel who may not consider your interests a higher priority than those of the insurer itself.
If you must accept the insurer’s choice of counsel, you should find out whether that attorney is experienced in employment law, which is a very specialized area. And just as with your malpractice policy, you will want to maintain as much control as possible over the settlement of claims. Ideally, no claim should be settled without your express permission.
As with any insurance policy you buy, be sure to choose an established carrier with ample experience in the field and solid financial strength. A low premium is no bargain if the carrier is new to EPLI or goes broke.
Above all, as with any insurance policy, make sure that you can live with the claims definition and exclusions in the policy you choose, and seek advice if you are unsure what your specific needs are before signing on the dotted line.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
No matter how complete your insurance portfolio, there is one policy – one you probably have never heard of – that you should definitely consider adding to it.
A while ago, I spoke with a dermatologist in California who experienced every employer’s nightmare: he fired an incompetent employee, who promptly sued him for wrongful termination and accused him of sexual harassment to boot. The charges were completely false, and the employee’s transgressions were well documented; but he was not insured against a suit of that type, and defending it would have been prohibitively expensive. He was forced to settle it for a significant sum of money.
Disasters like that are becoming more common. Plaintiffs’ attorneys know that most small businesses, including medical practices, are not insured against internal liability actions – and that settlements are cheaper than litigation.
Fortunately, there is a relatively inexpensive alternative: not covered by conventional liability insurance. These include wrongful termination, sexual harassment, discrimination, breach of employment contract, negligent hiring or evaluation, failure to promote, wrongful discipline, mismanagement of benefits, and the ever-popular “emotional distress.”
EPLI coverage would have permitted the California dermatologist to mount a proper defense against his employee’s groundless charges. In fact, there is a better than even chance that the lawsuit would have been dropped, or never filed to begin with.
Some liability carriers are beginning to cover some employee-related issues in “umbrella” policies, so before looking into EPLI, check your current coverage. Then, as with all insurance, you should shop around for the best price and carefully read the policies on your short list. All EPLI policies cover litigation against your practice and its owners by employees, but some cover only full-timers. Try to obtain the broadest coverage possible so that claims from part-time, temporary, and seasonal employees, and, if possible, even applicants for employment and former employees, also are covered.
You should also look for the most comprehensive policy in terms of coverage. Almost every EPLI policy covers the allegations mentioned above, but some offer a more comprehensive list of covered acts, such as invasion of privacy and defamation of character.
Also be aware of precisely what each policy does not cover. Most exclude punitive damages and court-imposed fines, as well as criminal acts, fraud, and other clearly illegal conduct. For example, you would not be covered if you fired an employee because he or she refused to falsify insurance claims.
Depending on where you practice, it may be necessary to ask an employment attorney to evaluate your individual EPLI needs. An underwriter cannot anticipate every eventuality for you, particularly if he or she does not live in your area and is not familiar with employment conditions in your community.
As with any liability policy, try to get a clause added that permits you to choose your own defense attorney. Better still, pick a specific attorney or firm that you trust and have that counsel named in an endorsement to the policy. Otherwise, the insurance carrier will select an attorney from its own panel who may not consider your interests a higher priority than those of the insurer itself.
If you must accept the insurer’s choice of counsel, you should find out whether that attorney is experienced in employment law, which is a very specialized area. And just as with your malpractice policy, you will want to maintain as much control as possible over the settlement of claims. Ideally, no claim should be settled without your express permission.
As with any insurance policy you buy, be sure to choose an established carrier with ample experience in the field and solid financial strength. A low premium is no bargain if the carrier is new to EPLI or goes broke.
Above all, as with any insurance policy, make sure that you can live with the claims definition and exclusions in the policy you choose, and seek advice if you are unsure what your specific needs are before signing on the dotted line.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
No matter how complete your insurance portfolio, there is one policy – one you probably have never heard of – that you should definitely consider adding to it.
A while ago, I spoke with a dermatologist in California who experienced every employer’s nightmare: he fired an incompetent employee, who promptly sued him for wrongful termination and accused him of sexual harassment to boot. The charges were completely false, and the employee’s transgressions were well documented; but he was not insured against a suit of that type, and defending it would have been prohibitively expensive. He was forced to settle it for a significant sum of money.
Disasters like that are becoming more common. Plaintiffs’ attorneys know that most small businesses, including medical practices, are not insured against internal liability actions – and that settlements are cheaper than litigation.
Fortunately, there is a relatively inexpensive alternative: not covered by conventional liability insurance. These include wrongful termination, sexual harassment, discrimination, breach of employment contract, negligent hiring or evaluation, failure to promote, wrongful discipline, mismanagement of benefits, and the ever-popular “emotional distress.”
EPLI coverage would have permitted the California dermatologist to mount a proper defense against his employee’s groundless charges. In fact, there is a better than even chance that the lawsuit would have been dropped, or never filed to begin with.
Some liability carriers are beginning to cover some employee-related issues in “umbrella” policies, so before looking into EPLI, check your current coverage. Then, as with all insurance, you should shop around for the best price and carefully read the policies on your short list. All EPLI policies cover litigation against your practice and its owners by employees, but some cover only full-timers. Try to obtain the broadest coverage possible so that claims from part-time, temporary, and seasonal employees, and, if possible, even applicants for employment and former employees, also are covered.
You should also look for the most comprehensive policy in terms of coverage. Almost every EPLI policy covers the allegations mentioned above, but some offer a more comprehensive list of covered acts, such as invasion of privacy and defamation of character.
Also be aware of precisely what each policy does not cover. Most exclude punitive damages and court-imposed fines, as well as criminal acts, fraud, and other clearly illegal conduct. For example, you would not be covered if you fired an employee because he or she refused to falsify insurance claims.
Depending on where you practice, it may be necessary to ask an employment attorney to evaluate your individual EPLI needs. An underwriter cannot anticipate every eventuality for you, particularly if he or she does not live in your area and is not familiar with employment conditions in your community.
As with any liability policy, try to get a clause added that permits you to choose your own defense attorney. Better still, pick a specific attorney or firm that you trust and have that counsel named in an endorsement to the policy. Otherwise, the insurance carrier will select an attorney from its own panel who may not consider your interests a higher priority than those of the insurer itself.
If you must accept the insurer’s choice of counsel, you should find out whether that attorney is experienced in employment law, which is a very specialized area. And just as with your malpractice policy, you will want to maintain as much control as possible over the settlement of claims. Ideally, no claim should be settled without your express permission.
As with any insurance policy you buy, be sure to choose an established carrier with ample experience in the field and solid financial strength. A low premium is no bargain if the carrier is new to EPLI or goes broke.
Above all, as with any insurance policy, make sure that you can live with the claims definition and exclusions in the policy you choose, and seek advice if you are unsure what your specific needs are before signing on the dotted line.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The Right Choice? Modifiable risk factors and surgical decision making
In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.1 Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.
I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.
In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.
My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.
I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.
Reference
1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.1 Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.
I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.
In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.
My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.
I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.
Reference
1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.1 Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.
I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.
In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.
My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.
I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.
Reference
1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In Memoriam: Dr. John Ochsner
John Lockwood Ochsner, MD, (1927-2018), a world-renowned heart surgeon, will be remembered as a charismatic and skilled surgeon, a dedicated teacher, a loving father, and a role model for the hundreds of surgeons he trained.
Dr. Ochsner was born in 1927 in Madison, Wisc., but was raised in New Orleans. and received his medical degree from Tulane University. He started his surgical residency at the University of Michigan but was drafted into military service during the Korean War. He then completed his residency at Baylor University and received his cardiac training under Michael DeBakey. MD,. Dr. DeBakey was a close family friend who had studied under John’s father at Tulane and had worked in the original Ochsner Clinic. John was very close to Dr. DeBakey, who was also John’s babysitter in early life.
Dr. John, as he was known, grew up in shadow of giants, including his father, Alton, who founded the Ochsner Clinic, and Michael DeBakey who was a protégé of Alton. As John was finishing his training with Dr. DeBakey he was asked to stay on in Houston as a member of Dr. DeBakey’s team. The Ochsner Clinic was expanding rapidly in New Orleans, however, and everyone was desirous of having John return. John initially planned to stay with Dr. DeBakey until the director of the Ochsner Clinic flew to Houston to meet with John to convince him to return to New Orleans. His argument was, “John, you will be a great surgeon wherever you practice, but there is only one hospital that has your name on the front of it!” John returned to the Ochsner Clinic in 1961, where he spent the next 57 years.
John Ochsner was revered as an innovative, energetic and talented surgeon, performing over 12,000 operations, including the first cardiac transplant in the Gulf South. He always said he was happiest in the operating room, and loved teaching young resident surgeons. He believed that “surgery is an art as much as a science. ... You have to improvise almost every case -- no two cases are the same - and that’s where the fun of surgery comes in, making something new that particular moment that you’ve never seen before. ... It’s like opening up a package; it’s always a little different.”
He authored more than 300 peer-reviewed publications and gave innumerable scientific lectures around the world. He served as President of the International Society for Cardiovascular Surgery as well as the American Association for Thoracic Surgery. Over his career, he was elected president of more than 10 medical associations.
John, like his father, was active in many aspects of New Orleans life. He was an avid golfer and tennis player, and was always ready with a joke. He lived life with humor and enthusiasm, and was a member of multiple social clubs, developing lifelong friends from around the world. He was particularly thrilled when he was chosen as Rex, King of Carnival, in 1990, following in the royal footsteps of his father, who was King of Rex in 1948. Both of his granddaughters were presented as Maids of the Rex organization.
John is survived by his wife of over 64 years, Mary Lou Ochsner; a sister, Isabel Mann: two sons, Dr. John Ochsner, Jr., and Frank Ochsner, and two daughters, Joby Ochsner and Dr. Katherine Isabel Ochsner; he has two grandchildren.
Larry H. Hollier, MD, Professor of Surgery, Chancellor, Louisiana State University Health Science Center at New Orleans
John Lockwood Ochsner, MD, (1927-2018), a world-renowned heart surgeon, will be remembered as a charismatic and skilled surgeon, a dedicated teacher, a loving father, and a role model for the hundreds of surgeons he trained.
Dr. Ochsner was born in 1927 in Madison, Wisc., but was raised in New Orleans. and received his medical degree from Tulane University. He started his surgical residency at the University of Michigan but was drafted into military service during the Korean War. He then completed his residency at Baylor University and received his cardiac training under Michael DeBakey. MD,. Dr. DeBakey was a close family friend who had studied under John’s father at Tulane and had worked in the original Ochsner Clinic. John was very close to Dr. DeBakey, who was also John’s babysitter in early life.
Dr. John, as he was known, grew up in shadow of giants, including his father, Alton, who founded the Ochsner Clinic, and Michael DeBakey who was a protégé of Alton. As John was finishing his training with Dr. DeBakey he was asked to stay on in Houston as a member of Dr. DeBakey’s team. The Ochsner Clinic was expanding rapidly in New Orleans, however, and everyone was desirous of having John return. John initially planned to stay with Dr. DeBakey until the director of the Ochsner Clinic flew to Houston to meet with John to convince him to return to New Orleans. His argument was, “John, you will be a great surgeon wherever you practice, but there is only one hospital that has your name on the front of it!” John returned to the Ochsner Clinic in 1961, where he spent the next 57 years.
John Ochsner was revered as an innovative, energetic and talented surgeon, performing over 12,000 operations, including the first cardiac transplant in the Gulf South. He always said he was happiest in the operating room, and loved teaching young resident surgeons. He believed that “surgery is an art as much as a science. ... You have to improvise almost every case -- no two cases are the same - and that’s where the fun of surgery comes in, making something new that particular moment that you’ve never seen before. ... It’s like opening up a package; it’s always a little different.”
He authored more than 300 peer-reviewed publications and gave innumerable scientific lectures around the world. He served as President of the International Society for Cardiovascular Surgery as well as the American Association for Thoracic Surgery. Over his career, he was elected president of more than 10 medical associations.
John, like his father, was active in many aspects of New Orleans life. He was an avid golfer and tennis player, and was always ready with a joke. He lived life with humor and enthusiasm, and was a member of multiple social clubs, developing lifelong friends from around the world. He was particularly thrilled when he was chosen as Rex, King of Carnival, in 1990, following in the royal footsteps of his father, who was King of Rex in 1948. Both of his granddaughters were presented as Maids of the Rex organization.
John is survived by his wife of over 64 years, Mary Lou Ochsner; a sister, Isabel Mann: two sons, Dr. John Ochsner, Jr., and Frank Ochsner, and two daughters, Joby Ochsner and Dr. Katherine Isabel Ochsner; he has two grandchildren.
Larry H. Hollier, MD, Professor of Surgery, Chancellor, Louisiana State University Health Science Center at New Orleans
John Lockwood Ochsner, MD, (1927-2018), a world-renowned heart surgeon, will be remembered as a charismatic and skilled surgeon, a dedicated teacher, a loving father, and a role model for the hundreds of surgeons he trained.
Dr. Ochsner was born in 1927 in Madison, Wisc., but was raised in New Orleans. and received his medical degree from Tulane University. He started his surgical residency at the University of Michigan but was drafted into military service during the Korean War. He then completed his residency at Baylor University and received his cardiac training under Michael DeBakey. MD,. Dr. DeBakey was a close family friend who had studied under John’s father at Tulane and had worked in the original Ochsner Clinic. John was very close to Dr. DeBakey, who was also John’s babysitter in early life.
Dr. John, as he was known, grew up in shadow of giants, including his father, Alton, who founded the Ochsner Clinic, and Michael DeBakey who was a protégé of Alton. As John was finishing his training with Dr. DeBakey he was asked to stay on in Houston as a member of Dr. DeBakey’s team. The Ochsner Clinic was expanding rapidly in New Orleans, however, and everyone was desirous of having John return. John initially planned to stay with Dr. DeBakey until the director of the Ochsner Clinic flew to Houston to meet with John to convince him to return to New Orleans. His argument was, “John, you will be a great surgeon wherever you practice, but there is only one hospital that has your name on the front of it!” John returned to the Ochsner Clinic in 1961, where he spent the next 57 years.
John Ochsner was revered as an innovative, energetic and talented surgeon, performing over 12,000 operations, including the first cardiac transplant in the Gulf South. He always said he was happiest in the operating room, and loved teaching young resident surgeons. He believed that “surgery is an art as much as a science. ... You have to improvise almost every case -- no two cases are the same - and that’s where the fun of surgery comes in, making something new that particular moment that you’ve never seen before. ... It’s like opening up a package; it’s always a little different.”
He authored more than 300 peer-reviewed publications and gave innumerable scientific lectures around the world. He served as President of the International Society for Cardiovascular Surgery as well as the American Association for Thoracic Surgery. Over his career, he was elected president of more than 10 medical associations.
John, like his father, was active in many aspects of New Orleans life. He was an avid golfer and tennis player, and was always ready with a joke. He lived life with humor and enthusiasm, and was a member of multiple social clubs, developing lifelong friends from around the world. He was particularly thrilled when he was chosen as Rex, King of Carnival, in 1990, following in the royal footsteps of his father, who was King of Rex in 1948. Both of his granddaughters were presented as Maids of the Rex organization.
John is survived by his wife of over 64 years, Mary Lou Ochsner; a sister, Isabel Mann: two sons, Dr. John Ochsner, Jr., and Frank Ochsner, and two daughters, Joby Ochsner and Dr. Katherine Isabel Ochsner; he has two grandchildren.
Larry H. Hollier, MD, Professor of Surgery, Chancellor, Louisiana State University Health Science Center at New Orleans
Positive change through advocacy
SHM seen as an ‘honest broker’ on Capitol Hill
Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.
As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.
In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.
The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.
When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.
We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.
That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.
Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.
Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.
The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.
The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:
- Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
- Successful support of risk adjustment of readmission rates for safety net hospitals.
- Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
- Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
- Establishment of a Hospitalist Measure set with CMS.
- Repeal of the Independent Advisory Board earlier this year.
- Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.
SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.
More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.
As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.
We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.
SHM seen as an ‘honest broker’ on Capitol Hill
SHM seen as an ‘honest broker’ on Capitol Hill
Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.
As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.
In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.
The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.
When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.
We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.
That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.
Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.
Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.
The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.
The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:
- Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
- Successful support of risk adjustment of readmission rates for safety net hospitals.
- Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
- Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
- Establishment of a Hospitalist Measure set with CMS.
- Repeal of the Independent Advisory Board earlier this year.
- Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.
SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.
More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.
As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.
We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.
Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.
As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.
In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.
The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.
When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.
We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.
That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.
Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.
Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.
The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.
The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:
- Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
- Successful support of risk adjustment of readmission rates for safety net hospitals.
- Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
- Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
- Establishment of a Hospitalist Measure set with CMS.
- Repeal of the Independent Advisory Board earlier this year.
- Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.
SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.
More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.
As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.
We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.
Sudden hearing loss
A 46-year-old man presents to your clinic with hearing loss and ear fullness. He awoke with sudden and unexplained right-sided hearing loss with aural fullness 6 days prior to presentation and reports associated unilateral tinnitus and vertigo. He denies otorrhea and otalgia. Hearing on the left is otherwise preserved, and he has no prior otologic history. He denies inciting events. He has never experienced this before.
On examination, the auricles are normal, and there are no vesicular lesions. His ear canals are patent and without occluding cerumen. Tympanic membranes are translucent and intact without effusion or retraction. On tuning fork examination, Weber lateralizes to the left, and air conduction is greater than bone conduction bilaterally.
What is the most likely diagnosis?
A. Otitis media with effusion.
B. Ménière’s disease.
C. Ramsay Hunt syndrome.
D. Sudden sensorineural hearing loss.
E. Bell’s palsy.
F. Otosclerosis.
G. Benign paroxysmal positional vertigo.
This patient is presenting with sudden sensorineural hearing loss (SSNHL). There are approximately 4,000 new cases of SSNHL reported each year in the United States, and many primary care physicians will encounter this disorder.1
Idiopathic SSNHL is an otolaryngology emergency, and recognition and prompt treatment is imperative to potentially salvage hearing and improve quality of life.2 The rates of spontaneous recovery within the literature vary widely from 32% to 65%. However, this constitutes a significant portion of patients who still require the use of hearing aids. Recovery at lower frequencies occurs more commonly, and the rates of true spontaneous recovery are likely approximately one-third of all cases, with only 15% of patients who recover fully.3
Patients with SSNHL present to an otolaryngologist on average 55 days after symptom onset. Yet it is believed that the earlier the intervention, the more improved the recovery, especially if instituted within 1-2 weeks.4 Most patients, however, initially present to their primary care physicians.
The history and physical are particularly important to rule out other etiologies of hearing loss, including otitis media with effusion, acute otitis media, and cerumen impaction.
The onset and progression of SSNHL are unique, in that patients will experience near immediate unilateral hearing loss, typically with a normal ear examination. Aural pressure and tinnitus are frequently reported in SSNHL. In fact, ear fullness is the most common presenting symptom, and tinnitus is reported nearly universally. Dizziness or vertigo does not refute the diagnosis of SSNHL, as this occurs in 30%-40% of cases and is a negative prognostic factor, along with profound sensorineural loss, contralateral hearing impairment, and delayed treatment.3,5
In 9 out of 10 patients with SSNHL, a precipitating factor or cause will never be identified, and approximately one-third of patients will spontaneously recover hearing.6
This has created controversial treatment options. Regardless, specialty guidelines advocate for early medical treatment with systemic corticosteroids within the first 14 days of symptom onset. Clinicians must be prepared to empirically and rapidly treat patients with suspected SSNHL without understanding the etiology and without conclusive audiologic or imaging data.
Other causes indeterminate of sudden hearing loss include autoimmune and Ménière’s disease; however, diagnosis and management of these disorders does not have the same urgency as that of SSNHL.
Otolaryngology follow-up for SSNHL is recommended to provide treatment options and counseling, monitor hearing thresholds, provide ongoing evaluation for hearing augmentation, and establish expert consultation to ensure there are no underlying causes.
Primary care providers need to institute the initial treatment recommendations, which include systemic steroids, potentially in combination with alternative treatment options. There is conflicting evidence on the efficacy of early high-dose steroid therapy in SSNHL. But, unfortunately, the alternative may include permanent unilateral deafness.7 The earlier the treatment, the better the outcomes, although oral steroids may contribute to significant improvement even at late presentation.4
Dosing recommendations vary, but include prednisone 1 mg/kg per day (maximum of 60 mg), methylprednisolone 48 mg/day, and dexamethasone 10 mg/day for 7-14 days prior to tapering. Examination and audiometry are ideally obtained at the time of symptom onset and immediately after treatment for full evaluation.
Evidence supports the use of intratympanic steroid injections after primary treatment failure, although there is increasing interest in combining transtympanic perfusion with oral steroids for primary treatment.7,8 In a survey of otolaryngologists, 86% of respondents reported the concomitant use of intratympanic steroid injections for primary treatment.9 Of these, greater than 50% and 32% used steroid injections up to 1 month, and up to 3 months following the onset of symptoms, respectively.
There may be benefit with hyperbaric oxygen therapy, which is rarely used in the United States.6 There may be benefit with a low side effect profile in combining systemic steroids with antioxidants, such as vitamins A, C, and E.10
In summary, SSNHL is not uncommon; ear fullness and tinnitus are common and may represent the chief complaint. A high index of suspicion is necessary, and decisions are often made without full knowledge of the etiology. Conductive hearing loss should be ruled out on history and examination. Initial diagnostic workup includes formal audiometry with initiation of high-dose corticosteroid therapy, ideally within 2 weeks of symptom onset.
Consultation to otolaryngology or neurotology is important for ongoing discussions regarding potential recovery, hearing augmentation, and to ensure there is no underlying condition.
Dr. Shinn is with the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, Tenn. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Otolaryngol Head Neck Surg. 2012;146(3 Suppl):S1-35.
2. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.1072.
3. Braz J Otorhinolaryngol. 2015 Oct-Sep;81(5):520-6.
4. Cureus. 2017 Dec;9(12):e1945.
5. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.0648.
6. Otolaryngol Clin North Am. 2008;41(3):633-49.
7. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):413-9.
8. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82.
9. Ann Otol Rhinol Laryngol. 2018 Jul;127(7):481-2.
10. Audiol Neurotol. 2018 Jun 22;23(1):1-7.
A 46-year-old man presents to your clinic with hearing loss and ear fullness. He awoke with sudden and unexplained right-sided hearing loss with aural fullness 6 days prior to presentation and reports associated unilateral tinnitus and vertigo. He denies otorrhea and otalgia. Hearing on the left is otherwise preserved, and he has no prior otologic history. He denies inciting events. He has never experienced this before.
On examination, the auricles are normal, and there are no vesicular lesions. His ear canals are patent and without occluding cerumen. Tympanic membranes are translucent and intact without effusion or retraction. On tuning fork examination, Weber lateralizes to the left, and air conduction is greater than bone conduction bilaterally.
What is the most likely diagnosis?
A. Otitis media with effusion.
B. Ménière’s disease.
C. Ramsay Hunt syndrome.
D. Sudden sensorineural hearing loss.
E. Bell’s palsy.
F. Otosclerosis.
G. Benign paroxysmal positional vertigo.
This patient is presenting with sudden sensorineural hearing loss (SSNHL). There are approximately 4,000 new cases of SSNHL reported each year in the United States, and many primary care physicians will encounter this disorder.1
Idiopathic SSNHL is an otolaryngology emergency, and recognition and prompt treatment is imperative to potentially salvage hearing and improve quality of life.2 The rates of spontaneous recovery within the literature vary widely from 32% to 65%. However, this constitutes a significant portion of patients who still require the use of hearing aids. Recovery at lower frequencies occurs more commonly, and the rates of true spontaneous recovery are likely approximately one-third of all cases, with only 15% of patients who recover fully.3
Patients with SSNHL present to an otolaryngologist on average 55 days after symptom onset. Yet it is believed that the earlier the intervention, the more improved the recovery, especially if instituted within 1-2 weeks.4 Most patients, however, initially present to their primary care physicians.
The history and physical are particularly important to rule out other etiologies of hearing loss, including otitis media with effusion, acute otitis media, and cerumen impaction.
The onset and progression of SSNHL are unique, in that patients will experience near immediate unilateral hearing loss, typically with a normal ear examination. Aural pressure and tinnitus are frequently reported in SSNHL. In fact, ear fullness is the most common presenting symptom, and tinnitus is reported nearly universally. Dizziness or vertigo does not refute the diagnosis of SSNHL, as this occurs in 30%-40% of cases and is a negative prognostic factor, along with profound sensorineural loss, contralateral hearing impairment, and delayed treatment.3,5
In 9 out of 10 patients with SSNHL, a precipitating factor or cause will never be identified, and approximately one-third of patients will spontaneously recover hearing.6
This has created controversial treatment options. Regardless, specialty guidelines advocate for early medical treatment with systemic corticosteroids within the first 14 days of symptom onset. Clinicians must be prepared to empirically and rapidly treat patients with suspected SSNHL without understanding the etiology and without conclusive audiologic or imaging data.
Other causes indeterminate of sudden hearing loss include autoimmune and Ménière’s disease; however, diagnosis and management of these disorders does not have the same urgency as that of SSNHL.
Otolaryngology follow-up for SSNHL is recommended to provide treatment options and counseling, monitor hearing thresholds, provide ongoing evaluation for hearing augmentation, and establish expert consultation to ensure there are no underlying causes.
Primary care providers need to institute the initial treatment recommendations, which include systemic steroids, potentially in combination with alternative treatment options. There is conflicting evidence on the efficacy of early high-dose steroid therapy in SSNHL. But, unfortunately, the alternative may include permanent unilateral deafness.7 The earlier the treatment, the better the outcomes, although oral steroids may contribute to significant improvement even at late presentation.4
Dosing recommendations vary, but include prednisone 1 mg/kg per day (maximum of 60 mg), methylprednisolone 48 mg/day, and dexamethasone 10 mg/day for 7-14 days prior to tapering. Examination and audiometry are ideally obtained at the time of symptom onset and immediately after treatment for full evaluation.
Evidence supports the use of intratympanic steroid injections after primary treatment failure, although there is increasing interest in combining transtympanic perfusion with oral steroids for primary treatment.7,8 In a survey of otolaryngologists, 86% of respondents reported the concomitant use of intratympanic steroid injections for primary treatment.9 Of these, greater than 50% and 32% used steroid injections up to 1 month, and up to 3 months following the onset of symptoms, respectively.
There may be benefit with hyperbaric oxygen therapy, which is rarely used in the United States.6 There may be benefit with a low side effect profile in combining systemic steroids with antioxidants, such as vitamins A, C, and E.10
In summary, SSNHL is not uncommon; ear fullness and tinnitus are common and may represent the chief complaint. A high index of suspicion is necessary, and decisions are often made without full knowledge of the etiology. Conductive hearing loss should be ruled out on history and examination. Initial diagnostic workup includes formal audiometry with initiation of high-dose corticosteroid therapy, ideally within 2 weeks of symptom onset.
Consultation to otolaryngology or neurotology is important for ongoing discussions regarding potential recovery, hearing augmentation, and to ensure there is no underlying condition.
Dr. Shinn is with the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, Tenn. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Otolaryngol Head Neck Surg. 2012;146(3 Suppl):S1-35.
2. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.1072.
3. Braz J Otorhinolaryngol. 2015 Oct-Sep;81(5):520-6.
4. Cureus. 2017 Dec;9(12):e1945.
5. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.0648.
6. Otolaryngol Clin North Am. 2008;41(3):633-49.
7. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):413-9.
8. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82.
9. Ann Otol Rhinol Laryngol. 2018 Jul;127(7):481-2.
10. Audiol Neurotol. 2018 Jun 22;23(1):1-7.
A 46-year-old man presents to your clinic with hearing loss and ear fullness. He awoke with sudden and unexplained right-sided hearing loss with aural fullness 6 days prior to presentation and reports associated unilateral tinnitus and vertigo. He denies otorrhea and otalgia. Hearing on the left is otherwise preserved, and he has no prior otologic history. He denies inciting events. He has never experienced this before.
On examination, the auricles are normal, and there are no vesicular lesions. His ear canals are patent and without occluding cerumen. Tympanic membranes are translucent and intact without effusion or retraction. On tuning fork examination, Weber lateralizes to the left, and air conduction is greater than bone conduction bilaterally.
What is the most likely diagnosis?
A. Otitis media with effusion.
B. Ménière’s disease.
C. Ramsay Hunt syndrome.
D. Sudden sensorineural hearing loss.
E. Bell’s palsy.
F. Otosclerosis.
G. Benign paroxysmal positional vertigo.
This patient is presenting with sudden sensorineural hearing loss (SSNHL). There are approximately 4,000 new cases of SSNHL reported each year in the United States, and many primary care physicians will encounter this disorder.1
Idiopathic SSNHL is an otolaryngology emergency, and recognition and prompt treatment is imperative to potentially salvage hearing and improve quality of life.2 The rates of spontaneous recovery within the literature vary widely from 32% to 65%. However, this constitutes a significant portion of patients who still require the use of hearing aids. Recovery at lower frequencies occurs more commonly, and the rates of true spontaneous recovery are likely approximately one-third of all cases, with only 15% of patients who recover fully.3
Patients with SSNHL present to an otolaryngologist on average 55 days after symptom onset. Yet it is believed that the earlier the intervention, the more improved the recovery, especially if instituted within 1-2 weeks.4 Most patients, however, initially present to their primary care physicians.
The history and physical are particularly important to rule out other etiologies of hearing loss, including otitis media with effusion, acute otitis media, and cerumen impaction.
The onset and progression of SSNHL are unique, in that patients will experience near immediate unilateral hearing loss, typically with a normal ear examination. Aural pressure and tinnitus are frequently reported in SSNHL. In fact, ear fullness is the most common presenting symptom, and tinnitus is reported nearly universally. Dizziness or vertigo does not refute the diagnosis of SSNHL, as this occurs in 30%-40% of cases and is a negative prognostic factor, along with profound sensorineural loss, contralateral hearing impairment, and delayed treatment.3,5
In 9 out of 10 patients with SSNHL, a precipitating factor or cause will never be identified, and approximately one-third of patients will spontaneously recover hearing.6
This has created controversial treatment options. Regardless, specialty guidelines advocate for early medical treatment with systemic corticosteroids within the first 14 days of symptom onset. Clinicians must be prepared to empirically and rapidly treat patients with suspected SSNHL without understanding the etiology and without conclusive audiologic or imaging data.
Other causes indeterminate of sudden hearing loss include autoimmune and Ménière’s disease; however, diagnosis and management of these disorders does not have the same urgency as that of SSNHL.
Otolaryngology follow-up for SSNHL is recommended to provide treatment options and counseling, monitor hearing thresholds, provide ongoing evaluation for hearing augmentation, and establish expert consultation to ensure there are no underlying causes.
Primary care providers need to institute the initial treatment recommendations, which include systemic steroids, potentially in combination with alternative treatment options. There is conflicting evidence on the efficacy of early high-dose steroid therapy in SSNHL. But, unfortunately, the alternative may include permanent unilateral deafness.7 The earlier the treatment, the better the outcomes, although oral steroids may contribute to significant improvement even at late presentation.4
Dosing recommendations vary, but include prednisone 1 mg/kg per day (maximum of 60 mg), methylprednisolone 48 mg/day, and dexamethasone 10 mg/day for 7-14 days prior to tapering. Examination and audiometry are ideally obtained at the time of symptom onset and immediately after treatment for full evaluation.
Evidence supports the use of intratympanic steroid injections after primary treatment failure, although there is increasing interest in combining transtympanic perfusion with oral steroids for primary treatment.7,8 In a survey of otolaryngologists, 86% of respondents reported the concomitant use of intratympanic steroid injections for primary treatment.9 Of these, greater than 50% and 32% used steroid injections up to 1 month, and up to 3 months following the onset of symptoms, respectively.
There may be benefit with hyperbaric oxygen therapy, which is rarely used in the United States.6 There may be benefit with a low side effect profile in combining systemic steroids with antioxidants, such as vitamins A, C, and E.10
In summary, SSNHL is not uncommon; ear fullness and tinnitus are common and may represent the chief complaint. A high index of suspicion is necessary, and decisions are often made without full knowledge of the etiology. Conductive hearing loss should be ruled out on history and examination. Initial diagnostic workup includes formal audiometry with initiation of high-dose corticosteroid therapy, ideally within 2 weeks of symptom onset.
Consultation to otolaryngology or neurotology is important for ongoing discussions regarding potential recovery, hearing augmentation, and to ensure there is no underlying condition.
Dr. Shinn is with the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, Tenn. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Otolaryngol Head Neck Surg. 2012;146(3 Suppl):S1-35.
2. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.1072.
3. Braz J Otorhinolaryngol. 2015 Oct-Sep;81(5):520-6.
4. Cureus. 2017 Dec;9(12):e1945.
5. JAMA Otolaryngol Head Neck Surg. 2018 Jun 21. doi: 10.1001/jamaoto.2018.0648.
6. Otolaryngol Clin North Am. 2008;41(3):633-49.
7. Curr Opin Otolaryngol Head Neck Surg. 2016 Oct;24(5):413-9.
8. Eur Arch Otorhinolaryngol. 2015 Oct;272(10):2777-82.
9. Ann Otol Rhinol Laryngol. 2018 Jul;127(7):481-2.
10. Audiol Neurotol. 2018 Jun 22;23(1):1-7.
The chief complaint
In medical school, they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.
“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure …”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry, too. Very sorry, indeed. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
In medical school, they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.
“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure …”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry, too. Very sorry, indeed. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
In medical school, they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.
“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure …”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry, too. Very sorry, indeed. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Denial of science isn’t fiction
Summer is often a time when we can take a break from our usual frenetic schedules. It is a time to catch up on nonurgent reading. I just completed 3 books of interest, including Bad Blood, by John Carreyrou, What the Eyes Don’t See, by Mona Hanna-Attisha, and Overcharged, by Charles Silver and David Hyman.
The common thread among them is their focus on the interplay among American medicine, politics, money, and denial of science. Carreyrou is a Wall Street Journal investigative reporter who describes the spectacular rise and ignominious fall of Theranos, a privately held company in the business of blood testing and diagnostics. Theranos claimed to have a secret process enabling them to run over 200 diagnostic blood tests on blood derived from a finger prick. At its peak, the company was valued at $10 billion but their secret process proved to be false science. They are now subject to multiple lawsuits and their leaders are under criminal investigation.
Dr. Attisha’s book describes the decisions made by Michigan political and administrative leaders that resulted in high levels of lead in Flint’s water supply. Dr. Attisha is a pediatrician in Flint who documented elevated lead levels in her small patients. When she tried to bring this to public attention, her data was met with enormous backlash by leaders who tried to deny facts and discredit her personally. Neurological damage from childhood lead poisoning is not reversible.
Hyman and Silver’s book (published by the Cato Institute) asserts that politics, third-party payers, and the health care industry, together, have devised a system of wealth transfer from taxpayers to health care providers. It provides examples where this system (that separates payment from health value) does real harm to individual people and the nation. Reading this book makes us think about who should hold the assets from which first-dollar medical payments derive. It reminded me of the famous saying by James Madison, “If all men were angels, there would be no need for government.”
In some circles, science, data, and the scientific method are not valued. In the end, as these books point out, everyone can be entitled to their opinion, but no one has the power to alter facts.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Summer is often a time when we can take a break from our usual frenetic schedules. It is a time to catch up on nonurgent reading. I just completed 3 books of interest, including Bad Blood, by John Carreyrou, What the Eyes Don’t See, by Mona Hanna-Attisha, and Overcharged, by Charles Silver and David Hyman.
The common thread among them is their focus on the interplay among American medicine, politics, money, and denial of science. Carreyrou is a Wall Street Journal investigative reporter who describes the spectacular rise and ignominious fall of Theranos, a privately held company in the business of blood testing and diagnostics. Theranos claimed to have a secret process enabling them to run over 200 diagnostic blood tests on blood derived from a finger prick. At its peak, the company was valued at $10 billion but their secret process proved to be false science. They are now subject to multiple lawsuits and their leaders are under criminal investigation.
Dr. Attisha’s book describes the decisions made by Michigan political and administrative leaders that resulted in high levels of lead in Flint’s water supply. Dr. Attisha is a pediatrician in Flint who documented elevated lead levels in her small patients. When she tried to bring this to public attention, her data was met with enormous backlash by leaders who tried to deny facts and discredit her personally. Neurological damage from childhood lead poisoning is not reversible.
Hyman and Silver’s book (published by the Cato Institute) asserts that politics, third-party payers, and the health care industry, together, have devised a system of wealth transfer from taxpayers to health care providers. It provides examples where this system (that separates payment from health value) does real harm to individual people and the nation. Reading this book makes us think about who should hold the assets from which first-dollar medical payments derive. It reminded me of the famous saying by James Madison, “If all men were angels, there would be no need for government.”
In some circles, science, data, and the scientific method are not valued. In the end, as these books point out, everyone can be entitled to their opinion, but no one has the power to alter facts.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Summer is often a time when we can take a break from our usual frenetic schedules. It is a time to catch up on nonurgent reading. I just completed 3 books of interest, including Bad Blood, by John Carreyrou, What the Eyes Don’t See, by Mona Hanna-Attisha, and Overcharged, by Charles Silver and David Hyman.
The common thread among them is their focus on the interplay among American medicine, politics, money, and denial of science. Carreyrou is a Wall Street Journal investigative reporter who describes the spectacular rise and ignominious fall of Theranos, a privately held company in the business of blood testing and diagnostics. Theranos claimed to have a secret process enabling them to run over 200 diagnostic blood tests on blood derived from a finger prick. At its peak, the company was valued at $10 billion but their secret process proved to be false science. They are now subject to multiple lawsuits and their leaders are under criminal investigation.
Dr. Attisha’s book describes the decisions made by Michigan political and administrative leaders that resulted in high levels of lead in Flint’s water supply. Dr. Attisha is a pediatrician in Flint who documented elevated lead levels in her small patients. When she tried to bring this to public attention, her data was met with enormous backlash by leaders who tried to deny facts and discredit her personally. Neurological damage from childhood lead poisoning is not reversible.
Hyman and Silver’s book (published by the Cato Institute) asserts that politics, third-party payers, and the health care industry, together, have devised a system of wealth transfer from taxpayers to health care providers. It provides examples where this system (that separates payment from health value) does real harm to individual people and the nation. Reading this book makes us think about who should hold the assets from which first-dollar medical payments derive. It reminded me of the famous saying by James Madison, “If all men were angels, there would be no need for government.”
In some circles, science, data, and the scientific method are not valued. In the end, as these books point out, everyone can be entitled to their opinion, but no one has the power to alter facts.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Does supplemental oxygen help COPD patients who have chronic stable moderate hypoxia?
New study a departure from previous research
Case
An 85-year-old man with long-standing chronic obstructive pulmonary disease (COPD) has a witnessed aspiration event while undergoing an outpatient procedure requiring conscious sedation. He is admitted to the hospital for observation overnight. The next morning, he feels well, but his oxygen saturation dips to 85% with ambulation. He reports this is not new for him, but he vehemently does not want supplemental oxygen.
Background
Patients with COPD and severe resting hypoxemia – arterial oxygen partial pressure less than or equal to 55 mm Hg or peripheral capillary oxygen saturation (SpO2) less than or equal to 88% – commonly are prescribed supplemental oxygen. The evidence supporting this practice is limited to two small trials from the 1970s that showed a survival benefit of long-term oxygen therapy (LTOT) in this population,1,2 but these trials may not be generalizable to patients today.
For patients with COPD and mild to moderate resting hypoxemia (SpO2, 89%-93%) or patients with exercise-induced hypoxemia, LTOT has not been shown to improve survival, although it may improve symptoms of dyspnea, exercise tolerance, and other patient reported outcomes. Given the costs, risks, and burdens associated with LTOT, a high-quality clinical trial assessing the effects of LTOT on clinically meaningful outcomes, such as survival or hospitalization, in patients with COPD and moderate hypoxemia has been long overdue.
Overview of the data
The utility of long-term treatment with supplemental oxygen in patients with stable COPD and moderate resting or exercise-induced desaturation was examined by the Long-Term Oxygen Treatment Trial (LOTT) Research Group. Results were published in the New England Journal of Medicine in October 2016 in the article, “A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation.”3
The study was initially designed to test whether the use of supplemental oxygen would lead to longer time until death as compared with no supplemental oxygen in the subgroup of COPD patients with stable disease and moderate resting desaturation (defined as resting SpO2 of 89%-93%). However, because of an enrollment of only 34 patients after 7 months, the trial was redesigned to include exercise-induced desaturation (defined as SpO2 of greater than or equal to 80% for at least 5 minutes, and less than 90% for at least 10 seconds, on a 6-minute walk test) and the secondary outcome of all-cause hospitalization. Hospitalization for any cause was combined with mortality into a new composite primary outcome.
This study was a randomized, controlled trial which enrolled patients at a total of 14 regional clinical centers and their associated sites for a total of 42 centers in the United States. The experimental arm consisted of a long term supplemental oxygen group, and the control group did not receive long term supplemental oxygen. Patients were assigned to groups in a 1:1 ratio and the study was not blinded. Patients with moderate resting desaturation were prescribed 24 hour oxygen at 2 L/min, and patients with moderate exercise-induced desaturation were prescribed oxygen at 2 L/min during exercise and sleep only. The primary outcome was a composite outcome of time until death or time until first hospitalization for any cause. There were multiple secondary outcomes, including incidence of COPD exacerbation, incidence of severe resting desaturation and severe exercise-induced desaturation, quality of life, sleep quality, depression and anxiety, adherence to regimen, 6-minute walk distance, spirometric measurements, risk of cardiovascular disease, and neurocognitive function.
Data were gathered via yearly visits, biannual telephone interviews, and questionnaires mailed at 4 months and 16 months. Adherence was assessed by inquiring about oxygen use every 4 months. If patients in the supplemental oxygen group used stationary oxygen concentrators, logs of meter readings were kept as well. The necessary final sample size was calculated using a time to composite event survival model with the use of the log-rank test statistic.
A total of 738 patients were enrolled in the trial between January 2009 and September 2015 and were followed for 1-6 years. A total of 97% of participants had at least 1 year of follow-up. Out of the 738 randomized patients, 133 (18%) had only resting desaturations, 319 (43%) had only exercise-induced desaturations, and 286 (39%) had both resting and exercise-induced desaturations. Baseline characteristics including age, sex, race, smoking status, quality of life scores, resting SpO2, and nadir SpO2 during the 6-minute walk test were similar between the two groups. The only significant difference noted by the authors between the two groups was a lower BODE (body mass index, airflow obstruction, dyspnea, and exercise) index, which was lower in the group with no supplemental oxygen.
In the time-to-event analysis, there was no significant difference between the two groups in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval, 0.79-1.12; P = .52). There were no significant differences in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91-1.13), COPD exacerbations (RR 1.08; 95% CI, 0.98-1.19), and COPD related hospitalizations (RR, 0.99; 95% CI, 0.83-1.17). There were also no differences between the experimental and control groups in quality of life, lung function, and 6-minute walk distance. There were no significant differences in the subgroups classified by desaturation profile, sex, race, nadir SpO2 during the 6-minute walk test, and forced expiratory volume in 1 second.
The findings in this study show that, in the subgroup of chronic obstructive pulmonary disease patients with stable COPD and moderate resting or exercise-induced desaturation, supplemental oxygen did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, rate of all hospitalizations, rate of all COPD exacerbations, or changes in metrics surrounding quality of life, anxiety/depression, or functional status. This supports earlier studies that demonstrated that long-term treatment with oxygen does not result in longer survival than does no long-term treatment with oxygen in patients with COPD and resting SpO2 of more than 88%.
The results of this study are a departure from previous studies that had shown improved mortality in patients with COPD and severe desaturation who were treated with LTOT. The authors hypothesized that this may have been caused by physiological effects of oxygen saturation on pulmonary vasoconstriction, release of mediators, and ventilator drive, which occur at an O2 saturation of 88% or less and may be more significant in patients with chronic hypoxemia. This trial also contrasted previous studies that had shown that oxygen therapy may reduce dyspnea in COPD patients with mild or no hypoxia because the LOTT trial showed no improvement in quality of life, anxiety, and depression measures in patients treated with long-term oxygen as compared with those treated with no oxygen.
Some limitations of the study included the absence of highly symptomatic patients or patients who the providers believed were too ill to participate, the effect of the unblinded nature of the study on outcomes that were patient reported, the lack of assessment of immediate effects of oxygen on exercise performance or symptoms, possible variability in amount of oxygen delivered, and the fact that patients may have overestimated their oxygen use.
In patients with stable COPD and moderate resting or exercise induced desaturation, long-term supplemental oxygen did not provide any benefit in regard to time until death or first hospitalization or any of the other measured outcomes.
Application of data to the case
Our patient has stable COPD and had only moderate exercise-induced desaturation. Long-term supplemental oxygen would not produce a benefit for him.
This study shows us that it would not increase his survival at this point; however, if he were to have worsening exercise-induced or new resting desaturation at some point in the future, supplemental oxygen would then be beneficial. At this point supplemental oxygen would not even affect his rate of hospitalization for COPD- or non-COPD–related reasons. Perhaps most importantly, adding oxygen therapy would not affect his overall quality of life, including his functional status and mood.
Bottom line
The addition of supplemental oxygen is not helpful for patients with COPD who have chronic stable moderate hypoxia.
Dr. Farber is a medical instructor in the Duke University Health System in Durham, N.C. Dr. Sata is a medical instructor in the Duke University Hospital. Dr. Wachter is an assistant professor of medicine at Duke University. Dr. Sharma is associate medical director for clinical education in hospital medicine at Duke Regional Hospital and an assistant professor of medicine at Duke University.
References
1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Ann Intern Med. 1980 Sep;93(3):391-8.
2. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet 1981 Mar 28;1(8222):681-6.
3. Long-term oxygen treatment trial research group et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016 Oct 27;375(17):1617-27.
Additional reading
Stoller JK et al. Oxygen therapy for patients with COPD: Current evidence and the Long-term Oxygen Treatment Trial. Chest. 2010 July;138:179-87.
Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.
Ameer F et al. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD000238.
Vestbo J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.
Quiz: Does this patient need oxygen?
You are caring for a 72-year-old man with stable COPD who was admitted for cellulitis. He is improving clinically on appropriate antibiotics, and he has been stable on room air every time you examine him. The nurse pages you on the day of discharge – a Sunday – informing you that his oxygen saturation dropped to 88% while he was walking the halls this morning. She asks whether he needs to stay in the hospital so you can arrange home supplemental oxygen therapy. What should you do?
A. Keep him in the hospital until you can arrange home oxygen therapy.
B. Discharge him home Sunday but have the oxygen company go out to his house first thing on Monday.
C. Discharge him home without supplemental oxygen therapy.
D. Check an arterial blood gas to help decide if you should set up oxygen therapy.
The answer is C. He meets the description of stable COPD with mild to moderate exercise-induced desaturation. The LOTT trial supports our clinical decision that he would not benefit from supplemental oxygen therapy at this point.
Key Points
- Long-term oxygen therapy (LTOT) is beneficial in patients with COPD and severe resting hypoxemia (arterial oxygen partial pressure ≤ 55 mm Hg or SpO2 ≤ 88%) and should be prescribed to improve survival in this population.
- Patients with COPD and mild to moderate resting hypoxemia or exercised-induced hypoxemia should not be routinely prescribed LTOT given the associated costs, risks, and burdens and the lack of evidence of benefit.
New study a departure from previous research
New study a departure from previous research
Case
An 85-year-old man with long-standing chronic obstructive pulmonary disease (COPD) has a witnessed aspiration event while undergoing an outpatient procedure requiring conscious sedation. He is admitted to the hospital for observation overnight. The next morning, he feels well, but his oxygen saturation dips to 85% with ambulation. He reports this is not new for him, but he vehemently does not want supplemental oxygen.
Background
Patients with COPD and severe resting hypoxemia – arterial oxygen partial pressure less than or equal to 55 mm Hg or peripheral capillary oxygen saturation (SpO2) less than or equal to 88% – commonly are prescribed supplemental oxygen. The evidence supporting this practice is limited to two small trials from the 1970s that showed a survival benefit of long-term oxygen therapy (LTOT) in this population,1,2 but these trials may not be generalizable to patients today.
For patients with COPD and mild to moderate resting hypoxemia (SpO2, 89%-93%) or patients with exercise-induced hypoxemia, LTOT has not been shown to improve survival, although it may improve symptoms of dyspnea, exercise tolerance, and other patient reported outcomes. Given the costs, risks, and burdens associated with LTOT, a high-quality clinical trial assessing the effects of LTOT on clinically meaningful outcomes, such as survival or hospitalization, in patients with COPD and moderate hypoxemia has been long overdue.
Overview of the data
The utility of long-term treatment with supplemental oxygen in patients with stable COPD and moderate resting or exercise-induced desaturation was examined by the Long-Term Oxygen Treatment Trial (LOTT) Research Group. Results were published in the New England Journal of Medicine in October 2016 in the article, “A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation.”3
The study was initially designed to test whether the use of supplemental oxygen would lead to longer time until death as compared with no supplemental oxygen in the subgroup of COPD patients with stable disease and moderate resting desaturation (defined as resting SpO2 of 89%-93%). However, because of an enrollment of only 34 patients after 7 months, the trial was redesigned to include exercise-induced desaturation (defined as SpO2 of greater than or equal to 80% for at least 5 minutes, and less than 90% for at least 10 seconds, on a 6-minute walk test) and the secondary outcome of all-cause hospitalization. Hospitalization for any cause was combined with mortality into a new composite primary outcome.
This study was a randomized, controlled trial which enrolled patients at a total of 14 regional clinical centers and their associated sites for a total of 42 centers in the United States. The experimental arm consisted of a long term supplemental oxygen group, and the control group did not receive long term supplemental oxygen. Patients were assigned to groups in a 1:1 ratio and the study was not blinded. Patients with moderate resting desaturation were prescribed 24 hour oxygen at 2 L/min, and patients with moderate exercise-induced desaturation were prescribed oxygen at 2 L/min during exercise and sleep only. The primary outcome was a composite outcome of time until death or time until first hospitalization for any cause. There were multiple secondary outcomes, including incidence of COPD exacerbation, incidence of severe resting desaturation and severe exercise-induced desaturation, quality of life, sleep quality, depression and anxiety, adherence to regimen, 6-minute walk distance, spirometric measurements, risk of cardiovascular disease, and neurocognitive function.
Data were gathered via yearly visits, biannual telephone interviews, and questionnaires mailed at 4 months and 16 months. Adherence was assessed by inquiring about oxygen use every 4 months. If patients in the supplemental oxygen group used stationary oxygen concentrators, logs of meter readings were kept as well. The necessary final sample size was calculated using a time to composite event survival model with the use of the log-rank test statistic.
A total of 738 patients were enrolled in the trial between January 2009 and September 2015 and were followed for 1-6 years. A total of 97% of participants had at least 1 year of follow-up. Out of the 738 randomized patients, 133 (18%) had only resting desaturations, 319 (43%) had only exercise-induced desaturations, and 286 (39%) had both resting and exercise-induced desaturations. Baseline characteristics including age, sex, race, smoking status, quality of life scores, resting SpO2, and nadir SpO2 during the 6-minute walk test were similar between the two groups. The only significant difference noted by the authors between the two groups was a lower BODE (body mass index, airflow obstruction, dyspnea, and exercise) index, which was lower in the group with no supplemental oxygen.
In the time-to-event analysis, there was no significant difference between the two groups in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval, 0.79-1.12; P = .52). There were no significant differences in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91-1.13), COPD exacerbations (RR 1.08; 95% CI, 0.98-1.19), and COPD related hospitalizations (RR, 0.99; 95% CI, 0.83-1.17). There were also no differences between the experimental and control groups in quality of life, lung function, and 6-minute walk distance. There were no significant differences in the subgroups classified by desaturation profile, sex, race, nadir SpO2 during the 6-minute walk test, and forced expiratory volume in 1 second.
The findings in this study show that, in the subgroup of chronic obstructive pulmonary disease patients with stable COPD and moderate resting or exercise-induced desaturation, supplemental oxygen did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, rate of all hospitalizations, rate of all COPD exacerbations, or changes in metrics surrounding quality of life, anxiety/depression, or functional status. This supports earlier studies that demonstrated that long-term treatment with oxygen does not result in longer survival than does no long-term treatment with oxygen in patients with COPD and resting SpO2 of more than 88%.
The results of this study are a departure from previous studies that had shown improved mortality in patients with COPD and severe desaturation who were treated with LTOT. The authors hypothesized that this may have been caused by physiological effects of oxygen saturation on pulmonary vasoconstriction, release of mediators, and ventilator drive, which occur at an O2 saturation of 88% or less and may be more significant in patients with chronic hypoxemia. This trial also contrasted previous studies that had shown that oxygen therapy may reduce dyspnea in COPD patients with mild or no hypoxia because the LOTT trial showed no improvement in quality of life, anxiety, and depression measures in patients treated with long-term oxygen as compared with those treated with no oxygen.
Some limitations of the study included the absence of highly symptomatic patients or patients who the providers believed were too ill to participate, the effect of the unblinded nature of the study on outcomes that were patient reported, the lack of assessment of immediate effects of oxygen on exercise performance or symptoms, possible variability in amount of oxygen delivered, and the fact that patients may have overestimated their oxygen use.
In patients with stable COPD and moderate resting or exercise induced desaturation, long-term supplemental oxygen did not provide any benefit in regard to time until death or first hospitalization or any of the other measured outcomes.
Application of data to the case
Our patient has stable COPD and had only moderate exercise-induced desaturation. Long-term supplemental oxygen would not produce a benefit for him.
This study shows us that it would not increase his survival at this point; however, if he were to have worsening exercise-induced or new resting desaturation at some point in the future, supplemental oxygen would then be beneficial. At this point supplemental oxygen would not even affect his rate of hospitalization for COPD- or non-COPD–related reasons. Perhaps most importantly, adding oxygen therapy would not affect his overall quality of life, including his functional status and mood.
Bottom line
The addition of supplemental oxygen is not helpful for patients with COPD who have chronic stable moderate hypoxia.
Dr. Farber is a medical instructor in the Duke University Health System in Durham, N.C. Dr. Sata is a medical instructor in the Duke University Hospital. Dr. Wachter is an assistant professor of medicine at Duke University. Dr. Sharma is associate medical director for clinical education in hospital medicine at Duke Regional Hospital and an assistant professor of medicine at Duke University.
References
1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Ann Intern Med. 1980 Sep;93(3):391-8.
2. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet 1981 Mar 28;1(8222):681-6.
3. Long-term oxygen treatment trial research group et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016 Oct 27;375(17):1617-27.
Additional reading
Stoller JK et al. Oxygen therapy for patients with COPD: Current evidence and the Long-term Oxygen Treatment Trial. Chest. 2010 July;138:179-87.
Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.
Ameer F et al. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD000238.
Vestbo J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.
Quiz: Does this patient need oxygen?
You are caring for a 72-year-old man with stable COPD who was admitted for cellulitis. He is improving clinically on appropriate antibiotics, and he has been stable on room air every time you examine him. The nurse pages you on the day of discharge – a Sunday – informing you that his oxygen saturation dropped to 88% while he was walking the halls this morning. She asks whether he needs to stay in the hospital so you can arrange home supplemental oxygen therapy. What should you do?
A. Keep him in the hospital until you can arrange home oxygen therapy.
B. Discharge him home Sunday but have the oxygen company go out to his house first thing on Monday.
C. Discharge him home without supplemental oxygen therapy.
D. Check an arterial blood gas to help decide if you should set up oxygen therapy.
The answer is C. He meets the description of stable COPD with mild to moderate exercise-induced desaturation. The LOTT trial supports our clinical decision that he would not benefit from supplemental oxygen therapy at this point.
Key Points
- Long-term oxygen therapy (LTOT) is beneficial in patients with COPD and severe resting hypoxemia (arterial oxygen partial pressure ≤ 55 mm Hg or SpO2 ≤ 88%) and should be prescribed to improve survival in this population.
- Patients with COPD and mild to moderate resting hypoxemia or exercised-induced hypoxemia should not be routinely prescribed LTOT given the associated costs, risks, and burdens and the lack of evidence of benefit.
Case
An 85-year-old man with long-standing chronic obstructive pulmonary disease (COPD) has a witnessed aspiration event while undergoing an outpatient procedure requiring conscious sedation. He is admitted to the hospital for observation overnight. The next morning, he feels well, but his oxygen saturation dips to 85% with ambulation. He reports this is not new for him, but he vehemently does not want supplemental oxygen.
Background
Patients with COPD and severe resting hypoxemia – arterial oxygen partial pressure less than or equal to 55 mm Hg or peripheral capillary oxygen saturation (SpO2) less than or equal to 88% – commonly are prescribed supplemental oxygen. The evidence supporting this practice is limited to two small trials from the 1970s that showed a survival benefit of long-term oxygen therapy (LTOT) in this population,1,2 but these trials may not be generalizable to patients today.
For patients with COPD and mild to moderate resting hypoxemia (SpO2, 89%-93%) or patients with exercise-induced hypoxemia, LTOT has not been shown to improve survival, although it may improve symptoms of dyspnea, exercise tolerance, and other patient reported outcomes. Given the costs, risks, and burdens associated with LTOT, a high-quality clinical trial assessing the effects of LTOT on clinically meaningful outcomes, such as survival or hospitalization, in patients with COPD and moderate hypoxemia has been long overdue.
Overview of the data
The utility of long-term treatment with supplemental oxygen in patients with stable COPD and moderate resting or exercise-induced desaturation was examined by the Long-Term Oxygen Treatment Trial (LOTT) Research Group. Results were published in the New England Journal of Medicine in October 2016 in the article, “A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation.”3
The study was initially designed to test whether the use of supplemental oxygen would lead to longer time until death as compared with no supplemental oxygen in the subgroup of COPD patients with stable disease and moderate resting desaturation (defined as resting SpO2 of 89%-93%). However, because of an enrollment of only 34 patients after 7 months, the trial was redesigned to include exercise-induced desaturation (defined as SpO2 of greater than or equal to 80% for at least 5 minutes, and less than 90% for at least 10 seconds, on a 6-minute walk test) and the secondary outcome of all-cause hospitalization. Hospitalization for any cause was combined with mortality into a new composite primary outcome.
This study was a randomized, controlled trial which enrolled patients at a total of 14 regional clinical centers and their associated sites for a total of 42 centers in the United States. The experimental arm consisted of a long term supplemental oxygen group, and the control group did not receive long term supplemental oxygen. Patients were assigned to groups in a 1:1 ratio and the study was not blinded. Patients with moderate resting desaturation were prescribed 24 hour oxygen at 2 L/min, and patients with moderate exercise-induced desaturation were prescribed oxygen at 2 L/min during exercise and sleep only. The primary outcome was a composite outcome of time until death or time until first hospitalization for any cause. There were multiple secondary outcomes, including incidence of COPD exacerbation, incidence of severe resting desaturation and severe exercise-induced desaturation, quality of life, sleep quality, depression and anxiety, adherence to regimen, 6-minute walk distance, spirometric measurements, risk of cardiovascular disease, and neurocognitive function.
Data were gathered via yearly visits, biannual telephone interviews, and questionnaires mailed at 4 months and 16 months. Adherence was assessed by inquiring about oxygen use every 4 months. If patients in the supplemental oxygen group used stationary oxygen concentrators, logs of meter readings were kept as well. The necessary final sample size was calculated using a time to composite event survival model with the use of the log-rank test statistic.
A total of 738 patients were enrolled in the trial between January 2009 and September 2015 and were followed for 1-6 years. A total of 97% of participants had at least 1 year of follow-up. Out of the 738 randomized patients, 133 (18%) had only resting desaturations, 319 (43%) had only exercise-induced desaturations, and 286 (39%) had both resting and exercise-induced desaturations. Baseline characteristics including age, sex, race, smoking status, quality of life scores, resting SpO2, and nadir SpO2 during the 6-minute walk test were similar between the two groups. The only significant difference noted by the authors between the two groups was a lower BODE (body mass index, airflow obstruction, dyspnea, and exercise) index, which was lower in the group with no supplemental oxygen.
In the time-to-event analysis, there was no significant difference between the two groups in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval, 0.79-1.12; P = .52). There were no significant differences in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91-1.13), COPD exacerbations (RR 1.08; 95% CI, 0.98-1.19), and COPD related hospitalizations (RR, 0.99; 95% CI, 0.83-1.17). There were also no differences between the experimental and control groups in quality of life, lung function, and 6-minute walk distance. There were no significant differences in the subgroups classified by desaturation profile, sex, race, nadir SpO2 during the 6-minute walk test, and forced expiratory volume in 1 second.
The findings in this study show that, in the subgroup of chronic obstructive pulmonary disease patients with stable COPD and moderate resting or exercise-induced desaturation, supplemental oxygen did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, rate of all hospitalizations, rate of all COPD exacerbations, or changes in metrics surrounding quality of life, anxiety/depression, or functional status. This supports earlier studies that demonstrated that long-term treatment with oxygen does not result in longer survival than does no long-term treatment with oxygen in patients with COPD and resting SpO2 of more than 88%.
The results of this study are a departure from previous studies that had shown improved mortality in patients with COPD and severe desaturation who were treated with LTOT. The authors hypothesized that this may have been caused by physiological effects of oxygen saturation on pulmonary vasoconstriction, release of mediators, and ventilator drive, which occur at an O2 saturation of 88% or less and may be more significant in patients with chronic hypoxemia. This trial also contrasted previous studies that had shown that oxygen therapy may reduce dyspnea in COPD patients with mild or no hypoxia because the LOTT trial showed no improvement in quality of life, anxiety, and depression measures in patients treated with long-term oxygen as compared with those treated with no oxygen.
Some limitations of the study included the absence of highly symptomatic patients or patients who the providers believed were too ill to participate, the effect of the unblinded nature of the study on outcomes that were patient reported, the lack of assessment of immediate effects of oxygen on exercise performance or symptoms, possible variability in amount of oxygen delivered, and the fact that patients may have overestimated their oxygen use.
In patients with stable COPD and moderate resting or exercise induced desaturation, long-term supplemental oxygen did not provide any benefit in regard to time until death or first hospitalization or any of the other measured outcomes.
Application of data to the case
Our patient has stable COPD and had only moderate exercise-induced desaturation. Long-term supplemental oxygen would not produce a benefit for him.
This study shows us that it would not increase his survival at this point; however, if he were to have worsening exercise-induced or new resting desaturation at some point in the future, supplemental oxygen would then be beneficial. At this point supplemental oxygen would not even affect his rate of hospitalization for COPD- or non-COPD–related reasons. Perhaps most importantly, adding oxygen therapy would not affect his overall quality of life, including his functional status and mood.
Bottom line
The addition of supplemental oxygen is not helpful for patients with COPD who have chronic stable moderate hypoxia.
Dr. Farber is a medical instructor in the Duke University Health System in Durham, N.C. Dr. Sata is a medical instructor in the Duke University Hospital. Dr. Wachter is an assistant professor of medicine at Duke University. Dr. Sharma is associate medical director for clinical education in hospital medicine at Duke Regional Hospital and an assistant professor of medicine at Duke University.
References
1. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Ann Intern Med. 1980 Sep;93(3):391-8.
2. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet 1981 Mar 28;1(8222):681-6.
3. Long-term oxygen treatment trial research group et al. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016 Oct 27;375(17):1617-27.
Additional reading
Stoller JK et al. Oxygen therapy for patients with COPD: Current evidence and the Long-term Oxygen Treatment Trial. Chest. 2010 July;138:179-87.
Qaseem A et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.
Ameer F et al. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD000238.
Vestbo J et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.
Quiz: Does this patient need oxygen?
You are caring for a 72-year-old man with stable COPD who was admitted for cellulitis. He is improving clinically on appropriate antibiotics, and he has been stable on room air every time you examine him. The nurse pages you on the day of discharge – a Sunday – informing you that his oxygen saturation dropped to 88% while he was walking the halls this morning. She asks whether he needs to stay in the hospital so you can arrange home supplemental oxygen therapy. What should you do?
A. Keep him in the hospital until you can arrange home oxygen therapy.
B. Discharge him home Sunday but have the oxygen company go out to his house first thing on Monday.
C. Discharge him home without supplemental oxygen therapy.
D. Check an arterial blood gas to help decide if you should set up oxygen therapy.
The answer is C. He meets the description of stable COPD with mild to moderate exercise-induced desaturation. The LOTT trial supports our clinical decision that he would not benefit from supplemental oxygen therapy at this point.
Key Points
- Long-term oxygen therapy (LTOT) is beneficial in patients with COPD and severe resting hypoxemia (arterial oxygen partial pressure ≤ 55 mm Hg or SpO2 ≤ 88%) and should be prescribed to improve survival in this population.
- Patients with COPD and mild to moderate resting hypoxemia or exercised-induced hypoxemia should not be routinely prescribed LTOT given the associated costs, risks, and burdens and the lack of evidence of benefit.
Five common pitfalls of retailing skin care
Others believe that providing patients with the correct skin care product recommendations for their skin’s needs is a crucial step to improving outcomes and educating patients.
There is a wide range of challenges related to skin care retail that many physicians face. I will be running a course on Skin Care Retail at the American Society for Dermatologic Surgery meeting in October in Scottsdale, Ariz., if you want to learn more or share your opinions. I have surveyed plastic surgeons and dermatologists via LinkedIn about what they believe are some of the biggest pitfalls to retailing skin care. Here, I will share some of their insights and suggestions for overcoming these obstacles.
1. Patients are more knowledgeable about skin care than ever before
Facing an increasing number of over-the-counter skin care products available, as well as buzzwords like “organic ingredients” and “vegan,” patients are now bombarded with information from a variety of different sources. Because of this, patients come to the doctor with preconceived ideas that can affect compliance if their specific needs and beliefs are not properly addressed.
For New York plastic surgeon Sonita M. Sadio, MD, this is one of the reasons why she chooses not to sell skin care in her office.
“My practice is highly consultative, and ongoing skin care recommendations are a significant part of what I do to optimize patient outcomes,” Dr. Sadio said. “Patients are well-educated about skin care today. They know their ingredients and insist on clean formulations, free of certain ingredients, such as ‘cruelty-free’ and ‘vegan.’ Others feel deprived if they are not using an expensive product in elegant packaging. Still, others insist on drugstore favorites or ‘eco’ offerings and have their own sense of what that means. My job is to optimize the clinical outcome while also meeting these patients needs to ensure compliance.”
Not all doctors have the time, knowledge or desire to personally design each patient’s skin care regimen. Many delegate this to the staff. However, it is impossible to ensure that your staff matches patients to the proper products unless they have had extensive training on both skin care products and how to match them to the patient’s skin issues.
2. Patients are wary when the doctors sells only one product brand
Many studies have shown that, although consumers desire a choice when making purchases, they get overwhelmed if they are presented with too many options. One study showed that it is optimal to carry at least 3 brands of products. For this reason, limiting the skin care you sell to one brand or doing your own private label is not optimal.
New York dermatologist Rebecca Tamez, MD, pointed out the same problem when selling practice-specific skin care. “At my previous job, we sold skin care products directly to patients. I had no issues selling products that were readily available in drugstores or online (such as Vanicream and EltaMD). We usually sold these around the same cost as the drugstore or Amazon. However, it was harder to sell the practice-specific skin care line. I feel patients were more wary of these products.”
3. Doctors do not want to feel like salespeople
If you have read my Dermatology News columns in the past, you may know that I think it is unethical for dermatologists to not offer specific skin care advice to their patients. If patients do not get ethical and scientific recommendations from us, they will follow the advice of a friend or salesperson or purchase based on often inflated marketing claims.
Dermatologists often tell me: “I am not a cosmetic dermatologist so I do not sell skin care.” I feel strongly that general dermatologists should be giving specific written skin care recommendations for their patients too. Acne, rosacea, melasma, eczema, psoriasis, keratosis pilaris, and many other conditions will improve faster with an efficacious skin care regimen, assuming the patient is compliant with the instructions. Retailing skin care improves compliance by eliminating a few barriers to beginning the skin care regimen. I believe that the mindset of dermatologists needs to change: It is not about selling products to patients, it is about educating them on what to use and offering the products out of convenience and the desire to improve compliance.
Meadowbrook, Pa., dermatologist Michael A. Tomeo, MD, explained an obstacle faced by many dermatologists:
“I suspect, like many of my colleagues,” said Dr. Tomeo, “that I am held back in terms of salesmanship, having been trained in the traditional way. Physicians of my generation were taught to be ethical and professional and to focus on academic and clinical excellence, and salesmanship and advertising one’s services were frowned upon. It takes time to reset one’s former proclivities. Cosmeceuticals and nutraceuticals are revolutionizing the skin care world, and as experts in all things skin, we need to be well informed and offer our patients safe, effective, and cutting-edge treatments.”
4. Providers are concerned about product costs and time constraints
Providing excellent patient care and improving outcomes is at the forefront of our business, but financial concerns and time constraints prevent some doctors from offering skin care to their patients.
Rochester Hills, Mich., plastic surgeon Richard Hainer, MD, has found that “skin care is often too complex with too many products and is not very profitable.” For those reasons, Dr. Hainer has chosen not to retail skin care in his practice.
Nampa, Idaho, dermatologist Ryan S. Owsley, MD, explained that “the required minimum purchases by some of the product lines can leave the practice with expired product if it is not selling a particular line well. Cost can also be an issue for some patients in the area we are located.”
As a burn survivor and burn surgeon, Mark McDonough, MD, from Orlando “has a long history with skin care and rejuvenation. I did have a private label skin care line, including a moisturizer, a hydroquinone product, a retinol cream, and a sunscreen,” Dr. McDonough said. “However, and regrettably, I have not kept up with marketing and promotion, with most of my energy invested in trauma and disease survivors through a book, a blog, and my platform through my website.”
Doing your own product line is costly and spending the time and resources to promote it is not always possible. Buying the minimum order of products is often expensive, and you will not be able to sell them without a proven methodology in place. New products enter the market frequently, and it is expensive to always carry the latest technologies because new minimum orders must be met with each new brand that you add.
5. Selling skin care requires ongoing education
Properly recommending and retailing skin care involves physician, staff, and patient education. Unfortunately, most practices rely on training from the cosmeceutical sales reps who obviously have a brand bias. There is minimal unbiased “brand agnostic” skin care training for dermatologists and their staff. In fact, the AAD meeting has only a few skin care lectures in the program. Plastic surgeon Gaurav Bharti, MD, of Charlotte, N.C., explained that “motivating staff to help with retail skin care can be challenging. The first step is to get the staff familiar with the products with open discussions with the representatives. The next step has been to have the staff actually use the products and believe in them. Once they believe in the product, we have used an incentivization model that’s simple, transparent, and predictable.”
We are all too busy to spend adequate time with our patients, so it is critical that our staff be able to properly recommended skin care for us. We have to ensure that our staff is taking an ethical and scientific approach to skin care retail rather than a financial one. Rigorous staff training on how to match skin care products to skin type is the key to improving outcomes with skin care recommendations.
In a similar sense, Cincinnati plastic surgeon Richard Williams, MD, commented that “aestheticians often succumb to the desires of our patients to carry too many products in inventory, for which they do not have enough knowledge of the product’s benefits. This can be a very frustrating challenge.”
Conclusion
Although there are many obstacles to retailing skin care in your medical practice, the benefits that it provides to both your patients (improved outcomes) and your practice (increased profitability) far outweigh the challenges. I solved these pitfalls in my own practice by developing a standardized staff training program and skin care diagnostic software that is now used by over 100 medical practices. If you want to start retaining skin care, my advice is develop a training plan and a methodology for the recommendation and patient education process before you spend a lot of money on the required minimum product order. Feel free to contact me for advice. Alternatively, if you already do a great job of retailing skin care and want to provide tips to include in my American Society for Dermatologic Surgery course, contact me on LinkedIn or [email protected]. You can also find blogs I have written on skin care retail advice at STSFranchise.com.
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); she also wrote 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.
Others believe that providing patients with the correct skin care product recommendations for their skin’s needs is a crucial step to improving outcomes and educating patients.
There is a wide range of challenges related to skin care retail that many physicians face. I will be running a course on Skin Care Retail at the American Society for Dermatologic Surgery meeting in October in Scottsdale, Ariz., if you want to learn more or share your opinions. I have surveyed plastic surgeons and dermatologists via LinkedIn about what they believe are some of the biggest pitfalls to retailing skin care. Here, I will share some of their insights and suggestions for overcoming these obstacles.
1. Patients are more knowledgeable about skin care than ever before
Facing an increasing number of over-the-counter skin care products available, as well as buzzwords like “organic ingredients” and “vegan,” patients are now bombarded with information from a variety of different sources. Because of this, patients come to the doctor with preconceived ideas that can affect compliance if their specific needs and beliefs are not properly addressed.
For New York plastic surgeon Sonita M. Sadio, MD, this is one of the reasons why she chooses not to sell skin care in her office.
“My practice is highly consultative, and ongoing skin care recommendations are a significant part of what I do to optimize patient outcomes,” Dr. Sadio said. “Patients are well-educated about skin care today. They know their ingredients and insist on clean formulations, free of certain ingredients, such as ‘cruelty-free’ and ‘vegan.’ Others feel deprived if they are not using an expensive product in elegant packaging. Still, others insist on drugstore favorites or ‘eco’ offerings and have their own sense of what that means. My job is to optimize the clinical outcome while also meeting these patients needs to ensure compliance.”
Not all doctors have the time, knowledge or desire to personally design each patient’s skin care regimen. Many delegate this to the staff. However, it is impossible to ensure that your staff matches patients to the proper products unless they have had extensive training on both skin care products and how to match them to the patient’s skin issues.
2. Patients are wary when the doctors sells only one product brand
Many studies have shown that, although consumers desire a choice when making purchases, they get overwhelmed if they are presented with too many options. One study showed that it is optimal to carry at least 3 brands of products. For this reason, limiting the skin care you sell to one brand or doing your own private label is not optimal.
New York dermatologist Rebecca Tamez, MD, pointed out the same problem when selling practice-specific skin care. “At my previous job, we sold skin care products directly to patients. I had no issues selling products that were readily available in drugstores or online (such as Vanicream and EltaMD). We usually sold these around the same cost as the drugstore or Amazon. However, it was harder to sell the practice-specific skin care line. I feel patients were more wary of these products.”
3. Doctors do not want to feel like salespeople
If you have read my Dermatology News columns in the past, you may know that I think it is unethical for dermatologists to not offer specific skin care advice to their patients. If patients do not get ethical and scientific recommendations from us, they will follow the advice of a friend or salesperson or purchase based on often inflated marketing claims.
Dermatologists often tell me: “I am not a cosmetic dermatologist so I do not sell skin care.” I feel strongly that general dermatologists should be giving specific written skin care recommendations for their patients too. Acne, rosacea, melasma, eczema, psoriasis, keratosis pilaris, and many other conditions will improve faster with an efficacious skin care regimen, assuming the patient is compliant with the instructions. Retailing skin care improves compliance by eliminating a few barriers to beginning the skin care regimen. I believe that the mindset of dermatologists needs to change: It is not about selling products to patients, it is about educating them on what to use and offering the products out of convenience and the desire to improve compliance.
Meadowbrook, Pa., dermatologist Michael A. Tomeo, MD, explained an obstacle faced by many dermatologists:
“I suspect, like many of my colleagues,” said Dr. Tomeo, “that I am held back in terms of salesmanship, having been trained in the traditional way. Physicians of my generation were taught to be ethical and professional and to focus on academic and clinical excellence, and salesmanship and advertising one’s services were frowned upon. It takes time to reset one’s former proclivities. Cosmeceuticals and nutraceuticals are revolutionizing the skin care world, and as experts in all things skin, we need to be well informed and offer our patients safe, effective, and cutting-edge treatments.”
4. Providers are concerned about product costs and time constraints
Providing excellent patient care and improving outcomes is at the forefront of our business, but financial concerns and time constraints prevent some doctors from offering skin care to their patients.
Rochester Hills, Mich., plastic surgeon Richard Hainer, MD, has found that “skin care is often too complex with too many products and is not very profitable.” For those reasons, Dr. Hainer has chosen not to retail skin care in his practice.
Nampa, Idaho, dermatologist Ryan S. Owsley, MD, explained that “the required minimum purchases by some of the product lines can leave the practice with expired product if it is not selling a particular line well. Cost can also be an issue for some patients in the area we are located.”
As a burn survivor and burn surgeon, Mark McDonough, MD, from Orlando “has a long history with skin care and rejuvenation. I did have a private label skin care line, including a moisturizer, a hydroquinone product, a retinol cream, and a sunscreen,” Dr. McDonough said. “However, and regrettably, I have not kept up with marketing and promotion, with most of my energy invested in trauma and disease survivors through a book, a blog, and my platform through my website.”
Doing your own product line is costly and spending the time and resources to promote it is not always possible. Buying the minimum order of products is often expensive, and you will not be able to sell them without a proven methodology in place. New products enter the market frequently, and it is expensive to always carry the latest technologies because new minimum orders must be met with each new brand that you add.
5. Selling skin care requires ongoing education
Properly recommending and retailing skin care involves physician, staff, and patient education. Unfortunately, most practices rely on training from the cosmeceutical sales reps who obviously have a brand bias. There is minimal unbiased “brand agnostic” skin care training for dermatologists and their staff. In fact, the AAD meeting has only a few skin care lectures in the program. Plastic surgeon Gaurav Bharti, MD, of Charlotte, N.C., explained that “motivating staff to help with retail skin care can be challenging. The first step is to get the staff familiar with the products with open discussions with the representatives. The next step has been to have the staff actually use the products and believe in them. Once they believe in the product, we have used an incentivization model that’s simple, transparent, and predictable.”
We are all too busy to spend adequate time with our patients, so it is critical that our staff be able to properly recommended skin care for us. We have to ensure that our staff is taking an ethical and scientific approach to skin care retail rather than a financial one. Rigorous staff training on how to match skin care products to skin type is the key to improving outcomes with skin care recommendations.
In a similar sense, Cincinnati plastic surgeon Richard Williams, MD, commented that “aestheticians often succumb to the desires of our patients to carry too many products in inventory, for which they do not have enough knowledge of the product’s benefits. This can be a very frustrating challenge.”
Conclusion
Although there are many obstacles to retailing skin care in your medical practice, the benefits that it provides to both your patients (improved outcomes) and your practice (increased profitability) far outweigh the challenges. I solved these pitfalls in my own practice by developing a standardized staff training program and skin care diagnostic software that is now used by over 100 medical practices. If you want to start retaining skin care, my advice is develop a training plan and a methodology for the recommendation and patient education process before you spend a lot of money on the required minimum product order. Feel free to contact me for advice. Alternatively, if you already do a great job of retailing skin care and want to provide tips to include in my American Society for Dermatologic Surgery course, contact me on LinkedIn or [email protected]. You can also find blogs I have written on skin care retail advice at STSFranchise.com.
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); she also wrote 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.
Others believe that providing patients with the correct skin care product recommendations for their skin’s needs is a crucial step to improving outcomes and educating patients.
There is a wide range of challenges related to skin care retail that many physicians face. I will be running a course on Skin Care Retail at the American Society for Dermatologic Surgery meeting in October in Scottsdale, Ariz., if you want to learn more or share your opinions. I have surveyed plastic surgeons and dermatologists via LinkedIn about what they believe are some of the biggest pitfalls to retailing skin care. Here, I will share some of their insights and suggestions for overcoming these obstacles.
1. Patients are more knowledgeable about skin care than ever before
Facing an increasing number of over-the-counter skin care products available, as well as buzzwords like “organic ingredients” and “vegan,” patients are now bombarded with information from a variety of different sources. Because of this, patients come to the doctor with preconceived ideas that can affect compliance if their specific needs and beliefs are not properly addressed.
For New York plastic surgeon Sonita M. Sadio, MD, this is one of the reasons why she chooses not to sell skin care in her office.
“My practice is highly consultative, and ongoing skin care recommendations are a significant part of what I do to optimize patient outcomes,” Dr. Sadio said. “Patients are well-educated about skin care today. They know their ingredients and insist on clean formulations, free of certain ingredients, such as ‘cruelty-free’ and ‘vegan.’ Others feel deprived if they are not using an expensive product in elegant packaging. Still, others insist on drugstore favorites or ‘eco’ offerings and have their own sense of what that means. My job is to optimize the clinical outcome while also meeting these patients needs to ensure compliance.”
Not all doctors have the time, knowledge or desire to personally design each patient’s skin care regimen. Many delegate this to the staff. However, it is impossible to ensure that your staff matches patients to the proper products unless they have had extensive training on both skin care products and how to match them to the patient’s skin issues.
2. Patients are wary when the doctors sells only one product brand
Many studies have shown that, although consumers desire a choice when making purchases, they get overwhelmed if they are presented with too many options. One study showed that it is optimal to carry at least 3 brands of products. For this reason, limiting the skin care you sell to one brand or doing your own private label is not optimal.
New York dermatologist Rebecca Tamez, MD, pointed out the same problem when selling practice-specific skin care. “At my previous job, we sold skin care products directly to patients. I had no issues selling products that were readily available in drugstores or online (such as Vanicream and EltaMD). We usually sold these around the same cost as the drugstore or Amazon. However, it was harder to sell the practice-specific skin care line. I feel patients were more wary of these products.”
3. Doctors do not want to feel like salespeople
If you have read my Dermatology News columns in the past, you may know that I think it is unethical for dermatologists to not offer specific skin care advice to their patients. If patients do not get ethical and scientific recommendations from us, they will follow the advice of a friend or salesperson or purchase based on often inflated marketing claims.
Dermatologists often tell me: “I am not a cosmetic dermatologist so I do not sell skin care.” I feel strongly that general dermatologists should be giving specific written skin care recommendations for their patients too. Acne, rosacea, melasma, eczema, psoriasis, keratosis pilaris, and many other conditions will improve faster with an efficacious skin care regimen, assuming the patient is compliant with the instructions. Retailing skin care improves compliance by eliminating a few barriers to beginning the skin care regimen. I believe that the mindset of dermatologists needs to change: It is not about selling products to patients, it is about educating them on what to use and offering the products out of convenience and the desire to improve compliance.
Meadowbrook, Pa., dermatologist Michael A. Tomeo, MD, explained an obstacle faced by many dermatologists:
“I suspect, like many of my colleagues,” said Dr. Tomeo, “that I am held back in terms of salesmanship, having been trained in the traditional way. Physicians of my generation were taught to be ethical and professional and to focus on academic and clinical excellence, and salesmanship and advertising one’s services were frowned upon. It takes time to reset one’s former proclivities. Cosmeceuticals and nutraceuticals are revolutionizing the skin care world, and as experts in all things skin, we need to be well informed and offer our patients safe, effective, and cutting-edge treatments.”
4. Providers are concerned about product costs and time constraints
Providing excellent patient care and improving outcomes is at the forefront of our business, but financial concerns and time constraints prevent some doctors from offering skin care to their patients.
Rochester Hills, Mich., plastic surgeon Richard Hainer, MD, has found that “skin care is often too complex with too many products and is not very profitable.” For those reasons, Dr. Hainer has chosen not to retail skin care in his practice.
Nampa, Idaho, dermatologist Ryan S. Owsley, MD, explained that “the required minimum purchases by some of the product lines can leave the practice with expired product if it is not selling a particular line well. Cost can also be an issue for some patients in the area we are located.”
As a burn survivor and burn surgeon, Mark McDonough, MD, from Orlando “has a long history with skin care and rejuvenation. I did have a private label skin care line, including a moisturizer, a hydroquinone product, a retinol cream, and a sunscreen,” Dr. McDonough said. “However, and regrettably, I have not kept up with marketing and promotion, with most of my energy invested in trauma and disease survivors through a book, a blog, and my platform through my website.”
Doing your own product line is costly and spending the time and resources to promote it is not always possible. Buying the minimum order of products is often expensive, and you will not be able to sell them without a proven methodology in place. New products enter the market frequently, and it is expensive to always carry the latest technologies because new minimum orders must be met with each new brand that you add.
5. Selling skin care requires ongoing education
Properly recommending and retailing skin care involves physician, staff, and patient education. Unfortunately, most practices rely on training from the cosmeceutical sales reps who obviously have a brand bias. There is minimal unbiased “brand agnostic” skin care training for dermatologists and their staff. In fact, the AAD meeting has only a few skin care lectures in the program. Plastic surgeon Gaurav Bharti, MD, of Charlotte, N.C., explained that “motivating staff to help with retail skin care can be challenging. The first step is to get the staff familiar with the products with open discussions with the representatives. The next step has been to have the staff actually use the products and believe in them. Once they believe in the product, we have used an incentivization model that’s simple, transparent, and predictable.”
We are all too busy to spend adequate time with our patients, so it is critical that our staff be able to properly recommended skin care for us. We have to ensure that our staff is taking an ethical and scientific approach to skin care retail rather than a financial one. Rigorous staff training on how to match skin care products to skin type is the key to improving outcomes with skin care recommendations.
In a similar sense, Cincinnati plastic surgeon Richard Williams, MD, commented that “aestheticians often succumb to the desires of our patients to carry too many products in inventory, for which they do not have enough knowledge of the product’s benefits. This can be a very frustrating challenge.”
Conclusion
Although there are many obstacles to retailing skin care in your medical practice, the benefits that it provides to both your patients (improved outcomes) and your practice (increased profitability) far outweigh the challenges. I solved these pitfalls in my own practice by developing a standardized staff training program and skin care diagnostic software that is now used by over 100 medical practices. If you want to start retaining skin care, my advice is develop a training plan and a methodology for the recommendation and patient education process before you spend a lot of money on the required minimum product order. Feel free to contact me for advice. Alternatively, if you already do a great job of retailing skin care and want to provide tips to include in my American Society for Dermatologic Surgery course, contact me on LinkedIn or [email protected]. You can also find blogs I have written on skin care retail advice at STSFranchise.com.
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); she also wrote 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.