Opinion

Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.

erhui1979/Getty Images

The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to discuss possible office surgery regulations with the medical board. We were secure in our personal knowledge that local anesthesia was very safe, and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.

It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.

“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.

I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.

Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.

I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.

Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.

I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.

I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.

We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).

The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.

The proposed restrictions evaporated. I and many others have since devoted our research efforts to solidifying dermatology’s safety and quality record. Dr. Bechtel, professor of dermatology at Ohio State University, Columbus, is now secretary of the state medical board. At the last annual state meeting, I thanked the brigadier general, the former secretary of the medical board, for his unlikely mentorship. He smiled and we got our picture taken together.

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

Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.

erhui1979/Getty Images

The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to discuss possible office surgery regulations with the medical board. We were secure in our personal knowledge that local anesthesia was very safe, and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.

It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.

“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.

I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.

Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.

I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.

Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.

I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.

I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.

We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).

The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.

The proposed restrictions evaporated. I and many others have since devoted our research efforts to solidifying dermatology’s safety and quality record. Dr. Bechtel, professor of dermatology at Ohio State University, Columbus, is now secretary of the state medical board. At the last annual state meeting, I thanked the brigadier general, the former secretary of the medical board, for his unlikely mentorship. He smiled and we got our picture taken together.

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

Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.

erhui1979/Getty Images

The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to discuss possible office surgery regulations with the medical board. We were secure in our personal knowledge that local anesthesia was very safe, and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.

It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.

“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.

I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.

Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.

I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.

Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.

I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.

I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.

We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).

The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.

The proposed restrictions evaporated. I and many others have since devoted our research efforts to solidifying dermatology’s safety and quality record. Dr. Bechtel, professor of dermatology at Ohio State University, Columbus, is now secretary of the state medical board. At the last annual state meeting, I thanked the brigadier general, the former secretary of the medical board, for his unlikely mentorship. He smiled and we got our picture taken together.

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

Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.

In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
 

A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.

B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.

C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.

D. The elevated blood levels indicate that the cause of death was an opioid overdose.

E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.

Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.

Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).

We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.

In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.¹ In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.

The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.

A recent article in the Washington Post draws attention to this situation.² It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.

Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.

Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.³ William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.

After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.

At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.

For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.⁴ The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.

Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.

The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”

Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.

A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.⁵ In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.⁶

While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.

It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”⁷

To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.

2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.

3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).

4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).

5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.

6. N Engl J Med. 2016 Apr 21;374(16):1501-4.

7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.

Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.

In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
 

A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.

B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.

C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.

D. The elevated blood levels indicate that the cause of death was an opioid overdose.

E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.

Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.

Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).

We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.

In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.¹ In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.

The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.

A recent article in the Washington Post draws attention to this situation.² It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.

Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.

Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.³ William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.

After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.

At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.

For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.⁴ The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.

Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.

The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”

Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.

A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.⁵ In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.⁶

While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.

It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”⁷

To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.

2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.

3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).

4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).

5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.

6. N Engl J Med. 2016 Apr 21;374(16):1501-4.

7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.

Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.

In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
 

A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.

B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.

C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.

D. The elevated blood levels indicate that the cause of death was an opioid overdose.

E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.

Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.

Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).

We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.

In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.¹ In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.

The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.

A recent article in the Washington Post draws attention to this situation.² It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.

Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.

Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.³ William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.

After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.

At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.

For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.⁴ The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.

Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.

The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”

Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.

A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.⁵ In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.⁶

While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.

It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”⁷

To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.

2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.

3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).

4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).

5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.

6. N Engl J Med. 2016 Apr 21;374(16):1501-4.

7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.

I’m in really good shape. Well, more like really not bad shape. I eat healthy food (see my previous column on diet) and work out nearly every day. I have done so for years. I’ve learned that working out doesn’t make much difference with my weight, but it makes a huge difference with my mood, even more so than meditating. That’s why I’ll never give it up.

My approach is to vary my routine, typically by month. I’ve done “BUD/S qualification” months where I do only push-ups, sit-ups, pull-ups, and runs to meet the minimum requirements for the Navy Seal Training. (It’s not as hard as you might think, although I’m pretty lenient on form.)

When I have an hour to exercise and I’m deep into a podcast, then I’ll just keep going. If I’m trying to work out a piece I’m writing, like this one, then I’ll go for a run along the harbor here in San Diego. If I have to catch an early flight or drive to LA for the day, then I might have only 15 minutes. In that instance, I do high-intensity sprints, also known as high-intensity interval training (HIIT). Although it’s hard to break a good sweat, these workouts are both challenging and rewarding.

Recently, I participated in a wonderful physician wellness program at Kaiser Permanente, San Diego, where, over several weeks, we learned about nutrition, practiced meditation, and did Tabatas. What’s a Tabata you ask? It’s a kick in the butt.

Tabata training is a type of HIIT training. Whereas HIIT workouts range from 15 to 45 minutes, Tabata workouts last 4 minutes. Yup, it’s a 4-minute workout that consists of 20 seconds of all-out, maximum effort, followed by 10 seconds of rest. The specific move you do for Tabatas is up to you, but it’s recommended that it be the same move for all 4 minutes. I like burpees which work your entire body – you jump, you drop into a push-up position, you pull your feet back in, and jump again. (Check out a video on YouTube.)

When we started the class, I thought Tabatas would be too easy for a gym rat like me. Plus, there were pediatricians, and even radiologists there, so how hard could they be? Let’s just say I couldn’t sit for 2 days after my first session: That’s how hard.

Tabatas are also a quick way to torch calories. A study published in the Journal of Sports Science and Medicine in 2013 found subjects who performed a 20-minute Tabata session experienced improved cardiorespiratory endurance and increased calorie burn (J Sports Sci Med. 2013 Sep;12[3]: 612-3).

Sometimes on a Monday, which is typically my difficult day, I’ll break out a few burpees in my office between patients. The energy jolt is real, and unlike caffeine, doesn’t leave me shaky. Because Tabatas require physical and mental focus, they’re an effective way to clear your mind after a grueling patient visit or if you’re feeling distracted. You simply can’t be thinking about that late patient or angry email when you’re jumping and lunging at full speed.

All the physicians in our program liked the Tabatas; many were even better than me. (Turns out we have pediatricians and radiologists who do things like run the Boston marathon and win Spartan races).

And if you start doing Tabatas, feel free to email me if you need a recommendation for a standing desk – you might not be able to sit as much afterward.


 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

I’m in really good shape. Well, more like really not bad shape. I eat healthy food (see my previous column on diet) and work out nearly every day. I have done so for years. I’ve learned that working out doesn’t make much difference with my weight, but it makes a huge difference with my mood, even more so than meditating. That’s why I’ll never give it up.

My approach is to vary my routine, typically by month. I’ve done “BUD/S qualification” months where I do only push-ups, sit-ups, pull-ups, and runs to meet the minimum requirements for the Navy Seal Training. (It’s not as hard as you might think, although I’m pretty lenient on form.)

When I have an hour to exercise and I’m deep into a podcast, then I’ll just keep going. If I’m trying to work out a piece I’m writing, like this one, then I’ll go for a run along the harbor here in San Diego. If I have to catch an early flight or drive to LA for the day, then I might have only 15 minutes. In that instance, I do high-intensity sprints, also known as high-intensity interval training (HIIT). Although it’s hard to break a good sweat, these workouts are both challenging and rewarding.

Recently, I participated in a wonderful physician wellness program at Kaiser Permanente, San Diego, where, over several weeks, we learned about nutrition, practiced meditation, and did Tabatas. What’s a Tabata you ask? It’s a kick in the butt.

Tabata training is a type of HIIT training. Whereas HIIT workouts range from 15 to 45 minutes, Tabata workouts last 4 minutes. Yup, it’s a 4-minute workout that consists of 20 seconds of all-out, maximum effort, followed by 10 seconds of rest. The specific move you do for Tabatas is up to you, but it’s recommended that it be the same move for all 4 minutes. I like burpees which work your entire body – you jump, you drop into a push-up position, you pull your feet back in, and jump again. (Check out a video on YouTube.)

When we started the class, I thought Tabatas would be too easy for a gym rat like me. Plus, there were pediatricians, and even radiologists there, so how hard could they be? Let’s just say I couldn’t sit for 2 days after my first session: That’s how hard.

Tabatas are also a quick way to torch calories. A study published in the Journal of Sports Science and Medicine in 2013 found subjects who performed a 20-minute Tabata session experienced improved cardiorespiratory endurance and increased calorie burn (J Sports Sci Med. 2013 Sep;12[3]: 612-3).

Sometimes on a Monday, which is typically my difficult day, I’ll break out a few burpees in my office between patients. The energy jolt is real, and unlike caffeine, doesn’t leave me shaky. Because Tabatas require physical and mental focus, they’re an effective way to clear your mind after a grueling patient visit or if you’re feeling distracted. You simply can’t be thinking about that late patient or angry email when you’re jumping and lunging at full speed.

All the physicians in our program liked the Tabatas; many were even better than me. (Turns out we have pediatricians and radiologists who do things like run the Boston marathon and win Spartan races).

And if you start doing Tabatas, feel free to email me if you need a recommendation for a standing desk – you might not be able to sit as much afterward.


 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

I’m in really good shape. Well, more like really not bad shape. I eat healthy food (see my previous column on diet) and work out nearly every day. I have done so for years. I’ve learned that working out doesn’t make much difference with my weight, but it makes a huge difference with my mood, even more so than meditating. That’s why I’ll never give it up.

My approach is to vary my routine, typically by month. I’ve done “BUD/S qualification” months where I do only push-ups, sit-ups, pull-ups, and runs to meet the minimum requirements for the Navy Seal Training. (It’s not as hard as you might think, although I’m pretty lenient on form.)

When I have an hour to exercise and I’m deep into a podcast, then I’ll just keep going. If I’m trying to work out a piece I’m writing, like this one, then I’ll go for a run along the harbor here in San Diego. If I have to catch an early flight or drive to LA for the day, then I might have only 15 minutes. In that instance, I do high-intensity sprints, also known as high-intensity interval training (HIIT). Although it’s hard to break a good sweat, these workouts are both challenging and rewarding.

Recently, I participated in a wonderful physician wellness program at Kaiser Permanente, San Diego, where, over several weeks, we learned about nutrition, practiced meditation, and did Tabatas. What’s a Tabata you ask? It’s a kick in the butt.

Tabata training is a type of HIIT training. Whereas HIIT workouts range from 15 to 45 minutes, Tabata workouts last 4 minutes. Yup, it’s a 4-minute workout that consists of 20 seconds of all-out, maximum effort, followed by 10 seconds of rest. The specific move you do for Tabatas is up to you, but it’s recommended that it be the same move for all 4 minutes. I like burpees which work your entire body – you jump, you drop into a push-up position, you pull your feet back in, and jump again. (Check out a video on YouTube.)

When we started the class, I thought Tabatas would be too easy for a gym rat like me. Plus, there were pediatricians, and even radiologists there, so how hard could they be? Let’s just say I couldn’t sit for 2 days after my first session: That’s how hard.

Tabatas are also a quick way to torch calories. A study published in the Journal of Sports Science and Medicine in 2013 found subjects who performed a 20-minute Tabata session experienced improved cardiorespiratory endurance and increased calorie burn (J Sports Sci Med. 2013 Sep;12[3]: 612-3).

Sometimes on a Monday, which is typically my difficult day, I’ll break out a few burpees in my office between patients. The energy jolt is real, and unlike caffeine, doesn’t leave me shaky. Because Tabatas require physical and mental focus, they’re an effective way to clear your mind after a grueling patient visit or if you’re feeling distracted. You simply can’t be thinking about that late patient or angry email when you’re jumping and lunging at full speed.

All the physicians in our program liked the Tabatas; many were even better than me. (Turns out we have pediatricians and radiologists who do things like run the Boston marathon and win Spartan races).

And if you start doing Tabatas, feel free to email me if you need a recommendation for a standing desk – you might not be able to sit as much afterward.


 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

“Suicide rates are increasing,” Dr. Igor Galynker said, “and I believe they will continue to rise. These are deaths of despair, and despair is increasing in our society.”

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

“Suicide rates are increasing,” Dr. Igor Galynker said, “and I believe they will continue to rise. These are deaths of despair, and despair is increasing in our society.”

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

“Suicide rates are increasing,” Dr. Igor Galynker said, “and I believe they will continue to rise. These are deaths of despair, and despair is increasing in our society.”

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

I was recently reminded of the importance of face-to-face meetings to gain understanding and to learn from the experiences of others. In this case, the lesson was delivered in the idyllic setting of Sunriver, Oregon, where the Oregon and Washington chapters of the American College of Surgeons held their annual meeting. I always come away from this meeting energized and inspired by the shared experiences of young and old, urban and rural. This meeting exceeded all expectations in the quality of the presentations but also, more importantly, in the quality of the exchange of ideas and viewpoints among surgeons across the full spectrum of practice types, geographical locations, and generations.

Community and rural surgeons were both well represented at this meeting, perhaps because our Oregon chapter president, Keith Thomas, is a rural surgeon; he had invited rural surgeon extraordinaire Tyler Hughes to be the keynote speaker; and the overarching theme of the meeting was “The Right Care in the Right Place.” The program featured controversial topics that were presented in a way that respected all views and shed more light than heat on the subject: a debate about whether (and which) cancers needed to be referred to tertiary centers, an exploration of how surgical care for all might be improved by regionalization in a matrix that could allow all patients to access timely and appropriate care, and even a discussion of a strategy through which we might build consensus for the prevention of firearm injuries and deaths while avoiding the “demonization of the enemy” that currently occurs whenever the subject is mentioned.

The residents’ and fellows’ presentations have evolved over the past few decades to include a broader range of research topics than those in prior meetings. This year, trainees gave papers not only on the treatment of specific surgical conditions or basic science studies but also on quality improvement, patient safety, ethics, end-of-life care, and cutting-edge technologies. Those who presented their research displayed the very best attributes of the millennial generation: creativity, altruism, and a commitment to make our shared future world a better, safer, more humane place. They fielded questions from the audience like “old pros,” demonstrating an impressive understanding of their subjects as well as a passion for their work.

Although the accelerating demands on our lives have led some to question whether the time required to attend a chapter meeting is worth the money and effort, I would argue that it is crucial to our future to do so. As surgical practice becomes more specialized and “siloed,” it is critical that we reaffirm what unites us rather than focus on what separates us. It is easy to attribute ill motives and malevolent characteristics to someone who sees things differently than you do. Is much more difficult to do so when you spend time with that person and learn about him or her as an individual. Local ACS chapter meetings accomplish that and more. Older surgeons nearing retirement and worried about the future of their communities can meet and mingle with residents and fellows who might become future partners. Former colleagues from medical school or residency who have pursued different practice paths can reacquaint themselves with one another, relive the good (and perhaps bad) old times, and share a chuckle or two. Surgeons who practice in the “ivory tower” can gain appreciation for the challenges of practicing in a resource-limited facility. Those from competing institutions or practices can learn that the “other” is facing the same issues and that common strategies for success might be found. We can all gain a greater understanding that the other person’s problems aren’t that different or less complex than ours.

In addition to providing a stimulating program, a successful chapter meeting requires skillful planning and execution by an experienced chapter manager. Our Oregon chapter is fortunate to have Harvey Gail, an outstanding manager who takes care of those essential tasks that make the meeting run smoothly so that we can focus on the substance of the meeting itself.

Attending a chapter meeting requires a relatively short time commitment of three days away from home – including a weekend – and a tank of gas. Some have suggested that holding the meeting in the largest city in the region would lessen travel time demands for many, but doing so would mean losing the low-key setting that creates the perfect atmosphere for developing professional and personal relationships and building a true community. The future survival of our profession depends on finding better, novel solutions to our common problems; we can accomplish that only by sharing our diverse perspectives and identifying solutions that meet all of our needs and those of our patients.

To those of you who rarely (or never) have attended a chapter meeting, you need to go. You’ll be surprised at how much you can learn from your fellow surgeons, who, I guarantee, are more like you than they are different.
 

Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

I was recently reminded of the importance of face-to-face meetings to gain understanding and to learn from the experiences of others. In this case, the lesson was delivered in the idyllic setting of Sunriver, Oregon, where the Oregon and Washington chapters of the American College of Surgeons held their annual meeting. I always come away from this meeting energized and inspired by the shared experiences of young and old, urban and rural. This meeting exceeded all expectations in the quality of the presentations but also, more importantly, in the quality of the exchange of ideas and viewpoints among surgeons across the full spectrum of practice types, geographical locations, and generations.

Community and rural surgeons were both well represented at this meeting, perhaps because our Oregon chapter president, Keith Thomas, is a rural surgeon; he had invited rural surgeon extraordinaire Tyler Hughes to be the keynote speaker; and the overarching theme of the meeting was “The Right Care in the Right Place.” The program featured controversial topics that were presented in a way that respected all views and shed more light than heat on the subject: a debate about whether (and which) cancers needed to be referred to tertiary centers, an exploration of how surgical care for all might be improved by regionalization in a matrix that could allow all patients to access timely and appropriate care, and even a discussion of a strategy through which we might build consensus for the prevention of firearm injuries and deaths while avoiding the “demonization of the enemy” that currently occurs whenever the subject is mentioned.

The residents’ and fellows’ presentations have evolved over the past few decades to include a broader range of research topics than those in prior meetings. This year, trainees gave papers not only on the treatment of specific surgical conditions or basic science studies but also on quality improvement, patient safety, ethics, end-of-life care, and cutting-edge technologies. Those who presented their research displayed the very best attributes of the millennial generation: creativity, altruism, and a commitment to make our shared future world a better, safer, more humane place. They fielded questions from the audience like “old pros,” demonstrating an impressive understanding of their subjects as well as a passion for their work.

Although the accelerating demands on our lives have led some to question whether the time required to attend a chapter meeting is worth the money and effort, I would argue that it is crucial to our future to do so. As surgical practice becomes more specialized and “siloed,” it is critical that we reaffirm what unites us rather than focus on what separates us. It is easy to attribute ill motives and malevolent characteristics to someone who sees things differently than you do. Is much more difficult to do so when you spend time with that person and learn about him or her as an individual. Local ACS chapter meetings accomplish that and more. Older surgeons nearing retirement and worried about the future of their communities can meet and mingle with residents and fellows who might become future partners. Former colleagues from medical school or residency who have pursued different practice paths can reacquaint themselves with one another, relive the good (and perhaps bad) old times, and share a chuckle or two. Surgeons who practice in the “ivory tower” can gain appreciation for the challenges of practicing in a resource-limited facility. Those from competing institutions or practices can learn that the “other” is facing the same issues and that common strategies for success might be found. We can all gain a greater understanding that the other person’s problems aren’t that different or less complex than ours.

In addition to providing a stimulating program, a successful chapter meeting requires skillful planning and execution by an experienced chapter manager. Our Oregon chapter is fortunate to have Harvey Gail, an outstanding manager who takes care of those essential tasks that make the meeting run smoothly so that we can focus on the substance of the meeting itself.

Attending a chapter meeting requires a relatively short time commitment of three days away from home – including a weekend – and a tank of gas. Some have suggested that holding the meeting in the largest city in the region would lessen travel time demands for many, but doing so would mean losing the low-key setting that creates the perfect atmosphere for developing professional and personal relationships and building a true community. The future survival of our profession depends on finding better, novel solutions to our common problems; we can accomplish that only by sharing our diverse perspectives and identifying solutions that meet all of our needs and those of our patients.

To those of you who rarely (or never) have attended a chapter meeting, you need to go. You’ll be surprised at how much you can learn from your fellow surgeons, who, I guarantee, are more like you than they are different.
 

Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

I was recently reminded of the importance of face-to-face meetings to gain understanding and to learn from the experiences of others. In this case, the lesson was delivered in the idyllic setting of Sunriver, Oregon, where the Oregon and Washington chapters of the American College of Surgeons held their annual meeting. I always come away from this meeting energized and inspired by the shared experiences of young and old, urban and rural. This meeting exceeded all expectations in the quality of the presentations but also, more importantly, in the quality of the exchange of ideas and viewpoints among surgeons across the full spectrum of practice types, geographical locations, and generations.

Community and rural surgeons were both well represented at this meeting, perhaps because our Oregon chapter president, Keith Thomas, is a rural surgeon; he had invited rural surgeon extraordinaire Tyler Hughes to be the keynote speaker; and the overarching theme of the meeting was “The Right Care in the Right Place.” The program featured controversial topics that were presented in a way that respected all views and shed more light than heat on the subject: a debate about whether (and which) cancers needed to be referred to tertiary centers, an exploration of how surgical care for all might be improved by regionalization in a matrix that could allow all patients to access timely and appropriate care, and even a discussion of a strategy through which we might build consensus for the prevention of firearm injuries and deaths while avoiding the “demonization of the enemy” that currently occurs whenever the subject is mentioned.

The residents’ and fellows’ presentations have evolved over the past few decades to include a broader range of research topics than those in prior meetings. This year, trainees gave papers not only on the treatment of specific surgical conditions or basic science studies but also on quality improvement, patient safety, ethics, end-of-life care, and cutting-edge technologies. Those who presented their research displayed the very best attributes of the millennial generation: creativity, altruism, and a commitment to make our shared future world a better, safer, more humane place. They fielded questions from the audience like “old pros,” demonstrating an impressive understanding of their subjects as well as a passion for their work.

Although the accelerating demands on our lives have led some to question whether the time required to attend a chapter meeting is worth the money and effort, I would argue that it is crucial to our future to do so. As surgical practice becomes more specialized and “siloed,” it is critical that we reaffirm what unites us rather than focus on what separates us. It is easy to attribute ill motives and malevolent characteristics to someone who sees things differently than you do. Is much more difficult to do so when you spend time with that person and learn about him or her as an individual. Local ACS chapter meetings accomplish that and more. Older surgeons nearing retirement and worried about the future of their communities can meet and mingle with residents and fellows who might become future partners. Former colleagues from medical school or residency who have pursued different practice paths can reacquaint themselves with one another, relive the good (and perhaps bad) old times, and share a chuckle or two. Surgeons who practice in the “ivory tower” can gain appreciation for the challenges of practicing in a resource-limited facility. Those from competing institutions or practices can learn that the “other” is facing the same issues and that common strategies for success might be found. We can all gain a greater understanding that the other person’s problems aren’t that different or less complex than ours.

In addition to providing a stimulating program, a successful chapter meeting requires skillful planning and execution by an experienced chapter manager. Our Oregon chapter is fortunate to have Harvey Gail, an outstanding manager who takes care of those essential tasks that make the meeting run smoothly so that we can focus on the substance of the meeting itself.

Attending a chapter meeting requires a relatively short time commitment of three days away from home – including a weekend – and a tank of gas. Some have suggested that holding the meeting in the largest city in the region would lessen travel time demands for many, but doing so would mean losing the low-key setting that creates the perfect atmosphere for developing professional and personal relationships and building a true community. The future survival of our profession depends on finding better, novel solutions to our common problems; we can accomplish that only by sharing our diverse perspectives and identifying solutions that meet all of our needs and those of our patients.

To those of you who rarely (or never) have attended a chapter meeting, you need to go. You’ll be surprised at how much you can learn from your fellow surgeons, who, I guarantee, are more like you than they are different.
 

Dr. Deveney is a professor of surgery and the vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

After my last column on credit cards, I was (as usual) inundated with questions, comments, and requests for copies of the letter we give to patients explaining our credit card policy.

alexialex/Getty Images

I’ve put together an FAQ to answer the most common questions, and a template for our credit card policy letter is posted on my blog at www.mdedge.com/edermatologynews. If you have a question not addressed here, feel free to ask, either on the website or via email ([email protected]).

How do you safeguard the credit information you keep on file?

The same way we do medical information; it’s all covered by the same HIPAA rules. If you have an EHR, it can go in the chart with everything else; if not, I suggest a separate portable file that can be locked up each night.

How do you keep the info current, as cards do expire?

We check expiration dates at each visit, and ask for a new number or date if the card has expired or is close.

Don’t your patients object to signing, in effect, a blank check?

They’re not “signing a blank check.” All credit card contracts give cardholders the right to challenge any charge against their account.

There were some initial objections, mostly from devotees of the financial “old school.” But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well, by decreasing the bills they will receive and the checks they must write, most come around.

How do you handle patients who refuse to hand over a number, particularly those who say they have no credit cards?

We used to let refusers slide, but now we’ve made the policy mandatory. Patients who refuse without a good reason are asked, like any patient who refuses to cooperate with any standard office policy, to go elsewhere. Life’s too short. And “I don’t have any credit cards” does not count as a good reason. Nearly everyone has credit cards in this day and age. For the occasional patient who does not have a credit card, my office manager does have authority to make exceptions on a case-by-case basis, however.

One cosmetic surgeon I know asks “no credit card” patients to pay a lawyer-style “retainer,” which is held in escrow, and used to pay receivable amounts as they come due. When presented with that alternative, he told me, most of them suddenly remember that they do have a credit card after all.

What’s the difference between this and “balance billing”?

All the difference in the world. “Balance billing” is billing patients for the difference between your normal fee and the insurer’s authorized payment. If your office has contracted to accept that particular insurance, you can’t do that; but you can bill for the portion of the insurer-determined payment not paid by the insurer. (Many contracts stipulate that you must do so.) For example, your normal fee is $200; the insurer approves $100, and pays 80% of that. The other $20 is the patient’s responsibility, and that is what you charge to the credit card – instead of sending out a statement for that amount.

Since we instituted this policy, one patient has called to ask if it is legal, and one insurance company has inquired about it. How do you respond to such queries?

Of course it’s legal; you are entitled to collect what is owed to you. Ask those patients if they question the legality every time they check into a hotel or rent a car.

We have had no inquiries from insurers, but my response would be that it’s none of their business. Again, you have every right to bill for the patient-owed portion of your fees – in fact, Medicare and many private insurers consider it an illegal “inducement” if you don’t – and third parties have no right to dictate how you can or cannot collect it.

In the past, another popular practice management columnist advised against adopting this policy.

Despite multiple requests from me and others, that columnist – who owns a medical billing company – has never, to my knowledge, offered a single convincing argument in support of that position.

 

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].

After my last column on credit cards, I was (as usual) inundated with questions, comments, and requests for copies of the letter we give to patients explaining our credit card policy.

alexialex/Getty Images

I’ve put together an FAQ to answer the most common questions, and a template for our credit card policy letter is posted on my blog at www.mdedge.com/edermatologynews. If you have a question not addressed here, feel free to ask, either on the website or via email ([email protected]).

How do you safeguard the credit information you keep on file?

The same way we do medical information; it’s all covered by the same HIPAA rules. If you have an EHR, it can go in the chart with everything else; if not, I suggest a separate portable file that can be locked up each night.

How do you keep the info current, as cards do expire?

We check expiration dates at each visit, and ask for a new number or date if the card has expired or is close.

Don’t your patients object to signing, in effect, a blank check?

They’re not “signing a blank check.” All credit card contracts give cardholders the right to challenge any charge against their account.

There were some initial objections, mostly from devotees of the financial “old school.” But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well, by decreasing the bills they will receive and the checks they must write, most come around.

How do you handle patients who refuse to hand over a number, particularly those who say they have no credit cards?

We used to let refusers slide, but now we’ve made the policy mandatory. Patients who refuse without a good reason are asked, like any patient who refuses to cooperate with any standard office policy, to go elsewhere. Life’s too short. And “I don’t have any credit cards” does not count as a good reason. Nearly everyone has credit cards in this day and age. For the occasional patient who does not have a credit card, my office manager does have authority to make exceptions on a case-by-case basis, however.

One cosmetic surgeon I know asks “no credit card” patients to pay a lawyer-style “retainer,” which is held in escrow, and used to pay receivable amounts as they come due. When presented with that alternative, he told me, most of them suddenly remember that they do have a credit card after all.

What’s the difference between this and “balance billing”?

All the difference in the world. “Balance billing” is billing patients for the difference between your normal fee and the insurer’s authorized payment. If your office has contracted to accept that particular insurance, you can’t do that; but you can bill for the portion of the insurer-determined payment not paid by the insurer. (Many contracts stipulate that you must do so.) For example, your normal fee is $200; the insurer approves $100, and pays 80% of that. The other $20 is the patient’s responsibility, and that is what you charge to the credit card – instead of sending out a statement for that amount.

Since we instituted this policy, one patient has called to ask if it is legal, and one insurance company has inquired about it. How do you respond to such queries?

Of course it’s legal; you are entitled to collect what is owed to you. Ask those patients if they question the legality every time they check into a hotel or rent a car.

We have had no inquiries from insurers, but my response would be that it’s none of their business. Again, you have every right to bill for the patient-owed portion of your fees – in fact, Medicare and many private insurers consider it an illegal “inducement” if you don’t – and third parties have no right to dictate how you can or cannot collect it.

In the past, another popular practice management columnist advised against adopting this policy.

Despite multiple requests from me and others, that columnist – who owns a medical billing company – has never, to my knowledge, offered a single convincing argument in support of that position.

 

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].

After my last column on credit cards, I was (as usual) inundated with questions, comments, and requests for copies of the letter we give to patients explaining our credit card policy.

alexialex/Getty Images

I’ve put together an FAQ to answer the most common questions, and a template for our credit card policy letter is posted on my blog at www.mdedge.com/edermatologynews. If you have a question not addressed here, feel free to ask, either on the website or via email ([email protected]).

How do you safeguard the credit information you keep on file?

The same way we do medical information; it’s all covered by the same HIPAA rules. If you have an EHR, it can go in the chart with everything else; if not, I suggest a separate portable file that can be locked up each night.

How do you keep the info current, as cards do expire?

We check expiration dates at each visit, and ask for a new number or date if the card has expired or is close.

Don’t your patients object to signing, in effect, a blank check?

They’re not “signing a blank check.” All credit card contracts give cardholders the right to challenge any charge against their account.

There were some initial objections, mostly from devotees of the financial “old school.” But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well, by decreasing the bills they will receive and the checks they must write, most come around.

How do you handle patients who refuse to hand over a number, particularly those who say they have no credit cards?

We used to let refusers slide, but now we’ve made the policy mandatory. Patients who refuse without a good reason are asked, like any patient who refuses to cooperate with any standard office policy, to go elsewhere. Life’s too short. And “I don’t have any credit cards” does not count as a good reason. Nearly everyone has credit cards in this day and age. For the occasional patient who does not have a credit card, my office manager does have authority to make exceptions on a case-by-case basis, however.

One cosmetic surgeon I know asks “no credit card” patients to pay a lawyer-style “retainer,” which is held in escrow, and used to pay receivable amounts as they come due. When presented with that alternative, he told me, most of them suddenly remember that they do have a credit card after all.

What’s the difference between this and “balance billing”?

All the difference in the world. “Balance billing” is billing patients for the difference between your normal fee and the insurer’s authorized payment. If your office has contracted to accept that particular insurance, you can’t do that; but you can bill for the portion of the insurer-determined payment not paid by the insurer. (Many contracts stipulate that you must do so.) For example, your normal fee is $200; the insurer approves $100, and pays 80% of that. The other $20 is the patient’s responsibility, and that is what you charge to the credit card – instead of sending out a statement for that amount.

Since we instituted this policy, one patient has called to ask if it is legal, and one insurance company has inquired about it. How do you respond to such queries?

Of course it’s legal; you are entitled to collect what is owed to you. Ask those patients if they question the legality every time they check into a hotel or rent a car.

We have had no inquiries from insurers, but my response would be that it’s none of their business. Again, you have every right to bill for the patient-owed portion of your fees – in fact, Medicare and many private insurers consider it an illegal “inducement” if you don’t – and third parties have no right to dictate how you can or cannot collect it.

In the past, another popular practice management columnist advised against adopting this policy.

Despite multiple requests from me and others, that columnist – who owns a medical billing company – has never, to my knowledge, offered a single convincing argument in support of that position.

 

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].

Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.¹

AlexRaths/Thinkstock

An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.² According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.³ In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.³ In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.⁴ The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.

MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.^5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).⁷ The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.

The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.^8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).¹¹ Since 2011, there are more than 400 PMHSs certified in the United States. PNPs with expertise in MH are a solution to addressing the growing need for access to high quality care for children and adolescents in PC settings. We share examples of services provided by PNPs across the United States.
 

At a federally qualified health center

Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.

“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
 

At an urban/suburban PC practice

alexsokolov/Thinkstock

Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.

“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
 

As an educator

Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.¹¹

Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.

“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”

The need and expectation that pediatric PC providers incorporate MH services is well documented.^2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
 

Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at [email protected].

References

1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.

2. Pediatrics. 2009 Apr;123(4):1248-51.

3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.

4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.

5. Pediatrics. 2015;135(5):909-17.

6. JAMA Pediatr. 2015;169(10):929-37.

7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.

8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.

9. J Nurse Pract. 2013;9(4):243-8.

10. J Pediatr Health Care. 2013; 27(3):162-3.

11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).

12. J Nurse Pract. 2013:9(3):142-8.

13. Pediatrics. 2018;141(3):e20174082

Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.¹

AlexRaths/Thinkstock

An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.² According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.³ In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.³ In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.⁴ The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.

MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.^5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).⁷ The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.

The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.^8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).¹¹ Since 2011, there are more than 400 PMHSs certified in the United States. PNPs with expertise in MH are a solution to addressing the growing need for access to high quality care for children and adolescents in PC settings. We share examples of services provided by PNPs across the United States.
 

At a federally qualified health center

Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.

“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
 

At an urban/suburban PC practice

alexsokolov/Thinkstock

Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.

“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
 

As an educator

Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.¹¹

Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.

“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”

The need and expectation that pediatric PC providers incorporate MH services is well documented.^2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
 

Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at [email protected].

References

1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.

2. Pediatrics. 2009 Apr;123(4):1248-51.

3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.

4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.

5. Pediatrics. 2015;135(5):909-17.

6. JAMA Pediatr. 2015;169(10):929-37.

7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.

8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.

9. J Nurse Pract. 2013;9(4):243-8.

10. J Pediatr Health Care. 2013; 27(3):162-3.

11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).

12. J Nurse Pract. 2013:9(3):142-8.

13. Pediatrics. 2018;141(3):e20174082

Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.¹

AlexRaths/Thinkstock

An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.² According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.³ In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.³ In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.⁴ The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.

MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.^5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).⁷ The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.

The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.^8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).¹¹ Since 2011, there are more than 400 PMHSs certified in the United States. PNPs with expertise in MH are a solution to addressing the growing need for access to high quality care for children and adolescents in PC settings. We share examples of services provided by PNPs across the United States.
 

At a federally qualified health center

Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.

“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
 

At an urban/suburban PC practice

alexsokolov/Thinkstock

Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.

“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
 

As an educator

Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.¹¹

Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.

“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”

The need and expectation that pediatric PC providers incorporate MH services is well documented.^2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
 

Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at [email protected].

References

1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.

2. Pediatrics. 2009 Apr;123(4):1248-51.

3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.

4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.

5. Pediatrics. 2015;135(5):909-17.

6. JAMA Pediatr. 2015;169(10):929-37.

7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.

8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.

9. J Nurse Pract. 2013;9(4):243-8.

10. J Pediatr Health Care. 2013; 27(3):162-3.

11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).

12. J Nurse Pract. 2013:9(3):142-8.

13. Pediatrics. 2018;141(3):e20174082

Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.

Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].

Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.

Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].

Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.

Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].

As a physician you are the embodiment of delayed gratification. You spent more than 20 years in school before you earned a degree that then allowed you spend another 3-plus years in training before anyone would consider you a “real” doctor. Somewhere along that long and shallow trajectory someone may have said, “You must have done really well on the marshmallow test.”

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

As a physician you are the embodiment of delayed gratification. You spent more than 20 years in school before you earned a degree that then allowed you spend another 3-plus years in training before anyone would consider you a “real” doctor. Somewhere along that long and shallow trajectory someone may have said, “You must have done really well on the marshmallow test.”

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

As a physician you are the embodiment of delayed gratification. You spent more than 20 years in school before you earned a degree that then allowed you spend another 3-plus years in training before anyone would consider you a “real” doctor. Somewhere along that long and shallow trajectory someone may have said, “You must have done really well on the marshmallow test.”

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

The number of births in the United States has fallen for the second year in a row. Births in 2017 were down 2% from 2016, bringing the birth rate to a 30-year low at 60 births per 1,000 women aged 15-44 years. This decline spanned nearly all maternal age groups, including teenagers (Hamilton et al. NVSS Vital Statistics Rapid Release Report No 004, May 2018).

In the crudest terms, babies represent the raw material of pediatrics. Without children, we pediatricians would have to begin treating those whining adults. Most of us chose pediatrics because we enjoy being around children, and many of us were motivated to study medicine by a desire to help sick children. Is this decline in the supply stream of patients something we should be worrying about?

gpointstudio/Thinkstock

AleksandarNakic/E+/Getty Images

You can worry about job security if you like, but in a quirky kind of way pediatrics is following along its own rules of supply and demand. And, you should rest easy ... that is until the next panicked call from a parent wakes you in the middle of the night.


 

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

The number of births in the United States has fallen for the second year in a row. Births in 2017 were down 2% from 2016, bringing the birth rate to a 30-year low at 60 births per 1,000 women aged 15-44 years. This decline spanned nearly all maternal age groups, including teenagers (Hamilton et al. NVSS Vital Statistics Rapid Release Report No 004, May 2018).

In the crudest terms, babies represent the raw material of pediatrics. Without children, we pediatricians would have to begin treating those whining adults. Most of us chose pediatrics because we enjoy being around children, and many of us were motivated to study medicine by a desire to help sick children. Is this decline in the supply stream of patients something we should be worrying about?

gpointstudio/Thinkstock

AleksandarNakic/E+/Getty Images

You can worry about job security if you like, but in a quirky kind of way pediatrics is following along its own rules of supply and demand. And, you should rest easy ... that is until the next panicked call from a parent wakes you in the middle of the night.


 

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

The number of births in the United States has fallen for the second year in a row. Births in 2017 were down 2% from 2016, bringing the birth rate to a 30-year low at 60 births per 1,000 women aged 15-44 years. This decline spanned nearly all maternal age groups, including teenagers (Hamilton et al. NVSS Vital Statistics Rapid Release Report No 004, May 2018).

In the crudest terms, babies represent the raw material of pediatrics. Without children, we pediatricians would have to begin treating those whining adults. Most of us chose pediatrics because we enjoy being around children, and many of us were motivated to study medicine by a desire to help sick children. Is this decline in the supply stream of patients something we should be worrying about?

gpointstudio/Thinkstock

AleksandarNakic/E+/Getty Images

You can worry about job security if you like, but in a quirky kind of way pediatrics is following along its own rules of supply and demand. And, you should rest easy ... that is until the next panicked call from a parent wakes you in the middle of the night.


 

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].