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Pamela Hyde steps down from top SAMHSA post
ROCKVILLE, MD. – Pamela S. Hyde has announced she is stepping down as administrator of the federal Substance Abuse and Mental Health Services Administration, effective Aug. 22.
In a blogpost dated Aug. 4, Ms. Hyde stated that “personal issues call me home to New Mexico.”
An internal memo from U.S. Department of Health & Human Services Secretary Sylvia Burwell praised Ms. Hyde for her “remarkable” commitment, calling her a “steadfast leader who has “worked to integrate behavioral health into all of HHS’ coverage, prevention, treatment, and human services programs.”
Ms. Hyde will be replaced at the Substance Abuse and Mental Health Services Administration (SAMHSA) in the interim by Principal Deputy Administrator Kana Enomoto.
The announcement comes amid a time when, driven in part by the alarming incarceration rates of those with serious mental illnesses such as schizophrenia, mental illness is a nascent concern, with no less than six major proposed legislative actions being debated currently in Congress.
Since the beginning of Ms. Hyde’s tenure in November 2009, SAMHSA has come under increasing fire from some in the mental health field including the Dr. E. Fuller Torrey, a psychiatrist who has complained in the National Review and elsewhere that the agency focuses more on mental wellness than mental illness.
Rep. Tim Murphy (R-Penn.), a clinical psychologist, also has publicly criticized SAMHSA for what he has characterized as SAMHSA’s lack of an evidence-based approach to dealing with mental health issues. In an interview earlier this year, Rep. Murphy accused SAMHSA of being “antipsychiatry” and operating from a “feel-good space.” Rep. Murphy, who has introduced legislation that would restructure the agency, said in that interview that his bill “drives the science on serious mental illness, because right now there is no science at SAMSHA.”
His bill also would require that the top leadership be held by a person with either a medical degree or an advanced degree in clinical psychology. Ms. Hyde is a lawyer by training. Ms. Enomoto holds a master’s degree in clinical psychology.
Asked whether the timing of Ms. Hyde’s resignation was related to the heightened level of criticism she has faced, a SAMHSA spokesperson reiterated that Ms. Hyde’s decision was “for personal reasons.”
On Twitter @whitneymcknight
ROCKVILLE, MD. – Pamela S. Hyde has announced she is stepping down as administrator of the federal Substance Abuse and Mental Health Services Administration, effective Aug. 22.
In a blogpost dated Aug. 4, Ms. Hyde stated that “personal issues call me home to New Mexico.”
An internal memo from U.S. Department of Health & Human Services Secretary Sylvia Burwell praised Ms. Hyde for her “remarkable” commitment, calling her a “steadfast leader who has “worked to integrate behavioral health into all of HHS’ coverage, prevention, treatment, and human services programs.”
Ms. Hyde will be replaced at the Substance Abuse and Mental Health Services Administration (SAMHSA) in the interim by Principal Deputy Administrator Kana Enomoto.
The announcement comes amid a time when, driven in part by the alarming incarceration rates of those with serious mental illnesses such as schizophrenia, mental illness is a nascent concern, with no less than six major proposed legislative actions being debated currently in Congress.
Since the beginning of Ms. Hyde’s tenure in November 2009, SAMHSA has come under increasing fire from some in the mental health field including the Dr. E. Fuller Torrey, a psychiatrist who has complained in the National Review and elsewhere that the agency focuses more on mental wellness than mental illness.
Rep. Tim Murphy (R-Penn.), a clinical psychologist, also has publicly criticized SAMHSA for what he has characterized as SAMHSA’s lack of an evidence-based approach to dealing with mental health issues. In an interview earlier this year, Rep. Murphy accused SAMHSA of being “antipsychiatry” and operating from a “feel-good space.” Rep. Murphy, who has introduced legislation that would restructure the agency, said in that interview that his bill “drives the science on serious mental illness, because right now there is no science at SAMSHA.”
His bill also would require that the top leadership be held by a person with either a medical degree or an advanced degree in clinical psychology. Ms. Hyde is a lawyer by training. Ms. Enomoto holds a master’s degree in clinical psychology.
Asked whether the timing of Ms. Hyde’s resignation was related to the heightened level of criticism she has faced, a SAMHSA spokesperson reiterated that Ms. Hyde’s decision was “for personal reasons.”
On Twitter @whitneymcknight
ROCKVILLE, MD. – Pamela S. Hyde has announced she is stepping down as administrator of the federal Substance Abuse and Mental Health Services Administration, effective Aug. 22.
In a blogpost dated Aug. 4, Ms. Hyde stated that “personal issues call me home to New Mexico.”
An internal memo from U.S. Department of Health & Human Services Secretary Sylvia Burwell praised Ms. Hyde for her “remarkable” commitment, calling her a “steadfast leader who has “worked to integrate behavioral health into all of HHS’ coverage, prevention, treatment, and human services programs.”
Ms. Hyde will be replaced at the Substance Abuse and Mental Health Services Administration (SAMHSA) in the interim by Principal Deputy Administrator Kana Enomoto.
The announcement comes amid a time when, driven in part by the alarming incarceration rates of those with serious mental illnesses such as schizophrenia, mental illness is a nascent concern, with no less than six major proposed legislative actions being debated currently in Congress.
Since the beginning of Ms. Hyde’s tenure in November 2009, SAMHSA has come under increasing fire from some in the mental health field including the Dr. E. Fuller Torrey, a psychiatrist who has complained in the National Review and elsewhere that the agency focuses more on mental wellness than mental illness.
Rep. Tim Murphy (R-Penn.), a clinical psychologist, also has publicly criticized SAMHSA for what he has characterized as SAMHSA’s lack of an evidence-based approach to dealing with mental health issues. In an interview earlier this year, Rep. Murphy accused SAMHSA of being “antipsychiatry” and operating from a “feel-good space.” Rep. Murphy, who has introduced legislation that would restructure the agency, said in that interview that his bill “drives the science on serious mental illness, because right now there is no science at SAMSHA.”
His bill also would require that the top leadership be held by a person with either a medical degree or an advanced degree in clinical psychology. Ms. Hyde is a lawyer by training. Ms. Enomoto holds a master’s degree in clinical psychology.
Asked whether the timing of Ms. Hyde’s resignation was related to the heightened level of criticism she has faced, a SAMHSA spokesperson reiterated that Ms. Hyde’s decision was “for personal reasons.”
On Twitter @whitneymcknight
Busting barriers to care for LGBT patients
The pivotal moment in Dr. David Jaspan’s decision to create an LGBT-friendly practice was when a first-year resident physician told him a lesbian woman had presented with advanced-stage cervical cancer to their Philadelphia-based community ob.gyn. clinic.
“She had health insurance. She lived within walking distance of the clinic,” recalled Dr. Jaspan, chairman of the Einstein Medical Center in Philadelphia.
The patient had been avoiding preventive care, including routine Pap smears, because she feared being judged for her sexuality, he said. “She had access to care, but was afraid to use it. That’s ridiculous. We had to do something.”
In a 2010 survey of nearly 5,000 LGBT (lesbian, gay, bisexual, transgender) individuals nationwide conducted by the LGBT advocacy group Lambda Legal, more than half of the nearly 400 transgender individuals, and nearly 10% of the entire gay, lesbian, and bisexual population surveyed said they believed they would be refused care if they sought it.
An analysis of the literature published in the last 5 years, conducted by Dr. Gloria Bachmann, professor and interim chair of obstetrics and gynecology at the Robert Wood Johnson Medical School in Newark, N.J., and her colleagues, showed that in the ob.gyn. setting, 2% of transgender respondents in one survey reported being physically attacked in a patient waiting area, while nearly 20% of respondents reported being denied care altogether.
Aside from these real or perceived fears of harm or denial, another barrier to care for the LGBT community appears to be a lack of education in the medical training establishment.
A survey published earlier this year in the American Journal of Public Health, and conducted by researchers from the University of California at Los Angeles, showed that of the half of all 138 U.S. academic medical faculty practices currently accredited by the Liaison Committee on Medical Education that responded to the survey, only 10% have standard procedures for connecting patients to LGBT-competent physicians.
The medical community at large seems to be more proactive about inclusion. In 2014, the Human Rights Campaign Foundation designated more than 400 community health care facilities across the country as leaders in LGBT health care equality, more than double the number they designated in 2013.
“I think that things are better than they used to be,” said Dr. Rachel Levine, Pennsylvania’s first transgender physician general.
Dr. Levine was appointed to her post earlier this year by Gov. Tom Wolf (D). “I can’t see someone being refused care because they are LGBT.” Besides, she added, “it’s not ethical.”
While not everyone will practice LGBT medicine, Dr. Levine said, “all medical personnel should have training in, and at least be aware of, the broad outlines of LGBT health issues.” She pointed to a growing number of organizations, such as the Institute of Medicine and the American Medical Association, that also offer guidelines for treating the LGBT population.
Achieving culturally competent care
For Dr. Jaspan, the will and desire to provide care was strong, even though he wasn’t entirely sure how to go about it. “I wondered, What if a man walked into our clinic? But it was clear to me, it doesn’t matter. What matters is that he chose to access care.”
Delivering what is largely referred to by LGBT health experts as “culturally competent care” comes down to two factors: gender neutrality and honesty, according to Dr. Bachmann.
“Unconscious biases find their way into personal and professional interactions, but defining all clinical encounters as gender equal works to eliminate that bias in clinical-patient interactions,” she said.
Gender neutrality helps to establish trust with a transgender patient and makes it easier to get a full history, including details about the surgical and management strategies for the patient’s transition, the difficulties the patient might be having, and how to get the assistance that patient might need, Dr. Bachmann said.
That leads to the second essential element of culturally competent care: honesty.
“[Physicians] don’t have to know everything,” Dr. Bachmann said. “Opening the lines of communication is probably the most important, and acknowledging that you might not have the most in-depth knowledge to meet the [LGBT patient’s] needs, but you do want to take the best care of them, and that you might need their assistance for that.”
Clear communication also helps maintain accurate electronic health records, particularly in the case of transgender patients, said Dr. Levine, who before assuming her role as Pennsylvania’s top physician, was the vice chair for clinical affairs for the department of pediatrics and chief of the division of adolescent medicine and eating disorders at the Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center.
“In the privacy of the examination room, ask the patient what name they would like to be called, what pronoun they would like you to use, and in the context of the visit, you use those,” Dr. Levine said.
But because both HIPPA and insurers require a person’s legal name and gender, it is important their EHRs reflect that information, while the dictation makes the patient’s preferences clear.
‘A very important lesson’
But sometimes, as Dr. Jaspan discovered, a notation is simply not enough.
Once Dr. Jaspan’s clinic officially announced it was LGBT friendly, the first patient from that community to enroll was a bearded transgender man who’d had his breasts removed, but still had a uterus and ovaries and so was in need of a pelvic ultrasound.
Dr. Jaspan wrote the script for the radiologist, but Dr. Michele Style, the resident who had first urged him to reach out to the LGBT community, pointed out the peril of not thinking through how the patient would be received at the radiology clinic. She told him that unless they gave fair warning, the radiology tech would call out the patient’s legal name, which would indicate a woman would respond, but instead, it would be a man who would reply.
“Rather than have the tech say, ‘Oh sorry, I have the wrong person,’ and create embarrassment for the patient, we needed a different plan,” he said.
Instead, Dr. Jaspan’s office contacted the radiology staff before the appointment, and they were “overwhelmingly happy to help,” he said. The patient was greeted by a staff member of the radiology clinic who was also part of the LGBT community and was escorted to the exam room without being called by name.
“It was a very important lesson,” Dr. Jaspan said.
Rainbow power
When word got out about plans to open the Pride Clinic at Einstein Medical Center in Philadelphia, Dr. Jaspan started receiving calls from people across the country offering to collaborate, or to give financial assistance.
“It was unbelievable,” Dr. Jaspan said. One important ally was the LGBT brown bag lunch group who met regularly at Einstein and whose members were happy to serve as a focus group for the project. “They also trained our staff on how to answer the phones so LGBT people would immediately feel at ease,” he said.
But what surprised Dr. Jaspan the most was the power of the rainbow. Although he expected the clinic would need some type of overhaul, the focus group assured him that simply by displaying a sticker of a rainbow – long the international symbol of the LGBT community – at the clinic’s entrance, as well as placing rainbow flags on the reception desk and the door of every examination room, LGBT individuals would know they were welcome.
“I thought it was so phenomenal there was that much power in a symbol,” Dr. Jaspan said. “I just couldn’t believe that would make that much difference, but it does.”
From start to finish, including applying for the designation as an LGBT health equality leader by the Human Rights Campaign Foundation and training his staff in how to take information from patients using language that makes no assumptions about their sexual identity or preferences, the process of officially opening his doors to Philadelphia’s LGBT community took a year. “But I was aggressive with it,” Dr. Jaspan added.
Since opening, the clinic has enrolled about 10 LGBT patients on its patient panel, all of whom have access to a network of physicians, including cardiologists, pediatricians, endocrinologists, psychiatrists, and the gynecologic oncologists who now care for the lesbian patient who first presented with advanced-stage cervical cancer.
“I learn something new every day, every single day,” said Dr. Jaspan. “Just because we’ve opened doesn’t mean we’re doing it right, but a [college-aged LGBT patient] we saw the other day said she’d spread the word because she thought we had done everything right.”
Checklist for transgender patient exams
The main barriers to getting basic health care in the lesbian, gay, bisexual, and transgender community are “anticipated, perceived, and actual insensitivity, or rejection,” said Walter O. Bockting, Ph.D., codirector of the LGBT Health Initiative and professor of medical psychology at the New York State Psychiatric Institute and the Columbia University School of Nursing.
Underlying that, he said, is the lack of training in LGBT health concerns for health care professionals, given this cohort’s “marginalization.”
Dr. Bockting shared his advice for providing the best possible primary care for transgender patients.
Mental health
Screen for depression and anxiety, create a network of mental health professionals with expertise in transgender-related concerns, and help patients with resilience-building strategies, Dr. Bockting advised.
Transgender women have a higher relative risk for depression and anxiety, he said. This is often a result of “social stigma attached to their nonconformity,” and rejection of their claimed sexual identity by family members, especially if they are a parent. Additionally, “simply having to deal with being transgender, the process of finding a comfortable gender role and expression, and parts of the coming out process may be stressful, contributing to feelings of vulnerability, and symptoms of depression and anxiety.”
Preventive care
Continue to perform pelvic exams and Pap smears in transgender men with a cervix and uterus, screen transgender men for uterine and breast cancers, and screen transgender women for prostate cancers, Dr. Bockting advised.
In addition to the medical interventions necessary to affirm gender identities, one’s sex at birth, and one’s sexual orientation, taking a complete medical history that includes what surgeries the patient has had to date, and what the subsequent management strategies have been, is essential to knowing which preventive care is most appropriate for the individual patient, he said.
“What being transgender means, and is, varies from person to person,” Dr. Bockting said. “Developing an understanding of what it means for a particular patient is key.”
Educate yourself
Own your limitations, but also seek to learn by enlisting colleagues with more expertise, Dr. Bockting advised.
If you have been treating anatomical women your entire career, being called upon to treat a transgender woman with prostate concerns can be daunting, he said. But understanding your limitations is good, according to Dr. Bockting, though even better is to “do your homework, and talk to colleagues and other experts about how to provide the best possible care.”
“It’s okay to admit you do not know it all,” he said. “That is often referred to as having ‘cultural humility.’ ”
Resources for providing LGBT care
For more information about creating an LGBT-friendly clinic, the following organizations can offer tips, support, and expertise:
This is one of the nation’s oldest LGBT-focused clinics, and the largest U.S. LGBT health research center, with locations throughout Boston.
617-927-6400
Initially opened in 1979 to serve San Francisco’s lesbian community, it now offers care and resources to the entire LGBT community.
415-565-7667
Also opened in 1979 to serve the LGBT community, it is one of the first AIDS-service organizations in the United States.
215-563-0652
World Professional Association for Transgender Health
Formerly the Harry Benjamin International Gender Dysphoria Association, in Minneapolis, WPATH promotes evidence-based care, education, research, advocacy, public policy, and respect in transgender health.
This LGBT advocacy group based in Washington, D.C., issues an annual report on leaders in LGBT health care delivery, and offers resources to help meet their criteria.
On Twitter @whitneymcknight
The pivotal moment in Dr. David Jaspan’s decision to create an LGBT-friendly practice was when a first-year resident physician told him a lesbian woman had presented with advanced-stage cervical cancer to their Philadelphia-based community ob.gyn. clinic.
“She had health insurance. She lived within walking distance of the clinic,” recalled Dr. Jaspan, chairman of the Einstein Medical Center in Philadelphia.
The patient had been avoiding preventive care, including routine Pap smears, because she feared being judged for her sexuality, he said. “She had access to care, but was afraid to use it. That’s ridiculous. We had to do something.”
In a 2010 survey of nearly 5,000 LGBT (lesbian, gay, bisexual, transgender) individuals nationwide conducted by the LGBT advocacy group Lambda Legal, more than half of the nearly 400 transgender individuals, and nearly 10% of the entire gay, lesbian, and bisexual population surveyed said they believed they would be refused care if they sought it.
An analysis of the literature published in the last 5 years, conducted by Dr. Gloria Bachmann, professor and interim chair of obstetrics and gynecology at the Robert Wood Johnson Medical School in Newark, N.J., and her colleagues, showed that in the ob.gyn. setting, 2% of transgender respondents in one survey reported being physically attacked in a patient waiting area, while nearly 20% of respondents reported being denied care altogether.
Aside from these real or perceived fears of harm or denial, another barrier to care for the LGBT community appears to be a lack of education in the medical training establishment.
A survey published earlier this year in the American Journal of Public Health, and conducted by researchers from the University of California at Los Angeles, showed that of the half of all 138 U.S. academic medical faculty practices currently accredited by the Liaison Committee on Medical Education that responded to the survey, only 10% have standard procedures for connecting patients to LGBT-competent physicians.
The medical community at large seems to be more proactive about inclusion. In 2014, the Human Rights Campaign Foundation designated more than 400 community health care facilities across the country as leaders in LGBT health care equality, more than double the number they designated in 2013.
“I think that things are better than they used to be,” said Dr. Rachel Levine, Pennsylvania’s first transgender physician general.
Dr. Levine was appointed to her post earlier this year by Gov. Tom Wolf (D). “I can’t see someone being refused care because they are LGBT.” Besides, she added, “it’s not ethical.”
While not everyone will practice LGBT medicine, Dr. Levine said, “all medical personnel should have training in, and at least be aware of, the broad outlines of LGBT health issues.” She pointed to a growing number of organizations, such as the Institute of Medicine and the American Medical Association, that also offer guidelines for treating the LGBT population.
Achieving culturally competent care
For Dr. Jaspan, the will and desire to provide care was strong, even though he wasn’t entirely sure how to go about it. “I wondered, What if a man walked into our clinic? But it was clear to me, it doesn’t matter. What matters is that he chose to access care.”
Delivering what is largely referred to by LGBT health experts as “culturally competent care” comes down to two factors: gender neutrality and honesty, according to Dr. Bachmann.
“Unconscious biases find their way into personal and professional interactions, but defining all clinical encounters as gender equal works to eliminate that bias in clinical-patient interactions,” she said.
Gender neutrality helps to establish trust with a transgender patient and makes it easier to get a full history, including details about the surgical and management strategies for the patient’s transition, the difficulties the patient might be having, and how to get the assistance that patient might need, Dr. Bachmann said.
That leads to the second essential element of culturally competent care: honesty.
“[Physicians] don’t have to know everything,” Dr. Bachmann said. “Opening the lines of communication is probably the most important, and acknowledging that you might not have the most in-depth knowledge to meet the [LGBT patient’s] needs, but you do want to take the best care of them, and that you might need their assistance for that.”
Clear communication also helps maintain accurate electronic health records, particularly in the case of transgender patients, said Dr. Levine, who before assuming her role as Pennsylvania’s top physician, was the vice chair for clinical affairs for the department of pediatrics and chief of the division of adolescent medicine and eating disorders at the Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center.
“In the privacy of the examination room, ask the patient what name they would like to be called, what pronoun they would like you to use, and in the context of the visit, you use those,” Dr. Levine said.
But because both HIPPA and insurers require a person’s legal name and gender, it is important their EHRs reflect that information, while the dictation makes the patient’s preferences clear.
‘A very important lesson’
But sometimes, as Dr. Jaspan discovered, a notation is simply not enough.
Once Dr. Jaspan’s clinic officially announced it was LGBT friendly, the first patient from that community to enroll was a bearded transgender man who’d had his breasts removed, but still had a uterus and ovaries and so was in need of a pelvic ultrasound.
Dr. Jaspan wrote the script for the radiologist, but Dr. Michele Style, the resident who had first urged him to reach out to the LGBT community, pointed out the peril of not thinking through how the patient would be received at the radiology clinic. She told him that unless they gave fair warning, the radiology tech would call out the patient’s legal name, which would indicate a woman would respond, but instead, it would be a man who would reply.
“Rather than have the tech say, ‘Oh sorry, I have the wrong person,’ and create embarrassment for the patient, we needed a different plan,” he said.
Instead, Dr. Jaspan’s office contacted the radiology staff before the appointment, and they were “overwhelmingly happy to help,” he said. The patient was greeted by a staff member of the radiology clinic who was also part of the LGBT community and was escorted to the exam room without being called by name.
“It was a very important lesson,” Dr. Jaspan said.
Rainbow power
When word got out about plans to open the Pride Clinic at Einstein Medical Center in Philadelphia, Dr. Jaspan started receiving calls from people across the country offering to collaborate, or to give financial assistance.
“It was unbelievable,” Dr. Jaspan said. One important ally was the LGBT brown bag lunch group who met regularly at Einstein and whose members were happy to serve as a focus group for the project. “They also trained our staff on how to answer the phones so LGBT people would immediately feel at ease,” he said.
But what surprised Dr. Jaspan the most was the power of the rainbow. Although he expected the clinic would need some type of overhaul, the focus group assured him that simply by displaying a sticker of a rainbow – long the international symbol of the LGBT community – at the clinic’s entrance, as well as placing rainbow flags on the reception desk and the door of every examination room, LGBT individuals would know they were welcome.
“I thought it was so phenomenal there was that much power in a symbol,” Dr. Jaspan said. “I just couldn’t believe that would make that much difference, but it does.”
From start to finish, including applying for the designation as an LGBT health equality leader by the Human Rights Campaign Foundation and training his staff in how to take information from patients using language that makes no assumptions about their sexual identity or preferences, the process of officially opening his doors to Philadelphia’s LGBT community took a year. “But I was aggressive with it,” Dr. Jaspan added.
Since opening, the clinic has enrolled about 10 LGBT patients on its patient panel, all of whom have access to a network of physicians, including cardiologists, pediatricians, endocrinologists, psychiatrists, and the gynecologic oncologists who now care for the lesbian patient who first presented with advanced-stage cervical cancer.
“I learn something new every day, every single day,” said Dr. Jaspan. “Just because we’ve opened doesn’t mean we’re doing it right, but a [college-aged LGBT patient] we saw the other day said she’d spread the word because she thought we had done everything right.”
Checklist for transgender patient exams
The main barriers to getting basic health care in the lesbian, gay, bisexual, and transgender community are “anticipated, perceived, and actual insensitivity, or rejection,” said Walter O. Bockting, Ph.D., codirector of the LGBT Health Initiative and professor of medical psychology at the New York State Psychiatric Institute and the Columbia University School of Nursing.
Underlying that, he said, is the lack of training in LGBT health concerns for health care professionals, given this cohort’s “marginalization.”
Dr. Bockting shared his advice for providing the best possible primary care for transgender patients.
Mental health
Screen for depression and anxiety, create a network of mental health professionals with expertise in transgender-related concerns, and help patients with resilience-building strategies, Dr. Bockting advised.
Transgender women have a higher relative risk for depression and anxiety, he said. This is often a result of “social stigma attached to their nonconformity,” and rejection of their claimed sexual identity by family members, especially if they are a parent. Additionally, “simply having to deal with being transgender, the process of finding a comfortable gender role and expression, and parts of the coming out process may be stressful, contributing to feelings of vulnerability, and symptoms of depression and anxiety.”
Preventive care
Continue to perform pelvic exams and Pap smears in transgender men with a cervix and uterus, screen transgender men for uterine and breast cancers, and screen transgender women for prostate cancers, Dr. Bockting advised.
In addition to the medical interventions necessary to affirm gender identities, one’s sex at birth, and one’s sexual orientation, taking a complete medical history that includes what surgeries the patient has had to date, and what the subsequent management strategies have been, is essential to knowing which preventive care is most appropriate for the individual patient, he said.
“What being transgender means, and is, varies from person to person,” Dr. Bockting said. “Developing an understanding of what it means for a particular patient is key.”
Educate yourself
Own your limitations, but also seek to learn by enlisting colleagues with more expertise, Dr. Bockting advised.
If you have been treating anatomical women your entire career, being called upon to treat a transgender woman with prostate concerns can be daunting, he said. But understanding your limitations is good, according to Dr. Bockting, though even better is to “do your homework, and talk to colleagues and other experts about how to provide the best possible care.”
“It’s okay to admit you do not know it all,” he said. “That is often referred to as having ‘cultural humility.’ ”
Resources for providing LGBT care
For more information about creating an LGBT-friendly clinic, the following organizations can offer tips, support, and expertise:
This is one of the nation’s oldest LGBT-focused clinics, and the largest U.S. LGBT health research center, with locations throughout Boston.
617-927-6400
Initially opened in 1979 to serve San Francisco’s lesbian community, it now offers care and resources to the entire LGBT community.
415-565-7667
Also opened in 1979 to serve the LGBT community, it is one of the first AIDS-service organizations in the United States.
215-563-0652
World Professional Association for Transgender Health
Formerly the Harry Benjamin International Gender Dysphoria Association, in Minneapolis, WPATH promotes evidence-based care, education, research, advocacy, public policy, and respect in transgender health.
This LGBT advocacy group based in Washington, D.C., issues an annual report on leaders in LGBT health care delivery, and offers resources to help meet their criteria.
On Twitter @whitneymcknight
The pivotal moment in Dr. David Jaspan’s decision to create an LGBT-friendly practice was when a first-year resident physician told him a lesbian woman had presented with advanced-stage cervical cancer to their Philadelphia-based community ob.gyn. clinic.
“She had health insurance. She lived within walking distance of the clinic,” recalled Dr. Jaspan, chairman of the Einstein Medical Center in Philadelphia.
The patient had been avoiding preventive care, including routine Pap smears, because she feared being judged for her sexuality, he said. “She had access to care, but was afraid to use it. That’s ridiculous. We had to do something.”
In a 2010 survey of nearly 5,000 LGBT (lesbian, gay, bisexual, transgender) individuals nationwide conducted by the LGBT advocacy group Lambda Legal, more than half of the nearly 400 transgender individuals, and nearly 10% of the entire gay, lesbian, and bisexual population surveyed said they believed they would be refused care if they sought it.
An analysis of the literature published in the last 5 years, conducted by Dr. Gloria Bachmann, professor and interim chair of obstetrics and gynecology at the Robert Wood Johnson Medical School in Newark, N.J., and her colleagues, showed that in the ob.gyn. setting, 2% of transgender respondents in one survey reported being physically attacked in a patient waiting area, while nearly 20% of respondents reported being denied care altogether.
Aside from these real or perceived fears of harm or denial, another barrier to care for the LGBT community appears to be a lack of education in the medical training establishment.
A survey published earlier this year in the American Journal of Public Health, and conducted by researchers from the University of California at Los Angeles, showed that of the half of all 138 U.S. academic medical faculty practices currently accredited by the Liaison Committee on Medical Education that responded to the survey, only 10% have standard procedures for connecting patients to LGBT-competent physicians.
The medical community at large seems to be more proactive about inclusion. In 2014, the Human Rights Campaign Foundation designated more than 400 community health care facilities across the country as leaders in LGBT health care equality, more than double the number they designated in 2013.
“I think that things are better than they used to be,” said Dr. Rachel Levine, Pennsylvania’s first transgender physician general.
Dr. Levine was appointed to her post earlier this year by Gov. Tom Wolf (D). “I can’t see someone being refused care because they are LGBT.” Besides, she added, “it’s not ethical.”
While not everyone will practice LGBT medicine, Dr. Levine said, “all medical personnel should have training in, and at least be aware of, the broad outlines of LGBT health issues.” She pointed to a growing number of organizations, such as the Institute of Medicine and the American Medical Association, that also offer guidelines for treating the LGBT population.
Achieving culturally competent care
For Dr. Jaspan, the will and desire to provide care was strong, even though he wasn’t entirely sure how to go about it. “I wondered, What if a man walked into our clinic? But it was clear to me, it doesn’t matter. What matters is that he chose to access care.”
Delivering what is largely referred to by LGBT health experts as “culturally competent care” comes down to two factors: gender neutrality and honesty, according to Dr. Bachmann.
“Unconscious biases find their way into personal and professional interactions, but defining all clinical encounters as gender equal works to eliminate that bias in clinical-patient interactions,” she said.
Gender neutrality helps to establish trust with a transgender patient and makes it easier to get a full history, including details about the surgical and management strategies for the patient’s transition, the difficulties the patient might be having, and how to get the assistance that patient might need, Dr. Bachmann said.
That leads to the second essential element of culturally competent care: honesty.
“[Physicians] don’t have to know everything,” Dr. Bachmann said. “Opening the lines of communication is probably the most important, and acknowledging that you might not have the most in-depth knowledge to meet the [LGBT patient’s] needs, but you do want to take the best care of them, and that you might need their assistance for that.”
Clear communication also helps maintain accurate electronic health records, particularly in the case of transgender patients, said Dr. Levine, who before assuming her role as Pennsylvania’s top physician, was the vice chair for clinical affairs for the department of pediatrics and chief of the division of adolescent medicine and eating disorders at the Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center.
“In the privacy of the examination room, ask the patient what name they would like to be called, what pronoun they would like you to use, and in the context of the visit, you use those,” Dr. Levine said.
But because both HIPPA and insurers require a person’s legal name and gender, it is important their EHRs reflect that information, while the dictation makes the patient’s preferences clear.
‘A very important lesson’
But sometimes, as Dr. Jaspan discovered, a notation is simply not enough.
Once Dr. Jaspan’s clinic officially announced it was LGBT friendly, the first patient from that community to enroll was a bearded transgender man who’d had his breasts removed, but still had a uterus and ovaries and so was in need of a pelvic ultrasound.
Dr. Jaspan wrote the script for the radiologist, but Dr. Michele Style, the resident who had first urged him to reach out to the LGBT community, pointed out the peril of not thinking through how the patient would be received at the radiology clinic. She told him that unless they gave fair warning, the radiology tech would call out the patient’s legal name, which would indicate a woman would respond, but instead, it would be a man who would reply.
“Rather than have the tech say, ‘Oh sorry, I have the wrong person,’ and create embarrassment for the patient, we needed a different plan,” he said.
Instead, Dr. Jaspan’s office contacted the radiology staff before the appointment, and they were “overwhelmingly happy to help,” he said. The patient was greeted by a staff member of the radiology clinic who was also part of the LGBT community and was escorted to the exam room without being called by name.
“It was a very important lesson,” Dr. Jaspan said.
Rainbow power
When word got out about plans to open the Pride Clinic at Einstein Medical Center in Philadelphia, Dr. Jaspan started receiving calls from people across the country offering to collaborate, or to give financial assistance.
“It was unbelievable,” Dr. Jaspan said. One important ally was the LGBT brown bag lunch group who met regularly at Einstein and whose members were happy to serve as a focus group for the project. “They also trained our staff on how to answer the phones so LGBT people would immediately feel at ease,” he said.
But what surprised Dr. Jaspan the most was the power of the rainbow. Although he expected the clinic would need some type of overhaul, the focus group assured him that simply by displaying a sticker of a rainbow – long the international symbol of the LGBT community – at the clinic’s entrance, as well as placing rainbow flags on the reception desk and the door of every examination room, LGBT individuals would know they were welcome.
“I thought it was so phenomenal there was that much power in a symbol,” Dr. Jaspan said. “I just couldn’t believe that would make that much difference, but it does.”
From start to finish, including applying for the designation as an LGBT health equality leader by the Human Rights Campaign Foundation and training his staff in how to take information from patients using language that makes no assumptions about their sexual identity or preferences, the process of officially opening his doors to Philadelphia’s LGBT community took a year. “But I was aggressive with it,” Dr. Jaspan added.
Since opening, the clinic has enrolled about 10 LGBT patients on its patient panel, all of whom have access to a network of physicians, including cardiologists, pediatricians, endocrinologists, psychiatrists, and the gynecologic oncologists who now care for the lesbian patient who first presented with advanced-stage cervical cancer.
“I learn something new every day, every single day,” said Dr. Jaspan. “Just because we’ve opened doesn’t mean we’re doing it right, but a [college-aged LGBT patient] we saw the other day said she’d spread the word because she thought we had done everything right.”
Checklist for transgender patient exams
The main barriers to getting basic health care in the lesbian, gay, bisexual, and transgender community are “anticipated, perceived, and actual insensitivity, or rejection,” said Walter O. Bockting, Ph.D., codirector of the LGBT Health Initiative and professor of medical psychology at the New York State Psychiatric Institute and the Columbia University School of Nursing.
Underlying that, he said, is the lack of training in LGBT health concerns for health care professionals, given this cohort’s “marginalization.”
Dr. Bockting shared his advice for providing the best possible primary care for transgender patients.
Mental health
Screen for depression and anxiety, create a network of mental health professionals with expertise in transgender-related concerns, and help patients with resilience-building strategies, Dr. Bockting advised.
Transgender women have a higher relative risk for depression and anxiety, he said. This is often a result of “social stigma attached to their nonconformity,” and rejection of their claimed sexual identity by family members, especially if they are a parent. Additionally, “simply having to deal with being transgender, the process of finding a comfortable gender role and expression, and parts of the coming out process may be stressful, contributing to feelings of vulnerability, and symptoms of depression and anxiety.”
Preventive care
Continue to perform pelvic exams and Pap smears in transgender men with a cervix and uterus, screen transgender men for uterine and breast cancers, and screen transgender women for prostate cancers, Dr. Bockting advised.
In addition to the medical interventions necessary to affirm gender identities, one’s sex at birth, and one’s sexual orientation, taking a complete medical history that includes what surgeries the patient has had to date, and what the subsequent management strategies have been, is essential to knowing which preventive care is most appropriate for the individual patient, he said.
“What being transgender means, and is, varies from person to person,” Dr. Bockting said. “Developing an understanding of what it means for a particular patient is key.”
Educate yourself
Own your limitations, but also seek to learn by enlisting colleagues with more expertise, Dr. Bockting advised.
If you have been treating anatomical women your entire career, being called upon to treat a transgender woman with prostate concerns can be daunting, he said. But understanding your limitations is good, according to Dr. Bockting, though even better is to “do your homework, and talk to colleagues and other experts about how to provide the best possible care.”
“It’s okay to admit you do not know it all,” he said. “That is often referred to as having ‘cultural humility.’ ”
Resources for providing LGBT care
For more information about creating an LGBT-friendly clinic, the following organizations can offer tips, support, and expertise:
This is one of the nation’s oldest LGBT-focused clinics, and the largest U.S. LGBT health research center, with locations throughout Boston.
617-927-6400
Initially opened in 1979 to serve San Francisco’s lesbian community, it now offers care and resources to the entire LGBT community.
415-565-7667
Also opened in 1979 to serve the LGBT community, it is one of the first AIDS-service organizations in the United States.
215-563-0652
World Professional Association for Transgender Health
Formerly the Harry Benjamin International Gender Dysphoria Association, in Minneapolis, WPATH promotes evidence-based care, education, research, advocacy, public policy, and respect in transgender health.
This LGBT advocacy group based in Washington, D.C., issues an annual report on leaders in LGBT health care delivery, and offers resources to help meet their criteria.
On Twitter @whitneymcknight
Pennsylvania welcomes first transgender physician general
Before her appointment earlier this year by Gov. Tom Wolf (D-Pa.) as the state’s physician general, Dr. Rachel Levine was vice chair for clinical affairs in the department of pediatrics and chief of the division of adolescent medicine and eating disorders at Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center. While on the faculty there, she decided to transition from her male birth sex to that of female.
Instead of being “marginalized, I was welcomed,” Dr. Levine said in an interview. “The faculty and administration were fantastic.”
That acceptance fuels Dr. Levine’s optimism that the medical profession’s sensitivity to the needs of the transgender community, including adolescents who seek to transition, is growing.
Just how many transgender Americans there are is unknown, according to Dr. Levine. “The statistics aren’t clear. I’ve heard one in a thousand, one in ten thousand, and one in three thousand. No one really knows. It depends on how you ask the question and what surveys you look at.”
But cultural awareness is growing, she said, which makes people more willing to identify themselves as a transgender person.
At the same time, she added, the medical community has more well-established standards of care that, 10 years from now, “will not seem as unique as they do now.”
She pointed to guidelines for developing, maintaining, and treating sexual characteristics in transgender persons published as far back as 2009 by the Endocrine Society and the establishment in the last decade of adolescent transgender medicine programs at the Children’s Hospital of Philadelphia, Boston Children’s Hospital, Children’s National Health System (Washington, D.C.), and the Center for Transyouth Health and Development at Children’s Hospital Los Angeles.
“It gets better. Society is evolving,” she said. That’s Dr. Levine’s message to everyone, but especially young people who may be questioning their sexual identity and fearing what might happen if they do not conform.
“What I like to emphasize is that I wasn’t nominated because I am an openly transgender woman, but they didn’t shy away from it. I was judged purely on my qualifications,” she said. “And the state senate, which is dominated by Republicans, to their great credit, viewed me on my professional qualifications and I was unanimously confirmed.”
On Twitter @whitneymcknight
Before her appointment earlier this year by Gov. Tom Wolf (D-Pa.) as the state’s physician general, Dr. Rachel Levine was vice chair for clinical affairs in the department of pediatrics and chief of the division of adolescent medicine and eating disorders at Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center. While on the faculty there, she decided to transition from her male birth sex to that of female.
Instead of being “marginalized, I was welcomed,” Dr. Levine said in an interview. “The faculty and administration were fantastic.”
That acceptance fuels Dr. Levine’s optimism that the medical profession’s sensitivity to the needs of the transgender community, including adolescents who seek to transition, is growing.
Just how many transgender Americans there are is unknown, according to Dr. Levine. “The statistics aren’t clear. I’ve heard one in a thousand, one in ten thousand, and one in three thousand. No one really knows. It depends on how you ask the question and what surveys you look at.”
But cultural awareness is growing, she said, which makes people more willing to identify themselves as a transgender person.
At the same time, she added, the medical community has more well-established standards of care that, 10 years from now, “will not seem as unique as they do now.”
She pointed to guidelines for developing, maintaining, and treating sexual characteristics in transgender persons published as far back as 2009 by the Endocrine Society and the establishment in the last decade of adolescent transgender medicine programs at the Children’s Hospital of Philadelphia, Boston Children’s Hospital, Children’s National Health System (Washington, D.C.), and the Center for Transyouth Health and Development at Children’s Hospital Los Angeles.
“It gets better. Society is evolving,” she said. That’s Dr. Levine’s message to everyone, but especially young people who may be questioning their sexual identity and fearing what might happen if they do not conform.
“What I like to emphasize is that I wasn’t nominated because I am an openly transgender woman, but they didn’t shy away from it. I was judged purely on my qualifications,” she said. “And the state senate, which is dominated by Republicans, to their great credit, viewed me on my professional qualifications and I was unanimously confirmed.”
On Twitter @whitneymcknight
Before her appointment earlier this year by Gov. Tom Wolf (D-Pa.) as the state’s physician general, Dr. Rachel Levine was vice chair for clinical affairs in the department of pediatrics and chief of the division of adolescent medicine and eating disorders at Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center. While on the faculty there, she decided to transition from her male birth sex to that of female.
Instead of being “marginalized, I was welcomed,” Dr. Levine said in an interview. “The faculty and administration were fantastic.”
That acceptance fuels Dr. Levine’s optimism that the medical profession’s sensitivity to the needs of the transgender community, including adolescents who seek to transition, is growing.
Just how many transgender Americans there are is unknown, according to Dr. Levine. “The statistics aren’t clear. I’ve heard one in a thousand, one in ten thousand, and one in three thousand. No one really knows. It depends on how you ask the question and what surveys you look at.”
But cultural awareness is growing, she said, which makes people more willing to identify themselves as a transgender person.
At the same time, she added, the medical community has more well-established standards of care that, 10 years from now, “will not seem as unique as they do now.”
She pointed to guidelines for developing, maintaining, and treating sexual characteristics in transgender persons published as far back as 2009 by the Endocrine Society and the establishment in the last decade of adolescent transgender medicine programs at the Children’s Hospital of Philadelphia, Boston Children’s Hospital, Children’s National Health System (Washington, D.C.), and the Center for Transyouth Health and Development at Children’s Hospital Los Angeles.
“It gets better. Society is evolving,” she said. That’s Dr. Levine’s message to everyone, but especially young people who may be questioning their sexual identity and fearing what might happen if they do not conform.
“What I like to emphasize is that I wasn’t nominated because I am an openly transgender woman, but they didn’t shy away from it. I was judged purely on my qualifications,” she said. “And the state senate, which is dominated by Republicans, to their great credit, viewed me on my professional qualifications and I was unanimously confirmed.”
On Twitter @whitneymcknight
Joint Commission offers perinatal care certification
Joint Commission-accredited health care organizations looking to up their perinatal care credentials now can, thanks to a new Perinatal Care Certification program.
The program was developed by the Joint Commission in response to data from the World Health Organization that shows at least 1,200 American women die during pregnancy or in childbirth annually. An additional 60,000 women in the U.S. suffer near-fatal perinatal complications.
“The certification will give providers an unparalleled advantage when it comes to preparing mothers for labor and delivery, while helping mothers and newborns if complications arise,” Wendi Roberts, executive director of The Joint Commission’s Certification Program, said in a statement.
The certification program, which covers prenatal care through postpartum care, requires early identification of high-risk pregnancies and births, transfers for women and babies who require a higher level of care, and ongoing quality improvement processes.
The program is aimed at reducing maternal and infant mortality and complications, unnecessary induction of labor, elective deliveries, and prematurity rates.
Along with improving patient outcomes, the program could also drive down the cost of maternity care, which the Joint Commission said reached $60 billion in 2012 the United States alone. Hospitals may be able to reduce costs associated with longer length of stay due to complications, according to the Joint Commission.
On Twitter @whitneymcknight
Joint Commission-accredited health care organizations looking to up their perinatal care credentials now can, thanks to a new Perinatal Care Certification program.
The program was developed by the Joint Commission in response to data from the World Health Organization that shows at least 1,200 American women die during pregnancy or in childbirth annually. An additional 60,000 women in the U.S. suffer near-fatal perinatal complications.
“The certification will give providers an unparalleled advantage when it comes to preparing mothers for labor and delivery, while helping mothers and newborns if complications arise,” Wendi Roberts, executive director of The Joint Commission’s Certification Program, said in a statement.
The certification program, which covers prenatal care through postpartum care, requires early identification of high-risk pregnancies and births, transfers for women and babies who require a higher level of care, and ongoing quality improvement processes.
The program is aimed at reducing maternal and infant mortality and complications, unnecessary induction of labor, elective deliveries, and prematurity rates.
Along with improving patient outcomes, the program could also drive down the cost of maternity care, which the Joint Commission said reached $60 billion in 2012 the United States alone. Hospitals may be able to reduce costs associated with longer length of stay due to complications, according to the Joint Commission.
On Twitter @whitneymcknight
Joint Commission-accredited health care organizations looking to up their perinatal care credentials now can, thanks to a new Perinatal Care Certification program.
The program was developed by the Joint Commission in response to data from the World Health Organization that shows at least 1,200 American women die during pregnancy or in childbirth annually. An additional 60,000 women in the U.S. suffer near-fatal perinatal complications.
“The certification will give providers an unparalleled advantage when it comes to preparing mothers for labor and delivery, while helping mothers and newborns if complications arise,” Wendi Roberts, executive director of The Joint Commission’s Certification Program, said in a statement.
The certification program, which covers prenatal care through postpartum care, requires early identification of high-risk pregnancies and births, transfers for women and babies who require a higher level of care, and ongoing quality improvement processes.
The program is aimed at reducing maternal and infant mortality and complications, unnecessary induction of labor, elective deliveries, and prematurity rates.
Along with improving patient outcomes, the program could also drive down the cost of maternity care, which the Joint Commission said reached $60 billion in 2012 the United States alone. Hospitals may be able to reduce costs associated with longer length of stay due to complications, according to the Joint Commission.
On Twitter @whitneymcknight
MOC changes intended to make process simpler, more impactful
Leveraging the maintenance of certification (MOC) requirements for better patient outcomes and higher reimbursements may now be easier because of recent policy changes at the American Board of Pediatrics.
“I think pediatricians have seen MOC [requirements] as onerous, but it’s a two-edged sword,” Dr. Francis E. Rushton, Jr., medical director of South Carolina’s QTIP (Quality Through Innovation in Pediatrics) Program, said in an interview. “This whole issue about forcing practitioners to think about whether they are achieving the health care goals that they intend for their patients – from a philosophical viewpoint, that’s good. From a bureaucratic standpoint, it’s been a real pain because in the past, to get their certification, pediatricians had to do things that didn’t necessarily mean anything to them in their practice.”
Following a barrage of complaints, the ABP earlier this year retooled parts of its MOC program, especially Part 4, which focuses on quality improvement and accounts for 40% of recertification credits every 5 years.
“Now pediatricians can decide what matters to them in their practice, and then they can apply quality-improvement science to reach those goals,” Dr. Virginia A. Moyer, ABP vice president of maintenance certification and quality, said in an interview.
Notably, the ABP has simplified its qualification process for “do-it-yourself” quality-improvement initiatives in practices of 10 members or less. Previously, requirements for Part 4 DIY offerings were largely based on the “types of projects coming out of large institutions,” and largely missed the mark for smaller practices, Dr. Moyer said. Fees have been lowered by as much as half and scaled to practice size as well.
Importantly, ABP now offers Part 4 credit for to any practice that is National Committee for Quality Assurance (NCQA) accredited as a patient-centered medical home. “That’s huge,” Dr. Moyer said. “There are probably 8,000 pediatricians in the country who are eligible for that, and the standards are rigorous.”
Allowing pediatricians to earn two distinctions with one task is a way to “use bureaucracy to [pediatricians’] advantage so they learn something new, improve outcomes, and potentially increase their reimbursements,” said Dr. Rushton. “And it gives pediatricians the tools they need to deal with the marketplace’s new focus on value.”
The American Academy of Pediatrics also supports streamlining accreditation activities. “The changes the ABP has made to their MOC Part 4 guidelines will make it easier for pediatricians to obtain MOC credit for quality improvement they are doing in their own practices,” Dr. Sandra G. Hassink, AAP president, said in an interview. Dr. Hassink said that in 2016, the AAP will launch an online tool to help smaller practices either lead or partner with other small groups to apply MOC-eligible quality improvement projects that “are based on accepted improvement science and methodology” to their practices.
Indeed, over the past 2 decades, advances in quality-improvement science has allowed more precise measurement of patient outcomes, helping to supplant fee-for-service payments with value-based care. According to Dr. Wendy Davis, associate director of the National Improvement Partnership Network and a professor of pediatrics at the University of Vermont, Burlington, this means that pediatricians who completed their training prior to the early 1990s often have the largest learning curve when it comes to targeting quality-improvement goals and crafting a plan to reach those goals.
“An accountable care organization overseeing health care delivery across many different practices and settings has to be sure that what they say is important to practice aligns with what the clinicians think is important,” said Dr. Davis. “Then the clinicians need to understand how to identify, measure, and create improvement processes to ensure what they believe will help improve patient care is also what they are evaluated against for reimbursement.”
The new MOC Part 4 pathways should help, according to Dr. Moyer. “We have tried very hard to use the kinds of measures that people would be collecting anyway. For pediatricians just getting started in [quality improvement], it really makes sense for them to do the kinds of projects that their insurers or accountable care organizations are pushing them to do.” Receiving the MOC credit for these projects, she said, will be evidence of their progress.
DIY quality-improvement credits are based on projects that follow a basic formula: identifying a gap in quality, stating the goal for decreasing or eliminating that gap, planning for how to do that, proving the plan was enacted, and demonstrating it was measured sequentially at least three times. Projects are typically prospective and can count for Part 4 credits more than once if the project continues over the course of more than one accreditation cycle. Small practices within larger institutions may also use this DIY model, or may show proof of having participated in institutional portfolio quality improvement programs.
For all physicians in a group to receive MOC credit, Dr. Moyer said they must be able to demonstrate they were “intellectually engaged” in all phases of the project. Participation is verified through a physician’s self-attestation that includes a brief, written “reflection” on the experience, and attestation from the project leader, Dr. Moyer said.
Dr. Chuck Norlin of the department of pediatrics at the University of Utah, Salt Lake City, said that he wonders if that will be enough to evaluate whether a physician was a “bystander, or was substantively involved in the process. Measuring self-attestation is challenging. It seems like it might be too easy for one or two physicians to do all the work.”
While quality improvement is not new in pediatrics, the timely reporting of the data is. “Using the MOC as a carrot does not seem to have increased the interest in participating in quality improvement by much, but it has made it much easier to get data back from the participating clinicians who now see not getting their MOC credit as the stick,” Dr. Norlin said.
On Twitter @whitneymcknight
Leveraging the maintenance of certification (MOC) requirements for better patient outcomes and higher reimbursements may now be easier because of recent policy changes at the American Board of Pediatrics.
“I think pediatricians have seen MOC [requirements] as onerous, but it’s a two-edged sword,” Dr. Francis E. Rushton, Jr., medical director of South Carolina’s QTIP (Quality Through Innovation in Pediatrics) Program, said in an interview. “This whole issue about forcing practitioners to think about whether they are achieving the health care goals that they intend for their patients – from a philosophical viewpoint, that’s good. From a bureaucratic standpoint, it’s been a real pain because in the past, to get their certification, pediatricians had to do things that didn’t necessarily mean anything to them in their practice.”
Following a barrage of complaints, the ABP earlier this year retooled parts of its MOC program, especially Part 4, which focuses on quality improvement and accounts for 40% of recertification credits every 5 years.
“Now pediatricians can decide what matters to them in their practice, and then they can apply quality-improvement science to reach those goals,” Dr. Virginia A. Moyer, ABP vice president of maintenance certification and quality, said in an interview.
Notably, the ABP has simplified its qualification process for “do-it-yourself” quality-improvement initiatives in practices of 10 members or less. Previously, requirements for Part 4 DIY offerings were largely based on the “types of projects coming out of large institutions,” and largely missed the mark for smaller practices, Dr. Moyer said. Fees have been lowered by as much as half and scaled to practice size as well.
Importantly, ABP now offers Part 4 credit for to any practice that is National Committee for Quality Assurance (NCQA) accredited as a patient-centered medical home. “That’s huge,” Dr. Moyer said. “There are probably 8,000 pediatricians in the country who are eligible for that, and the standards are rigorous.”
Allowing pediatricians to earn two distinctions with one task is a way to “use bureaucracy to [pediatricians’] advantage so they learn something new, improve outcomes, and potentially increase their reimbursements,” said Dr. Rushton. “And it gives pediatricians the tools they need to deal with the marketplace’s new focus on value.”
The American Academy of Pediatrics also supports streamlining accreditation activities. “The changes the ABP has made to their MOC Part 4 guidelines will make it easier for pediatricians to obtain MOC credit for quality improvement they are doing in their own practices,” Dr. Sandra G. Hassink, AAP president, said in an interview. Dr. Hassink said that in 2016, the AAP will launch an online tool to help smaller practices either lead or partner with other small groups to apply MOC-eligible quality improvement projects that “are based on accepted improvement science and methodology” to their practices.
Indeed, over the past 2 decades, advances in quality-improvement science has allowed more precise measurement of patient outcomes, helping to supplant fee-for-service payments with value-based care. According to Dr. Wendy Davis, associate director of the National Improvement Partnership Network and a professor of pediatrics at the University of Vermont, Burlington, this means that pediatricians who completed their training prior to the early 1990s often have the largest learning curve when it comes to targeting quality-improvement goals and crafting a plan to reach those goals.
“An accountable care organization overseeing health care delivery across many different practices and settings has to be sure that what they say is important to practice aligns with what the clinicians think is important,” said Dr. Davis. “Then the clinicians need to understand how to identify, measure, and create improvement processes to ensure what they believe will help improve patient care is also what they are evaluated against for reimbursement.”
The new MOC Part 4 pathways should help, according to Dr. Moyer. “We have tried very hard to use the kinds of measures that people would be collecting anyway. For pediatricians just getting started in [quality improvement], it really makes sense for them to do the kinds of projects that their insurers or accountable care organizations are pushing them to do.” Receiving the MOC credit for these projects, she said, will be evidence of their progress.
DIY quality-improvement credits are based on projects that follow a basic formula: identifying a gap in quality, stating the goal for decreasing or eliminating that gap, planning for how to do that, proving the plan was enacted, and demonstrating it was measured sequentially at least three times. Projects are typically prospective and can count for Part 4 credits more than once if the project continues over the course of more than one accreditation cycle. Small practices within larger institutions may also use this DIY model, or may show proof of having participated in institutional portfolio quality improvement programs.
For all physicians in a group to receive MOC credit, Dr. Moyer said they must be able to demonstrate they were “intellectually engaged” in all phases of the project. Participation is verified through a physician’s self-attestation that includes a brief, written “reflection” on the experience, and attestation from the project leader, Dr. Moyer said.
Dr. Chuck Norlin of the department of pediatrics at the University of Utah, Salt Lake City, said that he wonders if that will be enough to evaluate whether a physician was a “bystander, or was substantively involved in the process. Measuring self-attestation is challenging. It seems like it might be too easy for one or two physicians to do all the work.”
While quality improvement is not new in pediatrics, the timely reporting of the data is. “Using the MOC as a carrot does not seem to have increased the interest in participating in quality improvement by much, but it has made it much easier to get data back from the participating clinicians who now see not getting their MOC credit as the stick,” Dr. Norlin said.
On Twitter @whitneymcknight
Leveraging the maintenance of certification (MOC) requirements for better patient outcomes and higher reimbursements may now be easier because of recent policy changes at the American Board of Pediatrics.
“I think pediatricians have seen MOC [requirements] as onerous, but it’s a two-edged sword,” Dr. Francis E. Rushton, Jr., medical director of South Carolina’s QTIP (Quality Through Innovation in Pediatrics) Program, said in an interview. “This whole issue about forcing practitioners to think about whether they are achieving the health care goals that they intend for their patients – from a philosophical viewpoint, that’s good. From a bureaucratic standpoint, it’s been a real pain because in the past, to get their certification, pediatricians had to do things that didn’t necessarily mean anything to them in their practice.”
Following a barrage of complaints, the ABP earlier this year retooled parts of its MOC program, especially Part 4, which focuses on quality improvement and accounts for 40% of recertification credits every 5 years.
“Now pediatricians can decide what matters to them in their practice, and then they can apply quality-improvement science to reach those goals,” Dr. Virginia A. Moyer, ABP vice president of maintenance certification and quality, said in an interview.
Notably, the ABP has simplified its qualification process for “do-it-yourself” quality-improvement initiatives in practices of 10 members or less. Previously, requirements for Part 4 DIY offerings were largely based on the “types of projects coming out of large institutions,” and largely missed the mark for smaller practices, Dr. Moyer said. Fees have been lowered by as much as half and scaled to practice size as well.
Importantly, ABP now offers Part 4 credit for to any practice that is National Committee for Quality Assurance (NCQA) accredited as a patient-centered medical home. “That’s huge,” Dr. Moyer said. “There are probably 8,000 pediatricians in the country who are eligible for that, and the standards are rigorous.”
Allowing pediatricians to earn two distinctions with one task is a way to “use bureaucracy to [pediatricians’] advantage so they learn something new, improve outcomes, and potentially increase their reimbursements,” said Dr. Rushton. “And it gives pediatricians the tools they need to deal with the marketplace’s new focus on value.”
The American Academy of Pediatrics also supports streamlining accreditation activities. “The changes the ABP has made to their MOC Part 4 guidelines will make it easier for pediatricians to obtain MOC credit for quality improvement they are doing in their own practices,” Dr. Sandra G. Hassink, AAP president, said in an interview. Dr. Hassink said that in 2016, the AAP will launch an online tool to help smaller practices either lead or partner with other small groups to apply MOC-eligible quality improvement projects that “are based on accepted improvement science and methodology” to their practices.
Indeed, over the past 2 decades, advances in quality-improvement science has allowed more precise measurement of patient outcomes, helping to supplant fee-for-service payments with value-based care. According to Dr. Wendy Davis, associate director of the National Improvement Partnership Network and a professor of pediatrics at the University of Vermont, Burlington, this means that pediatricians who completed their training prior to the early 1990s often have the largest learning curve when it comes to targeting quality-improvement goals and crafting a plan to reach those goals.
“An accountable care organization overseeing health care delivery across many different practices and settings has to be sure that what they say is important to practice aligns with what the clinicians think is important,” said Dr. Davis. “Then the clinicians need to understand how to identify, measure, and create improvement processes to ensure what they believe will help improve patient care is also what they are evaluated against for reimbursement.”
The new MOC Part 4 pathways should help, according to Dr. Moyer. “We have tried very hard to use the kinds of measures that people would be collecting anyway. For pediatricians just getting started in [quality improvement], it really makes sense for them to do the kinds of projects that their insurers or accountable care organizations are pushing them to do.” Receiving the MOC credit for these projects, she said, will be evidence of their progress.
DIY quality-improvement credits are based on projects that follow a basic formula: identifying a gap in quality, stating the goal for decreasing or eliminating that gap, planning for how to do that, proving the plan was enacted, and demonstrating it was measured sequentially at least three times. Projects are typically prospective and can count for Part 4 credits more than once if the project continues over the course of more than one accreditation cycle. Small practices within larger institutions may also use this DIY model, or may show proof of having participated in institutional portfolio quality improvement programs.
For all physicians in a group to receive MOC credit, Dr. Moyer said they must be able to demonstrate they were “intellectually engaged” in all phases of the project. Participation is verified through a physician’s self-attestation that includes a brief, written “reflection” on the experience, and attestation from the project leader, Dr. Moyer said.
Dr. Chuck Norlin of the department of pediatrics at the University of Utah, Salt Lake City, said that he wonders if that will be enough to evaluate whether a physician was a “bystander, or was substantively involved in the process. Measuring self-attestation is challenging. It seems like it might be too easy for one or two physicians to do all the work.”
While quality improvement is not new in pediatrics, the timely reporting of the data is. “Using the MOC as a carrot does not seem to have increased the interest in participating in quality improvement by much, but it has made it much easier to get data back from the participating clinicians who now see not getting their MOC credit as the stick,” Dr. Norlin said.
On Twitter @whitneymcknight
VIDEO: How can opioid blocking help treat ‘food addiction’?
WASHINGTON – How do naltrexone and naloxone work in the brain to help treat opioid and alcohol dependence, and what are the implications for those who have what Dr. Mark S. Gold of the department of psychiatry at Washington University in St. Louis calls “food addiction”? In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Gold discusses the mechanism of action for these opioid agonists and their role in addiction treatment. The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – How do naltrexone and naloxone work in the brain to help treat opioid and alcohol dependence, and what are the implications for those who have what Dr. Mark S. Gold of the department of psychiatry at Washington University in St. Louis calls “food addiction”? In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Gold discusses the mechanism of action for these opioid agonists and their role in addiction treatment. The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – How do naltrexone and naloxone work in the brain to help treat opioid and alcohol dependence, and what are the implications for those who have what Dr. Mark S. Gold of the department of psychiatry at Washington University in St. Louis calls “food addiction”? In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Gold discusses the mechanism of action for these opioid agonists and their role in addiction treatment. The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
AT THE SUMMIT IN NEUROLOGY & PSYCHIATRY
VIDEO: Addiction-treatment workforce too small to cope with demand
WASHINGTON – “No one would say the reversal of the medical effects of [illicit drug use] is ‘treatment,’ ” says Dr. Mark S. Gold, an addiction specialist in the department of psychiatry at Washington University in St. Louis. That’s only the beginning, he says. After patients with drug addictions are stabilized, then begins the complicated and lengthy task of treatment. Yet, there is a coming shortage of medical personnel qualified to offer addiction treatment, says Dr. Gold, who cites that – in the next decade – the addiction-treatment workforce will be 10 times too small to meet the demand. In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Gold discusses ways that primary care physicians and others can help. The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – “No one would say the reversal of the medical effects of [illicit drug use] is ‘treatment,’ ” says Dr. Mark S. Gold, an addiction specialist in the department of psychiatry at Washington University in St. Louis. That’s only the beginning, he says. After patients with drug addictions are stabilized, then begins the complicated and lengthy task of treatment. Yet, there is a coming shortage of medical personnel qualified to offer addiction treatment, says Dr. Gold, who cites that – in the next decade – the addiction-treatment workforce will be 10 times too small to meet the demand. In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Gold discusses ways that primary care physicians and others can help. The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – “No one would say the reversal of the medical effects of [illicit drug use] is ‘treatment,’ ” says Dr. Mark S. Gold, an addiction specialist in the department of psychiatry at Washington University in St. Louis. That’s only the beginning, he says. After patients with drug addictions are stabilized, then begins the complicated and lengthy task of treatment. Yet, there is a coming shortage of medical personnel qualified to offer addiction treatment, says Dr. Gold, who cites that – in the next decade – the addiction-treatment workforce will be 10 times too small to meet the demand. In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Gold discusses ways that primary care physicians and others can help. The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
AT THE SUMMIT IN NEUROLOGY & PSYCHIATRY
VIDEO: Helping patients sleep better can be simple
WASHINGTON – Sleep disorders can be treated easily in the primary care setting, although there are times when it’s best to refer to a sleep clinic. Dr. Raman K. Malhotra of the department of neurology at Saint Louis University, shares ways to help determine when a patient is presenting with sleep disorders vs. mood disorders. He also offers tips for patients, who can get the rest they need, once their sleep habits are adjusted. Also discussed in this video, recorded at the meeting held by the Global Academy for Medical Education, is the use of melatonin and iron supplementation to combat restless legs syndrome. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
WASHINGTON – Sleep disorders can be treated easily in the primary care setting, although there are times when it’s best to refer to a sleep clinic. Dr. Raman K. Malhotra of the department of neurology at Saint Louis University, shares ways to help determine when a patient is presenting with sleep disorders vs. mood disorders. He also offers tips for patients, who can get the rest they need, once their sleep habits are adjusted. Also discussed in this video, recorded at the meeting held by the Global Academy for Medical Education, is the use of melatonin and iron supplementation to combat restless legs syndrome. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
WASHINGTON – Sleep disorders can be treated easily in the primary care setting, although there are times when it’s best to refer to a sleep clinic. Dr. Raman K. Malhotra of the department of neurology at Saint Louis University, shares ways to help determine when a patient is presenting with sleep disorders vs. mood disorders. He also offers tips for patients, who can get the rest they need, once their sleep habits are adjusted. Also discussed in this video, recorded at the meeting held by the Global Academy for Medical Education, is the use of melatonin and iron supplementation to combat restless legs syndrome. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
AT THE SUMMIT IN NEUROLOGY & PSYCHIATRY
VIDEO: The coming revolution in brain science
WASHINGTON – What is the chief role of the brain? According to Dr. Henry A. Nasrallah, professor and chair of the department of neurology & psychiatry at Saint Louis University, it is to generate the mind. In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Nasrallah explains how neurology and psychiatry, once considered two halves of the same field of study, separated, but are now reuniting. He also discusses what this means for the future of both mind and brain science.
The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – What is the chief role of the brain? According to Dr. Henry A. Nasrallah, professor and chair of the department of neurology & psychiatry at Saint Louis University, it is to generate the mind. In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Nasrallah explains how neurology and psychiatry, once considered two halves of the same field of study, separated, but are now reuniting. He also discusses what this means for the future of both mind and brain science.
The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – What is the chief role of the brain? According to Dr. Henry A. Nasrallah, professor and chair of the department of neurology & psychiatry at Saint Louis University, it is to generate the mind. In this video, recorded at the Summit in Neurology & Psychiatry held by the Global Academy for Medical Education, Dr. Nasrallah explains how neurology and psychiatry, once considered two halves of the same field of study, separated, but are now reuniting. He also discusses what this means for the future of both mind and brain science.
The Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
AT THE SUMMIT IN NEUROLOGY & PSYCHIATRY
VIDEO: Watch for anxiety, other symptoms in cannabis users on anti-cannabinoids
WASHINGTON – The physical withdrawal symptoms of cannabis users given anti-cannabinoids resemble those of people withdrawing from opioid use by taking naloxone, according to Dr. Mark S. Gold. In this interview, recorded at the Summit in Neurology & Psychiatry sponsored by the Global Academy for Medical Education, Dr. Gold of the department of psychiatry at Washington University in St. Louis, describes withdrawal from cannabis, including symptoms of anxiety, panic, and confusion. Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – The physical withdrawal symptoms of cannabis users given anti-cannabinoids resemble those of people withdrawing from opioid use by taking naloxone, according to Dr. Mark S. Gold. In this interview, recorded at the Summit in Neurology & Psychiatry sponsored by the Global Academy for Medical Education, Dr. Gold of the department of psychiatry at Washington University in St. Louis, describes withdrawal from cannabis, including symptoms of anxiety, panic, and confusion. Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
WASHINGTON – The physical withdrawal symptoms of cannabis users given anti-cannabinoids resemble those of people withdrawing from opioid use by taking naloxone, according to Dr. Mark S. Gold. In this interview, recorded at the Summit in Neurology & Psychiatry sponsored by the Global Academy for Medical Education, Dr. Gold of the department of psychiatry at Washington University in St. Louis, describes withdrawal from cannabis, including symptoms of anxiety, panic, and confusion. Global Academy and this news organization are owned by the same company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
AT THE SUMMIT IN NEUROLOGY & PSYCHIATRY
