Mixed Topics

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

NEW ORLEANS – Children who require more than 48 hours of intravenous therapy should receive long peripheral catheters initially rather than standard peripheral intravenous catheters, results from a randomized, controlled trial suggest.

Long peripheral catheters (LPCs) are relatively new, 8- to 15-cm long peripheral vascular devices that have been investigated extensively in adults. “It has been shown that these devices are safe and reliable peripheral vascular access devices for use in this population,” lead study author Maurizio Pacilli, MD, said in an interview in advance of the annual meeting of the American Academy of Pediatrics.

“In addition, LPCs may represent an improvement to the quality of care in adults, as demonstrated by multiple randomized controlled trials, where they outperformed peripheral intravenous catheters (PIVCs). There remains, however, a lack of controlled studies to determine if this effect is replicable in children.”

In what he said is the first study of its kind, Dr. Pacilli, a senior research fellow at Monash Children’s Hospital and Monash University, Melbourne, and colleagues performed an open-label randomized trial of 72 pediatric surgical patients aged 1 year and older who required more than 48 hours of IV therapy. They assigned 36 to receive a PIVCs while the remaining 36 children received an 8-cm 22-gauge LPC.

The mean age of patients was 9 years and 71% were boys. Dr. Pacilli reported that the IV therapy duration was a mean of 5 days, and that gender, age, weight, emergency status, and IV therapy duration were similar between the two groups. However, the mean lifespan of catheters was 3 days in PIVC group, compared with 5 days in the LPC group, a difference that reached statistical significance (P = .003). Patients in the PIVC group received a median of two catheters, compared with one in the LPC group (P = .0002). The researchers found that patients in the PIVC group were less likely than were those in the LPC group to complete treatment with a single catheter (39% vs. 81%, relative risk [RR] 2.1, P = .0006), while the rate of catheter failure was higher for PIVCs than for LPCs (67% vs. 19%, RR 3.4, P = .0001; 187 vs. 43 failures per 1,000 catheter days). Infiltration was the most common complication, and occurred in 33% of patients in the PIVC group vs. 3% in LPC group (RR 12, P = .001).

“Our results showed for the first time, without doubt, that children requiring more than 48 hours of intravenous therapy benefit from receiving LPCs, compared with traditional PIVCs,” Dr. Pacilli said. “Of failed catheters, PIVCs are most likely to infiltrate, while LPCs are most likely to occlude. This indicates an additional benefit of LPCs as occlusion is a relatively benign complication. In addition, in all domains of satisfaction, parents favor LPCs. According to the parents, there is a significant improvement in ‘pain and discomfort’ and ‘overall satisfaction’ with the use of LPCs in children.”

He acknowledged certain limitations of the study, including the fact that children younger than 1 year of age were not included in the analysis. “New devices, suitable for very young children, need to be developed, and further studies are needed to confirm the findings from our trial in children younger than 1 year,” he said.

Dr. Pacilli reported having no financial disclosures.

[email protected]

NEW ORLEANS – Children who require more than 48 hours of intravenous therapy should receive long peripheral catheters initially rather than standard peripheral intravenous catheters, results from a randomized, controlled trial suggest.

Long peripheral catheters (LPCs) are relatively new, 8- to 15-cm long peripheral vascular devices that have been investigated extensively in adults. “It has been shown that these devices are safe and reliable peripheral vascular access devices for use in this population,” lead study author Maurizio Pacilli, MD, said in an interview in advance of the annual meeting of the American Academy of Pediatrics.

“In addition, LPCs may represent an improvement to the quality of care in adults, as demonstrated by multiple randomized controlled trials, where they outperformed peripheral intravenous catheters (PIVCs). There remains, however, a lack of controlled studies to determine if this effect is replicable in children.”

In what he said is the first study of its kind, Dr. Pacilli, a senior research fellow at Monash Children’s Hospital and Monash University, Melbourne, and colleagues performed an open-label randomized trial of 72 pediatric surgical patients aged 1 year and older who required more than 48 hours of IV therapy. They assigned 36 to receive a PIVCs while the remaining 36 children received an 8-cm 22-gauge LPC.

The mean age of patients was 9 years and 71% were boys. Dr. Pacilli reported that the IV therapy duration was a mean of 5 days, and that gender, age, weight, emergency status, and IV therapy duration were similar between the two groups. However, the mean lifespan of catheters was 3 days in PIVC group, compared with 5 days in the LPC group, a difference that reached statistical significance (P = .003). Patients in the PIVC group received a median of two catheters, compared with one in the LPC group (P = .0002). The researchers found that patients in the PIVC group were less likely than were those in the LPC group to complete treatment with a single catheter (39% vs. 81%, relative risk [RR] 2.1, P = .0006), while the rate of catheter failure was higher for PIVCs than for LPCs (67% vs. 19%, RR 3.4, P = .0001; 187 vs. 43 failures per 1,000 catheter days). Infiltration was the most common complication, and occurred in 33% of patients in the PIVC group vs. 3% in LPC group (RR 12, P = .001).

“Our results showed for the first time, without doubt, that children requiring more than 48 hours of intravenous therapy benefit from receiving LPCs, compared with traditional PIVCs,” Dr. Pacilli said. “Of failed catheters, PIVCs are most likely to infiltrate, while LPCs are most likely to occlude. This indicates an additional benefit of LPCs as occlusion is a relatively benign complication. In addition, in all domains of satisfaction, parents favor LPCs. According to the parents, there is a significant improvement in ‘pain and discomfort’ and ‘overall satisfaction’ with the use of LPCs in children.”

He acknowledged certain limitations of the study, including the fact that children younger than 1 year of age were not included in the analysis. “New devices, suitable for very young children, need to be developed, and further studies are needed to confirm the findings from our trial in children younger than 1 year,” he said.

Dr. Pacilli reported having no financial disclosures.

[email protected]

NEW ORLEANS – Children who require more than 48 hours of intravenous therapy should receive long peripheral catheters initially rather than standard peripheral intravenous catheters, results from a randomized, controlled trial suggest.

Long peripheral catheters (LPCs) are relatively new, 8- to 15-cm long peripheral vascular devices that have been investigated extensively in adults. “It has been shown that these devices are safe and reliable peripheral vascular access devices for use in this population,” lead study author Maurizio Pacilli, MD, said in an interview in advance of the annual meeting of the American Academy of Pediatrics.

“In addition, LPCs may represent an improvement to the quality of care in adults, as demonstrated by multiple randomized controlled trials, where they outperformed peripheral intravenous catheters (PIVCs). There remains, however, a lack of controlled studies to determine if this effect is replicable in children.”

In what he said is the first study of its kind, Dr. Pacilli, a senior research fellow at Monash Children’s Hospital and Monash University, Melbourne, and colleagues performed an open-label randomized trial of 72 pediatric surgical patients aged 1 year and older who required more than 48 hours of IV therapy. They assigned 36 to receive a PIVCs while the remaining 36 children received an 8-cm 22-gauge LPC.

The mean age of patients was 9 years and 71% were boys. Dr. Pacilli reported that the IV therapy duration was a mean of 5 days, and that gender, age, weight, emergency status, and IV therapy duration were similar between the two groups. However, the mean lifespan of catheters was 3 days in PIVC group, compared with 5 days in the LPC group, a difference that reached statistical significance (P = .003). Patients in the PIVC group received a median of two catheters, compared with one in the LPC group (P = .0002). The researchers found that patients in the PIVC group were less likely than were those in the LPC group to complete treatment with a single catheter (39% vs. 81%, relative risk [RR] 2.1, P = .0006), while the rate of catheter failure was higher for PIVCs than for LPCs (67% vs. 19%, RR 3.4, P = .0001; 187 vs. 43 failures per 1,000 catheter days). Infiltration was the most common complication, and occurred in 33% of patients in the PIVC group vs. 3% in LPC group (RR 12, P = .001).

“Our results showed for the first time, without doubt, that children requiring more than 48 hours of intravenous therapy benefit from receiving LPCs, compared with traditional PIVCs,” Dr. Pacilli said. “Of failed catheters, PIVCs are most likely to infiltrate, while LPCs are most likely to occlude. This indicates an additional benefit of LPCs as occlusion is a relatively benign complication. In addition, in all domains of satisfaction, parents favor LPCs. According to the parents, there is a significant improvement in ‘pain and discomfort’ and ‘overall satisfaction’ with the use of LPCs in children.”

He acknowledged certain limitations of the study, including the fact that children younger than 1 year of age were not included in the analysis. “New devices, suitable for very young children, need to be developed, and further studies are needed to confirm the findings from our trial in children younger than 1 year,” he said.

Dr. Pacilli reported having no financial disclosures.

[email protected]

I have always enjoyed talking with my patients from coastal Louisiana. They enjoy life, embrace their environment, and give me a perspective which is both similar and different than that of residents of New Orleans where I practice hospital medicine.

Bernhard_Staehli/Thinkstock

Their hospitalization is often a reflective moment in their lives. Lately I have been asking them about their advice to their children concerning the future of southern Louisiana in reference to sea rise, global warming, and increasing climatic events. More often than not, they have been telling their children it is time to move away.

These are a people who have strong devotion to family, but they are also practical. More than anything they would like their children to stay and preserve their heritage, but concern for their children’s future outweighs that. They have not come to this conclusion by scientific reports, but rather by what is happening before them. This group of people doesn’t alarm easily, but they see the unrelenting evidence of land loss and sea rise before them with little reason to believe it will change.

I am normally not one to speak out about climate change. Like most I have listened to the continuous alarms sounded by experts but have always assumed someone more qualified than myself should lead the efforts. But when I see the tangible effects of climate change both in my own life and the lives of my patients, I feel a sense of urgency.

12 years

Twelve years. That is the time we have to significantly reduce carbon emissions before catastrophic and potentially irreversible events will occur. This evidence is according to the authors of the landmark report by the UN Intergovernmental Panel on Climate Change released in October 2018. The report states urgent and unprecedented changes are needed to limit temperature elevations of 1.5°C and 2°C, as compared with the preindustrial era. Exceeding a 2°C elevation will likely lead to global adverse events at an unprecedented level.¹

The events forecast by the U.N. report are not abstract, particularly as they relate to public health. With high confidence, the report outlines with high specificity: increases in extreme heat, floods, crop failures, and a multitude of economic and social stressors which will affect the care of our most vulnerable patients.¹

This statement by Dr. Dana Hanson, president of the World Medical Association, summarizes the effects of climate change on the delivery of health care: “Climate change represents an inevitable massive threat to global health that will likely eclipse the major pandemics as a leading cause of death in the 21st century.”

So, what does the health care system have to do with climate change and its primary driver, carbon emissions? More than I realized, as the U.S. health care industry produces 10% of the nation’s carbon emissions.² If the U.S. health care system was a country it would be ranked seventh, ahead of the United Kingdom; 10% of all smog and 9% of all particulate-related respiratory disease can be attributed to the carbon emissions of the health care industry. This breaks down to possibly 20,000 premature deaths per year.² Our current health care industry is a significant driver of environmentally related disease and will continue to be so, unless major change occurs.

Although much of it is behind the scenes, providing health care 24/7 is a highly energy-intensive and waste-producing endeavor. Many of the innovations to reduce carbon emissions that have been seen in other industries have lagged behind in health care, as we have focused on other issues.

But the health care system is transitioning. It strives to address the whole person, including where they live, work, and play. A key component of this will be addressing our impact on the environments we serve. How can we make that argument if we don’t first address our own impact on the climate?

Carbon-neutral health care

Health care is one of the few industries that has the economic clout, the scientific basis, the community engagement, and perhaps most importantly the motivations to “first, do no harm” that could lead a national (if not a global) transformation in environmental stewardship among all industries.

Many agree that action is needed, but is essential that we set specific meaningful goals that take into account the urgency of the situation. One possible solution is to encourage every health care system to begin the process of becoming carbon neutral. Simply defined, carbon neutrality is balancing the activities that result in carbon emissions with activities that reduce carbon emissions. Carbon neutrality has become the standard by which an industry’s commitment to reducing carbon emissions is measured. The measurement is standardized and achievable, and the basic concept is understood by most. It results not only in long-term benefits to climate change, but immediate improvement of air quality in the local community. In addition, achieving carbon neutrality serves as a catalyst of new desired industries, improves employee morale, and aids in recruitment.³

So, what would a carbon-neutral health care system look like? In short, sustainability should be considered in all of its actions. Risks and benefits would be contemplated, as we do with all treatments, except now environmental risks would be brought into the equation. This includes the obvious, such as purchasing and supporting the development of renewable energy, but also transportation of patients and employees, food supply chains, and even the use of virtual visits to reduce the environmental impact of patient transportation.

I am optimistic that carbon neutrality is achievable in the health care sector. It can drive economic development and engage the community in environmental stewardship efforts. But time is of the essence and leaders for these efforts are needed now. As hospitalists, we are on the front lines of the health care system. We see the direct impact of social, economic, and environmental issues on our patients. We have credibility with both our patients and hospital administration. Among all industries, there need to be champions of environmental sustainability efforts. Hospitalists are uniquely positioned to fill that role.

My concern is that 12 years is right around the corner. We are at an inflection point on our efforts to reduce carbon emissions and that is good, but time has become our enemy. The difference between terrible and unlivable will be our, and the world’s, response to reducing carbon emissions.

It is time for bold action from us, the health care community. It is our moment and our place to lead those efforts, so let’s take advantage of both this challenge and this opportunity. Consider leading those efforts in your health care system.

Dr. Conrad is medical director of community affairs and health policy at Ochsner Health Systems in New Orleans.

References

1. Special Report on Global Warming of 1.5°C. Incheon [Republic of Korea]: Intergovernmental Panel on Climate Change. 7 Oct 2018.

2. Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE. 11(6):e0157014.

3. McCunn LJ, Gifford R. Do green offices affect employee engagement and environmental attitudes? Archit Sci Rev. 55:2;128-34. doi: 10.1080/00038628.2012.667939.
 

I have always enjoyed talking with my patients from coastal Louisiana. They enjoy life, embrace their environment, and give me a perspective which is both similar and different than that of residents of New Orleans where I practice hospital medicine.

Bernhard_Staehli/Thinkstock

Their hospitalization is often a reflective moment in their lives. Lately I have been asking them about their advice to their children concerning the future of southern Louisiana in reference to sea rise, global warming, and increasing climatic events. More often than not, they have been telling their children it is time to move away.

These are a people who have strong devotion to family, but they are also practical. More than anything they would like their children to stay and preserve their heritage, but concern for their children’s future outweighs that. They have not come to this conclusion by scientific reports, but rather by what is happening before them. This group of people doesn’t alarm easily, but they see the unrelenting evidence of land loss and sea rise before them with little reason to believe it will change.

I am normally not one to speak out about climate change. Like most I have listened to the continuous alarms sounded by experts but have always assumed someone more qualified than myself should lead the efforts. But when I see the tangible effects of climate change both in my own life and the lives of my patients, I feel a sense of urgency.

12 years

Twelve years. That is the time we have to significantly reduce carbon emissions before catastrophic and potentially irreversible events will occur. This evidence is according to the authors of the landmark report by the UN Intergovernmental Panel on Climate Change released in October 2018. The report states urgent and unprecedented changes are needed to limit temperature elevations of 1.5°C and 2°C, as compared with the preindustrial era. Exceeding a 2°C elevation will likely lead to global adverse events at an unprecedented level.¹

The events forecast by the U.N. report are not abstract, particularly as they relate to public health. With high confidence, the report outlines with high specificity: increases in extreme heat, floods, crop failures, and a multitude of economic and social stressors which will affect the care of our most vulnerable patients.¹

This statement by Dr. Dana Hanson, president of the World Medical Association, summarizes the effects of climate change on the delivery of health care: “Climate change represents an inevitable massive threat to global health that will likely eclipse the major pandemics as a leading cause of death in the 21st century.”

So, what does the health care system have to do with climate change and its primary driver, carbon emissions? More than I realized, as the U.S. health care industry produces 10% of the nation’s carbon emissions.² If the U.S. health care system was a country it would be ranked seventh, ahead of the United Kingdom; 10% of all smog and 9% of all particulate-related respiratory disease can be attributed to the carbon emissions of the health care industry. This breaks down to possibly 20,000 premature deaths per year.² Our current health care industry is a significant driver of environmentally related disease and will continue to be so, unless major change occurs.

Although much of it is behind the scenes, providing health care 24/7 is a highly energy-intensive and waste-producing endeavor. Many of the innovations to reduce carbon emissions that have been seen in other industries have lagged behind in health care, as we have focused on other issues.

But the health care system is transitioning. It strives to address the whole person, including where they live, work, and play. A key component of this will be addressing our impact on the environments we serve. How can we make that argument if we don’t first address our own impact on the climate?

Carbon-neutral health care

Health care is one of the few industries that has the economic clout, the scientific basis, the community engagement, and perhaps most importantly the motivations to “first, do no harm” that could lead a national (if not a global) transformation in environmental stewardship among all industries.

Many agree that action is needed, but is essential that we set specific meaningful goals that take into account the urgency of the situation. One possible solution is to encourage every health care system to begin the process of becoming carbon neutral. Simply defined, carbon neutrality is balancing the activities that result in carbon emissions with activities that reduce carbon emissions. Carbon neutrality has become the standard by which an industry’s commitment to reducing carbon emissions is measured. The measurement is standardized and achievable, and the basic concept is understood by most. It results not only in long-term benefits to climate change, but immediate improvement of air quality in the local community. In addition, achieving carbon neutrality serves as a catalyst of new desired industries, improves employee morale, and aids in recruitment.³

So, what would a carbon-neutral health care system look like? In short, sustainability should be considered in all of its actions. Risks and benefits would be contemplated, as we do with all treatments, except now environmental risks would be brought into the equation. This includes the obvious, such as purchasing and supporting the development of renewable energy, but also transportation of patients and employees, food supply chains, and even the use of virtual visits to reduce the environmental impact of patient transportation.

I am optimistic that carbon neutrality is achievable in the health care sector. It can drive economic development and engage the community in environmental stewardship efforts. But time is of the essence and leaders for these efforts are needed now. As hospitalists, we are on the front lines of the health care system. We see the direct impact of social, economic, and environmental issues on our patients. We have credibility with both our patients and hospital administration. Among all industries, there need to be champions of environmental sustainability efforts. Hospitalists are uniquely positioned to fill that role.

My concern is that 12 years is right around the corner. We are at an inflection point on our efforts to reduce carbon emissions and that is good, but time has become our enemy. The difference between terrible and unlivable will be our, and the world’s, response to reducing carbon emissions.

It is time for bold action from us, the health care community. It is our moment and our place to lead those efforts, so let’s take advantage of both this challenge and this opportunity. Consider leading those efforts in your health care system.

Dr. Conrad is medical director of community affairs and health policy at Ochsner Health Systems in New Orleans.

References

1. Special Report on Global Warming of 1.5°C. Incheon [Republic of Korea]: Intergovernmental Panel on Climate Change. 7 Oct 2018.

2. Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE. 11(6):e0157014.

3. McCunn LJ, Gifford R. Do green offices affect employee engagement and environmental attitudes? Archit Sci Rev. 55:2;128-34. doi: 10.1080/00038628.2012.667939.
 

I have always enjoyed talking with my patients from coastal Louisiana. They enjoy life, embrace their environment, and give me a perspective which is both similar and different than that of residents of New Orleans where I practice hospital medicine.

Bernhard_Staehli/Thinkstock

Their hospitalization is often a reflective moment in their lives. Lately I have been asking them about their advice to their children concerning the future of southern Louisiana in reference to sea rise, global warming, and increasing climatic events. More often than not, they have been telling their children it is time to move away.

These are a people who have strong devotion to family, but they are also practical. More than anything they would like their children to stay and preserve their heritage, but concern for their children’s future outweighs that. They have not come to this conclusion by scientific reports, but rather by what is happening before them. This group of people doesn’t alarm easily, but they see the unrelenting evidence of land loss and sea rise before them with little reason to believe it will change.

I am normally not one to speak out about climate change. Like most I have listened to the continuous alarms sounded by experts but have always assumed someone more qualified than myself should lead the efforts. But when I see the tangible effects of climate change both in my own life and the lives of my patients, I feel a sense of urgency.

12 years

Twelve years. That is the time we have to significantly reduce carbon emissions before catastrophic and potentially irreversible events will occur. This evidence is according to the authors of the landmark report by the UN Intergovernmental Panel on Climate Change released in October 2018. The report states urgent and unprecedented changes are needed to limit temperature elevations of 1.5°C and 2°C, as compared with the preindustrial era. Exceeding a 2°C elevation will likely lead to global adverse events at an unprecedented level.¹

The events forecast by the U.N. report are not abstract, particularly as they relate to public health. With high confidence, the report outlines with high specificity: increases in extreme heat, floods, crop failures, and a multitude of economic and social stressors which will affect the care of our most vulnerable patients.¹

This statement by Dr. Dana Hanson, president of the World Medical Association, summarizes the effects of climate change on the delivery of health care: “Climate change represents an inevitable massive threat to global health that will likely eclipse the major pandemics as a leading cause of death in the 21st century.”

So, what does the health care system have to do with climate change and its primary driver, carbon emissions? More than I realized, as the U.S. health care industry produces 10% of the nation’s carbon emissions.² If the U.S. health care system was a country it would be ranked seventh, ahead of the United Kingdom; 10% of all smog and 9% of all particulate-related respiratory disease can be attributed to the carbon emissions of the health care industry. This breaks down to possibly 20,000 premature deaths per year.² Our current health care industry is a significant driver of environmentally related disease and will continue to be so, unless major change occurs.

Although much of it is behind the scenes, providing health care 24/7 is a highly energy-intensive and waste-producing endeavor. Many of the innovations to reduce carbon emissions that have been seen in other industries have lagged behind in health care, as we have focused on other issues.

But the health care system is transitioning. It strives to address the whole person, including where they live, work, and play. A key component of this will be addressing our impact on the environments we serve. How can we make that argument if we don’t first address our own impact on the climate?

Carbon-neutral health care

Health care is one of the few industries that has the economic clout, the scientific basis, the community engagement, and perhaps most importantly the motivations to “first, do no harm” that could lead a national (if not a global) transformation in environmental stewardship among all industries.

Many agree that action is needed, but is essential that we set specific meaningful goals that take into account the urgency of the situation. One possible solution is to encourage every health care system to begin the process of becoming carbon neutral. Simply defined, carbon neutrality is balancing the activities that result in carbon emissions with activities that reduce carbon emissions. Carbon neutrality has become the standard by which an industry’s commitment to reducing carbon emissions is measured. The measurement is standardized and achievable, and the basic concept is understood by most. It results not only in long-term benefits to climate change, but immediate improvement of air quality in the local community. In addition, achieving carbon neutrality serves as a catalyst of new desired industries, improves employee morale, and aids in recruitment.³

So, what would a carbon-neutral health care system look like? In short, sustainability should be considered in all of its actions. Risks and benefits would be contemplated, as we do with all treatments, except now environmental risks would be brought into the equation. This includes the obvious, such as purchasing and supporting the development of renewable energy, but also transportation of patients and employees, food supply chains, and even the use of virtual visits to reduce the environmental impact of patient transportation.

I am optimistic that carbon neutrality is achievable in the health care sector. It can drive economic development and engage the community in environmental stewardship efforts. But time is of the essence and leaders for these efforts are needed now. As hospitalists, we are on the front lines of the health care system. We see the direct impact of social, economic, and environmental issues on our patients. We have credibility with both our patients and hospital administration. Among all industries, there need to be champions of environmental sustainability efforts. Hospitalists are uniquely positioned to fill that role.

My concern is that 12 years is right around the corner. We are at an inflection point on our efforts to reduce carbon emissions and that is good, but time has become our enemy. The difference between terrible and unlivable will be our, and the world’s, response to reducing carbon emissions.

It is time for bold action from us, the health care community. It is our moment and our place to lead those efforts, so let’s take advantage of both this challenge and this opportunity. Consider leading those efforts in your health care system.

Dr. Conrad is medical director of community affairs and health policy at Ochsner Health Systems in New Orleans.

References

1. Special Report on Global Warming of 1.5°C. Incheon [Republic of Korea]: Intergovernmental Panel on Climate Change. 7 Oct 2018.

2. Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE. 11(6):e0157014.

3. McCunn LJ, Gifford R. Do green offices affect employee engagement and environmental attitudes? Archit Sci Rev. 55:2;128-34. doi: 10.1080/00038628.2012.667939.
 

The Batman characters have been cultural icons for generations – spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West’s campy televised rendition of Batman? The October release of “Joker” has been breaking contemporary box office records.

(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized – like many people with obvious mental illness.

Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children’s hospital – where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.

In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur’s problems and the Joker’s origin story. Then the funding for Arthur’s mental health treatment (even if it was not good treatment) was cut – a problem not just in Gotham.

While some of Arthur Fleck’s symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, “The worst part about having mental illness is people expect you to behave as if you DONT.” A smiley face in the ‘O’ suggests that his affect is inappropriate even in his writing. Arthur’s condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).

Wikimedia Commons

In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film – and further perpetuates the misunderstanding that people with mental illness “get away” with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film “Taxi Driver.” Let’s presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur’s pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive – certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact – for example, on live television, or when he was alone with his mother in the hospital.

In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in “Joker.” We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix’s Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!
 

Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.

The Batman characters have been cultural icons for generations – spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West’s campy televised rendition of Batman? The October release of “Joker” has been breaking contemporary box office records.

(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized – like many people with obvious mental illness.

Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children’s hospital – where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.

In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur’s problems and the Joker’s origin story. Then the funding for Arthur’s mental health treatment (even if it was not good treatment) was cut – a problem not just in Gotham.

While some of Arthur Fleck’s symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, “The worst part about having mental illness is people expect you to behave as if you DONT.” A smiley face in the ‘O’ suggests that his affect is inappropriate even in his writing. Arthur’s condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).

Wikimedia Commons

In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film – and further perpetuates the misunderstanding that people with mental illness “get away” with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film “Taxi Driver.” Let’s presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur’s pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive – certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact – for example, on live television, or when he was alone with his mother in the hospital.

In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in “Joker.” We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix’s Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!
 

Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.

The Batman characters have been cultural icons for generations – spanning more than three-quarters of a century. How many of us had Batman (or the Joker) on our school lunch box or watched reruns of Adam West’s campy televised rendition of Batman? The October release of “Joker” has been breaking contemporary box office records.

(Spoiler alert!) The Todd Phillips film associates mental illness with violent acts, spurring a slew of articles explaining that this association is uncommon and may promote stigmatization and public fear of people with obvious symptoms of mental illness. The protagonist, Arthur Fleck (Joaquin Phoenix), suffers from a condition in which his affect and facial expressions are not appropriate to his emotions or to the situation. He laughs uncontrollably when a situation is sad or upsetting. Sometimes he laughs and cries at the same time. As a result, he often is misunderstood, ridiculed, and victimized – like many people with obvious mental illness.

Arthur Fleck is a loner who has difficulty with relationships and self-esteem, and is beaten severely while at work as a clown. Shortly after the incident, he is given a gun by one of his coworkers. He keeps it with him even when working as a clown in a children’s hospital – where it is accidentally revealed, and he is subsequently fired. Still in his clown garb, he later uses the gun when he is mocked and assaulted on the subway by three Gotham City bankers.

In an unusual tone, his mental health worker reminds him early in the film that he is prescribed seven different psychotropic medications, helping to cement for the viewer that mental illness is the cause of Arthur’s problems and the Joker’s origin story. Then the funding for Arthur’s mental health treatment (even if it was not good treatment) was cut – a problem not just in Gotham.

While some of Arthur Fleck’s symptoms are consistent with real mental illness, the combination of symptoms is unusual. Although he is being treated with a variety of medications, it is unclear whether any of them are helping him or what exactly they are helping him with. (Ironically, once he is off of his medications, he becomes a better dresser and a better dancer.) He writes in a disorganized way in his journal; the only intelligible sentence that is focused on is, “The worst part about having mental illness is people expect you to behave as if you DONT.” A smiley face in the ‘O’ suggests that his affect is inappropriate even in his writing. Arthur’s condition of uncontrollable laughing and/or crying, associated with head trauma, appears more consistent with the neurologic condition pseudobulbar affect rather than a mental illness. In addition to pseudobulbar affect, Arthur demonstrates a constellation of symptoms of different kinds of mental illness, including erotomanic delusions, ideas of reference, and disorganized thinking. He also does not appear to take social cues, such as knowing when he is being mocked. He appears to believe that his neighbor is his girlfriend (as the viewer was similarly led to believe), eventually breaking into her apartment where he thought he belonged, much to her horror when she finds him there. Some of his symptoms may run in his family (whether it be his biological or adoptive family).

Wikimedia Commons

In the final scenes, Arthur Fleck (who is now the Joker) is apparently back in the white-walled Arkham State Hospital, with an implication that he has gotten away with the murders, either found incompetent or insane. This, too, has negative implications for the public viewing the film – and further perpetuates the misunderstanding that people with mental illness “get away” with their crimes. In reality, depending on the study, approximately one-quarter of those who pleaded insanity were found insane, and those facing jury trials (and public perception) are less likely to be found insane than those with bench trials. Public misinterpretations and outrage over the idea that a mentally unwell person might be found insane rather than guilty have existed for centuries, perhaps most memorably when John Hinckley Jr. attempted to assassinate former President Ronald Reagan, after identifying with a character in the film “Taxi Driver.” Let’s presume that Gotham has an insanity defense similar to other places in America. Then, in order to be found insane, Arthur’s pseudobulbar affect or his (unclear) mental illness would have either caused him not to know the nature and consequences of his acts, and/or to appreciate the wrongfulness of his acts (if we are fairly certain that Gotham is actually New York City). Neither of these appear to be true from the film. He knew that he was killing. No delusions or hallucinations made him think his acts were not wrong. Rather, he had an arguably rational motive – certainly the multitudes wearing clown masks in the subsequent uprisings against the powerful also believed his motive to be rational. He deliberately killed the bankers who mocked and beat him. He was also able to defer his killings until what he calculated was the right time to have the most impact – for example, on live television, or when he was alone with his mother in the hospital.

In closing, unrealistic portrayals of the link between mental illness, violence, and forensic hospitalization are seen on the silver screen in “Joker.” We hope that others who feign mental illness symptoms to evade criminal responsibility will emulate Joaquin Phoenix’s Joker as it will make it much easier for forensic psychiatrists to ferret out malingerers!
 

Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington, D.C.: American Psychiatric Association Publishing [2019]), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law. Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill-Cornell Medical Center.

If you were a physician hospitalist in a group serving adults in 2017 you probably worked with nurse practitioners (NPs) and/or physician assistants (PAs). Seventy-seven percent of hospital medicine groups (HMGs) employed NPs and PAs that year.

In addition, the larger the group, the more likely the group was to have NPs and PAs as part of their practice model – 89% of hospital medicine groups with more than 30 physician had NPs and/or PAs as partners. In addition, the mean number of physicians for adult hospital medicine groups was 17.9. The same practices employed an average of 3.5 NPs, and 2.6 PAs.

Based on these numbers, there are just under three physicians per NP and PA in the typical HMG serving adults. This is all according to data from the 2018 State of Hospital Medicine (SoHM) report that was published in 2019 by the Society of Hospital Medicine.

These observations lead to a number of questions. One thing that is not clear from the SoHM is why NPs and PAs are becoming a larger part of the hospital medicine workforce, but there are some insights and conjecture that can be drawn from the data. The first is economics. Over 6 years, the median incomes of NPs and PAs have risen a relatively modest 10%; over the same period physician hospitalists have seen a whopping 23.6% median pay increase.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

If you were a physician hospitalist in a group serving adults in 2017 you probably worked with nurse practitioners (NPs) and/or physician assistants (PAs). Seventy-seven percent of hospital medicine groups (HMGs) employed NPs and PAs that year.

In addition, the larger the group, the more likely the group was to have NPs and PAs as part of their practice model – 89% of hospital medicine groups with more than 30 physician had NPs and/or PAs as partners. In addition, the mean number of physicians for adult hospital medicine groups was 17.9. The same practices employed an average of 3.5 NPs, and 2.6 PAs.

Based on these numbers, there are just under three physicians per NP and PA in the typical HMG serving adults. This is all according to data from the 2018 State of Hospital Medicine (SoHM) report that was published in 2019 by the Society of Hospital Medicine.

These observations lead to a number of questions. One thing that is not clear from the SoHM is why NPs and PAs are becoming a larger part of the hospital medicine workforce, but there are some insights and conjecture that can be drawn from the data. The first is economics. Over 6 years, the median incomes of NPs and PAs have risen a relatively modest 10%; over the same period physician hospitalists have seen a whopping 23.6% median pay increase.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

If you were a physician hospitalist in a group serving adults in 2017 you probably worked with nurse practitioners (NPs) and/or physician assistants (PAs). Seventy-seven percent of hospital medicine groups (HMGs) employed NPs and PAs that year.

In addition, the larger the group, the more likely the group was to have NPs and PAs as part of their practice model – 89% of hospital medicine groups with more than 30 physician had NPs and/or PAs as partners. In addition, the mean number of physicians for adult hospital medicine groups was 17.9. The same practices employed an average of 3.5 NPs, and 2.6 PAs.

Based on these numbers, there are just under three physicians per NP and PA in the typical HMG serving adults. This is all according to data from the 2018 State of Hospital Medicine (SoHM) report that was published in 2019 by the Society of Hospital Medicine.

These observations lead to a number of questions. One thing that is not clear from the SoHM is why NPs and PAs are becoming a larger part of the hospital medicine workforce, but there are some insights and conjecture that can be drawn from the data. The first is economics. Over 6 years, the median incomes of NPs and PAs have risen a relatively modest 10%; over the same period physician hospitalists have seen a whopping 23.6% median pay increase.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

A cardiologist friend of mine told me a story about one of his patients. The man had recently been in to see him for an office visit. He had quite a scare needing two stents after an episode of prolonged chest pain and, during the office visit, apparently had said that he had “found religion” and was going to change his ways. He showed off the Fitbit that he had gotten and shared his excitement about using a new app to track his diet on his smart phone. His blood pressure was a little elevated, so my friend added a third antihypertensive in an effort to get his blood pressure under control. He referred the patient back to his primary care physician to address his elevated hemoglobin A_1c.

My friend saw the patient again a couple of weeks later – this time at the mall. As he was driving through the parking lot, he noticed his patient sitting on a bench outside the entrance. He also noticed a cigarette in his patient’s right hand and saw the Fitbit still on his wrist. Now, it’s not that there is anything wrong with wearing a Fitbit, but …

My friend is an incredibly respectful person, and very nice. He decided not to say hello and risk embarrassing his patient, so he walked to a different door far from the bench and went inside. Nonetheless, the image bothered him. It bothered him enough to repeat the story to me 2 weeks later. It bothers me too.

The other day I was talking to a healthy young nurse with whom I work. She has been trying to get into shape, and her goal is to get to the gym 5 days a week after work. She read on a popular website that she should use a heart rate monitor to keep track of her training and that, if her heart rate is too slow, she should run faster and, if her heart rate is too fast, she should slow down. She was discouraged the other day, however, because her watch indicated that her pulse was going up to 170 while she was running hard, and she had heard that could be dangerous for her heart.

When she doesn’t push hard, though, she told me that her heart rate often plateaus at about 110, sometimes 115. She has been finding it difficult to achieve her calculated target heart rate of 120-160 beats per minute. She is frustrated and was going to skip her workout that evening. I explained to her that she should stop checking her pulse and just run – if she felt she was running too slow she could run faster.

Technology holds great promise to help us improve our health, but an over-reliance on technology can get in our way. With everything that we have learned about science and technology, the reality is that we are still people, with all our weaknesses and strengths. We often set goals with ambivalence, then rush forward hoping that a technological solution will move us in the direction we think we want to move. Unfortunately, owning a Fitbit will not make us more fit, and checking our pulse every five minutes while working out will not lead to a better exercise session. With the availability of so much technology for tracking our daily exercise, vital signs, and various other measures of health, we need to be more careful than ever to determine specifically what it is that we are trying to accomplish with the use of our technology.

When it comes to good health, it is the fundamentals that matter, and achieving the fundamentals requires being mindful and making repeated efforts to master them. For almost all adults, the most important habits to develop are still related to diet and exercise. Consuming the right diet and exercising adequately requires that the correct choices be made each and every day, all day long. Technology can help but will not do it for us. We need to be thoughtful about how we use technology and explicit about how we expect it to help. After a reasonable amount of time, we should evaluate to see if it is working for us. If it is, then we should continue to use it. If it is not, then we should stop using it or make a different change, like performing a new type of exercise.

Our goal should be to have intelligent empathic integration of technological and behavioral techniques to achieve an optimal health outcome. Putting running shoes by the bed at night is a great thing to do to encourage us to run in the morning. Choosing motivational music can help us get the energy and enthusiasm to go for that run (our favorites include the Rocky theme song and “I Didn’t Come this Far to Only Come this Far”). A visual reminder over the refrigerator can “nudge” us to make good choices as we open the door.

For those who want to learn more about how to integrate behavioral management into their advice for patients we highly recommend reading “Switch: How to Change Things When Change Is Hard” by Chip Heath and “Nudge: Improving Decisions About Health, Wealth, and Happiness” by Richard Thaler. We have always been, and remain, excited about the promise of technology to help us accomplish our goals. That said, we told the nurse to stop checking her pulse, to put on some music, and to appreciate the leaves on the trees this autumn while she was running. As for the gentleman outside the mall, well …

We are interested in your thoughts. Please email us at [email protected].

Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

A cardiologist friend of mine told me a story about one of his patients. The man had recently been in to see him for an office visit. He had quite a scare needing two stents after an episode of prolonged chest pain and, during the office visit, apparently had said that he had “found religion” and was going to change his ways. He showed off the Fitbit that he had gotten and shared his excitement about using a new app to track his diet on his smart phone. His blood pressure was a little elevated, so my friend added a third antihypertensive in an effort to get his blood pressure under control. He referred the patient back to his primary care physician to address his elevated hemoglobin A_1c.

My friend saw the patient again a couple of weeks later – this time at the mall. As he was driving through the parking lot, he noticed his patient sitting on a bench outside the entrance. He also noticed a cigarette in his patient’s right hand and saw the Fitbit still on his wrist. Now, it’s not that there is anything wrong with wearing a Fitbit, but …

My friend is an incredibly respectful person, and very nice. He decided not to say hello and risk embarrassing his patient, so he walked to a different door far from the bench and went inside. Nonetheless, the image bothered him. It bothered him enough to repeat the story to me 2 weeks later. It bothers me too.

The other day I was talking to a healthy young nurse with whom I work. She has been trying to get into shape, and her goal is to get to the gym 5 days a week after work. She read on a popular website that she should use a heart rate monitor to keep track of her training and that, if her heart rate is too slow, she should run faster and, if her heart rate is too fast, she should slow down. She was discouraged the other day, however, because her watch indicated that her pulse was going up to 170 while she was running hard, and she had heard that could be dangerous for her heart.

When she doesn’t push hard, though, she told me that her heart rate often plateaus at about 110, sometimes 115. She has been finding it difficult to achieve her calculated target heart rate of 120-160 beats per minute. She is frustrated and was going to skip her workout that evening. I explained to her that she should stop checking her pulse and just run – if she felt she was running too slow she could run faster.

Technology holds great promise to help us improve our health, but an over-reliance on technology can get in our way. With everything that we have learned about science and technology, the reality is that we are still people, with all our weaknesses and strengths. We often set goals with ambivalence, then rush forward hoping that a technological solution will move us in the direction we think we want to move. Unfortunately, owning a Fitbit will not make us more fit, and checking our pulse every five minutes while working out will not lead to a better exercise session. With the availability of so much technology for tracking our daily exercise, vital signs, and various other measures of health, we need to be more careful than ever to determine specifically what it is that we are trying to accomplish with the use of our technology.

When it comes to good health, it is the fundamentals that matter, and achieving the fundamentals requires being mindful and making repeated efforts to master them. For almost all adults, the most important habits to develop are still related to diet and exercise. Consuming the right diet and exercising adequately requires that the correct choices be made each and every day, all day long. Technology can help but will not do it for us. We need to be thoughtful about how we use technology and explicit about how we expect it to help. After a reasonable amount of time, we should evaluate to see if it is working for us. If it is, then we should continue to use it. If it is not, then we should stop using it or make a different change, like performing a new type of exercise.

Our goal should be to have intelligent empathic integration of technological and behavioral techniques to achieve an optimal health outcome. Putting running shoes by the bed at night is a great thing to do to encourage us to run in the morning. Choosing motivational music can help us get the energy and enthusiasm to go for that run (our favorites include the Rocky theme song and “I Didn’t Come this Far to Only Come this Far”). A visual reminder over the refrigerator can “nudge” us to make good choices as we open the door.

For those who want to learn more about how to integrate behavioral management into their advice for patients we highly recommend reading “Switch: How to Change Things When Change Is Hard” by Chip Heath and “Nudge: Improving Decisions About Health, Wealth, and Happiness” by Richard Thaler. We have always been, and remain, excited about the promise of technology to help us accomplish our goals. That said, we told the nurse to stop checking her pulse, to put on some music, and to appreciate the leaves on the trees this autumn while she was running. As for the gentleman outside the mall, well …

We are interested in your thoughts. Please email us at [email protected].

Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

A cardiologist friend of mine told me a story about one of his patients. The man had recently been in to see him for an office visit. He had quite a scare needing two stents after an episode of prolonged chest pain and, during the office visit, apparently had said that he had “found religion” and was going to change his ways. He showed off the Fitbit that he had gotten and shared his excitement about using a new app to track his diet on his smart phone. His blood pressure was a little elevated, so my friend added a third antihypertensive in an effort to get his blood pressure under control. He referred the patient back to his primary care physician to address his elevated hemoglobin A_1c.

My friend saw the patient again a couple of weeks later – this time at the mall. As he was driving through the parking lot, he noticed his patient sitting on a bench outside the entrance. He also noticed a cigarette in his patient’s right hand and saw the Fitbit still on his wrist. Now, it’s not that there is anything wrong with wearing a Fitbit, but …

My friend is an incredibly respectful person, and very nice. He decided not to say hello and risk embarrassing his patient, so he walked to a different door far from the bench and went inside. Nonetheless, the image bothered him. It bothered him enough to repeat the story to me 2 weeks later. It bothers me too.

The other day I was talking to a healthy young nurse with whom I work. She has been trying to get into shape, and her goal is to get to the gym 5 days a week after work. She read on a popular website that she should use a heart rate monitor to keep track of her training and that, if her heart rate is too slow, she should run faster and, if her heart rate is too fast, she should slow down. She was discouraged the other day, however, because her watch indicated that her pulse was going up to 170 while she was running hard, and she had heard that could be dangerous for her heart.

When she doesn’t push hard, though, she told me that her heart rate often plateaus at about 110, sometimes 115. She has been finding it difficult to achieve her calculated target heart rate of 120-160 beats per minute. She is frustrated and was going to skip her workout that evening. I explained to her that she should stop checking her pulse and just run – if she felt she was running too slow she could run faster.

Technology holds great promise to help us improve our health, but an over-reliance on technology can get in our way. With everything that we have learned about science and technology, the reality is that we are still people, with all our weaknesses and strengths. We often set goals with ambivalence, then rush forward hoping that a technological solution will move us in the direction we think we want to move. Unfortunately, owning a Fitbit will not make us more fit, and checking our pulse every five minutes while working out will not lead to a better exercise session. With the availability of so much technology for tracking our daily exercise, vital signs, and various other measures of health, we need to be more careful than ever to determine specifically what it is that we are trying to accomplish with the use of our technology.

When it comes to good health, it is the fundamentals that matter, and achieving the fundamentals requires being mindful and making repeated efforts to master them. For almost all adults, the most important habits to develop are still related to diet and exercise. Consuming the right diet and exercising adequately requires that the correct choices be made each and every day, all day long. Technology can help but will not do it for us. We need to be thoughtful about how we use technology and explicit about how we expect it to help. After a reasonable amount of time, we should evaluate to see if it is working for us. If it is, then we should continue to use it. If it is not, then we should stop using it or make a different change, like performing a new type of exercise.

Our goal should be to have intelligent empathic integration of technological and behavioral techniques to achieve an optimal health outcome. Putting running shoes by the bed at night is a great thing to do to encourage us to run in the morning. Choosing motivational music can help us get the energy and enthusiasm to go for that run (our favorites include the Rocky theme song and “I Didn’t Come this Far to Only Come this Far”). A visual reminder over the refrigerator can “nudge” us to make good choices as we open the door.

For those who want to learn more about how to integrate behavioral management into their advice for patients we highly recommend reading “Switch: How to Change Things When Change Is Hard” by Chip Heath and “Nudge: Improving Decisions About Health, Wealth, and Happiness” by Richard Thaler. We have always been, and remain, excited about the promise of technology to help us accomplish our goals. That said, we told the nurse to stop checking her pulse, to put on some music, and to appreciate the leaves on the trees this autumn while she was running. As for the gentleman outside the mall, well …

We are interested in your thoughts. Please email us at [email protected].

Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

The Centers for Medicare & Medicaid Services needs to be doing a better job overseeing the administrative costs associated with the implementation of work requirements in Medicaid, the Government Accountability Office said in a new report.

thinkstockphotos.com

The government watchdog found two key weaknesses in CMS’s oversight of the administrative costs of the Medicaid demonstration projects related to work requirements for Medicaid.

First, the GAO report notes that no consideration of the administrative costs of the work requirements is given during the administration of the approval process.

The GAO reports that, of five states’ approvals, the estimated administrative costs range from the low end of $6.1 million for New Hampshire (with 50,000 beneficiaries subject to the work requirement) to $271.6 million for Kentucky (with 620,000 beneficiaries subject to the work requirement). Indiana, with 420,000 beneficiaries subject to work requirements, has an estimated cost of $35.1 million.

A significant portion of Kentucky’s funding was for a the development of a new information technology system to help track work requirements.

“GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approvals,” the report states. “Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS’s assessment of whether a demonstration is budget neutral – that is, that federal spending will be no higher under the demonstration than it would have been without it.”

The GAO also reported that, by not requiring cost estimates, it also fails to meet the demonstration objective of transparency, something that goes hand in hand with budget neutrality.

The second weakness identified by GAO is that current procedures “may be insufficient to ensure that costs are allowable and matched at the correct rate.” Three of the five states examined in the report had received CMS approval for federal funds for administrative costs that were either not allowable for matching or were matched at higher rates than appropriate, based on CMS guidance.

The government watchdog noted that CMS did implement “procedures that may provide additional information on demonstrations’ administrative costs. ... However, it is unclear whether these efforts will result in data that improves CMS’s oversight.”

The GAO made three recommendations in the report. First, the CMS should require states to submit public projections of administrative costs when seeking approval for demonstration projects. Second, the administrative costs should be a part of the calculation for assessing the budget neutrality of demonstration project applications. Finally, CMS should do a better job assessing the risk that federal funds are being used to cover administrative costs that are not allowable and should improve oversight procedures as needed.

The GAO report included the Department of Health & Human Services’s response to the recommendations. To the first, the agency said that “its experience suggests that demonstration administrative costs will be a relatively small portion of total costs and therefore HHS believes making information about these costs available would provide stakeholders little to no value.”

Similarly, to the second recommendation, HHS countered that the information would provide little to no value given that administrative costs represent a relatively small portion of the total demonstration costs.

To the final recommendation on the need for better risk assessment, HHS said its existing approach “is appropriate for the low level of risk that administrative expenditures represent. ... CMS officials told us that they had not assessed wither current procedures sufficiently address risks posed by administrative costs for work requirements and had no plans to do so.”

[email protected]

The Centers for Medicare & Medicaid Services needs to be doing a better job overseeing the administrative costs associated with the implementation of work requirements in Medicaid, the Government Accountability Office said in a new report.

thinkstockphotos.com

The government watchdog found two key weaknesses in CMS’s oversight of the administrative costs of the Medicaid demonstration projects related to work requirements for Medicaid.

First, the GAO report notes that no consideration of the administrative costs of the work requirements is given during the administration of the approval process.

The GAO reports that, of five states’ approvals, the estimated administrative costs range from the low end of $6.1 million for New Hampshire (with 50,000 beneficiaries subject to the work requirement) to $271.6 million for Kentucky (with 620,000 beneficiaries subject to the work requirement). Indiana, with 420,000 beneficiaries subject to work requirements, has an estimated cost of $35.1 million.

A significant portion of Kentucky’s funding was for a the development of a new information technology system to help track work requirements.

“GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approvals,” the report states. “Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS’s assessment of whether a demonstration is budget neutral – that is, that federal spending will be no higher under the demonstration than it would have been without it.”

The GAO also reported that, by not requiring cost estimates, it also fails to meet the demonstration objective of transparency, something that goes hand in hand with budget neutrality.

The second weakness identified by GAO is that current procedures “may be insufficient to ensure that costs are allowable and matched at the correct rate.” Three of the five states examined in the report had received CMS approval for federal funds for administrative costs that were either not allowable for matching or were matched at higher rates than appropriate, based on CMS guidance.

The government watchdog noted that CMS did implement “procedures that may provide additional information on demonstrations’ administrative costs. ... However, it is unclear whether these efforts will result in data that improves CMS’s oversight.”

The GAO made three recommendations in the report. First, the CMS should require states to submit public projections of administrative costs when seeking approval for demonstration projects. Second, the administrative costs should be a part of the calculation for assessing the budget neutrality of demonstration project applications. Finally, CMS should do a better job assessing the risk that federal funds are being used to cover administrative costs that are not allowable and should improve oversight procedures as needed.

The GAO report included the Department of Health & Human Services’s response to the recommendations. To the first, the agency said that “its experience suggests that demonstration administrative costs will be a relatively small portion of total costs and therefore HHS believes making information about these costs available would provide stakeholders little to no value.”

Similarly, to the second recommendation, HHS countered that the information would provide little to no value given that administrative costs represent a relatively small portion of the total demonstration costs.

To the final recommendation on the need for better risk assessment, HHS said its existing approach “is appropriate for the low level of risk that administrative expenditures represent. ... CMS officials told us that they had not assessed wither current procedures sufficiently address risks posed by administrative costs for work requirements and had no plans to do so.”

[email protected]

The Centers for Medicare & Medicaid Services needs to be doing a better job overseeing the administrative costs associated with the implementation of work requirements in Medicaid, the Government Accountability Office said in a new report.

thinkstockphotos.com

The government watchdog found two key weaknesses in CMS’s oversight of the administrative costs of the Medicaid demonstration projects related to work requirements for Medicaid.

First, the GAO report notes that no consideration of the administrative costs of the work requirements is given during the administration of the approval process.

The GAO reports that, of five states’ approvals, the estimated administrative costs range from the low end of $6.1 million for New Hampshire (with 50,000 beneficiaries subject to the work requirement) to $271.6 million for Kentucky (with 620,000 beneficiaries subject to the work requirement). Indiana, with 420,000 beneficiaries subject to work requirements, has an estimated cost of $35.1 million.

A significant portion of Kentucky’s funding was for a the development of a new information technology system to help track work requirements.

“GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approvals,” the report states. “Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS’s assessment of whether a demonstration is budget neutral – that is, that federal spending will be no higher under the demonstration than it would have been without it.”

The GAO also reported that, by not requiring cost estimates, it also fails to meet the demonstration objective of transparency, something that goes hand in hand with budget neutrality.

The second weakness identified by GAO is that current procedures “may be insufficient to ensure that costs are allowable and matched at the correct rate.” Three of the five states examined in the report had received CMS approval for federal funds for administrative costs that were either not allowable for matching or were matched at higher rates than appropriate, based on CMS guidance.

The government watchdog noted that CMS did implement “procedures that may provide additional information on demonstrations’ administrative costs. ... However, it is unclear whether these efforts will result in data that improves CMS’s oversight.”

The GAO made three recommendations in the report. First, the CMS should require states to submit public projections of administrative costs when seeking approval for demonstration projects. Second, the administrative costs should be a part of the calculation for assessing the budget neutrality of demonstration project applications. Finally, CMS should do a better job assessing the risk that federal funds are being used to cover administrative costs that are not allowable and should improve oversight procedures as needed.

The GAO report included the Department of Health & Human Services’s response to the recommendations. To the first, the agency said that “its experience suggests that demonstration administrative costs will be a relatively small portion of total costs and therefore HHS believes making information about these costs available would provide stakeholders little to no value.”

Similarly, to the second recommendation, HHS countered that the information would provide little to no value given that administrative costs represent a relatively small portion of the total demonstration costs.

To the final recommendation on the need for better risk assessment, HHS said its existing approach “is appropriate for the low level of risk that administrative expenditures represent. ... CMS officials told us that they had not assessed wither current procedures sufficiently address risks posed by administrative costs for work requirements and had no plans to do so.”

[email protected]

Gastroenterology

Pantoprazole to prevent gastroduodenal events in patients receiving rivaroxaban and/or aspirin in a randomized, double-blind, placebo-controlled trial. Moayyedi P et al. 2019 Aug;157(2):403-12. doi. org/10.1053/j.gastro.2019.04.04.



How to foster academic promotion and career advancement of women in gastroenterology. Zimmermann EM. 2019 Sep;157(3):598-601. doi: 10.1053/j.gastro.2019.07.041.



AGA Clinical Practice Guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). Smalley W et al. 2019 Sep;157(3):851-4. doi: 10.1053/j.gastro.2019.07.004.



Gluten does not induce gastrointestinal symptoms in healthy volunteers: A double-blind randomized placebo trial. Croall ID et al. 2019 Sep;157(3):881-883. doi: 10.1053/j.gastro.2019.05.015.



How to advance research, education, and training in the study of rare diseases. Groft SC et al. 2019 Oct;157(4):917-21. doi. org/10.1053/j.gastro.2019.08.010.



Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Pohl H et al. 2019 Oct;157(4):977-984.e3. doi: 10.1053/j.gastro.2019.03.019.


 

Clinical Gastroenterology and Hepatology

Fibroscan for the rest of us – How to incorporate Fibroscan into management of patients with liver disease. Sozio MS. 2019 Aug;17(9):1714-7 doi. org/10.1016/j.cgh.2019.02.014.



Physician practice management and private equity: Market forces drive change. Gilreath M et al. 2019 Sep;17(10):1924-8.e2. doi: 10.1016/j.cgh.2019.05.001.

Migration of patients for liver transplantation and waitlist outcomes. Kwong AJ et al. 2019 Oct;17(11):2347-55.e5. doi: 10.1016/j.cgh.2019.04.060.

Gastroenterology

Pantoprazole to prevent gastroduodenal events in patients receiving rivaroxaban and/or aspirin in a randomized, double-blind, placebo-controlled trial. Moayyedi P et al. 2019 Aug;157(2):403-12. doi. org/10.1053/j.gastro.2019.04.04.



How to foster academic promotion and career advancement of women in gastroenterology. Zimmermann EM. 2019 Sep;157(3):598-601. doi: 10.1053/j.gastro.2019.07.041.



AGA Clinical Practice Guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). Smalley W et al. 2019 Sep;157(3):851-4. doi: 10.1053/j.gastro.2019.07.004.



Gluten does not induce gastrointestinal symptoms in healthy volunteers: A double-blind randomized placebo trial. Croall ID et al. 2019 Sep;157(3):881-883. doi: 10.1053/j.gastro.2019.05.015.



How to advance research, education, and training in the study of rare diseases. Groft SC et al. 2019 Oct;157(4):917-21. doi. org/10.1053/j.gastro.2019.08.010.



Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Pohl H et al. 2019 Oct;157(4):977-984.e3. doi: 10.1053/j.gastro.2019.03.019.


 

Clinical Gastroenterology and Hepatology

Fibroscan for the rest of us – How to incorporate Fibroscan into management of patients with liver disease. Sozio MS. 2019 Aug;17(9):1714-7 doi. org/10.1016/j.cgh.2019.02.014.



Physician practice management and private equity: Market forces drive change. Gilreath M et al. 2019 Sep;17(10):1924-8.e2. doi: 10.1016/j.cgh.2019.05.001.

Migration of patients for liver transplantation and waitlist outcomes. Kwong AJ et al. 2019 Oct;17(11):2347-55.e5. doi: 10.1016/j.cgh.2019.04.060.

Gastroenterology

Pantoprazole to prevent gastroduodenal events in patients receiving rivaroxaban and/or aspirin in a randomized, double-blind, placebo-controlled trial. Moayyedi P et al. 2019 Aug;157(2):403-12. doi. org/10.1053/j.gastro.2019.04.04.



How to foster academic promotion and career advancement of women in gastroenterology. Zimmermann EM. 2019 Sep;157(3):598-601. doi: 10.1053/j.gastro.2019.07.041.



AGA Clinical Practice Guidelines on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome in adults (IBS-D). Smalley W et al. 2019 Sep;157(3):851-4. doi: 10.1053/j.gastro.2019.07.004.



Gluten does not induce gastrointestinal symptoms in healthy volunteers: A double-blind randomized placebo trial. Croall ID et al. 2019 Sep;157(3):881-883. doi: 10.1053/j.gastro.2019.05.015.



How to advance research, education, and training in the study of rare diseases. Groft SC et al. 2019 Oct;157(4):917-21. doi. org/10.1053/j.gastro.2019.08.010.



Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Pohl H et al. 2019 Oct;157(4):977-984.e3. doi: 10.1053/j.gastro.2019.03.019.


 

Clinical Gastroenterology and Hepatology

Fibroscan for the rest of us – How to incorporate Fibroscan into management of patients with liver disease. Sozio MS. 2019 Aug;17(9):1714-7 doi. org/10.1016/j.cgh.2019.02.014.



Physician practice management and private equity: Market forces drive change. Gilreath M et al. 2019 Sep;17(10):1924-8.e2. doi: 10.1016/j.cgh.2019.05.001.

Migration of patients for liver transplantation and waitlist outcomes. Kwong AJ et al. 2019 Oct;17(11):2347-55.e5. doi: 10.1016/j.cgh.2019.04.060.

I love empty storefronts. The realtor headshot in the window is a sign of hope. What was here is no more. What is coming will be better.

anyaberkut/Getty Images

I’ve waited a year for one such sign to come down and scaffolding to go up. Just one block from my condo, my curiosity has been slaked: a yoga studio! At first, disappointment; so many potentials unrealized: a coffee shop, cleaners, speakeasy! Yet, I decided to make the best of it. I bought Rainbow sandals, a Lululemon mat, and a pack of 10 classes. As it turns out, yoga can transform your life.

I didn’t realize how beautifully yoga combines physical exertion, meditation, and spirituality. It is both a model for understanding and a ritualistic training for life. Take resting pigeon for example. (Yogis reading this will forgive my imperfect explanation.) This moderately difficult pose opens your hip and stretches your glutes. Imagine doing a split but with your front knee bent and your forehead and arms resting on the floor in front of you. Done correctly, it puts a stretch deep into the hip of the forward leg. It is uncomfortable. Holding it for a minute or 2 is hard. But rather than just focusing on releasing, with each breath you find yourself deepening the stretch. Sweat streams down your arms and the discomfort builds as you hold. All you can think about is your breath. Then, it’s over. You feel freer, lighter than you were before. The deeper the discomfort, the deeper the delight that arises afterward. You are wise, yogis would say, to have chosen “the good over the pleasant.”

We have many opportunities for resting pigeon in everyday life. The patient to be added to your Monday morning clinic – which already had added patients. The Friday afternoon Mohs case that went to periosteum and still needs a flap to close. The “yet another” GI bleed patient that needs to be scoped tonight. These are all deep stretches, uncomfortable hip openings. Part of what I learned from yoga is to not give in to fear of what is ahead. Rather, when you must be uncomfortable, breathe and lean into it. Choosing the good sometimes means choosing suffering, but it isn’t the pain that makes it hard to bear. It is a lack of significance for that difficulty. By choosing what is good, you answer the question: “Who am I?” I am the one able and willing to endure inconvenience or disquiet to help others. This is my job, what I’m here to do. The pose, the call, the case will be over quickly. The freedom you feel after, along with the satisfaction you have served your purpose, will sustain you.

There are many poses and endless lessons from yoga. In fact, doing yoga is called “practicing.” Each time you learn and try. Each time you are imperfect and uncomfortable and reemerge sweaty and satisfied, just a little better human than you were before.
 

Dr. Benabio is director of health care 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 love empty storefronts. The realtor headshot in the window is a sign of hope. What was here is no more. What is coming will be better.

anyaberkut/Getty Images

I’ve waited a year for one such sign to come down and scaffolding to go up. Just one block from my condo, my curiosity has been slaked: a yoga studio! At first, disappointment; so many potentials unrealized: a coffee shop, cleaners, speakeasy! Yet, I decided to make the best of it. I bought Rainbow sandals, a Lululemon mat, and a pack of 10 classes. As it turns out, yoga can transform your life.

I didn’t realize how beautifully yoga combines physical exertion, meditation, and spirituality. It is both a model for understanding and a ritualistic training for life. Take resting pigeon for example. (Yogis reading this will forgive my imperfect explanation.) This moderately difficult pose opens your hip and stretches your glutes. Imagine doing a split but with your front knee bent and your forehead and arms resting on the floor in front of you. Done correctly, it puts a stretch deep into the hip of the forward leg. It is uncomfortable. Holding it for a minute or 2 is hard. But rather than just focusing on releasing, with each breath you find yourself deepening the stretch. Sweat streams down your arms and the discomfort builds as you hold. All you can think about is your breath. Then, it’s over. You feel freer, lighter than you were before. The deeper the discomfort, the deeper the delight that arises afterward. You are wise, yogis would say, to have chosen “the good over the pleasant.”

We have many opportunities for resting pigeon in everyday life. The patient to be added to your Monday morning clinic – which already had added patients. The Friday afternoon Mohs case that went to periosteum and still needs a flap to close. The “yet another” GI bleed patient that needs to be scoped tonight. These are all deep stretches, uncomfortable hip openings. Part of what I learned from yoga is to not give in to fear of what is ahead. Rather, when you must be uncomfortable, breathe and lean into it. Choosing the good sometimes means choosing suffering, but it isn’t the pain that makes it hard to bear. It is a lack of significance for that difficulty. By choosing what is good, you answer the question: “Who am I?” I am the one able and willing to endure inconvenience or disquiet to help others. This is my job, what I’m here to do. The pose, the call, the case will be over quickly. The freedom you feel after, along with the satisfaction you have served your purpose, will sustain you.

There are many poses and endless lessons from yoga. In fact, doing yoga is called “practicing.” Each time you learn and try. Each time you are imperfect and uncomfortable and reemerge sweaty and satisfied, just a little better human than you were before.
 

Dr. Benabio is director of health care 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 love empty storefronts. The realtor headshot in the window is a sign of hope. What was here is no more. What is coming will be better.

anyaberkut/Getty Images

I’ve waited a year for one such sign to come down and scaffolding to go up. Just one block from my condo, my curiosity has been slaked: a yoga studio! At first, disappointment; so many potentials unrealized: a coffee shop, cleaners, speakeasy! Yet, I decided to make the best of it. I bought Rainbow sandals, a Lululemon mat, and a pack of 10 classes. As it turns out, yoga can transform your life.

I didn’t realize how beautifully yoga combines physical exertion, meditation, and spirituality. It is both a model for understanding and a ritualistic training for life. Take resting pigeon for example. (Yogis reading this will forgive my imperfect explanation.) This moderately difficult pose opens your hip and stretches your glutes. Imagine doing a split but with your front knee bent and your forehead and arms resting on the floor in front of you. Done correctly, it puts a stretch deep into the hip of the forward leg. It is uncomfortable. Holding it for a minute or 2 is hard. But rather than just focusing on releasing, with each breath you find yourself deepening the stretch. Sweat streams down your arms and the discomfort builds as you hold. All you can think about is your breath. Then, it’s over. You feel freer, lighter than you were before. The deeper the discomfort, the deeper the delight that arises afterward. You are wise, yogis would say, to have chosen “the good over the pleasant.”

We have many opportunities for resting pigeon in everyday life. The patient to be added to your Monday morning clinic – which already had added patients. The Friday afternoon Mohs case that went to periosteum and still needs a flap to close. The “yet another” GI bleed patient that needs to be scoped tonight. These are all deep stretches, uncomfortable hip openings. Part of what I learned from yoga is to not give in to fear of what is ahead. Rather, when you must be uncomfortable, breathe and lean into it. Choosing the good sometimes means choosing suffering, but it isn’t the pain that makes it hard to bear. It is a lack of significance for that difficulty. By choosing what is good, you answer the question: “Who am I?” I am the one able and willing to endure inconvenience or disquiet to help others. This is my job, what I’m here to do. The pose, the call, the case will be over quickly. The freedom you feel after, along with the satisfaction you have served your purpose, will sustain you.

There are many poses and endless lessons from yoga. In fact, doing yoga is called “practicing.” Each time you learn and try. Each time you are imperfect and uncomfortable and reemerge sweaty and satisfied, just a little better human than you were before.
 

Dr. Benabio is director of health care 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].

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.