SAN DIEGO – Intensive blood pressure control over 4 years reduced the overall risk of all-cause dementia by 17%, compared with standard care, but in subanalyses of the Systolic Blood Pressure Intervention Trial (SPRINT) it was also associated with significant decreases in cognitive function and total brain volume, researchers said at the Clinical Trials on Alzheimer’s Disease conference.

Michele G. Sullivan/MDedge News

Whether these between-group differences were clinically meaningful was the topic of some debate, but they were enough to prompt Mary Sano, PhD, to strongly state her reservations.

“The cardiovascular effects of SPRINT were impressive, but I am concerned about minimizing the potentially negative effect on cognition,” said Dr. Sano, professor of psychiatry and director of the Alzheimer’s Disease Research Center at the Icahn School of Medicine at Mount Sinai, New York. “Do I really want to treat a healthy, nonimpaired patient like this if I have to warn them that their cognition might actually get worse? We just cannot minimize this risk. There is very strong evidence that [intensive treatment of blood pressure] might be a step backward in cognition. Would you lower your own blood pressure at a risk of losing some points on your cognition?”

The subanalyses were conducted as part of the SPRINT Memory and Cognition In Decreased Hypertension (SPRINT MIND) substudy, which looked at cardiovascular and mortality outcomes in 9,361 subjects whose hypertension was managed intensively or by standard care (target systolic blood pressure less than 120 mm Hg vs. less than 140 mm Hg). The trial was stopped early because of a 25% reduction in the primary composite cardiovascular disease endpoint and a 27% reduction in all-cause mortality in the intensive-treatment group.

SPRINT MIND examined the risks of incident probable dementia, mild cognitive impairment (MCI), and a composite outcome of both. Intensive control reduced the risk of MCI by 19% and the combined outcome by 15%.

At the conference, SPRINT MIND investigators presented three long-term subanalyses with a median intervention and follow-up time of about 4 years.

Sarah Gaussoin of Wake Forest University, Winston-Salem, N.C., presented unpublished data detailing the effects of intensive control on several dementia subtypes: nonamnestic single domain, nonamnestic multidomain, amnestic single domain, and amnestic multidomain. There were 640 subjects in this analysis.

After a median of 3.3 years of intervention and 5 years of follow-up, there were no differences in the rate of incident probable dementia between the single- and multidomain nonamnestic groups. “We did see a strong 22% decreased risk in single-domain versus multidomain amnestic MCI, however,” she said.

Nicholas Pajewski, PhD, also of Wake Forest University, discussed more detailed cognitive outcomes in SPRINT MIND among 2,900 subjects who had a full battery of cognitive testing at every assessment over 5 years. The outcomes included memory deficit and processing speed.

Dr. Pajewski reported finding no significant difference between the groups in the rates of memory decline in either outcome. But there was a greater rate of decline in processing speed in the intensively treated group, he added. The difference was small but statistically significant.

The difference was largely driven by results of a single cognitive test – the Trail Making Test Part A. “It corresponded to about a 1.25-second increase over 4 years,” in processing speed on this test, Dr. Pajewski said.

There were no between-group differences in any of the other domains explored, including language, executive function, global cognitive function, or the Montreal Cognitive Assessment.

“Obviously, these results are perplexing,” given the overall positive results of SPRINT MIND, he said. “Intensive blood pressure control is a beneficial thing, and we expected to see an effect on memory, or a blunting of decline, and instead we saw some small decrements going the other way. This led us to speculate about what’s going on.”

The trial relied on a narrow definition of MCI that might have affected the outcomes. There was also a very broad range of ages in the study, ranging from 53 to 86 years. More importantly, he said, the original SPRINT study didn’t collect cognitive data at baseline, so there was no way to know how many subjects already might have had MCI when they entered the trial.

Ilya Nasrallah, MD, PhD, of the University of Pennsylvania, Philadelphia, presented MRI data on white-matter lesions, hippocampal volume fractional anisotropy in the cingulum, and cerebral blood flow. The median time between scans was 4 years, with a median treatment time of 3.4 years.

The standard-care group showed a significantly greater increase in white-matter lesion volume at the follow-up scan than did the intensive-treatment group (1.45 cm³ vs. 0.92 cm³). But the intensively treated group had significantly more brain atrophy, losing a median of 30.6 cm^3, compared with a loss of 26.9 cm³ in the standard-treatment group.

“It was a very small difference amounting to less than 1% of the total brain volume, but it was still statistically significant,” Dr. Nasrallah said.

Loss of gray-matter volume drove about two-thirds of the difference in the intensively treated group. There was a corresponding increase in cerebrospinal fluid volume that was driven by differences in the ventricles and the subarachnoid space.

However, there were no significant differences in right, left, or total hippocampal volume. There also were no differences in cingulate bundle anisotropy or cerebral blood flow.

SPRINT was funded by the National Institutes of Health. None of the investigators reported having financial conflicts of interest.

msullivan@mdedge.com

SAN DIEGO – Intensive blood pressure control over 4 years reduced the overall risk of all-cause dementia by 17%, compared with standard care, but in subanalyses of the Systolic Blood Pressure Intervention Trial (SPRINT) it was also associated with significant decreases in cognitive function and total brain volume, researchers said at the Clinical Trials on Alzheimer’s Disease conference.

Michele G. Sullivan/MDedge News

Whether these between-group differences were clinically meaningful was the topic of some debate, but they were enough to prompt Mary Sano, PhD, to strongly state her reservations.

“The cardiovascular effects of SPRINT were impressive, but I am concerned about minimizing the potentially negative effect on cognition,” said Dr. Sano, professor of psychiatry and director of the Alzheimer’s Disease Research Center at the Icahn School of Medicine at Mount Sinai, New York. “Do I really want to treat a healthy, nonimpaired patient like this if I have to warn them that their cognition might actually get worse? We just cannot minimize this risk. There is very strong evidence that [intensive treatment of blood pressure] might be a step backward in cognition. Would you lower your own blood pressure at a risk of losing some points on your cognition?”

The subanalyses were conducted as part of the SPRINT Memory and Cognition In Decreased Hypertension (SPRINT MIND) substudy, which looked at cardiovascular and mortality outcomes in 9,361 subjects whose hypertension was managed intensively or by standard care (target systolic blood pressure less than 120 mm Hg vs. less than 140 mm Hg). The trial was stopped early because of a 25% reduction in the primary composite cardiovascular disease endpoint and a 27% reduction in all-cause mortality in the intensive-treatment group.

SPRINT MIND examined the risks of incident probable dementia, mild cognitive impairment (MCI), and a composite outcome of both. Intensive control reduced the risk of MCI by 19% and the combined outcome by 15%.

At the conference, SPRINT MIND investigators presented three long-term subanalyses with a median intervention and follow-up time of about 4 years.

Sarah Gaussoin of Wake Forest University, Winston-Salem, N.C., presented unpublished data detailing the effects of intensive control on several dementia subtypes: nonamnestic single domain, nonamnestic multidomain, amnestic single domain, and amnestic multidomain. There were 640 subjects in this analysis.

After a median of 3.3 years of intervention and 5 years of follow-up, there were no differences in the rate of incident probable dementia between the single- and multidomain nonamnestic groups. “We did see a strong 22% decreased risk in single-domain versus multidomain amnestic MCI, however,” she said.

Nicholas Pajewski, PhD, also of Wake Forest University, discussed more detailed cognitive outcomes in SPRINT MIND among 2,900 subjects who had a full battery of cognitive testing at every assessment over 5 years. The outcomes included memory deficit and processing speed.

Dr. Pajewski reported finding no significant difference between the groups in the rates of memory decline in either outcome. But there was a greater rate of decline in processing speed in the intensively treated group, he added. The difference was small but statistically significant.

The difference was largely driven by results of a single cognitive test – the Trail Making Test Part A. “It corresponded to about a 1.25-second increase over 4 years,” in processing speed on this test, Dr. Pajewski said.

There were no between-group differences in any of the other domains explored, including language, executive function, global cognitive function, or the Montreal Cognitive Assessment.

“Obviously, these results are perplexing,” given the overall positive results of SPRINT MIND, he said. “Intensive blood pressure control is a beneficial thing, and we expected to see an effect on memory, or a blunting of decline, and instead we saw some small decrements going the other way. This led us to speculate about what’s going on.”

The trial relied on a narrow definition of MCI that might have affected the outcomes. There was also a very broad range of ages in the study, ranging from 53 to 86 years. More importantly, he said, the original SPRINT study didn’t collect cognitive data at baseline, so there was no way to know how many subjects already might have had MCI when they entered the trial.

Ilya Nasrallah, MD, PhD, of the University of Pennsylvania, Philadelphia, presented MRI data on white-matter lesions, hippocampal volume fractional anisotropy in the cingulum, and cerebral blood flow. The median time between scans was 4 years, with a median treatment time of 3.4 years.

The standard-care group showed a significantly greater increase in white-matter lesion volume at the follow-up scan than did the intensive-treatment group (1.45 cm³ vs. 0.92 cm³). But the intensively treated group had significantly more brain atrophy, losing a median of 30.6 cm^3, compared with a loss of 26.9 cm³ in the standard-treatment group.

“It was a very small difference amounting to less than 1% of the total brain volume, but it was still statistically significant,” Dr. Nasrallah said.

Loss of gray-matter volume drove about two-thirds of the difference in the intensively treated group. There was a corresponding increase in cerebrospinal fluid volume that was driven by differences in the ventricles and the subarachnoid space.

However, there were no significant differences in right, left, or total hippocampal volume. There also were no differences in cingulate bundle anisotropy or cerebral blood flow.

SPRINT was funded by the National Institutes of Health. None of the investigators reported having financial conflicts of interest.

msullivan@mdedge.com

SAN DIEGO – Intensive blood pressure control over 4 years reduced the overall risk of all-cause dementia by 17%, compared with standard care, but in subanalyses of the Systolic Blood Pressure Intervention Trial (SPRINT) it was also associated with significant decreases in cognitive function and total brain volume, researchers said at the Clinical Trials on Alzheimer’s Disease conference.

Michele G. Sullivan/MDedge News

Whether these between-group differences were clinically meaningful was the topic of some debate, but they were enough to prompt Mary Sano, PhD, to strongly state her reservations.

“The cardiovascular effects of SPRINT were impressive, but I am concerned about minimizing the potentially negative effect on cognition,” said Dr. Sano, professor of psychiatry and director of the Alzheimer’s Disease Research Center at the Icahn School of Medicine at Mount Sinai, New York. “Do I really want to treat a healthy, nonimpaired patient like this if I have to warn them that their cognition might actually get worse? We just cannot minimize this risk. There is very strong evidence that [intensive treatment of blood pressure] might be a step backward in cognition. Would you lower your own blood pressure at a risk of losing some points on your cognition?”

The subanalyses were conducted as part of the SPRINT Memory and Cognition In Decreased Hypertension (SPRINT MIND) substudy, which looked at cardiovascular and mortality outcomes in 9,361 subjects whose hypertension was managed intensively or by standard care (target systolic blood pressure less than 120 mm Hg vs. less than 140 mm Hg). The trial was stopped early because of a 25% reduction in the primary composite cardiovascular disease endpoint and a 27% reduction in all-cause mortality in the intensive-treatment group.

SPRINT MIND examined the risks of incident probable dementia, mild cognitive impairment (MCI), and a composite outcome of both. Intensive control reduced the risk of MCI by 19% and the combined outcome by 15%.

At the conference, SPRINT MIND investigators presented three long-term subanalyses with a median intervention and follow-up time of about 4 years.

Sarah Gaussoin of Wake Forest University, Winston-Salem, N.C., presented unpublished data detailing the effects of intensive control on several dementia subtypes: nonamnestic single domain, nonamnestic multidomain, amnestic single domain, and amnestic multidomain. There were 640 subjects in this analysis.

After a median of 3.3 years of intervention and 5 years of follow-up, there were no differences in the rate of incident probable dementia between the single- and multidomain nonamnestic groups. “We did see a strong 22% decreased risk in single-domain versus multidomain amnestic MCI, however,” she said.

Nicholas Pajewski, PhD, also of Wake Forest University, discussed more detailed cognitive outcomes in SPRINT MIND among 2,900 subjects who had a full battery of cognitive testing at every assessment over 5 years. The outcomes included memory deficit and processing speed.

Dr. Pajewski reported finding no significant difference between the groups in the rates of memory decline in either outcome. But there was a greater rate of decline in processing speed in the intensively treated group, he added. The difference was small but statistically significant.

The difference was largely driven by results of a single cognitive test – the Trail Making Test Part A. “It corresponded to about a 1.25-second increase over 4 years,” in processing speed on this test, Dr. Pajewski said.

There were no between-group differences in any of the other domains explored, including language, executive function, global cognitive function, or the Montreal Cognitive Assessment.

“Obviously, these results are perplexing,” given the overall positive results of SPRINT MIND, he said. “Intensive blood pressure control is a beneficial thing, and we expected to see an effect on memory, or a blunting of decline, and instead we saw some small decrements going the other way. This led us to speculate about what’s going on.”

The trial relied on a narrow definition of MCI that might have affected the outcomes. There was also a very broad range of ages in the study, ranging from 53 to 86 years. More importantly, he said, the original SPRINT study didn’t collect cognitive data at baseline, so there was no way to know how many subjects already might have had MCI when they entered the trial.

Ilya Nasrallah, MD, PhD, of the University of Pennsylvania, Philadelphia, presented MRI data on white-matter lesions, hippocampal volume fractional anisotropy in the cingulum, and cerebral blood flow. The median time between scans was 4 years, with a median treatment time of 3.4 years.

The standard-care group showed a significantly greater increase in white-matter lesion volume at the follow-up scan than did the intensive-treatment group (1.45 cm³ vs. 0.92 cm³). But the intensively treated group had significantly more brain atrophy, losing a median of 30.6 cm^3, compared with a loss of 26.9 cm³ in the standard-treatment group.

“It was a very small difference amounting to less than 1% of the total brain volume, but it was still statistically significant,” Dr. Nasrallah said.

Loss of gray-matter volume drove about two-thirds of the difference in the intensively treated group. There was a corresponding increase in cerebrospinal fluid volume that was driven by differences in the ventricles and the subarachnoid space.

However, there were no significant differences in right, left, or total hippocampal volume. There also were no differences in cingulate bundle anisotropy or cerebral blood flow.

SPRINT was funded by the National Institutes of Health. None of the investigators reported having financial conflicts of interest.

msullivan@mdedge.com

Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.¹

Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.

The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”^2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.⁴ Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.

The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.⁵ Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.

Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.^6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.^7-10

Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.^11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues² and with milder symptoms.³ As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.

Acknowledgement

We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.

1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.

3. Gut. 2004;53(SUPPL. 4):40-4.

4. Virtual Mentor. 2013;15(11):982-7.

5. J Hosp Med. 2013;8(5):271-7.

6. Int J Health Care Qual Assur. 2011;24(4):266-73.

7. J Cutan Aesthet Surg. 2010;3(3):151-5.

8. Am J Med. 2005;118(10):1126-33.

9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.

11. J Diabetes Metab. 2012;3(7):1000210.

12. Am Heart J. 2000;140(1):105-10.

13. J Clin Gastroenterol. 2018;52(7):614-21.

14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.

16. Ann Intern Med. 2006;144(9):665-72.

Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.

Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.¹

Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.

The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”^2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.⁴ Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.

The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.⁵ Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.

Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.^6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.^7-10

Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.^11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues² and with milder symptoms.³ As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.

Acknowledgement

We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.

1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.

3. Gut. 2004;53(SUPPL. 4):40-4.

4. Virtual Mentor. 2013;15(11):982-7.

5. J Hosp Med. 2013;8(5):271-7.

6. Int J Health Care Qual Assur. 2011;24(4):266-73.

7. J Cutan Aesthet Surg. 2010;3(3):151-5.

8. Am J Med. 2005;118(10):1126-33.

9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.

11. J Diabetes Metab. 2012;3(7):1000210.

12. Am Heart J. 2000;140(1):105-10.

13. J Clin Gastroenterol. 2018;52(7):614-21.

14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.

16. Ann Intern Med. 2006;144(9):665-72.

Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.

Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.¹

Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.

The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”^2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.⁴ Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.

The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.⁵ Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.

Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.^6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.^7-10

Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.^11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues² and with milder symptoms.³ As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.

Acknowledgement

We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.

1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.

3. Gut. 2004;53(SUPPL. 4):40-4.

4. Virtual Mentor. 2013;15(11):982-7.

5. J Hosp Med. 2013;8(5):271-7.

6. Int J Health Care Qual Assur. 2011;24(4):266-73.

7. J Cutan Aesthet Surg. 2010;3(3):151-5.

8. Am J Med. 2005;118(10):1126-33.

9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.

11. J Diabetes Metab. 2012;3(7):1000210.

12. Am Heart J. 2000;140(1):105-10.

13. J Clin Gastroenterol. 2018;52(7):614-21.

14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.

16. Ann Intern Med. 2006;144(9):665-72.

Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.

Angioedema induced by angiotensin-converting enzyme inhibitors (ACEIs) is present in from 0.1% to 0.7% of treated patients and more often involves the head, neck, face, lips, tongue, and larynx.¹ ACEI-induced angioedema results from inhibition of angiotensin-converting enzyme (ACE), which results in reduced degradation and resultant accumulation of bradykinin, a potent inflammatory mediator.²

The treatment of choice is discontinuing all ACEIs; however, the patient may be at increased risk of a subsequent angioedema attack for many weeks.³ Antihistamines (H₁ and H₂ receptor blockade), epinephrine, and glucocorticoids are effective in allergic/histaminergic angioedema but are usually ineffective for hereditary angioedema or ACEI angioedema and are not recommended for acute therapy.⁴ Kallikrein-bradykinin pathway targeted therapies are now approved by the Food and Drug Administration (FDA) for hereditary angioedema attacks and have been studied for ACEI-induced angioedema. Ecallantide and icatibant inhibit conversion of precursors to bradykinin. Multiple randomized trials of ecallantide have not shown any advantage over traditional therapies.⁵ On the other hand, icatibant has shown resolution of angioedema in several case reports and in a randomized trial.⁶ Icatibant for ACEI-induced angioedema continues to be off-label because the data are conflicting.

Case Presentation

A 67-year-old man presented with a medical history of arterial hypertension (diagnosed 17 years previously), hypercholesterolemia, type 2 diabetes mellitus, alcohol dependence, and obesity. His outpatient medications included simvastatin, aripiprazole, losartan/hydrochlorothiazide, and amlodipine. He was voluntarily admitted for inpatient detoxification. After evaluation by the internist, medication reconciliation was done, and the therapy was adjusted according to medication availability. He reported having no drug allergies, and the losartan was changed for lisinopril. About 24 hours after the first dose of lisinopril, the patient developed swelling of the lips. Antihistamine and IV steroids were administered, and the ACEI was discontinued. His baseline vital signs were temperature 98° F, heart rate 83 beats per minute, respiratory rate 19 breaths per minute, blood pressure 150/94, and oxygen saturation 98% by pulse oximeter.

During the night shift the patient’s symptoms worsened, developing difficulty swallowing and shortness of breath. He was transferred to the medicine intensive care unit (MICU), intubated, and placed on mechanical ventilation to protect his airway. Laryngoscopic examination was notable for edematous tongue, uvula, and larynx. Also, the patient had mild stridor. His laboratory test results showed normal levels of complement, tryptase, and C1 esterase. On the fourth day after admission to MICU (Figure 1), the patient extubated himself. At that time, he did not present stridor or respiratory distress and remained at the MICU for 24 hours for close monitoring.

Thirty-six hours after self-extubation the patient developed stridor and shortness of breath at the general medicine ward. In view of his clinical presentation of recurrent ACEI-induced angioedema, the Anesthesiology Service was consulted. Direct visualization of the airways showed edema of the epiglottis and vocal cords, requiring nasotracheal intubation. Two units of fresh frozen plasma (FFP) were administered. Complete resolution of angioedema took at least 72 hours even after the administration of FFP. As part of the ventilator-associated pneumonia prevention bundle, the patient continued with daily spontaneous breathing trials. On the fourth day, he was he was extubated after a cuff-leak test was positive and his rapid shallow breathing index was adequate.

The cuff-leak test is usually done to predict postextubation stridor. It consists of deflating the endotracheal tube cuff to verify if gas can pass around the tube. Absence of cuff leak is suggestive of airway edema, a risk factor for postextubation stridor and failure of extubation. For example, if the patient has an endotracheal tube that is too large in relation to the patient’s airway, the leak test can result in a false negative. In this case, fiber optic visualization of the airway can confirm the endotracheal tube occluding all the airway even with the cuff deflated and without evidence of swelling of the vocal cords. The rapid shallow breathing index is a ratio of respiratory rate over tidal volume in liters and is used to predict successful extubation. Values < 105 have a high sensitivity for successful extubation.

The patient remained under observation for 24 hours in the MICU and then was transferred to the general medicine ward. Unfortunately, 36 hours after, the patient had a new episode of angioedema requiring endotracheal intubation and placement on mechanical ventilation. This was his third episode of angioedema; he had a difficult airway classified as a Cormack-Lehane grade 3, requiring intubation with fiber-optic laryngoscope. In view of the recurrent events, a tracheostomy was done several days later. Figure 2 shows posttracheostomy X-ray with adequate position of the tracheostomy tube.

The patient was transferred to the Respiratory Care Unit and weaned off mechanical ventilation. He completed an intensive physical rehabilitation program and was discharged home. On discharge, he was followed by the Otorhinolaryngology Service and was decannulated about 5 months after. After tracheostomy decannulation, he developed asymptomatic stridor. A neck computer tomography scan revealed soft tissue thickening at the anterior and lateral aspects of the proximal tracheal likely representing granulation tissue/scarring. The findings were consistent with proximal tracheal stenosis sequelae of tracheostomy and intubation. In Figure 3, the upper portion of the curve represents the expiratory limb of the forced vital capacity and the lower portion represents inspiration. The flow-volume loop graph showed flattening of the inspiratory limb. There was a plateau in the inspiratory limb, suggestive of limitation of inspiratory flow as seen in variable extrathoracic lesions, such as glotticstricture, tumors, and vocal cord paralysis.⁷ The findings on the flow-volume loop were consistent with the subglottic stenosis identified by laryngoscopic examination. The patient was reluctant to undergo further interventions.

Discussion

The standard therapy for ACEI-inducedangioedema continues to be airway management and discontinuation of medication. However, life-threatening progression of symptoms have led to the use of off-label therapies, including FFP and bradykinin receptor antagonists, such as icatibant, which has been approved by the FDA for the treatment of hereditary angioedema. Icatibant is expensive and most hospitals do not have access to it. When considering the bradykinin pathway for therapy, FFP is commonly used. The cases described in the literature that have reported success with the use of FFP have used up to 2 units. There is no reported benefit of its use beyond 2 units. The initial randomized trials of icatibant for ACEI angioedema showed decreased time of resolution of angioedema.⁶ However, repeated trials showed conflicting results. At Veterans Affairs Caribbean Healthcare System, this medication was not available, and we decided to use FFP to improve the patient’s symptoms.

The administration of 2 units of FFP has been documented on case reports as a method to decrease the time of resolution of angioedema and the risk of recurrence. The mechanism of action thought to be involved includes the degradation of bradykinin by the enzyme ACE into inactive peptides and by supplying C1 inhibitor.⁸ No randomized clinical trial has investigated the use of FFP for the treatment of ACEI-induced angioedema. However, a retrospective cohort study report compared patients who presented with acute (nonhereditary) angioedema and airway compromise and received FFP with patients who were not treated with FFP.⁹ The study suggested a shorter ICU stay in the group treated with FFP, but the findings did not present statistical outcomes.

Nevertheless, our patient had recurrent ACEI-induced angioedema refractory to FFP. In addition to ACE or kininase II, FFP contains high-molecular weight-kininogen and kallikrein, the substrates that form bradykinin, which explained the mechanism of worsening angioedema.¹⁰ No randomized trials have investigated the use of FFP for the treatment of bradykinin-induced angioedema nor the appropriate dose.

Conclusion

In view of the emerging case reports of the effectiveness of FFP, this case of refractory angioedema raises concern for its true effectiveness and other possible factors involved in the mechanism of recurrence. Probably it would be unwise to conduct randomized studies in clinical situations such as the ones outlined. A collection of case series where FFP administration was done may be a more reasonable source of conclusions to be analyzed by a panel of experts.

Angioedema induced by angiotensin-converting enzyme inhibitors (ACEIs) is present in from 0.1% to 0.7% of treated patients and more often involves the head, neck, face, lips, tongue, and larynx.¹ ACEI-induced angioedema results from inhibition of angiotensin-converting enzyme (ACE), which results in reduced degradation and resultant accumulation of bradykinin, a potent inflammatory mediator.²

The treatment of choice is discontinuing all ACEIs; however, the patient may be at increased risk of a subsequent angioedema attack for many weeks.³ Antihistamines (H₁ and H₂ receptor blockade), epinephrine, and glucocorticoids are effective in allergic/histaminergic angioedema but are usually ineffective for hereditary angioedema or ACEI angioedema and are not recommended for acute therapy.⁴ Kallikrein-bradykinin pathway targeted therapies are now approved by the Food and Drug Administration (FDA) for hereditary angioedema attacks and have been studied for ACEI-induced angioedema. Ecallantide and icatibant inhibit conversion of precursors to bradykinin. Multiple randomized trials of ecallantide have not shown any advantage over traditional therapies.⁵ On the other hand, icatibant has shown resolution of angioedema in several case reports and in a randomized trial.⁶ Icatibant for ACEI-induced angioedema continues to be off-label because the data are conflicting.

Case Presentation

A 67-year-old man presented with a medical history of arterial hypertension (diagnosed 17 years previously), hypercholesterolemia, type 2 diabetes mellitus, alcohol dependence, and obesity. His outpatient medications included simvastatin, aripiprazole, losartan/hydrochlorothiazide, and amlodipine. He was voluntarily admitted for inpatient detoxification. After evaluation by the internist, medication reconciliation was done, and the therapy was adjusted according to medication availability. He reported having no drug allergies, and the losartan was changed for lisinopril. About 24 hours after the first dose of lisinopril, the patient developed swelling of the lips. Antihistamine and IV steroids were administered, and the ACEI was discontinued. His baseline vital signs were temperature 98° F, heart rate 83 beats per minute, respiratory rate 19 breaths per minute, blood pressure 150/94, and oxygen saturation 98% by pulse oximeter.

During the night shift the patient’s symptoms worsened, developing difficulty swallowing and shortness of breath. He was transferred to the medicine intensive care unit (MICU), intubated, and placed on mechanical ventilation to protect his airway. Laryngoscopic examination was notable for edematous tongue, uvula, and larynx. Also, the patient had mild stridor. His laboratory test results showed normal levels of complement, tryptase, and C1 esterase. On the fourth day after admission to MICU (Figure 1), the patient extubated himself. At that time, he did not present stridor or respiratory distress and remained at the MICU for 24 hours for close monitoring.

Thirty-six hours after self-extubation the patient developed stridor and shortness of breath at the general medicine ward. In view of his clinical presentation of recurrent ACEI-induced angioedema, the Anesthesiology Service was consulted. Direct visualization of the airways showed edema of the epiglottis and vocal cords, requiring nasotracheal intubation. Two units of fresh frozen plasma (FFP) were administered. Complete resolution of angioedema took at least 72 hours even after the administration of FFP. As part of the ventilator-associated pneumonia prevention bundle, the patient continued with daily spontaneous breathing trials. On the fourth day, he was he was extubated after a cuff-leak test was positive and his rapid shallow breathing index was adequate.

The cuff-leak test is usually done to predict postextubation stridor. It consists of deflating the endotracheal tube cuff to verify if gas can pass around the tube. Absence of cuff leak is suggestive of airway edema, a risk factor for postextubation stridor and failure of extubation. For example, if the patient has an endotracheal tube that is too large in relation to the patient’s airway, the leak test can result in a false negative. In this case, fiber optic visualization of the airway can confirm the endotracheal tube occluding all the airway even with the cuff deflated and without evidence of swelling of the vocal cords. The rapid shallow breathing index is a ratio of respiratory rate over tidal volume in liters and is used to predict successful extubation. Values < 105 have a high sensitivity for successful extubation.

The patient remained under observation for 24 hours in the MICU and then was transferred to the general medicine ward. Unfortunately, 36 hours after, the patient had a new episode of angioedema requiring endotracheal intubation and placement on mechanical ventilation. This was his third episode of angioedema; he had a difficult airway classified as a Cormack-Lehane grade 3, requiring intubation with fiber-optic laryngoscope. In view of the recurrent events, a tracheostomy was done several days later. Figure 2 shows posttracheostomy X-ray with adequate position of the tracheostomy tube.

The patient was transferred to the Respiratory Care Unit and weaned off mechanical ventilation. He completed an intensive physical rehabilitation program and was discharged home. On discharge, he was followed by the Otorhinolaryngology Service and was decannulated about 5 months after. After tracheostomy decannulation, he developed asymptomatic stridor. A neck computer tomography scan revealed soft tissue thickening at the anterior and lateral aspects of the proximal tracheal likely representing granulation tissue/scarring. The findings were consistent with proximal tracheal stenosis sequelae of tracheostomy and intubation. In Figure 3, the upper portion of the curve represents the expiratory limb of the forced vital capacity and the lower portion represents inspiration. The flow-volume loop graph showed flattening of the inspiratory limb. There was a plateau in the inspiratory limb, suggestive of limitation of inspiratory flow as seen in variable extrathoracic lesions, such as glotticstricture, tumors, and vocal cord paralysis.⁷ The findings on the flow-volume loop were consistent with the subglottic stenosis identified by laryngoscopic examination. The patient was reluctant to undergo further interventions.

Discussion

The standard therapy for ACEI-inducedangioedema continues to be airway management and discontinuation of medication. However, life-threatening progression of symptoms have led to the use of off-label therapies, including FFP and bradykinin receptor antagonists, such as icatibant, which has been approved by the FDA for the treatment of hereditary angioedema. Icatibant is expensive and most hospitals do not have access to it. When considering the bradykinin pathway for therapy, FFP is commonly used. The cases described in the literature that have reported success with the use of FFP have used up to 2 units. There is no reported benefit of its use beyond 2 units. The initial randomized trials of icatibant for ACEI angioedema showed decreased time of resolution of angioedema.⁶ However, repeated trials showed conflicting results. At Veterans Affairs Caribbean Healthcare System, this medication was not available, and we decided to use FFP to improve the patient’s symptoms.

The administration of 2 units of FFP has been documented on case reports as a method to decrease the time of resolution of angioedema and the risk of recurrence. The mechanism of action thought to be involved includes the degradation of bradykinin by the enzyme ACE into inactive peptides and by supplying C1 inhibitor.⁸ No randomized clinical trial has investigated the use of FFP for the treatment of ACEI-induced angioedema. However, a retrospective cohort study report compared patients who presented with acute (nonhereditary) angioedema and airway compromise and received FFP with patients who were not treated with FFP.⁹ The study suggested a shorter ICU stay in the group treated with FFP, but the findings did not present statistical outcomes.

Nevertheless, our patient had recurrent ACEI-induced angioedema refractory to FFP. In addition to ACE or kininase II, FFP contains high-molecular weight-kininogen and kallikrein, the substrates that form bradykinin, which explained the mechanism of worsening angioedema.¹⁰ No randomized trials have investigated the use of FFP for the treatment of bradykinin-induced angioedema nor the appropriate dose.

Conclusion

In view of the emerging case reports of the effectiveness of FFP, this case of refractory angioedema raises concern for its true effectiveness and other possible factors involved in the mechanism of recurrence. Probably it would be unwise to conduct randomized studies in clinical situations such as the ones outlined. A collection of case series where FFP administration was done may be a more reasonable source of conclusions to be analyzed by a panel of experts.

Angioedema induced by angiotensin-converting enzyme inhibitors (ACEIs) is present in from 0.1% to 0.7% of treated patients and more often involves the head, neck, face, lips, tongue, and larynx.¹ ACEI-induced angioedema results from inhibition of angiotensin-converting enzyme (ACE), which results in reduced degradation and resultant accumulation of bradykinin, a potent inflammatory mediator.²

The treatment of choice is discontinuing all ACEIs; however, the patient may be at increased risk of a subsequent angioedema attack for many weeks.³ Antihistamines (H₁ and H₂ receptor blockade), epinephrine, and glucocorticoids are effective in allergic/histaminergic angioedema but are usually ineffective for hereditary angioedema or ACEI angioedema and are not recommended for acute therapy.⁴ Kallikrein-bradykinin pathway targeted therapies are now approved by the Food and Drug Administration (FDA) for hereditary angioedema attacks and have been studied for ACEI-induced angioedema. Ecallantide and icatibant inhibit conversion of precursors to bradykinin. Multiple randomized trials of ecallantide have not shown any advantage over traditional therapies.⁵ On the other hand, icatibant has shown resolution of angioedema in several case reports and in a randomized trial.⁶ Icatibant for ACEI-induced angioedema continues to be off-label because the data are conflicting.

Case Presentation

A 67-year-old man presented with a medical history of arterial hypertension (diagnosed 17 years previously), hypercholesterolemia, type 2 diabetes mellitus, alcohol dependence, and obesity. His outpatient medications included simvastatin, aripiprazole, losartan/hydrochlorothiazide, and amlodipine. He was voluntarily admitted for inpatient detoxification. After evaluation by the internist, medication reconciliation was done, and the therapy was adjusted according to medication availability. He reported having no drug allergies, and the losartan was changed for lisinopril. About 24 hours after the first dose of lisinopril, the patient developed swelling of the lips. Antihistamine and IV steroids were administered, and the ACEI was discontinued. His baseline vital signs were temperature 98° F, heart rate 83 beats per minute, respiratory rate 19 breaths per minute, blood pressure 150/94, and oxygen saturation 98% by pulse oximeter.

During the night shift the patient’s symptoms worsened, developing difficulty swallowing and shortness of breath. He was transferred to the medicine intensive care unit (MICU), intubated, and placed on mechanical ventilation to protect his airway. Laryngoscopic examination was notable for edematous tongue, uvula, and larynx. Also, the patient had mild stridor. His laboratory test results showed normal levels of complement, tryptase, and C1 esterase. On the fourth day after admission to MICU (Figure 1), the patient extubated himself. At that time, he did not present stridor or respiratory distress and remained at the MICU for 24 hours for close monitoring.

Thirty-six hours after self-extubation the patient developed stridor and shortness of breath at the general medicine ward. In view of his clinical presentation of recurrent ACEI-induced angioedema, the Anesthesiology Service was consulted. Direct visualization of the airways showed edema of the epiglottis and vocal cords, requiring nasotracheal intubation. Two units of fresh frozen plasma (FFP) were administered. Complete resolution of angioedema took at least 72 hours even after the administration of FFP. As part of the ventilator-associated pneumonia prevention bundle, the patient continued with daily spontaneous breathing trials. On the fourth day, he was he was extubated after a cuff-leak test was positive and his rapid shallow breathing index was adequate.

The cuff-leak test is usually done to predict postextubation stridor. It consists of deflating the endotracheal tube cuff to verify if gas can pass around the tube. Absence of cuff leak is suggestive of airway edema, a risk factor for postextubation stridor and failure of extubation. For example, if the patient has an endotracheal tube that is too large in relation to the patient’s airway, the leak test can result in a false negative. In this case, fiber optic visualization of the airway can confirm the endotracheal tube occluding all the airway even with the cuff deflated and without evidence of swelling of the vocal cords. The rapid shallow breathing index is a ratio of respiratory rate over tidal volume in liters and is used to predict successful extubation. Values < 105 have a high sensitivity for successful extubation.

The patient remained under observation for 24 hours in the MICU and then was transferred to the general medicine ward. Unfortunately, 36 hours after, the patient had a new episode of angioedema requiring endotracheal intubation and placement on mechanical ventilation. This was his third episode of angioedema; he had a difficult airway classified as a Cormack-Lehane grade 3, requiring intubation with fiber-optic laryngoscope. In view of the recurrent events, a tracheostomy was done several days later. Figure 2 shows posttracheostomy X-ray with adequate position of the tracheostomy tube.

The patient was transferred to the Respiratory Care Unit and weaned off mechanical ventilation. He completed an intensive physical rehabilitation program and was discharged home. On discharge, he was followed by the Otorhinolaryngology Service and was decannulated about 5 months after. After tracheostomy decannulation, he developed asymptomatic stridor. A neck computer tomography scan revealed soft tissue thickening at the anterior and lateral aspects of the proximal tracheal likely representing granulation tissue/scarring. The findings were consistent with proximal tracheal stenosis sequelae of tracheostomy and intubation. In Figure 3, the upper portion of the curve represents the expiratory limb of the forced vital capacity and the lower portion represents inspiration. The flow-volume loop graph showed flattening of the inspiratory limb. There was a plateau in the inspiratory limb, suggestive of limitation of inspiratory flow as seen in variable extrathoracic lesions, such as glotticstricture, tumors, and vocal cord paralysis.⁷ The findings on the flow-volume loop were consistent with the subglottic stenosis identified by laryngoscopic examination. The patient was reluctant to undergo further interventions.

Discussion

The standard therapy for ACEI-inducedangioedema continues to be airway management and discontinuation of medication. However, life-threatening progression of symptoms have led to the use of off-label therapies, including FFP and bradykinin receptor antagonists, such as icatibant, which has been approved by the FDA for the treatment of hereditary angioedema. Icatibant is expensive and most hospitals do not have access to it. When considering the bradykinin pathway for therapy, FFP is commonly used. The cases described in the literature that have reported success with the use of FFP have used up to 2 units. There is no reported benefit of its use beyond 2 units. The initial randomized trials of icatibant for ACEI angioedema showed decreased time of resolution of angioedema.⁶ However, repeated trials showed conflicting results. At Veterans Affairs Caribbean Healthcare System, this medication was not available, and we decided to use FFP to improve the patient’s symptoms.

The administration of 2 units of FFP has been documented on case reports as a method to decrease the time of resolution of angioedema and the risk of recurrence. The mechanism of action thought to be involved includes the degradation of bradykinin by the enzyme ACE into inactive peptides and by supplying C1 inhibitor.⁸ No randomized clinical trial has investigated the use of FFP for the treatment of ACEI-induced angioedema. However, a retrospective cohort study report compared patients who presented with acute (nonhereditary) angioedema and airway compromise and received FFP with patients who were not treated with FFP.⁹ The study suggested a shorter ICU stay in the group treated with FFP, but the findings did not present statistical outcomes.

Nevertheless, our patient had recurrent ACEI-induced angioedema refractory to FFP. In addition to ACE or kininase II, FFP contains high-molecular weight-kininogen and kallikrein, the substrates that form bradykinin, which explained the mechanism of worsening angioedema.¹⁰ No randomized trials have investigated the use of FFP for the treatment of bradykinin-induced angioedema nor the appropriate dose.

Conclusion

In view of the emerging case reports of the effectiveness of FFP, this case of refractory angioedema raises concern for its true effectiveness and other possible factors involved in the mechanism of recurrence. Probably it would be unwise to conduct randomized studies in clinical situations such as the ones outlined. A collection of case series where FFP administration was done may be a more reasonable source of conclusions to be analyzed by a panel of experts.

Women are more likely to experience acute toxic effects from chemoradiotherapy for rectal cancer than men, but this does not appear to negatively impact treatment adherence or outcomes, research suggests.

In a research letter published in JAMA Oncology, Markus Diefenhardt, MD, from the University of Frankfurt and coauthors wrote that, while the risk of toxic chemotherapy effects was known to be greater in women for a number of cancers, this association was relatively unexplored for rectal cancer.

The researchers performed a pooled analysis of data from two phase 3, randomized clinical trials, involving 1,016 patients with rectal cancer – 28.6% of whom were female – treated with fluorouracil-based chemoradiotherapy followed by surgery and adjuvant fluorouracil.

They found that women experienced significantly higher rates of leukopenia and diarrhea than men. Grade 3-4 leukopenia was experienced by 28.6% of women, compared with 20.5% of men, and grades 3-4 diarrhea was experienced by 17.2% of women, compared with 8.1% of men.

Despite this, the study found similar rates of adherence to treatment between men and women both for neoadjuvant and adjuvant chemoradiotherapy. Women also had similar rates of disease-free survival and overall survival as men, and there were no significant differences in local recurrence or distant metastases.

“Although to our knowledge no data support using different chemotherapy regimens for men and women with rectal cancer, increased awareness of a higher risk of toxic effects among women may facilitate refinement of fluorouracil-based chemoradiotherapy and adjuvant chemotherapy, such as tailored patient education, closer monitoring of adverse effects, and earlier introduction of supportive measures,” the authors wrote.

The authors proposed several possible explanations for the higher rate of toxic effects in women. For example, women may have lower levels of the enzyme dihydropyridine dehydrogenase, which catabolizes fluorouracil, which could result in overdosing of fluorouracil. Similarly, sex-specific body fat composition could also contribute to fluorouracil overdosing in women.

The study also saw fewer postoperative complications in women, which the authors suggested could be related to the lower rate of abdominoperineal resections in women.

The two clinical trials included in the study were funded by German Cancer Aid. One author declared funding from German Cancer Aid, another declared a range of honoraria, research fees and institutional funding from the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Diefendhardt M et al. JAMA Oncol. 2019 Dec 5. doi: 10.1001/jamaoncol.2019.5102.

Women are more likely to experience acute toxic effects from chemoradiotherapy for rectal cancer than men, but this does not appear to negatively impact treatment adherence or outcomes, research suggests.

In a research letter published in JAMA Oncology, Markus Diefenhardt, MD, from the University of Frankfurt and coauthors wrote that, while the risk of toxic chemotherapy effects was known to be greater in women for a number of cancers, this association was relatively unexplored for rectal cancer.

The researchers performed a pooled analysis of data from two phase 3, randomized clinical trials, involving 1,016 patients with rectal cancer – 28.6% of whom were female – treated with fluorouracil-based chemoradiotherapy followed by surgery and adjuvant fluorouracil.

They found that women experienced significantly higher rates of leukopenia and diarrhea than men. Grade 3-4 leukopenia was experienced by 28.6% of women, compared with 20.5% of men, and grades 3-4 diarrhea was experienced by 17.2% of women, compared with 8.1% of men.

Despite this, the study found similar rates of adherence to treatment between men and women both for neoadjuvant and adjuvant chemoradiotherapy. Women also had similar rates of disease-free survival and overall survival as men, and there were no significant differences in local recurrence or distant metastases.

“Although to our knowledge no data support using different chemotherapy regimens for men and women with rectal cancer, increased awareness of a higher risk of toxic effects among women may facilitate refinement of fluorouracil-based chemoradiotherapy and adjuvant chemotherapy, such as tailored patient education, closer monitoring of adverse effects, and earlier introduction of supportive measures,” the authors wrote.

The authors proposed several possible explanations for the higher rate of toxic effects in women. For example, women may have lower levels of the enzyme dihydropyridine dehydrogenase, which catabolizes fluorouracil, which could result in overdosing of fluorouracil. Similarly, sex-specific body fat composition could also contribute to fluorouracil overdosing in women.

The study also saw fewer postoperative complications in women, which the authors suggested could be related to the lower rate of abdominoperineal resections in women.

The two clinical trials included in the study were funded by German Cancer Aid. One author declared funding from German Cancer Aid, another declared a range of honoraria, research fees and institutional funding from the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Diefendhardt M et al. JAMA Oncol. 2019 Dec 5. doi: 10.1001/jamaoncol.2019.5102.

Women are more likely to experience acute toxic effects from chemoradiotherapy for rectal cancer than men, but this does not appear to negatively impact treatment adherence or outcomes, research suggests.

In a research letter published in JAMA Oncology, Markus Diefenhardt, MD, from the University of Frankfurt and coauthors wrote that, while the risk of toxic chemotherapy effects was known to be greater in women for a number of cancers, this association was relatively unexplored for rectal cancer.

The researchers performed a pooled analysis of data from two phase 3, randomized clinical trials, involving 1,016 patients with rectal cancer – 28.6% of whom were female – treated with fluorouracil-based chemoradiotherapy followed by surgery and adjuvant fluorouracil.

They found that women experienced significantly higher rates of leukopenia and diarrhea than men. Grade 3-4 leukopenia was experienced by 28.6% of women, compared with 20.5% of men, and grades 3-4 diarrhea was experienced by 17.2% of women, compared with 8.1% of men.

Despite this, the study found similar rates of adherence to treatment between men and women both for neoadjuvant and adjuvant chemoradiotherapy. Women also had similar rates of disease-free survival and overall survival as men, and there were no significant differences in local recurrence or distant metastases.

“Although to our knowledge no data support using different chemotherapy regimens for men and women with rectal cancer, increased awareness of a higher risk of toxic effects among women may facilitate refinement of fluorouracil-based chemoradiotherapy and adjuvant chemotherapy, such as tailored patient education, closer monitoring of adverse effects, and earlier introduction of supportive measures,” the authors wrote.

The authors proposed several possible explanations for the higher rate of toxic effects in women. For example, women may have lower levels of the enzyme dihydropyridine dehydrogenase, which catabolizes fluorouracil, which could result in overdosing of fluorouracil. Similarly, sex-specific body fat composition could also contribute to fluorouracil overdosing in women.

The study also saw fewer postoperative complications in women, which the authors suggested could be related to the lower rate of abdominoperineal resections in women.

The two clinical trials included in the study were funded by German Cancer Aid. One author declared funding from German Cancer Aid, another declared a range of honoraria, research fees and institutional funding from the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Diefendhardt M et al. JAMA Oncol. 2019 Dec 5. doi: 10.1001/jamaoncol.2019.5102.

Millennials, defined as those born between 1981 and 1996, currently comprise 15% of all active physicians in the US.^1,2 A recent survey found that nearly 4 of 5 US millennial physicians have a desire for cross-sectional work in areas beyond patient care, such as academic research, health care consulting, entrepreneurship, and health care administration.³

For employers and educators, a better understanding of these preferences, through consideration of the unique education and skill set of the millennial physician workforce, may lead to more effective recruitment of young physicians and improved health systems, avoiding a mismatch between health care provider skills and available jobs that can be costly for both employers and employees.⁴

This article describes how US millennial physicians are choosing to cross-train (obtaining multiple degrees and/or completing combined medical residency training) throughout undergraduate, medical, and graduate medical education. We also outline ways in which the current physician marketplace may not match the skills of this population and suggest some ways that health care organizations could capitalize on this trend toward more cross-trained personnel in order to effectively recruit and retain the next generation of physicians.

Millennial Education

Undergraduates

The number of interdisciplinary undergraduate majors increased by almost 250% from 1975 to 2000.⁵ In 2010, nearly 20% of US college students graduated with 2 majors, representing a 70% increase in double majors between 2001 and 2011.^6,7 One emerging category of interdisciplinary majors in US colleges is health humanities programs, which have quadrupled since 2000.⁸

Medical school applicants and matriculants reflect this trend. Whereas in 1994, only 19% of applicants to medical school held nonscience degrees, about one-third of applicants now hold such degrees.^9,10 We have found no aggregated data on double majors entering US medical schools, but public class profiles suggest that medical school matriculants mirror their undergraduate counterparts in their tendency to hold double majors. In 2016, for example, 15% of the incoming class at the University of Michigan Medical School was composed of double majors, increasing to over 25% in 2017.¹¹

Medical Students

Early dual-degree programs in undergraduate medical training were reserved for MD/PhD programs.¹² Most US MD/PhD programs (90 out of 151) now offer doctorates in social sciences, humanities, or other nontraditional fields of graduate medical study, reflecting a shift in interests of those seeking dual-degree training in undergraduate medical education.¹³ While only 3 MD/PhD programs in the 1970s included trainees in the social sciences, 17 such programs exist today.¹⁴

Interest in dual-degree programs offering master’s level study has also increased over the past decade. In 2017, 87 medical schools offered programs for students to pursue a master of public health (MPH) and 41 offered master of science degrees in various fields, up from 52 and 37 institutions, respectively in 2006.¹⁵ The number of schools offering combined training in nonscience fields has also grown, with 63 institutions now offering a master of business administration (MBA), nearly double the number offered in 2006.¹⁵ At some institutions more than 20% of students are earning a master’s degree or doctorate in addition to their MD degree.¹⁶

Residents

The authors found no documentation of US residency training programs, outside of those in the specialty of preventive medicine, providing trainees with formal opportunities to obtain an MBA or MPH prior to 2001.¹⁷ However, of the 510 internal medicine residency programs listed on the American Medical Association residency and fellowship database (freida.ama-assn.org), 45 identified as having established a pathway for residents to pursue an MBA, MPH, or PhD during residency.¹⁸

Over the past 20 years, combined residency programs have increased 49% (from 128 to 191), which is triple the 16% rate (1,350 to 1,562) of increase in programs in internal medicine, pediatrics, family medicine, psychiatry, and emergency medicine.^19,20 A 2009 moratorium on the creation of new combined residency programs in psychiatry and neurology was lifted in 2016and is likely to increase the rate of total combined programs.²¹

The Table shows the number of categorical and combined residency programs available in 1996 and in 2016. Over 2 decades, 17 new specialty combinations became available for residency training. While there were no combined training programs within these 17 new combinations in 1996,there were 66 programs with these combinations in 2016.^19,20

Although surgical specialties are notably absent from the list of combined residency options, likely due to the duration of surgical training, some surgical training programs do offer pathways that culminate in combined degrees,²² and a high number of surgery program directors agree that residents should receive formal training in business and practice management.²³

The Medical Job Market

Although today’s young physicians are cross-trained in multiple disciplines, the current job market may not directly match these skill sets. Of the 7,235 jobs listed by the New England Journal of Medicine (NEJM) career center (www.nejmcareercenter.org/jobs), only 54 were targeted at those with combined training, the majority of which were aimed at those trained in internal medicine/pediatrics. Of the combined specialties in the Table, formal positions were listed for only 6.²⁴ A search of nearly 1,500 federal medical positions on USAJOBS (www.usajobs.gov) found only 4 jobs that combined specialties, all restricted to internal medicine/pediatrics.²⁵ When searching for jobs containing the terms MBA, MPH, and public health there were only 8 such positions on NEJM and 7 on USAJOBS.^24,25 Although the totality of the medical marketplace may not be best encompassed by these sources, the authors believe NEJM and USAJOBS are somewhat representative of the opportunities for physicians in the US.

Medical jobs tailored to cross-trained physicians do not appear to have kept pace with the numbers of such specialists currently in medical school and residency training. Though millennials are cross-training in increasing numbers, we surmise that they are not doing so as a direct result of the job market.

Future Medicine

Regardless of the mismatch between cross-trained physicians and the current job market, millennials may be well suited for future health systems. In 2001, the National Academies of Sciences, Engineering and Medicine (NASEM) called for increasing interdisciplinary training and improving cross-functional team performance as a major goal for health care providers in twenty-first century health systems.²⁶ NASEM also recommended that academic medical centers develop medical leaders who can manage systems changes required to enhance health, a proposal supported by the fact that hospitals with medically trained CEOs outperform others.^27,28

Public Health 3.0, a federal initiative to improve and integrate public health efforts, also emphasizes cross-disciplinary teams and cross-sector partnerships,²⁹ while the Centers for Medicare and Medicaid Services (CMS) has incentivized the development of interprofessional health care teams.³⁰ While cross-training does not automatically connote interdisciplinary training, we believe that cross-training may reveal or develop an interdisciplinary mind-set that may support and embrace interdisciplinary performance. Finally, the US Department of Health and Human Services’ (HHS) Strategic Goals emphasize integrated care for vulnerable populations, something that cross-trained physicians may be especially poised to accomplish.³¹

A Path Forward

The education, training, and priorities of young physicians demonstrates career interests that diverge from mainstream, traditional options. Data provided herein describe the increasing rates at which millennial physicians are cross-training and have suggested that the current marketplace may not match the interests of this population. The ultimate question is where such cross-trained physicians fit into today’s (or tomorrow’s) health system?

It may be easiest to deploy cross-trained physicians in their respective clinical departments (eg, having a physician trained in internal medicine and pediatrics perform clinical duties in both a medicine department and a pediatrics department). But < 40% of dual-boarded physicians practice both specialties in which they’re trained, so other opportunities should be pursued.^32,33 One strategy may be to embrace the promise of interdisciplinary care, as supported by Public Health 3.0 and NASEM.^26,29 Our evidence may demonstrate that the interdisciplinary mind-set may be more readily evident in the millennial generation, and that this mind-set may improve interdisciplinary care.

As health is impacted both by direct clinical care as well as programs designed to address population health, cross-trained physicians may be better equipped to integrate aspects of clinical care spanning a variety of clinical fields as well as orchestrating programs designed to improve health at the population level. This mind-set may be best captured by organizations willing to adapt their medical positions to emphasize multidisciplinary training, skills, and capabilities. For example, a physician trained in internal medicine and psychiatry may have the unique training and skill-set to establish an integrated behavioral health clinic that crosses boundaries between traditional departments, emphasizing the whole health of the clinic’s population and not simply focusing on providing services of a particular specialty. Hiring cross-trained physicians throughout such a clinic may benefit the operations of the clinic and improve not only the services provided, but ultimately, the health of that clinic’s patients. By embracing cross-trained physicians, health care organizations and educators may better meet the needs of their employees, likely resulting in a more cost-effective investment for employers, employees, and the health system as a whole.⁴ Additionally, patient health may also improve.

There is evidence that cross-trained physicians are already likely to hold leadership positions compared with their categorically-trained counterparts, and this may reflect the benefits of an interdisciplinary mind-set.³³ Perhaps a cross-trained physician is more likely to see beyond standard, specialty-based institutional barriers and develop processes and programs designed for overall patient benefit. Leadership is a skill that many millennials clearly wish to enhance throughout their career.³⁴ Recruiting cross-trained physicians for leadership positions may reveal synergies between such training and an ability to lead health care organizations into the future.

Many millennial physicians are bringing a new set of skills into the medical marketplace. Health organizations should identify ways to recruit for these skills and deploy them within their systems in order to have more dedicated, engaged employees, more effective health systems, and ultimately, healthier patients.

Acknowledgments
Data from this analysis were presented at the 10th Consortium of Universities for Global Health conference in 2019.³⁵

Millennials, defined as those born between 1981 and 1996, currently comprise 15% of all active physicians in the US.^1,2 A recent survey found that nearly 4 of 5 US millennial physicians have a desire for cross-sectional work in areas beyond patient care, such as academic research, health care consulting, entrepreneurship, and health care administration.³

For employers and educators, a better understanding of these preferences, through consideration of the unique education and skill set of the millennial physician workforce, may lead to more effective recruitment of young physicians and improved health systems, avoiding a mismatch between health care provider skills and available jobs that can be costly for both employers and employees.⁴

This article describes how US millennial physicians are choosing to cross-train (obtaining multiple degrees and/or completing combined medical residency training) throughout undergraduate, medical, and graduate medical education. We also outline ways in which the current physician marketplace may not match the skills of this population and suggest some ways that health care organizations could capitalize on this trend toward more cross-trained personnel in order to effectively recruit and retain the next generation of physicians.

Millennial Education

Undergraduates

The number of interdisciplinary undergraduate majors increased by almost 250% from 1975 to 2000.⁵ In 2010, nearly 20% of US college students graduated with 2 majors, representing a 70% increase in double majors between 2001 and 2011.^6,7 One emerging category of interdisciplinary majors in US colleges is health humanities programs, which have quadrupled since 2000.⁸

Medical school applicants and matriculants reflect this trend. Whereas in 1994, only 19% of applicants to medical school held nonscience degrees, about one-third of applicants now hold such degrees.^9,10 We have found no aggregated data on double majors entering US medical schools, but public class profiles suggest that medical school matriculants mirror their undergraduate counterparts in their tendency to hold double majors. In 2016, for example, 15% of the incoming class at the University of Michigan Medical School was composed of double majors, increasing to over 25% in 2017.¹¹

Medical Students

Early dual-degree programs in undergraduate medical training were reserved for MD/PhD programs.¹² Most US MD/PhD programs (90 out of 151) now offer doctorates in social sciences, humanities, or other nontraditional fields of graduate medical study, reflecting a shift in interests of those seeking dual-degree training in undergraduate medical education.¹³ While only 3 MD/PhD programs in the 1970s included trainees in the social sciences, 17 such programs exist today.¹⁴

Interest in dual-degree programs offering master’s level study has also increased over the past decade. In 2017, 87 medical schools offered programs for students to pursue a master of public health (MPH) and 41 offered master of science degrees in various fields, up from 52 and 37 institutions, respectively in 2006.¹⁵ The number of schools offering combined training in nonscience fields has also grown, with 63 institutions now offering a master of business administration (MBA), nearly double the number offered in 2006.¹⁵ At some institutions more than 20% of students are earning a master’s degree or doctorate in addition to their MD degree.¹⁶

Residents

The authors found no documentation of US residency training programs, outside of those in the specialty of preventive medicine, providing trainees with formal opportunities to obtain an MBA or MPH prior to 2001.¹⁷ However, of the 510 internal medicine residency programs listed on the American Medical Association residency and fellowship database (freida.ama-assn.org), 45 identified as having established a pathway for residents to pursue an MBA, MPH, or PhD during residency.¹⁸

Over the past 20 years, combined residency programs have increased 49% (from 128 to 191), which is triple the 16% rate (1,350 to 1,562) of increase in programs in internal medicine, pediatrics, family medicine, psychiatry, and emergency medicine.^19,20 A 2009 moratorium on the creation of new combined residency programs in psychiatry and neurology was lifted in 2016and is likely to increase the rate of total combined programs.²¹

The Table shows the number of categorical and combined residency programs available in 1996 and in 2016. Over 2 decades, 17 new specialty combinations became available for residency training. While there were no combined training programs within these 17 new combinations in 1996,there were 66 programs with these combinations in 2016.^19,20

Although surgical specialties are notably absent from the list of combined residency options, likely due to the duration of surgical training, some surgical training programs do offer pathways that culminate in combined degrees,²² and a high number of surgery program directors agree that residents should receive formal training in business and practice management.²³

The Medical Job Market

Although today’s young physicians are cross-trained in multiple disciplines, the current job market may not directly match these skill sets. Of the 7,235 jobs listed by the New England Journal of Medicine (NEJM) career center (www.nejmcareercenter.org/jobs), only 54 were targeted at those with combined training, the majority of which were aimed at those trained in internal medicine/pediatrics. Of the combined specialties in the Table, formal positions were listed for only 6.²⁴ A search of nearly 1,500 federal medical positions on USAJOBS (www.usajobs.gov) found only 4 jobs that combined specialties, all restricted to internal medicine/pediatrics.²⁵ When searching for jobs containing the terms MBA, MPH, and public health there were only 8 such positions on NEJM and 7 on USAJOBS.^24,25 Although the totality of the medical marketplace may not be best encompassed by these sources, the authors believe NEJM and USAJOBS are somewhat representative of the opportunities for physicians in the US.

Medical jobs tailored to cross-trained physicians do not appear to have kept pace with the numbers of such specialists currently in medical school and residency training. Though millennials are cross-training in increasing numbers, we surmise that they are not doing so as a direct result of the job market.

Future Medicine

Regardless of the mismatch between cross-trained physicians and the current job market, millennials may be well suited for future health systems. In 2001, the National Academies of Sciences, Engineering and Medicine (NASEM) called for increasing interdisciplinary training and improving cross-functional team performance as a major goal for health care providers in twenty-first century health systems.²⁶ NASEM also recommended that academic medical centers develop medical leaders who can manage systems changes required to enhance health, a proposal supported by the fact that hospitals with medically trained CEOs outperform others.^27,28

Public Health 3.0, a federal initiative to improve and integrate public health efforts, also emphasizes cross-disciplinary teams and cross-sector partnerships,²⁹ while the Centers for Medicare and Medicaid Services (CMS) has incentivized the development of interprofessional health care teams.³⁰ While cross-training does not automatically connote interdisciplinary training, we believe that cross-training may reveal or develop an interdisciplinary mind-set that may support and embrace interdisciplinary performance. Finally, the US Department of Health and Human Services’ (HHS) Strategic Goals emphasize integrated care for vulnerable populations, something that cross-trained physicians may be especially poised to accomplish.³¹

A Path Forward

The education, training, and priorities of young physicians demonstrates career interests that diverge from mainstream, traditional options. Data provided herein describe the increasing rates at which millennial physicians are cross-training and have suggested that the current marketplace may not match the interests of this population. The ultimate question is where such cross-trained physicians fit into today’s (or tomorrow’s) health system?

It may be easiest to deploy cross-trained physicians in their respective clinical departments (eg, having a physician trained in internal medicine and pediatrics perform clinical duties in both a medicine department and a pediatrics department). But < 40% of dual-boarded physicians practice both specialties in which they’re trained, so other opportunities should be pursued.^32,33 One strategy may be to embrace the promise of interdisciplinary care, as supported by Public Health 3.0 and NASEM.^26,29 Our evidence may demonstrate that the interdisciplinary mind-set may be more readily evident in the millennial generation, and that this mind-set may improve interdisciplinary care.

As health is impacted both by direct clinical care as well as programs designed to address population health, cross-trained physicians may be better equipped to integrate aspects of clinical care spanning a variety of clinical fields as well as orchestrating programs designed to improve health at the population level. This mind-set may be best captured by organizations willing to adapt their medical positions to emphasize multidisciplinary training, skills, and capabilities. For example, a physician trained in internal medicine and psychiatry may have the unique training and skill-set to establish an integrated behavioral health clinic that crosses boundaries between traditional departments, emphasizing the whole health of the clinic’s population and not simply focusing on providing services of a particular specialty. Hiring cross-trained physicians throughout such a clinic may benefit the operations of the clinic and improve not only the services provided, but ultimately, the health of that clinic’s patients. By embracing cross-trained physicians, health care organizations and educators may better meet the needs of their employees, likely resulting in a more cost-effective investment for employers, employees, and the health system as a whole.⁴ Additionally, patient health may also improve.

There is evidence that cross-trained physicians are already likely to hold leadership positions compared with their categorically-trained counterparts, and this may reflect the benefits of an interdisciplinary mind-set.³³ Perhaps a cross-trained physician is more likely to see beyond standard, specialty-based institutional barriers and develop processes and programs designed for overall patient benefit. Leadership is a skill that many millennials clearly wish to enhance throughout their career.³⁴ Recruiting cross-trained physicians for leadership positions may reveal synergies between such training and an ability to lead health care organizations into the future.

Many millennial physicians are bringing a new set of skills into the medical marketplace. Health organizations should identify ways to recruit for these skills and deploy them within their systems in order to have more dedicated, engaged employees, more effective health systems, and ultimately, healthier patients.

Acknowledgments
Data from this analysis were presented at the 10th Consortium of Universities for Global Health conference in 2019.³⁵

Millennials, defined as those born between 1981 and 1996, currently comprise 15% of all active physicians in the US.^1,2 A recent survey found that nearly 4 of 5 US millennial physicians have a desire for cross-sectional work in areas beyond patient care, such as academic research, health care consulting, entrepreneurship, and health care administration.³

For employers and educators, a better understanding of these preferences, through consideration of the unique education and skill set of the millennial physician workforce, may lead to more effective recruitment of young physicians and improved health systems, avoiding a mismatch between health care provider skills and available jobs that can be costly for both employers and employees.⁴

This article describes how US millennial physicians are choosing to cross-train (obtaining multiple degrees and/or completing combined medical residency training) throughout undergraduate, medical, and graduate medical education. We also outline ways in which the current physician marketplace may not match the skills of this population and suggest some ways that health care organizations could capitalize on this trend toward more cross-trained personnel in order to effectively recruit and retain the next generation of physicians.

Millennial Education

Undergraduates

The number of interdisciplinary undergraduate majors increased by almost 250% from 1975 to 2000.⁵ In 2010, nearly 20% of US college students graduated with 2 majors, representing a 70% increase in double majors between 2001 and 2011.^6,7 One emerging category of interdisciplinary majors in US colleges is health humanities programs, which have quadrupled since 2000.⁸

Medical school applicants and matriculants reflect this trend. Whereas in 1994, only 19% of applicants to medical school held nonscience degrees, about one-third of applicants now hold such degrees.^9,10 We have found no aggregated data on double majors entering US medical schools, but public class profiles suggest that medical school matriculants mirror their undergraduate counterparts in their tendency to hold double majors. In 2016, for example, 15% of the incoming class at the University of Michigan Medical School was composed of double majors, increasing to over 25% in 2017.¹¹

Medical Students

Early dual-degree programs in undergraduate medical training were reserved for MD/PhD programs.¹² Most US MD/PhD programs (90 out of 151) now offer doctorates in social sciences, humanities, or other nontraditional fields of graduate medical study, reflecting a shift in interests of those seeking dual-degree training in undergraduate medical education.¹³ While only 3 MD/PhD programs in the 1970s included trainees in the social sciences, 17 such programs exist today.¹⁴

Interest in dual-degree programs offering master’s level study has also increased over the past decade. In 2017, 87 medical schools offered programs for students to pursue a master of public health (MPH) and 41 offered master of science degrees in various fields, up from 52 and 37 institutions, respectively in 2006.¹⁵ The number of schools offering combined training in nonscience fields has also grown, with 63 institutions now offering a master of business administration (MBA), nearly double the number offered in 2006.¹⁵ At some institutions more than 20% of students are earning a master’s degree or doctorate in addition to their MD degree.¹⁶

Residents

The authors found no documentation of US residency training programs, outside of those in the specialty of preventive medicine, providing trainees with formal opportunities to obtain an MBA or MPH prior to 2001.¹⁷ However, of the 510 internal medicine residency programs listed on the American Medical Association residency and fellowship database (freida.ama-assn.org), 45 identified as having established a pathway for residents to pursue an MBA, MPH, or PhD during residency.¹⁸

Over the past 20 years, combined residency programs have increased 49% (from 128 to 191), which is triple the 16% rate (1,350 to 1,562) of increase in programs in internal medicine, pediatrics, family medicine, psychiatry, and emergency medicine.^19,20 A 2009 moratorium on the creation of new combined residency programs in psychiatry and neurology was lifted in 2016and is likely to increase the rate of total combined programs.²¹

The Table shows the number of categorical and combined residency programs available in 1996 and in 2016. Over 2 decades, 17 new specialty combinations became available for residency training. While there were no combined training programs within these 17 new combinations in 1996,there were 66 programs with these combinations in 2016.^19,20

Although surgical specialties are notably absent from the list of combined residency options, likely due to the duration of surgical training, some surgical training programs do offer pathways that culminate in combined degrees,²² and a high number of surgery program directors agree that residents should receive formal training in business and practice management.²³

The Medical Job Market

Although today’s young physicians are cross-trained in multiple disciplines, the current job market may not directly match these skill sets. Of the 7,235 jobs listed by the New England Journal of Medicine (NEJM) career center (www.nejmcareercenter.org/jobs), only 54 were targeted at those with combined training, the majority of which were aimed at those trained in internal medicine/pediatrics. Of the combined specialties in the Table, formal positions were listed for only 6.²⁴ A search of nearly 1,500 federal medical positions on USAJOBS (www.usajobs.gov) found only 4 jobs that combined specialties, all restricted to internal medicine/pediatrics.²⁵ When searching for jobs containing the terms MBA, MPH, and public health there were only 8 such positions on NEJM and 7 on USAJOBS.^24,25 Although the totality of the medical marketplace may not be best encompassed by these sources, the authors believe NEJM and USAJOBS are somewhat representative of the opportunities for physicians in the US.

Medical jobs tailored to cross-trained physicians do not appear to have kept pace with the numbers of such specialists currently in medical school and residency training. Though millennials are cross-training in increasing numbers, we surmise that they are not doing so as a direct result of the job market.

Future Medicine

Regardless of the mismatch between cross-trained physicians and the current job market, millennials may be well suited for future health systems. In 2001, the National Academies of Sciences, Engineering and Medicine (NASEM) called for increasing interdisciplinary training and improving cross-functional team performance as a major goal for health care providers in twenty-first century health systems.²⁶ NASEM also recommended that academic medical centers develop medical leaders who can manage systems changes required to enhance health, a proposal supported by the fact that hospitals with medically trained CEOs outperform others.^27,28

Public Health 3.0, a federal initiative to improve and integrate public health efforts, also emphasizes cross-disciplinary teams and cross-sector partnerships,²⁹ while the Centers for Medicare and Medicaid Services (CMS) has incentivized the development of interprofessional health care teams.³⁰ While cross-training does not automatically connote interdisciplinary training, we believe that cross-training may reveal or develop an interdisciplinary mind-set that may support and embrace interdisciplinary performance. Finally, the US Department of Health and Human Services’ (HHS) Strategic Goals emphasize integrated care for vulnerable populations, something that cross-trained physicians may be especially poised to accomplish.³¹

A Path Forward

The education, training, and priorities of young physicians demonstrates career interests that diverge from mainstream, traditional options. Data provided herein describe the increasing rates at which millennial physicians are cross-training and have suggested that the current marketplace may not match the interests of this population. The ultimate question is where such cross-trained physicians fit into today’s (or tomorrow’s) health system?

It may be easiest to deploy cross-trained physicians in their respective clinical departments (eg, having a physician trained in internal medicine and pediatrics perform clinical duties in both a medicine department and a pediatrics department). But < 40% of dual-boarded physicians practice both specialties in which they’re trained, so other opportunities should be pursued.^32,33 One strategy may be to embrace the promise of interdisciplinary care, as supported by Public Health 3.0 and NASEM.^26,29 Our evidence may demonstrate that the interdisciplinary mind-set may be more readily evident in the millennial generation, and that this mind-set may improve interdisciplinary care.

As health is impacted both by direct clinical care as well as programs designed to address population health, cross-trained physicians may be better equipped to integrate aspects of clinical care spanning a variety of clinical fields as well as orchestrating programs designed to improve health at the population level. This mind-set may be best captured by organizations willing to adapt their medical positions to emphasize multidisciplinary training, skills, and capabilities. For example, a physician trained in internal medicine and psychiatry may have the unique training and skill-set to establish an integrated behavioral health clinic that crosses boundaries between traditional departments, emphasizing the whole health of the clinic’s population and not simply focusing on providing services of a particular specialty. Hiring cross-trained physicians throughout such a clinic may benefit the operations of the clinic and improve not only the services provided, but ultimately, the health of that clinic’s patients. By embracing cross-trained physicians, health care organizations and educators may better meet the needs of their employees, likely resulting in a more cost-effective investment for employers, employees, and the health system as a whole.⁴ Additionally, patient health may also improve.

There is evidence that cross-trained physicians are already likely to hold leadership positions compared with their categorically-trained counterparts, and this may reflect the benefits of an interdisciplinary mind-set.³³ Perhaps a cross-trained physician is more likely to see beyond standard, specialty-based institutional barriers and develop processes and programs designed for overall patient benefit. Leadership is a skill that many millennials clearly wish to enhance throughout their career.³⁴ Recruiting cross-trained physicians for leadership positions may reveal synergies between such training and an ability to lead health care organizations into the future.

Many millennial physicians are bringing a new set of skills into the medical marketplace. Health organizations should identify ways to recruit for these skills and deploy them within their systems in order to have more dedicated, engaged employees, more effective health systems, and ultimately, healthier patients.

Acknowledgments
Data from this analysis were presented at the 10th Consortium of Universities for Global Health conference in 2019.³⁵

High reliability organizations (HROs) incorporate continuous process improvement through leadership commitment to create a safety culture that works toward creating a zero-harm environment.¹ The Veterans Health Administration (VHA) has set transformational goals for becoming an HRO. In this article, we describe VIONE, an expanding medication deprescribing clinical program, which exemplifies the translation of HRO principles into health care system models. Both VIONE and HRO are globally relevant.

Reducing medication errors and related adverse drug events are important for achieving zero harm. Preventable medical errors rank behind heart disease and cancer as the third leading cause of death in the US.² The simultaneous use of multiple medications can lead to dangerous drug interactions, adverse outcomes, and challenges with adherence. When a person is taking multiple medicines, known as polypharmacy, it is more likely that some are potentially inappropriate medications (PIM). Current literature highlights the prevalence and dangers of polypharmacy, which ranks among the top 10 common causes of death in the US, as well as suggestions to address preventable adverse outcomes from polypharmacy and PIM.^3-5

Deprescribing of PIM frequently results in better disease management with improved health outcomes and quality of life.⁴ Many health care settings lack standardized approaches or set expectations to proactively deprescribe PIM. There has been insufficient emphasis on how to make decisions for deprescribing medications when therapeutic benefits are not clear and/or when the adverse effects may outweigh the therapeutic benefits.⁵

It is imperative to provide practice guidance for deprescribing nonessential medications along with systems-based infrastructure to enable integrated and effective assessments during opportune moments in the health care continuum. Multimodal approaches that include education, risk stratification, population health management interventions, research and resource allocation can help transform organizational culture in health care facilities toward HRO models of care, aiming at zero harm to patients.

The practical lessons learned from VIONE implementation science experiences on various scales and under diverse circumstances, cumulative wisdom from hindsight, foresight and critical insights gathered during nationwide spread of VIONE over the past 3 years continues to propel us toward the desirable direction and core concepts of an HRO.

The VIONE program facilitates practical, real-time interventions that could be tailored to various health care settings, organizational needs, and available resources. VIONE implements an electronic Computerized Patient Record System (CPRS) tool to enable planned cessation of nonessential medications that are potentially harmful, inappropriate, not indicated, or not necessary. The VIONE tool supports systematic, individualized assessment and adjustment through 5 filters (Figure 1). It prompts providers to assign 1 of these filters intuitively and objectively. VIONE combines clinical evidence for best practices, an interprofessional team approach, patient engagement, adapted use of existing medical records systems, and HRO principles for effective implementation.

As a tool to support safer prescribing practices, VIONE aligns closely with HRO principles (Table 1) and core pillars (Table 2).^6-8 A zero-harm safety culture necessitates that medications be used for correct reasons, over a correct duration of time, and following a correct schedule while monitoring for adverse outcomes. However, reality generally falls significantly short of this for a myriad of reasons, such as compromised health literacy, functional limitations, affordability, communication gaps, patients seen by multiple providers, and an accumulation of prescriptions due to comorbidities, symptom progression, and management of adverse effects. Through a sharpened focus on both precision medicine and competent prescription management, VIONE is a viable opportunity for investing in the zero-harm philosophy that is integral to an HRO.

Design and Implementation 

Initially launched in 2016 in a 15-bed inpatient, subacute rehabilitation unit within a VHA tertiary care facility, VIONE has been sustained and gradually expanded to 38 other VHA facility programs (Figure 2). Recognizing the potential value if adopted into widespread use, VIONE was a Gold Status winner in the VHA Under Secretary for Health Shark Tank-style competition in 2017 and was selected by the VHA Diffusion of Excellence as an innovation worthy of scale and spread through national dissemination.⁹ A toolkit for VIONE implementation, patient and provider brochures, VIONE vignette, and National Dialog template also have been created.¹⁰

Implementing VIONE in a new facility requires an actively engaged core team committed to patient safety and reduction of polypharmacy and PIM, interest and availability to lead project implementation strategies, along with meaningful local organizational support. The current structure for VIONE spread is as follows:

• Interested VHA participants review information and contact vavione@va.gov.
• The VIONE team orients implementing champions, mainly pharmacists, physicians, nurse practitioners, and physician assistants at a facility program level, offering guidance and available resources.
• Clinical Application Coordinators at Central Arkansas VA Healthcare System and participating facilities collaborate to add deprescribing menu options in CPRS and install the VIONE Polypharmacy Reminder Dialog template.
• Through close and ongoing collaborations, medical providers and clinical pharmacists proceed with deprescribing, aiming at planned cessation of nonessential and PIM, using the mnemonic prompt of VIONE. Vital and Important medications are continued and consolidated while a methodical plan is developed to deprescribe any medications that could lead to more harm than benefit and qualify based on the filters of Optional, Not indicated, and Every medicine has a diagnosis/reason. They select the proper discontinuation reasons in the CPRS medication menu (Figure 3) and document the rationale in the progress notes. It is highly encouraged that the collaborating pharmacists and health care providers add each other as cosigners and communicate effectively. Clinical pharmacy specialists also use the VIONE Polypharmacy Reminder Dialog Template (RDT) to document complete medication reviews with veterans to include deprescribing rationale and document shared decision making.

• A VIONE national dashboard captures deprescribing data in real time and automates reporting with daily updates that are readily accessible to all implementing facilities. Minimum data captured include the number of unique veterans impacted, number of medications deprescribed, cumulative cost avoidance to date, and number of prescriptions deprescribed per veteran. The dashboard facilitates real-time use of individual patient data and has also been designed to capture data from VHA administrative data portals and Corporate Data Warehouse.

Results

As of October 31, 2019, the assessment of polypharmacy using the VIONE tool across VHA sites has benefited > 60,000 unique veterans, of whom 49.2% were in urban areas, 47.7% in rural areas, and 3.1% in highly rural areas. Elderly male veterans comprised a clear majority. More than 128,000 medications have been deprescribed. The top classes of medications deprescribed are antihypertensives, over-the-counter medications, and antidiabetic medications. An annualized cost avoidance of > $4.0 million has been achieved. Cost avoidance is the cost of medications that otherwise would have continued to be filled and paid for by the VHA if they had not been deprescribed, projected for a maximum of 365 days. The calculation methodology can be summarized as follows:

The calculations reported in Table 3 and Figure 4 are conservative and include only chronic outpatient prescriptions and do not account for medications deprescribed in inpatient units, nursing home, community living centers, or domiciliary populations. Data tracked separately from inpatient and community living center patient populations indicated an additional 25,536 deprescribed medications, across 28 VA facilities, impacting 7,076 veterans with an average 2.15 medications deprescribed per veteran. The additional achieved cost avoidance was $370,272 (based on $14.50 average cost per prescription). Medications restarted within 30 days of deprescribing are not included in these calculations.

The cost avoidance calculation further excludes the effects of VIONE implementation on many other types of interventions. These interventions include, but are not limited to, changing from aggressive care to end of life, comfort care when strongly indicated; reduced emergency department visits or invasive diagnostic and therapeutic approaches, when not indicated; medical supplies, antimicrobial preparations; labor costs related to packaging, mailing, and administering prescriptions; reduced/prevented clinical waste; reduced decompensation of systemic illnesses and subsequent health care needs precipitated by iatrogenic disturbances and prolonged convalescence; and overall changes to prescribing practices through purposeful and targeted interactions with colleagues across various disciplines and various hierarchical levels.

Discussion

The VIONE clinical program exemplifies the translation of HRO principles into health care system practices. VIONE offers a systematic approach to improve medication management with an emphasis on deprescribing nonessential medications across various health care settings, facilitating VHA efforts toward zero harm. It demonstrates close alignment with the key building blocks of an HRO. Effective VIONE incorporation into an organizational culture reflects leadership commitment to safety and reliability in their vision and actions. By empowering staff to proactively reduce inappropriate medications and thereby prevent patient harm, VIONE contributes to enhancing an enterprise-wide culture of safety, with fewer errors and greater reliability. As a standardized decision support tool for the ongoing practice of assessment and planned cessation of potentially inappropriate medications, VIONE illustrates how continuous process improvement can be a part of staff-engaged, veteran-centered, highly reliable care. The standardization of the VIONE tool promotes achievement and sustainment of desired HRO principles and practices within health care delivery systems.

Conclusions

The VIONE program was launched not as a cost savings or research program but as a practical, real-time bedside or ambulatory care intervention to improve patient safety. Its value is reflected in the overwhelming response from scholarly and well-engaged colleagues expressing serious interests in expanding collaborations and tailoring efforts to add more depth and breadth to VIONE related efforts.

Acknowledgments
The authors express their gratitude to Central Arkansas VA Healthcare System leadership, Clinical Applications Coordinators, and colleagues for their unconditional support, to the Diffusion of Excellence programs at US Department of Veterans Affairs Central Office for their endorsement, and to the many VHA participants who renew our optimism and energy as we continue this exciting journey. We also thank Bridget B. Kelly for her assistance in writing and editing of the manuscript.

High reliability organizations (HROs) incorporate continuous process improvement through leadership commitment to create a safety culture that works toward creating a zero-harm environment.¹ The Veterans Health Administration (VHA) has set transformational goals for becoming an HRO. In this article, we describe VIONE, an expanding medication deprescribing clinical program, which exemplifies the translation of HRO principles into health care system models. Both VIONE and HRO are globally relevant.

Reducing medication errors and related adverse drug events are important for achieving zero harm. Preventable medical errors rank behind heart disease and cancer as the third leading cause of death in the US.² The simultaneous use of multiple medications can lead to dangerous drug interactions, adverse outcomes, and challenges with adherence. When a person is taking multiple medicines, known as polypharmacy, it is more likely that some are potentially inappropriate medications (PIM). Current literature highlights the prevalence and dangers of polypharmacy, which ranks among the top 10 common causes of death in the US, as well as suggestions to address preventable adverse outcomes from polypharmacy and PIM.^3-5

Deprescribing of PIM frequently results in better disease management with improved health outcomes and quality of life.⁴ Many health care settings lack standardized approaches or set expectations to proactively deprescribe PIM. There has been insufficient emphasis on how to make decisions for deprescribing medications when therapeutic benefits are not clear and/or when the adverse effects may outweigh the therapeutic benefits.⁵

It is imperative to provide practice guidance for deprescribing nonessential medications along with systems-based infrastructure to enable integrated and effective assessments during opportune moments in the health care continuum. Multimodal approaches that include education, risk stratification, population health management interventions, research and resource allocation can help transform organizational culture in health care facilities toward HRO models of care, aiming at zero harm to patients.

The practical lessons learned from VIONE implementation science experiences on various scales and under diverse circumstances, cumulative wisdom from hindsight, foresight and critical insights gathered during nationwide spread of VIONE over the past 3 years continues to propel us toward the desirable direction and core concepts of an HRO.

The VIONE program facilitates practical, real-time interventions that could be tailored to various health care settings, organizational needs, and available resources. VIONE implements an electronic Computerized Patient Record System (CPRS) tool to enable planned cessation of nonessential medications that are potentially harmful, inappropriate, not indicated, or not necessary. The VIONE tool supports systematic, individualized assessment and adjustment through 5 filters (Figure 1). It prompts providers to assign 1 of these filters intuitively and objectively. VIONE combines clinical evidence for best practices, an interprofessional team approach, patient engagement, adapted use of existing medical records systems, and HRO principles for effective implementation.

As a tool to support safer prescribing practices, VIONE aligns closely with HRO principles (Table 1) and core pillars (Table 2).^6-8 A zero-harm safety culture necessitates that medications be used for correct reasons, over a correct duration of time, and following a correct schedule while monitoring for adverse outcomes. However, reality generally falls significantly short of this for a myriad of reasons, such as compromised health literacy, functional limitations, affordability, communication gaps, patients seen by multiple providers, and an accumulation of prescriptions due to comorbidities, symptom progression, and management of adverse effects. Through a sharpened focus on both precision medicine and competent prescription management, VIONE is a viable opportunity for investing in the zero-harm philosophy that is integral to an HRO.

Design and Implementation 

Initially launched in 2016 in a 15-bed inpatient, subacute rehabilitation unit within a VHA tertiary care facility, VIONE has been sustained and gradually expanded to 38 other VHA facility programs (Figure 2). Recognizing the potential value if adopted into widespread use, VIONE was a Gold Status winner in the VHA Under Secretary for Health Shark Tank-style competition in 2017 and was selected by the VHA Diffusion of Excellence as an innovation worthy of scale and spread through national dissemination.⁹ A toolkit for VIONE implementation, patient and provider brochures, VIONE vignette, and National Dialog template also have been created.¹⁰

Implementing VIONE in a new facility requires an actively engaged core team committed to patient safety and reduction of polypharmacy and PIM, interest and availability to lead project implementation strategies, along with meaningful local organizational support. The current structure for VIONE spread is as follows:

• Interested VHA participants review information and contact vavione@va.gov.
• The VIONE team orients implementing champions, mainly pharmacists, physicians, nurse practitioners, and physician assistants at a facility program level, offering guidance and available resources.
• Clinical Application Coordinators at Central Arkansas VA Healthcare System and participating facilities collaborate to add deprescribing menu options in CPRS and install the VIONE Polypharmacy Reminder Dialog template.
• Through close and ongoing collaborations, medical providers and clinical pharmacists proceed with deprescribing, aiming at planned cessation of nonessential and PIM, using the mnemonic prompt of VIONE. Vital and Important medications are continued and consolidated while a methodical plan is developed to deprescribe any medications that could lead to more harm than benefit and qualify based on the filters of Optional, Not indicated, and Every medicine has a diagnosis/reason. They select the proper discontinuation reasons in the CPRS medication menu (Figure 3) and document the rationale in the progress notes. It is highly encouraged that the collaborating pharmacists and health care providers add each other as cosigners and communicate effectively. Clinical pharmacy specialists also use the VIONE Polypharmacy Reminder Dialog Template (RDT) to document complete medication reviews with veterans to include deprescribing rationale and document shared decision making.

• A VIONE national dashboard captures deprescribing data in real time and automates reporting with daily updates that are readily accessible to all implementing facilities. Minimum data captured include the number of unique veterans impacted, number of medications deprescribed, cumulative cost avoidance to date, and number of prescriptions deprescribed per veteran. The dashboard facilitates real-time use of individual patient data and has also been designed to capture data from VHA administrative data portals and Corporate Data Warehouse.

Results

As of October 31, 2019, the assessment of polypharmacy using the VIONE tool across VHA sites has benefited > 60,000 unique veterans, of whom 49.2% were in urban areas, 47.7% in rural areas, and 3.1% in highly rural areas. Elderly male veterans comprised a clear majority. More than 128,000 medications have been deprescribed. The top classes of medications deprescribed are antihypertensives, over-the-counter medications, and antidiabetic medications. An annualized cost avoidance of > $4.0 million has been achieved. Cost avoidance is the cost of medications that otherwise would have continued to be filled and paid for by the VHA if they had not been deprescribed, projected for a maximum of 365 days. The calculation methodology can be summarized as follows:

The calculations reported in Table 3 and Figure 4 are conservative and include only chronic outpatient prescriptions and do not account for medications deprescribed in inpatient units, nursing home, community living centers, or domiciliary populations. Data tracked separately from inpatient and community living center patient populations indicated an additional 25,536 deprescribed medications, across 28 VA facilities, impacting 7,076 veterans with an average 2.15 medications deprescribed per veteran. The additional achieved cost avoidance was $370,272 (based on $14.50 average cost per prescription). Medications restarted within 30 days of deprescribing are not included in these calculations.

The cost avoidance calculation further excludes the effects of VIONE implementation on many other types of interventions. These interventions include, but are not limited to, changing from aggressive care to end of life, comfort care when strongly indicated; reduced emergency department visits or invasive diagnostic and therapeutic approaches, when not indicated; medical supplies, antimicrobial preparations; labor costs related to packaging, mailing, and administering prescriptions; reduced/prevented clinical waste; reduced decompensation of systemic illnesses and subsequent health care needs precipitated by iatrogenic disturbances and prolonged convalescence; and overall changes to prescribing practices through purposeful and targeted interactions with colleagues across various disciplines and various hierarchical levels.

Discussion

The VIONE clinical program exemplifies the translation of HRO principles into health care system practices. VIONE offers a systematic approach to improve medication management with an emphasis on deprescribing nonessential medications across various health care settings, facilitating VHA efforts toward zero harm. It demonstrates close alignment with the key building blocks of an HRO. Effective VIONE incorporation into an organizational culture reflects leadership commitment to safety and reliability in their vision and actions. By empowering staff to proactively reduce inappropriate medications and thereby prevent patient harm, VIONE contributes to enhancing an enterprise-wide culture of safety, with fewer errors and greater reliability. As a standardized decision support tool for the ongoing practice of assessment and planned cessation of potentially inappropriate medications, VIONE illustrates how continuous process improvement can be a part of staff-engaged, veteran-centered, highly reliable care. The standardization of the VIONE tool promotes achievement and sustainment of desired HRO principles and practices within health care delivery systems.

Conclusions

The VIONE program was launched not as a cost savings or research program but as a practical, real-time bedside or ambulatory care intervention to improve patient safety. Its value is reflected in the overwhelming response from scholarly and well-engaged colleagues expressing serious interests in expanding collaborations and tailoring efforts to add more depth and breadth to VIONE related efforts.

Acknowledgments
The authors express their gratitude to Central Arkansas VA Healthcare System leadership, Clinical Applications Coordinators, and colleagues for their unconditional support, to the Diffusion of Excellence programs at US Department of Veterans Affairs Central Office for their endorsement, and to the many VHA participants who renew our optimism and energy as we continue this exciting journey. We also thank Bridget B. Kelly for her assistance in writing and editing of the manuscript.

High reliability organizations (HROs) incorporate continuous process improvement through leadership commitment to create a safety culture that works toward creating a zero-harm environment.¹ The Veterans Health Administration (VHA) has set transformational goals for becoming an HRO. In this article, we describe VIONE, an expanding medication deprescribing clinical program, which exemplifies the translation of HRO principles into health care system models. Both VIONE and HRO are globally relevant.

Reducing medication errors and related adverse drug events are important for achieving zero harm. Preventable medical errors rank behind heart disease and cancer as the third leading cause of death in the US.² The simultaneous use of multiple medications can lead to dangerous drug interactions, adverse outcomes, and challenges with adherence. When a person is taking multiple medicines, known as polypharmacy, it is more likely that some are potentially inappropriate medications (PIM). Current literature highlights the prevalence and dangers of polypharmacy, which ranks among the top 10 common causes of death in the US, as well as suggestions to address preventable adverse outcomes from polypharmacy and PIM.^3-5

Deprescribing of PIM frequently results in better disease management with improved health outcomes and quality of life.⁴ Many health care settings lack standardized approaches or set expectations to proactively deprescribe PIM. There has been insufficient emphasis on how to make decisions for deprescribing medications when therapeutic benefits are not clear and/or when the adverse effects may outweigh the therapeutic benefits.⁵

It is imperative to provide practice guidance for deprescribing nonessential medications along with systems-based infrastructure to enable integrated and effective assessments during opportune moments in the health care continuum. Multimodal approaches that include education, risk stratification, population health management interventions, research and resource allocation can help transform organizational culture in health care facilities toward HRO models of care, aiming at zero harm to patients.

The practical lessons learned from VIONE implementation science experiences on various scales and under diverse circumstances, cumulative wisdom from hindsight, foresight and critical insights gathered during nationwide spread of VIONE over the past 3 years continues to propel us toward the desirable direction and core concepts of an HRO.

The VIONE program facilitates practical, real-time interventions that could be tailored to various health care settings, organizational needs, and available resources. VIONE implements an electronic Computerized Patient Record System (CPRS) tool to enable planned cessation of nonessential medications that are potentially harmful, inappropriate, not indicated, or not necessary. The VIONE tool supports systematic, individualized assessment and adjustment through 5 filters (Figure 1). It prompts providers to assign 1 of these filters intuitively and objectively. VIONE combines clinical evidence for best practices, an interprofessional team approach, patient engagement, adapted use of existing medical records systems, and HRO principles for effective implementation.

As a tool to support safer prescribing practices, VIONE aligns closely with HRO principles (Table 1) and core pillars (Table 2).^6-8 A zero-harm safety culture necessitates that medications be used for correct reasons, over a correct duration of time, and following a correct schedule while monitoring for adverse outcomes. However, reality generally falls significantly short of this for a myriad of reasons, such as compromised health literacy, functional limitations, affordability, communication gaps, patients seen by multiple providers, and an accumulation of prescriptions due to comorbidities, symptom progression, and management of adverse effects. Through a sharpened focus on both precision medicine and competent prescription management, VIONE is a viable opportunity for investing in the zero-harm philosophy that is integral to an HRO.

Design and Implementation 

Initially launched in 2016 in a 15-bed inpatient, subacute rehabilitation unit within a VHA tertiary care facility, VIONE has been sustained and gradually expanded to 38 other VHA facility programs (Figure 2). Recognizing the potential value if adopted into widespread use, VIONE was a Gold Status winner in the VHA Under Secretary for Health Shark Tank-style competition in 2017 and was selected by the VHA Diffusion of Excellence as an innovation worthy of scale and spread through national dissemination.⁹ A toolkit for VIONE implementation, patient and provider brochures, VIONE vignette, and National Dialog template also have been created.¹⁰

Implementing VIONE in a new facility requires an actively engaged core team committed to patient safety and reduction of polypharmacy and PIM, interest and availability to lead project implementation strategies, along with meaningful local organizational support. The current structure for VIONE spread is as follows:

• Interested VHA participants review information and contact vavione@va.gov.
• The VIONE team orients implementing champions, mainly pharmacists, physicians, nurse practitioners, and physician assistants at a facility program level, offering guidance and available resources.
• Clinical Application Coordinators at Central Arkansas VA Healthcare System and participating facilities collaborate to add deprescribing menu options in CPRS and install the VIONE Polypharmacy Reminder Dialog template.
• Through close and ongoing collaborations, medical providers and clinical pharmacists proceed with deprescribing, aiming at planned cessation of nonessential and PIM, using the mnemonic prompt of VIONE. Vital and Important medications are continued and consolidated while a methodical plan is developed to deprescribe any medications that could lead to more harm than benefit and qualify based on the filters of Optional, Not indicated, and Every medicine has a diagnosis/reason. They select the proper discontinuation reasons in the CPRS medication menu (Figure 3) and document the rationale in the progress notes. It is highly encouraged that the collaborating pharmacists and health care providers add each other as cosigners and communicate effectively. Clinical pharmacy specialists also use the VIONE Polypharmacy Reminder Dialog Template (RDT) to document complete medication reviews with veterans to include deprescribing rationale and document shared decision making.

• A VIONE national dashboard captures deprescribing data in real time and automates reporting with daily updates that are readily accessible to all implementing facilities. Minimum data captured include the number of unique veterans impacted, number of medications deprescribed, cumulative cost avoidance to date, and number of prescriptions deprescribed per veteran. The dashboard facilitates real-time use of individual patient data and has also been designed to capture data from VHA administrative data portals and Corporate Data Warehouse.

Results

As of October 31, 2019, the assessment of polypharmacy using the VIONE tool across VHA sites has benefited > 60,000 unique veterans, of whom 49.2% were in urban areas, 47.7% in rural areas, and 3.1% in highly rural areas. Elderly male veterans comprised a clear majority. More than 128,000 medications have been deprescribed. The top classes of medications deprescribed are antihypertensives, over-the-counter medications, and antidiabetic medications. An annualized cost avoidance of > $4.0 million has been achieved. Cost avoidance is the cost of medications that otherwise would have continued to be filled and paid for by the VHA if they had not been deprescribed, projected for a maximum of 365 days. The calculation methodology can be summarized as follows:

The calculations reported in Table 3 and Figure 4 are conservative and include only chronic outpatient prescriptions and do not account for medications deprescribed in inpatient units, nursing home, community living centers, or domiciliary populations. Data tracked separately from inpatient and community living center patient populations indicated an additional 25,536 deprescribed medications, across 28 VA facilities, impacting 7,076 veterans with an average 2.15 medications deprescribed per veteran. The additional achieved cost avoidance was $370,272 (based on $14.50 average cost per prescription). Medications restarted within 30 days of deprescribing are not included in these calculations.

The cost avoidance calculation further excludes the effects of VIONE implementation on many other types of interventions. These interventions include, but are not limited to, changing from aggressive care to end of life, comfort care when strongly indicated; reduced emergency department visits or invasive diagnostic and therapeutic approaches, when not indicated; medical supplies, antimicrobial preparations; labor costs related to packaging, mailing, and administering prescriptions; reduced/prevented clinical waste; reduced decompensation of systemic illnesses and subsequent health care needs precipitated by iatrogenic disturbances and prolonged convalescence; and overall changes to prescribing practices through purposeful and targeted interactions with colleagues across various disciplines and various hierarchical levels.

Discussion

The VIONE clinical program exemplifies the translation of HRO principles into health care system practices. VIONE offers a systematic approach to improve medication management with an emphasis on deprescribing nonessential medications across various health care settings, facilitating VHA efforts toward zero harm. It demonstrates close alignment with the key building blocks of an HRO. Effective VIONE incorporation into an organizational culture reflects leadership commitment to safety and reliability in their vision and actions. By empowering staff to proactively reduce inappropriate medications and thereby prevent patient harm, VIONE contributes to enhancing an enterprise-wide culture of safety, with fewer errors and greater reliability. As a standardized decision support tool for the ongoing practice of assessment and planned cessation of potentially inappropriate medications, VIONE illustrates how continuous process improvement can be a part of staff-engaged, veteran-centered, highly reliable care. The standardization of the VIONE tool promotes achievement and sustainment of desired HRO principles and practices within health care delivery systems.

Conclusions

The VIONE program was launched not as a cost savings or research program but as a practical, real-time bedside or ambulatory care intervention to improve patient safety. Its value is reflected in the overwhelming response from scholarly and well-engaged colleagues expressing serious interests in expanding collaborations and tailoring efforts to add more depth and breadth to VIONE related efforts.

Acknowledgments
The authors express their gratitude to Central Arkansas VA Healthcare System leadership, Clinical Applications Coordinators, and colleagues for their unconditional support, to the Diffusion of Excellence programs at US Department of Veterans Affairs Central Office for their endorsement, and to the many VHA participants who renew our optimism and energy as we continue this exciting journey. We also thank Bridget B. Kelly for her assistance in writing and editing of the manuscript.

The Korean War lasted from June 25, 1950 through July 27, 1953. Although many veterans of the Korean War experienced traumas during extremely stressful combat conditions. However, they would not have been diagnosed with posttraumatic stress disorder (PTSD) at the time because the latter did not exist as a formal diagnosis until the publication of the third edition of the Diagnostic and Statistical Manual (DSM) in 1980.¹ Prior to 1980, psychiatric syndromes resulting from war and combat exposure where known by numerous other terms including shell shock, chronic traumatic war neurosis, and combat fatigue/combat exhaustion.^2,3 Military psychiatrists attended to combat fatigue during the course of the Korean War, but as was true of World War I and II, the focus was on returning soldiers to duty. Combat fatigue was generally viewed as a transient condition.^4-8

Although now octo- and nonagenarians, in 2019 there are 1.2 million living Korean War veterans in the US, representing 6.7% of all current veterans.⁹ Understanding their war experiences and the nature of their current and past presentation of PTSD is relevant not only in formal mental health settings, but in primary care settings, including home-based primary care, as well as community living centers, skilled nursing facilities and assisted living facilities. Older adults with PTSD often present with somatic concerns rather than spontaneously reporting mental health symptoms.¹⁰ Beyond the short-term clinical management of Korean War veterans with PTSD, consideration of their experiences also has long-term relevance for the appropriate treatment of other veteran cohorts as they age in coming decades.

The purpose of this article is to provide a clinically focused overview of PTSD in Korean War veterans, to help promote understanding of this often-forgotten group of veterans, and to foster optimized personalized care. This overview will include a description of the Korean War veteran population and the Korean War itself, the manifestations and identification of PTSD among Korean War veterans, and treatment approaches using evidence-based psychotherapies and pharmacotherapies. Finally, we provide recommendations for future research to address present empirical gaps in the understanding and treatment of Korean War veterans with PTSD.

Causes and Course of the Korean War

When working with Korean War veterans it is important to consider the special nature of that specific conflict. Space considerations limit our ability to do justice to the complex history and numerous battles of the Korean War, but information in the following summary was gleaned from several excellent histories.^11-13

The Korean War has been referred to as The Forgotten War, a concern expressed even during the latter parts of the war.^14,15 But the war and its veterans warrant remembering. The root and proximal causes of the Korean War are complex and not fully agreed upon by the main participants.^16-19 In part this may reflect the fact that there was no clear victor in the Korean War, so that the different protagonists have developed their own versions of the history of the conflict. Also, US involvement and the public reaction to the war must be viewed within the larger historical context of that time. This context included the recent end of 4 years of US involvement in World War II (1941-1945) and the subsequent rapid rise of Cold War tensions between the US and the Soviet Union. The latter also included a worldwide fear of nuclear war and the US fear of the global spread of communism. These fears were fueled by the Soviet-led Berlin Blockade from June 1948 through May 1949, the Soviet Union’s successful atomic bomb test in August 1949, the founding of the People’s Republic of China in October 1949, and the February 1950 Sino-Soviet Treaty of Friendship and Alliance.¹³

In the closing days of World War II, the US and Soviet Union agreed to a temporary division of Korea along the 38th parallel to facilitate timely and efficient surrender of Japanese troops. But as Cold War tensions rose, the temporary division became permanent, and Soviet- and US-backed governments of the north and south, respectively, were officially established on the Korean peninsula in 1948. Although by 1949 the Soviets and US had withdrawn most troops from the peninsula, tensions between the north and south continued to mount and hostilities increased. To this day the exact causes of the eruption of war remain disputed, although it is clear that ideological as well as economic factors played a role, and both leaders of North and South Korea were pledging to reunite the peninsula under their respective leadership.^16-19 The tension culminated on June 25, 1950, when North Korean troops crossed the 38th parallel and invaded South Korea. On June 27, 1950, President Truman ordered US naval and air forces to support South Korea and then ordered the involvement of ground troops on June 30.^16,17,19

Although several other member countries of the United Nations (UN) provided troops, 90% of the troops were from the US. About 5.7 million US military personnel served during the war, including about 1.8 million in Korea itself. The US forces experienced approximately 34,000 battle-related deaths, 103,000 were wounded, and 7,000 were prisoners of war (POWs).^11,20-22 The nature and events of the Korean War made it particularly stressful and traumatizing for the soldiers, sailors, and marines involved throughout its entire course. These included near defeat in the early months, a widely alternating war front along the north/south axis during the first year, and subsequently, not only intense constant battles on the fronts, but also a demanding and exhausting guerrilla war in the south, which lasted throughout the remainder of the conflict.^11,15 The US troops during the initial months of the war have been described as outnumbered and underprepared, as many in the initial phase were reassigned from peace-time occupation duty in Japan.⁷

The first year of war was characterized by a repeated north-to-south/south-to-north shifts in control of territory. During the first 3 months, the North Korean forces overwhelmed the South and captured control of all but 2 South Korean cities in the far southeastern region (Pusan, now Busan; and Daegu), and US and UN forces were forced to retreat to the perimeter around Pusan. The intense Battle of Pusan Perimeter lasted from August 4, 1950 to September 18, 1950, and resulted in massive causalities as well as a flood of civilian refugees.

The course of the war began to change in early September 1950 with the landing of amphibious US/UN forces at Inchon, behind North Korean lines, which cut off southern supply routes for the North Korean troops.¹¹ US/UN forces soon crossed to the north of the 38th parallel and captured the North Korean capital, Pyongyang, on October 19, 1950. They continued to push north and approached the Yalu River border with China by late November 1950, but then the Chinese introduced their own troops forcing a southward retreat of US/UN troops during which there were again numerous US/UN casualties. Chinese troops retook Seoul in late December 1950/early January 1951. However, the US/UN forces soon recaptured Seoul and advanced back to the 38th parallel. This back-and-forth across the 38th parallel continued until July 1951 when the front line of battle stabilized there. Although the line stabilized, intense battles and casualties continued for 2 more years. During this period US/UN troops also had to deal with guerrilla warfare behind the front lines due to the actions of communist partisans and isolated North Korean troops. This situation continued until the armistice was signed July 27, 1953.

Trauma and Characteristic Stresses of the War

There were many factors that made the Korean War experience different from previous wars, particularly World War II. For example, in contrast to the strong public support during and after World War II, public support for the Korean War in the US was low, particularly during its final year.²³ In public opinion polls from October 1952 through April 1953, only 23% to 39% reported feeling that the war was worth fighting.²³ A retrospective 1985 survey also found that 70% of World War II veterans, but only 33% of Korean War veterans reported feeling appreciated by the US public on their return from the war.²⁴

Those fighting in the initial months of the war faced a particularly grim situation. According to LTC Philip Smith, who served as Division Psychiatrist on the Masan Front (Pusan Perimeter) during August and September of 1950, “Fighting was almost continuous and all available troops were on the fighting front… For the most part these soldiers were soft from occupation duty, many had not received adequate combat basic training, no refresher combat training in Korea had as yet been instituted,” he reported.⁷ “The extremes of climate coupled with the generally rugged mountainous terrain in Korea were physical factors of importance…These men were psychologically unprepared for the horrors and isolation of war.” LTC Smith noted that the change in status from civilian or occupation life to the marked deprivation of the war in Korea had been “too abrupt to allow as yet for a reasonable adjustment to the new setting” and that as a result “the highest rate of wounded and neuropsychiatric casualties in the Korean campaign resulted.”⁷

Even after this initial period, the nature of the shifting war, the challenging terrain, the high military casualty rate, and the high rate of civilian casualties and displacement continued throughout the war. The climate was also harsh; Korean War veterans were more likely than were those in World War II or Vietnam to experience injuries related to exposure to extreme cold during the winters (frostbite was among the most common service disabilities).¹⁴ During the Chosin Reservoir Campaign in late 1950, temperatures were as low as -50° F with a wind chill as low as -100° F.²⁵ In addition to cold injuries, other physical health concerns for Korean War veterans were noise injuries from gunfire and explosions and occupational hazards, such as exposure to asbestos, radiation, and polychlorinated biphenyls (PCBs).²⁶

PTSD in Korean War Veterans

It is clear that Korean War combat veterans were exposed to traumatic events. It is unknown how many developed PTSD. While notions of psychological distress and disability related to combat trauma exposure have existed for centuries, Korean War and World War II veterans are a remaining link to pre-DSM PTSD mental health in the military. Military/forward psychiatry—psychiatric services near the battle zone rather than requiring evacuation of patients—was present in Korea from the early months of the war, but the focus of forward psychiatry was to reduce psychiatric causalities from combat fatigue and maximize rapid return-to-duty.^4-6 With no real conception of PTSD, there were limited treatments available, and evidenced-based trauma-focused treatments for PTSD would not be introduced for at least another 4 decades.^27-29

Skinner and Kaplick conducted a historical review of case descriptions of trauma-related conditions from World War I through the Vietnam War and noted the consistent inclusion of hyperarousal and intrusive symptoms, although there also was a greater emphasis on somatic conversion or hysteria symptoms in the earlier descriptions.³⁰ By the Korean War, descriptions of combat fatigue included a number of symptoms that overlap with PTSD, including preoccupation with the traumatic stressor, nightmares, irritability/anger, increased startle, and hyperarousal.³¹ But following the acute phases, attention to any chronic problems associated with these conditions waned. As was acknowledged by a military psychiatrist in a 1954 talk, studies of the long-term adjustment of those who had “broken down in combat” were sorely needed.⁶ In a small 1965 study reported by Archibald and Tuddenham, persistent symptoms of combat fatigue among Korean War veterans were definitely present, and there was even a suggestion that the symptoms had increased over the decade since the war.³²

Given the stoicism that typified cultural expectations for military men during this period, Korean War veterans may also have been reluctant to seek mental health treatment either at the time or later. In short, it is likely that a nontrivial proportion of Korean War veterans with PTSD were underdiagnosed and received suboptimal or no mental health treatment for decades following their war experiences.³³ Although the nature of the war, deployment, and public support were distinct in World War II vs the Korean War, the absence of attention to the long-term effects of disorders related to combat trauma and the cultural expectations for stoicism suggest that PTSD among aging World War II veterans may also have gone underrecognized and undertreated.

Apart from the lack of interest in chronic effects of stressors, another problem that has plagued the limited empirical research on Korean War veterans has been the propensity to combine Korean War with World War II veteran samples in studies. Because World War II veterans have outnumbered Korean War veterans until recently, combined samples tended to have relatively few Korean War veterans. Nevertheless, from those studies that have been reported in which 2 groups were compared, important differences have been revealed. Specifically, although precise estimates of the prevalence of PTSD among Korean War combat veterans have varied depending on sampling and method, studies from the 1990s and early 2000s suggested that the prevalence of PTSD and other mental health concerns as well as the severity of symptoms, suicide risk, and psychosocial adjustment difficulties were worse among Korean War combat veterans relative to those among World War II combat veterans; however, both groups had lower prevalence than did Vietnam War combat veterans.^21,34-37 Several authors speculated that these differences in outcome were at least partially due to differences in public support for the respective wars.^36,37

Although there has been a paucity of research on psychiatric issues and PTSD in Korean War veterans, POWs who were very likely to have been exposed to extreme psychological traumas have received some attention. There have been comparisons of mortality and morbidity among POWs from the Korean War (PWK), World War II Pacific Theater (PWJ), and Europe (PWE).³⁸ Among measures that were administered to the former POWs, the overall pattern seen from survey data in the mid-1960s revealed significantly worse health and functioning among the PWK and PWJ groups relative to the PWE group, with psychiatric difficulties being the most commonly reported impairments among the former 2 groups. This pattern was found most strongly with regards to objective measures, such as hospitalizations for “psychoneuroses,” and US Department of Veterans Affairs (VA) disability records, as well as based on self-reported psychosocial/recreational difficulties measured using the Cornell Medical Index (CMI).³⁸

Gold and colleagues reported a follow-up study of more than 700 former POWs who were reinterviewed between 1989 and 1992.³⁹ Although there was no scale of PTSD symptoms prior to formulation of the diagnosis in 1980, the CMI was a self-reported checklist that included a large range of both medical as well as behavioral and psychiatric symptoms. Thus, using CMI survey responses from 1965, the authors examined the factor structure (ie, the correlational relationships between multiple scale items and subgroupings of items) of the CMI relative to diagnosis of PTSD in 1989 to 1992 based on results from the Structured Clinical Interview for the DSM-III-R (SCID). The intent was to help discern whether the component domains of PTSD were present and intercorrelated in a pattern similar to that of the contemporary diagnosis. The investigators examined the factor structure of 20 psychological items from the CMI that appeared relevant to PTSD criteria using the 1965 data. Three factors (subgroups of highly intercorrelated items) were found: irritability (31% of variance), fearfulness/anxiousness (9% of the variance), and social withdrawal (7% of the variance). Although these did not directly correspond to, or fully cover, DSM PTSD domains or criteria, there does appear to be a thematic resemblance of the CMI findings with PTSD, including alterations in arousal and mood, vigilance, and startle.

Identification and Treatment of PTSD in Older Veterans

Of the 1.2 million living Korean War veterans in the US, 36.3% use VA provided health care.⁴⁰ There are a number of complicating factors to consider in the current identification and treatment of PTSD in this cohort, including their advanced age; physical, cognitive, and social changes associated with normal aging; the associated medical and cognitive comorbidities; and the specific social-contextual factors in that age cohort. Any combination of these factors may complicate recognition, diagnosis, and treatment. It is also important to be cognizant of the additional stressors that may have been experienced by ethnic minorites and women serving in Korea, which are poorly documented and studied. Racial integration of the US military began during the Korean War, but the general pattern was for African American soldiers to be assigned to all-white units, rather than the reverse.^14,41,42 And although the majority of military personnel serving in Korea were male, there were women serving in health care positions at mobile army surgical hospital (MASH) units, medical air evacuation (Medevac) aircraft, and off-shore hospital ships.

The clinical presentation of PTSD in older adults has varied, which may partially relate to the time elapsed since the index trauma. For example, older veterans in general may show less avoidance behavior as a part of PTSD, but in those who experience trauma later in life there may actually be greater avoidance.^43,44 There have also been discrepant reports of intrusion or reexperiencing of symptoms, with these also potentially reduced in older veterans.^43,44 However, sleep disturbances seem to be very common among elderly combat veterans, and attention should be paid to the possible presence of sleep apnea, which may be more common in veterans with PTSD in general.^43,45,46

PTSD symptoms may reemerge after decades of remission or quiescence during retirement and/or with the emergence of neurocognitive impairment, such as Alzheimer disease or dementia. These individuals may have more difficulty engaging in distracting activities and work and spend more time engaging in reminiscence about the past, which can include increased focus on traumatic memories.^45,47 Davison and colleagues have suggested a concept they call later-adulthood trauma reengagement (LATR) where later in life combat veterans may “confront and rework their wartime memories in an effort to find meaning and build coherence.”⁴⁸ This process can be a double-edged sword, leading at times positively to enhanced personal growth or negatively to increased symptoms; preventive interventions may be able foster a more positive outcome.⁴⁸

There is some evidence supporting the validity of the Clinician Administered PTSD Scale (CAPS) for the evaluation of PTSD in older adults, although this was based on the DSM-III-revised criteria for PTSD and an earlier version of CAPS.⁴⁹ Bhattarai and colleagues examined responses to the 35-item Mississippi Scale for Combat-Related PTSD (M-PTSD) using VA clinical data collected between 2008 and 2015 on veterans of each combat era from World War II through the post-9/11.⁵⁰ Strong internal consistency and test-retest reliability of the M-PTSD was observed within each veteran era sample. However, using chart diagnosis of PTSD as the criterion standard, the cut-scores for optimal balance of sensitivity and specificity of the M-PTSD scores were substantially lower for the older cohorts (World War II and Korean War veterans) relative to those for Vietnam and more recent veteran cohorts. The authors concluded that M-PTSD can be validly used to screen for PTSD in veterans within each of these cohorts but recommended using lower than standard cut-scores for Korean War and World War II veterans.⁵⁰

This is also consistent with reports that suggest the use of lower cut-scores on self-administered PTSD symptom screens.^43,44 For the clinician interested in quantifying the severity of PTSD, the most recent tools available are the CAPS-5 and the PCL-5, which have both been created in accordance with the DSM-5. The CAPS-5 is a rater-administered tool, and the PCL-5 is self-administered by the veteran. Although there has been little research using these newer tools in geriatric populations, they can currently serve as a means of tracking the severity of PTSD while we await measures that are better validated in Korean War and other older veterans.

Beyond specific empirical guidance, VA clinicians must presently rely on clinical observations and experience. Patients from the Korean War cohort often present at the insistence of a family member for changes in sleep, mood, behavior, or cognition. When the veterans themselves present, older adults with PTSD often focus more on somatic concerns (including pain, sleep, and gastrointestinal disturbance) than psychiatric problems per se. The latter tendency may in part be due to the salience of such symptoms for them, but perhaps also due to considerable stigma of mental health care that is still largely present in this group.^43,44

Psychotherapy

Current VA treatment guidelines recommend trauma-focused therapies, with the strongest evidence base for prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) therapies.⁵¹Unfortunately, there is a dearth of published empirical data to evaluate the risks and effectiveness of these therapies not just in the context of Korean War veterans, but among any older adult with PTSD population.^33,44,52,53 Recently, Thorp and colleagues published the first randomized controlled trial comparing PE to a relaxation training (RT) therapy among older veterans (83% were from the Vietnam era).⁵⁴ RT is frequently used as a control condition for RCTs involving trauma-focused therapies. They found PE as well as RT to be well-tolerated by participants. They also found some evidence for superior efficacy in PE relative to RT, although the persistence of that improvement was less for self-rated vs clinician-rated symptoms. As the investigators noted, only 35% of those receiving PE exhibited clinically significant change, and 77% still met diagnostic criteria for PTSD, suggesting a persistence of symptom distress and need for further intervention research to advance treatment for PTSD in older adults.

There have been several excellent prior reviews discussing treatment of PTSD in older adults generally.^10,43,44,52 These reviews have invariably expressed concern about the lack of sufficient empirical studies, but based on evidence from studies and case reports, there seems to be tentative support that trauma-focused therapies are acceptable and efficacious for use with older adults with PTSD. In their recent scoping review, Pless Kaiser and colleagues made several recommendations for trauma-focused therapy with older adults, including slow/careful pacing and use of compensatory aids for cognitive and sensory deficits.⁴⁴ When cognitive impairment has exacerbated PTSD symptoms, they suggest therapists consider using an adapted form of CPT completed without a trauma narrative. For PE they recommend extending content across sessions and involving spouse or caregivers to assist with in vivo exposure and homework completion.⁴⁴

Recent studies suggest that PTSD may be a risk factor for the later development of neurodegenerative disorders, and it is often during assessments for dementia that a revelation of PTSD occurs.^10,43,47,55 Cognitive impairment may also be of relevance in deciding on the type of psychotherapy to be implemented, as it may have more adverse effects on the effectiveness of CPT than of exposure-based treatments (PE or EMDR). It may be useful to perform a cognitive assessment prior to initiation of a cognitive-based therapy, although extensive cognitive testing may not be practical or may be contraindicated because of fatigue. A brief screening tool such as the Montreal Cognitive Assessment or the Mini-Mental State Examinationmay be helpful.^{56, 57}

Prolonged exposure has been reported by many clinicians to be effective in older adults with PTSD; however, due consideration should be given to the needs of individuals, as many have functioned for decades by suppressing memories. Cognitive impairment may be important, as cognitive resources may have been utilized to cope with earlier traumas, and there may be a recrudescence or exacerbation of PTSD symptoms as these resources are compromised. There may therefore be a reemergence of symptoms that are more amenable to an exposure-based treatment. Veterans with PTSD and dementia can present particularly difficult treatment dilemmas because with progression of the dementia, standard PTSD treatments, including exposure-based treatments, may cease to be viable. Instead, the focus of intervention may need to be on specific environmental triggers and behavioral approaches that may also be designed to aid caregivers.

Apart from the treatment needs for specific PTSD symptoms, the decades-long effects of poor sleep, irritability, hypervigilance, and dissociation also have social consequences for patients, including marital discord and divorce, and social and family isolation that should be addressed in therapy when appropriate. In addition, many Korean War veterans, like all veterans, sought postmilitary employment in professions that are associated with higher rates of exposure to psychological trauma, such as police or fire departments, and this may have an exacerbating effect on PTSD.⁵⁸

Pharmacotherapy

There is very little empirical evidence guiding pharmacologic approaches to PTSD in older veterans. This population is at increased risk for many comorbidities, and pharmacologic treatments many require dosage adjustments, as is the case for any geriatric patient. Selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) medications have been proposed for some cases of PTSD.^59,60 Health care providers may consider the SSRIs escitalopram or sertraline preferentially given their decreased potential for drug-drug interactions, anticholinergic effects, or cardiac toxicity compared with that of other drugs in this class.^60,61 As venlafaxine can increase blood pressure, especially at higher doses, prescribers may choose duloxetine as an alternative if a SNRI is indicated.⁶⁰ For veterans when prazosin is being considered for nightmare control, monitoring for hypotension, orthostasis, and the administration of other antihypertensives or prostatic hypertrophy medications is necessary.⁶¹ The use of benzodiazepines, while not recommended for PTSD, should be viewed with even greater trepidation in a geriatric population given enhanced risk of falls and confusion in the geriatric veteran population.^60,62

Conclusions

Many of the oldest veterans (aged > 80 years) are from the Korean War era. The harsh and unique nature of the war, as well as the differences in context and support from the US public, and the outcome of the war, may have all contributed to and elevation of “combat fatigue” and PTSD among combat veterans from the Korean War. As the “forgotten war” cohort also has been forgotten by researchers, relatively little is known about posttraumatic stress sequelae of these veterans in the decades following the war.

From available evidence, we can readily surmise that problems were underrecognized and suboptimally diagnosed and treated. There is tentative evidence supporting the use of standard interviews and rating scales, such as the CAPS, M-PTSD, and PCL, but lower cut-scores than applied with Vietnam and later veteran cohorts are generally recommended to avoid excessive false negative errors. In terms of psychotherapy treatment, there is again a stark paucity of systematic research, but the limited evidence from studies of PTSD treatment in older adults from the general population tentatively support the acceptability and potential efficacy of recognized evidence-based trauma-focused psychotherapies for PTSD. Research on medication treatment is similarly lacking, but the general recommendations for the use of SSRI or SNRI medications seem to be valid, at least in our clinical experience, and the general rules for geriatric psychopharmacology definitely apply here—start low, go slow.

There are several important avenues for future research. Most pressing among these are establishing the effectiveness of existing treatments, and the modifications that may be needed in the broader context of the above factors, as well as the physical and cognitive changes associated with advanced age. Further research on the phenomenologic aspects of PTSD among Korean War and subsequent cohorts are also needed, as the information obtained will not only guide more effective personalized treatment of the Korean War veterans who remain with us, but also inform future generations of care in terms of the degree and dimensions of variability that may present between cohorts and within cohorts over the life span.

The Korean War lasted from June 25, 1950 through July 27, 1953. Although many veterans of the Korean War experienced traumas during extremely stressful combat conditions. However, they would not have been diagnosed with posttraumatic stress disorder (PTSD) at the time because the latter did not exist as a formal diagnosis until the publication of the third edition of the Diagnostic and Statistical Manual (DSM) in 1980.¹ Prior to 1980, psychiatric syndromes resulting from war and combat exposure where known by numerous other terms including shell shock, chronic traumatic war neurosis, and combat fatigue/combat exhaustion.^2,3 Military psychiatrists attended to combat fatigue during the course of the Korean War, but as was true of World War I and II, the focus was on returning soldiers to duty. Combat fatigue was generally viewed as a transient condition.^4-8

Although now octo- and nonagenarians, in 2019 there are 1.2 million living Korean War veterans in the US, representing 6.7% of all current veterans.⁹ Understanding their war experiences and the nature of their current and past presentation of PTSD is relevant not only in formal mental health settings, but in primary care settings, including home-based primary care, as well as community living centers, skilled nursing facilities and assisted living facilities. Older adults with PTSD often present with somatic concerns rather than spontaneously reporting mental health symptoms.¹⁰ Beyond the short-term clinical management of Korean War veterans with PTSD, consideration of their experiences also has long-term relevance for the appropriate treatment of other veteran cohorts as they age in coming decades.

The purpose of this article is to provide a clinically focused overview of PTSD in Korean War veterans, to help promote understanding of this often-forgotten group of veterans, and to foster optimized personalized care. This overview will include a description of the Korean War veteran population and the Korean War itself, the manifestations and identification of PTSD among Korean War veterans, and treatment approaches using evidence-based psychotherapies and pharmacotherapies. Finally, we provide recommendations for future research to address present empirical gaps in the understanding and treatment of Korean War veterans with PTSD.

Causes and Course of the Korean War

When working with Korean War veterans it is important to consider the special nature of that specific conflict. Space considerations limit our ability to do justice to the complex history and numerous battles of the Korean War, but information in the following summary was gleaned from several excellent histories.^11-13

The Korean War has been referred to as The Forgotten War, a concern expressed even during the latter parts of the war.^14,15 But the war and its veterans warrant remembering. The root and proximal causes of the Korean War are complex and not fully agreed upon by the main participants.^16-19 In part this may reflect the fact that there was no clear victor in the Korean War, so that the different protagonists have developed their own versions of the history of the conflict. Also, US involvement and the public reaction to the war must be viewed within the larger historical context of that time. This context included the recent end of 4 years of US involvement in World War II (1941-1945) and the subsequent rapid rise of Cold War tensions between the US and the Soviet Union. The latter also included a worldwide fear of nuclear war and the US fear of the global spread of communism. These fears were fueled by the Soviet-led Berlin Blockade from June 1948 through May 1949, the Soviet Union’s successful atomic bomb test in August 1949, the founding of the People’s Republic of China in October 1949, and the February 1950 Sino-Soviet Treaty of Friendship and Alliance.¹³

In the closing days of World War II, the US and Soviet Union agreed to a temporary division of Korea along the 38th parallel to facilitate timely and efficient surrender of Japanese troops. But as Cold War tensions rose, the temporary division became permanent, and Soviet- and US-backed governments of the north and south, respectively, were officially established on the Korean peninsula in 1948. Although by 1949 the Soviets and US had withdrawn most troops from the peninsula, tensions between the north and south continued to mount and hostilities increased. To this day the exact causes of the eruption of war remain disputed, although it is clear that ideological as well as economic factors played a role, and both leaders of North and South Korea were pledging to reunite the peninsula under their respective leadership.^16-19 The tension culminated on June 25, 1950, when North Korean troops crossed the 38th parallel and invaded South Korea. On June 27, 1950, President Truman ordered US naval and air forces to support South Korea and then ordered the involvement of ground troops on June 30.^16,17,19

Although several other member countries of the United Nations (UN) provided troops, 90% of the troops were from the US. About 5.7 million US military personnel served during the war, including about 1.8 million in Korea itself. The US forces experienced approximately 34,000 battle-related deaths, 103,000 were wounded, and 7,000 were prisoners of war (POWs).^11,20-22 The nature and events of the Korean War made it particularly stressful and traumatizing for the soldiers, sailors, and marines involved throughout its entire course. These included near defeat in the early months, a widely alternating war front along the north/south axis during the first year, and subsequently, not only intense constant battles on the fronts, but also a demanding and exhausting guerrilla war in the south, which lasted throughout the remainder of the conflict.^11,15 The US troops during the initial months of the war have been described as outnumbered and underprepared, as many in the initial phase were reassigned from peace-time occupation duty in Japan.⁷

The first year of war was characterized by a repeated north-to-south/south-to-north shifts in control of territory. During the first 3 months, the North Korean forces overwhelmed the South and captured control of all but 2 South Korean cities in the far southeastern region (Pusan, now Busan; and Daegu), and US and UN forces were forced to retreat to the perimeter around Pusan. The intense Battle of Pusan Perimeter lasted from August 4, 1950 to September 18, 1950, and resulted in massive causalities as well as a flood of civilian refugees.

The course of the war began to change in early September 1950 with the landing of amphibious US/UN forces at Inchon, behind North Korean lines, which cut off southern supply routes for the North Korean troops.¹¹ US/UN forces soon crossed to the north of the 38th parallel and captured the North Korean capital, Pyongyang, on October 19, 1950. They continued to push north and approached the Yalu River border with China by late November 1950, but then the Chinese introduced their own troops forcing a southward retreat of US/UN troops during which there were again numerous US/UN casualties. Chinese troops retook Seoul in late December 1950/early January 1951. However, the US/UN forces soon recaptured Seoul and advanced back to the 38th parallel. This back-and-forth across the 38th parallel continued until July 1951 when the front line of battle stabilized there. Although the line stabilized, intense battles and casualties continued for 2 more years. During this period US/UN troops also had to deal with guerrilla warfare behind the front lines due to the actions of communist partisans and isolated North Korean troops. This situation continued until the armistice was signed July 27, 1953.

Trauma and Characteristic Stresses of the War

There were many factors that made the Korean War experience different from previous wars, particularly World War II. For example, in contrast to the strong public support during and after World War II, public support for the Korean War in the US was low, particularly during its final year.²³ In public opinion polls from October 1952 through April 1953, only 23% to 39% reported feeling that the war was worth fighting.²³ A retrospective 1985 survey also found that 70% of World War II veterans, but only 33% of Korean War veterans reported feeling appreciated by the US public on their return from the war.²⁴

Those fighting in the initial months of the war faced a particularly grim situation. According to LTC Philip Smith, who served as Division Psychiatrist on the Masan Front (Pusan Perimeter) during August and September of 1950, “Fighting was almost continuous and all available troops were on the fighting front… For the most part these soldiers were soft from occupation duty, many had not received adequate combat basic training, no refresher combat training in Korea had as yet been instituted,” he reported.⁷ “The extremes of climate coupled with the generally rugged mountainous terrain in Korea were physical factors of importance…These men were psychologically unprepared for the horrors and isolation of war.” LTC Smith noted that the change in status from civilian or occupation life to the marked deprivation of the war in Korea had been “too abrupt to allow as yet for a reasonable adjustment to the new setting” and that as a result “the highest rate of wounded and neuropsychiatric casualties in the Korean campaign resulted.”⁷

Even after this initial period, the nature of the shifting war, the challenging terrain, the high military casualty rate, and the high rate of civilian casualties and displacement continued throughout the war. The climate was also harsh; Korean War veterans were more likely than were those in World War II or Vietnam to experience injuries related to exposure to extreme cold during the winters (frostbite was among the most common service disabilities).¹⁴ During the Chosin Reservoir Campaign in late 1950, temperatures were as low as -50° F with a wind chill as low as -100° F.²⁵ In addition to cold injuries, other physical health concerns for Korean War veterans were noise injuries from gunfire and explosions and occupational hazards, such as exposure to asbestos, radiation, and polychlorinated biphenyls (PCBs).²⁶

PTSD in Korean War Veterans

It is clear that Korean War combat veterans were exposed to traumatic events. It is unknown how many developed PTSD. While notions of psychological distress and disability related to combat trauma exposure have existed for centuries, Korean War and World War II veterans are a remaining link to pre-DSM PTSD mental health in the military. Military/forward psychiatry—psychiatric services near the battle zone rather than requiring evacuation of patients—was present in Korea from the early months of the war, but the focus of forward psychiatry was to reduce psychiatric causalities from combat fatigue and maximize rapid return-to-duty.^4-6 With no real conception of PTSD, there were limited treatments available, and evidenced-based trauma-focused treatments for PTSD would not be introduced for at least another 4 decades.^27-29

Skinner and Kaplick conducted a historical review of case descriptions of trauma-related conditions from World War I through the Vietnam War and noted the consistent inclusion of hyperarousal and intrusive symptoms, although there also was a greater emphasis on somatic conversion or hysteria symptoms in the earlier descriptions.³⁰ By the Korean War, descriptions of combat fatigue included a number of symptoms that overlap with PTSD, including preoccupation with the traumatic stressor, nightmares, irritability/anger, increased startle, and hyperarousal.³¹ But following the acute phases, attention to any chronic problems associated with these conditions waned. As was acknowledged by a military psychiatrist in a 1954 talk, studies of the long-term adjustment of those who had “broken down in combat” were sorely needed.⁶ In a small 1965 study reported by Archibald and Tuddenham, persistent symptoms of combat fatigue among Korean War veterans were definitely present, and there was even a suggestion that the symptoms had increased over the decade since the war.³²

Given the stoicism that typified cultural expectations for military men during this period, Korean War veterans may also have been reluctant to seek mental health treatment either at the time or later. In short, it is likely that a nontrivial proportion of Korean War veterans with PTSD were underdiagnosed and received suboptimal or no mental health treatment for decades following their war experiences.³³ Although the nature of the war, deployment, and public support were distinct in World War II vs the Korean War, the absence of attention to the long-term effects of disorders related to combat trauma and the cultural expectations for stoicism suggest that PTSD among aging World War II veterans may also have gone underrecognized and undertreated.

Apart from the lack of interest in chronic effects of stressors, another problem that has plagued the limited empirical research on Korean War veterans has been the propensity to combine Korean War with World War II veteran samples in studies. Because World War II veterans have outnumbered Korean War veterans until recently, combined samples tended to have relatively few Korean War veterans. Nevertheless, from those studies that have been reported in which 2 groups were compared, important differences have been revealed. Specifically, although precise estimates of the prevalence of PTSD among Korean War combat veterans have varied depending on sampling and method, studies from the 1990s and early 2000s suggested that the prevalence of PTSD and other mental health concerns as well as the severity of symptoms, suicide risk, and psychosocial adjustment difficulties were worse among Korean War combat veterans relative to those among World War II combat veterans; however, both groups had lower prevalence than did Vietnam War combat veterans.^21,34-37 Several authors speculated that these differences in outcome were at least partially due to differences in public support for the respective wars.^36,37

Although there has been a paucity of research on psychiatric issues and PTSD in Korean War veterans, POWs who were very likely to have been exposed to extreme psychological traumas have received some attention. There have been comparisons of mortality and morbidity among POWs from the Korean War (PWK), World War II Pacific Theater (PWJ), and Europe (PWE).³⁸ Among measures that were administered to the former POWs, the overall pattern seen from survey data in the mid-1960s revealed significantly worse health and functioning among the PWK and PWJ groups relative to the PWE group, with psychiatric difficulties being the most commonly reported impairments among the former 2 groups. This pattern was found most strongly with regards to objective measures, such as hospitalizations for “psychoneuroses,” and US Department of Veterans Affairs (VA) disability records, as well as based on self-reported psychosocial/recreational difficulties measured using the Cornell Medical Index (CMI).³⁸

Gold and colleagues reported a follow-up study of more than 700 former POWs who were reinterviewed between 1989 and 1992.³⁹ Although there was no scale of PTSD symptoms prior to formulation of the diagnosis in 1980, the CMI was a self-reported checklist that included a large range of both medical as well as behavioral and psychiatric symptoms. Thus, using CMI survey responses from 1965, the authors examined the factor structure (ie, the correlational relationships between multiple scale items and subgroupings of items) of the CMI relative to diagnosis of PTSD in 1989 to 1992 based on results from the Structured Clinical Interview for the DSM-III-R (SCID). The intent was to help discern whether the component domains of PTSD were present and intercorrelated in a pattern similar to that of the contemporary diagnosis. The investigators examined the factor structure of 20 psychological items from the CMI that appeared relevant to PTSD criteria using the 1965 data. Three factors (subgroups of highly intercorrelated items) were found: irritability (31% of variance), fearfulness/anxiousness (9% of the variance), and social withdrawal (7% of the variance). Although these did not directly correspond to, or fully cover, DSM PTSD domains or criteria, there does appear to be a thematic resemblance of the CMI findings with PTSD, including alterations in arousal and mood, vigilance, and startle.

Identification and Treatment of PTSD in Older Veterans

Of the 1.2 million living Korean War veterans in the US, 36.3% use VA provided health care.⁴⁰ There are a number of complicating factors to consider in the current identification and treatment of PTSD in this cohort, including their advanced age; physical, cognitive, and social changes associated with normal aging; the associated medical and cognitive comorbidities; and the specific social-contextual factors in that age cohort. Any combination of these factors may complicate recognition, diagnosis, and treatment. It is also important to be cognizant of the additional stressors that may have been experienced by ethnic minorites and women serving in Korea, which are poorly documented and studied. Racial integration of the US military began during the Korean War, but the general pattern was for African American soldiers to be assigned to all-white units, rather than the reverse.^14,41,42 And although the majority of military personnel serving in Korea were male, there were women serving in health care positions at mobile army surgical hospital (MASH) units, medical air evacuation (Medevac) aircraft, and off-shore hospital ships.

The clinical presentation of PTSD in older adults has varied, which may partially relate to the time elapsed since the index trauma. For example, older veterans in general may show less avoidance behavior as a part of PTSD, but in those who experience trauma later in life there may actually be greater avoidance.^43,44 There have also been discrepant reports of intrusion or reexperiencing of symptoms, with these also potentially reduced in older veterans.^43,44 However, sleep disturbances seem to be very common among elderly combat veterans, and attention should be paid to the possible presence of sleep apnea, which may be more common in veterans with PTSD in general.^43,45,46

PTSD symptoms may reemerge after decades of remission or quiescence during retirement and/or with the emergence of neurocognitive impairment, such as Alzheimer disease or dementia. These individuals may have more difficulty engaging in distracting activities and work and spend more time engaging in reminiscence about the past, which can include increased focus on traumatic memories.^45,47 Davison and colleagues have suggested a concept they call later-adulthood trauma reengagement (LATR) where later in life combat veterans may “confront and rework their wartime memories in an effort to find meaning and build coherence.”⁴⁸ This process can be a double-edged sword, leading at times positively to enhanced personal growth or negatively to increased symptoms; preventive interventions may be able foster a more positive outcome.⁴⁸

There is some evidence supporting the validity of the Clinician Administered PTSD Scale (CAPS) for the evaluation of PTSD in older adults, although this was based on the DSM-III-revised criteria for PTSD and an earlier version of CAPS.⁴⁹ Bhattarai and colleagues examined responses to the 35-item Mississippi Scale for Combat-Related PTSD (M-PTSD) using VA clinical data collected between 2008 and 2015 on veterans of each combat era from World War II through the post-9/11.⁵⁰ Strong internal consistency and test-retest reliability of the M-PTSD was observed within each veteran era sample. However, using chart diagnosis of PTSD as the criterion standard, the cut-scores for optimal balance of sensitivity and specificity of the M-PTSD scores were substantially lower for the older cohorts (World War II and Korean War veterans) relative to those for Vietnam and more recent veteran cohorts. The authors concluded that M-PTSD can be validly used to screen for PTSD in veterans within each of these cohorts but recommended using lower than standard cut-scores for Korean War and World War II veterans.⁵⁰

This is also consistent with reports that suggest the use of lower cut-scores on self-administered PTSD symptom screens.^43,44 For the clinician interested in quantifying the severity of PTSD, the most recent tools available are the CAPS-5 and the PCL-5, which have both been created in accordance with the DSM-5. The CAPS-5 is a rater-administered tool, and the PCL-5 is self-administered by the veteran. Although there has been little research using these newer tools in geriatric populations, they can currently serve as a means of tracking the severity of PTSD while we await measures that are better validated in Korean War and other older veterans.

Beyond specific empirical guidance, VA clinicians must presently rely on clinical observations and experience. Patients from the Korean War cohort often present at the insistence of a family member for changes in sleep, mood, behavior, or cognition. When the veterans themselves present, older adults with PTSD often focus more on somatic concerns (including pain, sleep, and gastrointestinal disturbance) than psychiatric problems per se. The latter tendency may in part be due to the salience of such symptoms for them, but perhaps also due to considerable stigma of mental health care that is still largely present in this group.^43,44

Psychotherapy

Current VA treatment guidelines recommend trauma-focused therapies, with the strongest evidence base for prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) therapies.⁵¹Unfortunately, there is a dearth of published empirical data to evaluate the risks and effectiveness of these therapies not just in the context of Korean War veterans, but among any older adult with PTSD population.^33,44,52,53 Recently, Thorp and colleagues published the first randomized controlled trial comparing PE to a relaxation training (RT) therapy among older veterans (83% were from the Vietnam era).⁵⁴ RT is frequently used as a control condition for RCTs involving trauma-focused therapies. They found PE as well as RT to be well-tolerated by participants. They also found some evidence for superior efficacy in PE relative to RT, although the persistence of that improvement was less for self-rated vs clinician-rated symptoms. As the investigators noted, only 35% of those receiving PE exhibited clinically significant change, and 77% still met diagnostic criteria for PTSD, suggesting a persistence of symptom distress and need for further intervention research to advance treatment for PTSD in older adults.

There have been several excellent prior reviews discussing treatment of PTSD in older adults generally.^10,43,44,52 These reviews have invariably expressed concern about the lack of sufficient empirical studies, but based on evidence from studies and case reports, there seems to be tentative support that trauma-focused therapies are acceptable and efficacious for use with older adults with PTSD. In their recent scoping review, Pless Kaiser and colleagues made several recommendations for trauma-focused therapy with older adults, including slow/careful pacing and use of compensatory aids for cognitive and sensory deficits.⁴⁴ When cognitive impairment has exacerbated PTSD symptoms, they suggest therapists consider using an adapted form of CPT completed without a trauma narrative. For PE they recommend extending content across sessions and involving spouse or caregivers to assist with in vivo exposure and homework completion.⁴⁴

Recent studies suggest that PTSD may be a risk factor for the later development of neurodegenerative disorders, and it is often during assessments for dementia that a revelation of PTSD occurs.^10,43,47,55 Cognitive impairment may also be of relevance in deciding on the type of psychotherapy to be implemented, as it may have more adverse effects on the effectiveness of CPT than of exposure-based treatments (PE or EMDR). It may be useful to perform a cognitive assessment prior to initiation of a cognitive-based therapy, although extensive cognitive testing may not be practical or may be contraindicated because of fatigue. A brief screening tool such as the Montreal Cognitive Assessment or the Mini-Mental State Examinationmay be helpful.^{56, 57}

Prolonged exposure has been reported by many clinicians to be effective in older adults with PTSD; however, due consideration should be given to the needs of individuals, as many have functioned for decades by suppressing memories. Cognitive impairment may be important, as cognitive resources may have been utilized to cope with earlier traumas, and there may be a recrudescence or exacerbation of PTSD symptoms as these resources are compromised. There may therefore be a reemergence of symptoms that are more amenable to an exposure-based treatment. Veterans with PTSD and dementia can present particularly difficult treatment dilemmas because with progression of the dementia, standard PTSD treatments, including exposure-based treatments, may cease to be viable. Instead, the focus of intervention may need to be on specific environmental triggers and behavioral approaches that may also be designed to aid caregivers.

Apart from the treatment needs for specific PTSD symptoms, the decades-long effects of poor sleep, irritability, hypervigilance, and dissociation also have social consequences for patients, including marital discord and divorce, and social and family isolation that should be addressed in therapy when appropriate. In addition, many Korean War veterans, like all veterans, sought postmilitary employment in professions that are associated with higher rates of exposure to psychological trauma, such as police or fire departments, and this may have an exacerbating effect on PTSD.⁵⁸

Pharmacotherapy

There is very little empirical evidence guiding pharmacologic approaches to PTSD in older veterans. This population is at increased risk for many comorbidities, and pharmacologic treatments many require dosage adjustments, as is the case for any geriatric patient. Selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) medications have been proposed for some cases of PTSD.^59,60 Health care providers may consider the SSRIs escitalopram or sertraline preferentially given their decreased potential for drug-drug interactions, anticholinergic effects, or cardiac toxicity compared with that of other drugs in this class.^60,61 As venlafaxine can increase blood pressure, especially at higher doses, prescribers may choose duloxetine as an alternative if a SNRI is indicated.⁶⁰ For veterans when prazosin is being considered for nightmare control, monitoring for hypotension, orthostasis, and the administration of other antihypertensives or prostatic hypertrophy medications is necessary.⁶¹ The use of benzodiazepines, while not recommended for PTSD, should be viewed with even greater trepidation in a geriatric population given enhanced risk of falls and confusion in the geriatric veteran population.^60,62

Conclusions

Many of the oldest veterans (aged > 80 years) are from the Korean War era. The harsh and unique nature of the war, as well as the differences in context and support from the US public, and the outcome of the war, may have all contributed to and elevation of “combat fatigue” and PTSD among combat veterans from the Korean War. As the “forgotten war” cohort also has been forgotten by researchers, relatively little is known about posttraumatic stress sequelae of these veterans in the decades following the war.

From available evidence, we can readily surmise that problems were underrecognized and suboptimally diagnosed and treated. There is tentative evidence supporting the use of standard interviews and rating scales, such as the CAPS, M-PTSD, and PCL, but lower cut-scores than applied with Vietnam and later veteran cohorts are generally recommended to avoid excessive false negative errors. In terms of psychotherapy treatment, there is again a stark paucity of systematic research, but the limited evidence from studies of PTSD treatment in older adults from the general population tentatively support the acceptability and potential efficacy of recognized evidence-based trauma-focused psychotherapies for PTSD. Research on medication treatment is similarly lacking, but the general recommendations for the use of SSRI or SNRI medications seem to be valid, at least in our clinical experience, and the general rules for geriatric psychopharmacology definitely apply here—start low, go slow.

There are several important avenues for future research. Most pressing among these are establishing the effectiveness of existing treatments, and the modifications that may be needed in the broader context of the above factors, as well as the physical and cognitive changes associated with advanced age. Further research on the phenomenologic aspects of PTSD among Korean War and subsequent cohorts are also needed, as the information obtained will not only guide more effective personalized treatment of the Korean War veterans who remain with us, but also inform future generations of care in terms of the degree and dimensions of variability that may present between cohorts and within cohorts over the life span.

The Korean War lasted from June 25, 1950 through July 27, 1953. Although many veterans of the Korean War experienced traumas during extremely stressful combat conditions. However, they would not have been diagnosed with posttraumatic stress disorder (PTSD) at the time because the latter did not exist as a formal diagnosis until the publication of the third edition of the Diagnostic and Statistical Manual (DSM) in 1980.¹ Prior to 1980, psychiatric syndromes resulting from war and combat exposure where known by numerous other terms including shell shock, chronic traumatic war neurosis, and combat fatigue/combat exhaustion.^2,3 Military psychiatrists attended to combat fatigue during the course of the Korean War, but as was true of World War I and II, the focus was on returning soldiers to duty. Combat fatigue was generally viewed as a transient condition.^4-8

Although now octo- and nonagenarians, in 2019 there are 1.2 million living Korean War veterans in the US, representing 6.7% of all current veterans.⁹ Understanding their war experiences and the nature of their current and past presentation of PTSD is relevant not only in formal mental health settings, but in primary care settings, including home-based primary care, as well as community living centers, skilled nursing facilities and assisted living facilities. Older adults with PTSD often present with somatic concerns rather than spontaneously reporting mental health symptoms.¹⁰ Beyond the short-term clinical management of Korean War veterans with PTSD, consideration of their experiences also has long-term relevance for the appropriate treatment of other veteran cohorts as they age in coming decades.

The purpose of this article is to provide a clinically focused overview of PTSD in Korean War veterans, to help promote understanding of this often-forgotten group of veterans, and to foster optimized personalized care. This overview will include a description of the Korean War veteran population and the Korean War itself, the manifestations and identification of PTSD among Korean War veterans, and treatment approaches using evidence-based psychotherapies and pharmacotherapies. Finally, we provide recommendations for future research to address present empirical gaps in the understanding and treatment of Korean War veterans with PTSD.

Causes and Course of the Korean War

When working with Korean War veterans it is important to consider the special nature of that specific conflict. Space considerations limit our ability to do justice to the complex history and numerous battles of the Korean War, but information in the following summary was gleaned from several excellent histories.^11-13

The Korean War has been referred to as The Forgotten War, a concern expressed even during the latter parts of the war.^14,15 But the war and its veterans warrant remembering. The root and proximal causes of the Korean War are complex and not fully agreed upon by the main participants.^16-19 In part this may reflect the fact that there was no clear victor in the Korean War, so that the different protagonists have developed their own versions of the history of the conflict. Also, US involvement and the public reaction to the war must be viewed within the larger historical context of that time. This context included the recent end of 4 years of US involvement in World War II (1941-1945) and the subsequent rapid rise of Cold War tensions between the US and the Soviet Union. The latter also included a worldwide fear of nuclear war and the US fear of the global spread of communism. These fears were fueled by the Soviet-led Berlin Blockade from June 1948 through May 1949, the Soviet Union’s successful atomic bomb test in August 1949, the founding of the People’s Republic of China in October 1949, and the February 1950 Sino-Soviet Treaty of Friendship and Alliance.¹³

In the closing days of World War II, the US and Soviet Union agreed to a temporary division of Korea along the 38th parallel to facilitate timely and efficient surrender of Japanese troops. But as Cold War tensions rose, the temporary division became permanent, and Soviet- and US-backed governments of the north and south, respectively, were officially established on the Korean peninsula in 1948. Although by 1949 the Soviets and US had withdrawn most troops from the peninsula, tensions between the north and south continued to mount and hostilities increased. To this day the exact causes of the eruption of war remain disputed, although it is clear that ideological as well as economic factors played a role, and both leaders of North and South Korea were pledging to reunite the peninsula under their respective leadership.^16-19 The tension culminated on June 25, 1950, when North Korean troops crossed the 38th parallel and invaded South Korea. On June 27, 1950, President Truman ordered US naval and air forces to support South Korea and then ordered the involvement of ground troops on June 30.^16,17,19

Although several other member countries of the United Nations (UN) provided troops, 90% of the troops were from the US. About 5.7 million US military personnel served during the war, including about 1.8 million in Korea itself. The US forces experienced approximately 34,000 battle-related deaths, 103,000 were wounded, and 7,000 were prisoners of war (POWs).^11,20-22 The nature and events of the Korean War made it particularly stressful and traumatizing for the soldiers, sailors, and marines involved throughout its entire course. These included near defeat in the early months, a widely alternating war front along the north/south axis during the first year, and subsequently, not only intense constant battles on the fronts, but also a demanding and exhausting guerrilla war in the south, which lasted throughout the remainder of the conflict.^11,15 The US troops during the initial months of the war have been described as outnumbered and underprepared, as many in the initial phase were reassigned from peace-time occupation duty in Japan.⁷

The first year of war was characterized by a repeated north-to-south/south-to-north shifts in control of territory. During the first 3 months, the North Korean forces overwhelmed the South and captured control of all but 2 South Korean cities in the far southeastern region (Pusan, now Busan; and Daegu), and US and UN forces were forced to retreat to the perimeter around Pusan. The intense Battle of Pusan Perimeter lasted from August 4, 1950 to September 18, 1950, and resulted in massive causalities as well as a flood of civilian refugees.

The course of the war began to change in early September 1950 with the landing of amphibious US/UN forces at Inchon, behind North Korean lines, which cut off southern supply routes for the North Korean troops.¹¹ US/UN forces soon crossed to the north of the 38th parallel and captured the North Korean capital, Pyongyang, on October 19, 1950. They continued to push north and approached the Yalu River border with China by late November 1950, but then the Chinese introduced their own troops forcing a southward retreat of US/UN troops during which there were again numerous US/UN casualties. Chinese troops retook Seoul in late December 1950/early January 1951. However, the US/UN forces soon recaptured Seoul and advanced back to the 38th parallel. This back-and-forth across the 38th parallel continued until July 1951 when the front line of battle stabilized there. Although the line stabilized, intense battles and casualties continued for 2 more years. During this period US/UN troops also had to deal with guerrilla warfare behind the front lines due to the actions of communist partisans and isolated North Korean troops. This situation continued until the armistice was signed July 27, 1953.

Trauma and Characteristic Stresses of the War

There were many factors that made the Korean War experience different from previous wars, particularly World War II. For example, in contrast to the strong public support during and after World War II, public support for the Korean War in the US was low, particularly during its final year.²³ In public opinion polls from October 1952 through April 1953, only 23% to 39% reported feeling that the war was worth fighting.²³ A retrospective 1985 survey also found that 70% of World War II veterans, but only 33% of Korean War veterans reported feeling appreciated by the US public on their return from the war.²⁴

Those fighting in the initial months of the war faced a particularly grim situation. According to LTC Philip Smith, who served as Division Psychiatrist on the Masan Front (Pusan Perimeter) during August and September of 1950, “Fighting was almost continuous and all available troops were on the fighting front… For the most part these soldiers were soft from occupation duty, many had not received adequate combat basic training, no refresher combat training in Korea had as yet been instituted,” he reported.⁷ “The extremes of climate coupled with the generally rugged mountainous terrain in Korea were physical factors of importance…These men were psychologically unprepared for the horrors and isolation of war.” LTC Smith noted that the change in status from civilian or occupation life to the marked deprivation of the war in Korea had been “too abrupt to allow as yet for a reasonable adjustment to the new setting” and that as a result “the highest rate of wounded and neuropsychiatric casualties in the Korean campaign resulted.”⁷

Even after this initial period, the nature of the shifting war, the challenging terrain, the high military casualty rate, and the high rate of civilian casualties and displacement continued throughout the war. The climate was also harsh; Korean War veterans were more likely than were those in World War II or Vietnam to experience injuries related to exposure to extreme cold during the winters (frostbite was among the most common service disabilities).¹⁴ During the Chosin Reservoir Campaign in late 1950, temperatures were as low as -50° F with a wind chill as low as -100° F.²⁵ In addition to cold injuries, other physical health concerns for Korean War veterans were noise injuries from gunfire and explosions and occupational hazards, such as exposure to asbestos, radiation, and polychlorinated biphenyls (PCBs).²⁶

PTSD in Korean War Veterans

It is clear that Korean War combat veterans were exposed to traumatic events. It is unknown how many developed PTSD. While notions of psychological distress and disability related to combat trauma exposure have existed for centuries, Korean War and World War II veterans are a remaining link to pre-DSM PTSD mental health in the military. Military/forward psychiatry—psychiatric services near the battle zone rather than requiring evacuation of patients—was present in Korea from the early months of the war, but the focus of forward psychiatry was to reduce psychiatric causalities from combat fatigue and maximize rapid return-to-duty.^4-6 With no real conception of PTSD, there were limited treatments available, and evidenced-based trauma-focused treatments for PTSD would not be introduced for at least another 4 decades.^27-29

Skinner and Kaplick conducted a historical review of case descriptions of trauma-related conditions from World War I through the Vietnam War and noted the consistent inclusion of hyperarousal and intrusive symptoms, although there also was a greater emphasis on somatic conversion or hysteria symptoms in the earlier descriptions.³⁰ By the Korean War, descriptions of combat fatigue included a number of symptoms that overlap with PTSD, including preoccupation with the traumatic stressor, nightmares, irritability/anger, increased startle, and hyperarousal.³¹ But following the acute phases, attention to any chronic problems associated with these conditions waned. As was acknowledged by a military psychiatrist in a 1954 talk, studies of the long-term adjustment of those who had “broken down in combat” were sorely needed.⁶ In a small 1965 study reported by Archibald and Tuddenham, persistent symptoms of combat fatigue among Korean War veterans were definitely present, and there was even a suggestion that the symptoms had increased over the decade since the war.³²

Given the stoicism that typified cultural expectations for military men during this period, Korean War veterans may also have been reluctant to seek mental health treatment either at the time or later. In short, it is likely that a nontrivial proportion of Korean War veterans with PTSD were underdiagnosed and received suboptimal or no mental health treatment for decades following their war experiences.³³ Although the nature of the war, deployment, and public support were distinct in World War II vs the Korean War, the absence of attention to the long-term effects of disorders related to combat trauma and the cultural expectations for stoicism suggest that PTSD among aging World War II veterans may also have gone underrecognized and undertreated.

Apart from the lack of interest in chronic effects of stressors, another problem that has plagued the limited empirical research on Korean War veterans has been the propensity to combine Korean War with World War II veteran samples in studies. Because World War II veterans have outnumbered Korean War veterans until recently, combined samples tended to have relatively few Korean War veterans. Nevertheless, from those studies that have been reported in which 2 groups were compared, important differences have been revealed. Specifically, although precise estimates of the prevalence of PTSD among Korean War combat veterans have varied depending on sampling and method, studies from the 1990s and early 2000s suggested that the prevalence of PTSD and other mental health concerns as well as the severity of symptoms, suicide risk, and psychosocial adjustment difficulties were worse among Korean War combat veterans relative to those among World War II combat veterans; however, both groups had lower prevalence than did Vietnam War combat veterans.^21,34-37 Several authors speculated that these differences in outcome were at least partially due to differences in public support for the respective wars.^36,37

Although there has been a paucity of research on psychiatric issues and PTSD in Korean War veterans, POWs who were very likely to have been exposed to extreme psychological traumas have received some attention. There have been comparisons of mortality and morbidity among POWs from the Korean War (PWK), World War II Pacific Theater (PWJ), and Europe (PWE).³⁸ Among measures that were administered to the former POWs, the overall pattern seen from survey data in the mid-1960s revealed significantly worse health and functioning among the PWK and PWJ groups relative to the PWE group, with psychiatric difficulties being the most commonly reported impairments among the former 2 groups. This pattern was found most strongly with regards to objective measures, such as hospitalizations for “psychoneuroses,” and US Department of Veterans Affairs (VA) disability records, as well as based on self-reported psychosocial/recreational difficulties measured using the Cornell Medical Index (CMI).³⁸

Gold and colleagues reported a follow-up study of more than 700 former POWs who were reinterviewed between 1989 and 1992.³⁹ Although there was no scale of PTSD symptoms prior to formulation of the diagnosis in 1980, the CMI was a self-reported checklist that included a large range of both medical as well as behavioral and psychiatric symptoms. Thus, using CMI survey responses from 1965, the authors examined the factor structure (ie, the correlational relationships between multiple scale items and subgroupings of items) of the CMI relative to diagnosis of PTSD in 1989 to 1992 based on results from the Structured Clinical Interview for the DSM-III-R (SCID). The intent was to help discern whether the component domains of PTSD were present and intercorrelated in a pattern similar to that of the contemporary diagnosis. The investigators examined the factor structure of 20 psychological items from the CMI that appeared relevant to PTSD criteria using the 1965 data. Three factors (subgroups of highly intercorrelated items) were found: irritability (31% of variance), fearfulness/anxiousness (9% of the variance), and social withdrawal (7% of the variance). Although these did not directly correspond to, or fully cover, DSM PTSD domains or criteria, there does appear to be a thematic resemblance of the CMI findings with PTSD, including alterations in arousal and mood, vigilance, and startle.

Identification and Treatment of PTSD in Older Veterans

Of the 1.2 million living Korean War veterans in the US, 36.3% use VA provided health care.⁴⁰ There are a number of complicating factors to consider in the current identification and treatment of PTSD in this cohort, including their advanced age; physical, cognitive, and social changes associated with normal aging; the associated medical and cognitive comorbidities; and the specific social-contextual factors in that age cohort. Any combination of these factors may complicate recognition, diagnosis, and treatment. It is also important to be cognizant of the additional stressors that may have been experienced by ethnic minorites and women serving in Korea, which are poorly documented and studied. Racial integration of the US military began during the Korean War, but the general pattern was for African American soldiers to be assigned to all-white units, rather than the reverse.^14,41,42 And although the majority of military personnel serving in Korea were male, there were women serving in health care positions at mobile army surgical hospital (MASH) units, medical air evacuation (Medevac) aircraft, and off-shore hospital ships.

The clinical presentation of PTSD in older adults has varied, which may partially relate to the time elapsed since the index trauma. For example, older veterans in general may show less avoidance behavior as a part of PTSD, but in those who experience trauma later in life there may actually be greater avoidance.^43,44 There have also been discrepant reports of intrusion or reexperiencing of symptoms, with these also potentially reduced in older veterans.^43,44 However, sleep disturbances seem to be very common among elderly combat veterans, and attention should be paid to the possible presence of sleep apnea, which may be more common in veterans with PTSD in general.^43,45,46

PTSD symptoms may reemerge after decades of remission or quiescence during retirement and/or with the emergence of neurocognitive impairment, such as Alzheimer disease or dementia. These individuals may have more difficulty engaging in distracting activities and work and spend more time engaging in reminiscence about the past, which can include increased focus on traumatic memories.^45,47 Davison and colleagues have suggested a concept they call later-adulthood trauma reengagement (LATR) where later in life combat veterans may “confront and rework their wartime memories in an effort to find meaning and build coherence.”⁴⁸ This process can be a double-edged sword, leading at times positively to enhanced personal growth or negatively to increased symptoms; preventive interventions may be able foster a more positive outcome.⁴⁸

There is some evidence supporting the validity of the Clinician Administered PTSD Scale (CAPS) for the evaluation of PTSD in older adults, although this was based on the DSM-III-revised criteria for PTSD and an earlier version of CAPS.⁴⁹ Bhattarai and colleagues examined responses to the 35-item Mississippi Scale for Combat-Related PTSD (M-PTSD) using VA clinical data collected between 2008 and 2015 on veterans of each combat era from World War II through the post-9/11.⁵⁰ Strong internal consistency and test-retest reliability of the M-PTSD was observed within each veteran era sample. However, using chart diagnosis of PTSD as the criterion standard, the cut-scores for optimal balance of sensitivity and specificity of the M-PTSD scores were substantially lower for the older cohorts (World War II and Korean War veterans) relative to those for Vietnam and more recent veteran cohorts. The authors concluded that M-PTSD can be validly used to screen for PTSD in veterans within each of these cohorts but recommended using lower than standard cut-scores for Korean War and World War II veterans.⁵⁰

This is also consistent with reports that suggest the use of lower cut-scores on self-administered PTSD symptom screens.^43,44 For the clinician interested in quantifying the severity of PTSD, the most recent tools available are the CAPS-5 and the PCL-5, which have both been created in accordance with the DSM-5. The CAPS-5 is a rater-administered tool, and the PCL-5 is self-administered by the veteran. Although there has been little research using these newer tools in geriatric populations, they can currently serve as a means of tracking the severity of PTSD while we await measures that are better validated in Korean War and other older veterans.

Beyond specific empirical guidance, VA clinicians must presently rely on clinical observations and experience. Patients from the Korean War cohort often present at the insistence of a family member for changes in sleep, mood, behavior, or cognition. When the veterans themselves present, older adults with PTSD often focus more on somatic concerns (including pain, sleep, and gastrointestinal disturbance) than psychiatric problems per se. The latter tendency may in part be due to the salience of such symptoms for them, but perhaps also due to considerable stigma of mental health care that is still largely present in this group.^43,44

Psychotherapy

Current VA treatment guidelines recommend trauma-focused therapies, with the strongest evidence base for prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR) therapies.⁵¹Unfortunately, there is a dearth of published empirical data to evaluate the risks and effectiveness of these therapies not just in the context of Korean War veterans, but among any older adult with PTSD population.^33,44,52,53 Recently, Thorp and colleagues published the first randomized controlled trial comparing PE to a relaxation training (RT) therapy among older veterans (83% were from the Vietnam era).⁵⁴ RT is frequently used as a control condition for RCTs involving trauma-focused therapies. They found PE as well as RT to be well-tolerated by participants. They also found some evidence for superior efficacy in PE relative to RT, although the persistence of that improvement was less for self-rated vs clinician-rated symptoms. As the investigators noted, only 35% of those receiving PE exhibited clinically significant change, and 77% still met diagnostic criteria for PTSD, suggesting a persistence of symptom distress and need for further intervention research to advance treatment for PTSD in older adults.

There have been several excellent prior reviews discussing treatment of PTSD in older adults generally.^10,43,44,52 These reviews have invariably expressed concern about the lack of sufficient empirical studies, but based on evidence from studies and case reports, there seems to be tentative support that trauma-focused therapies are acceptable and efficacious for use with older adults with PTSD. In their recent scoping review, Pless Kaiser and colleagues made several recommendations for trauma-focused therapy with older adults, including slow/careful pacing and use of compensatory aids for cognitive and sensory deficits.⁴⁴ When cognitive impairment has exacerbated PTSD symptoms, they suggest therapists consider using an adapted form of CPT completed without a trauma narrative. For PE they recommend extending content across sessions and involving spouse or caregivers to assist with in vivo exposure and homework completion.⁴⁴

Recent studies suggest that PTSD may be a risk factor for the later development of neurodegenerative disorders, and it is often during assessments for dementia that a revelation of PTSD occurs.^10,43,47,55 Cognitive impairment may also be of relevance in deciding on the type of psychotherapy to be implemented, as it may have more adverse effects on the effectiveness of CPT than of exposure-based treatments (PE or EMDR). It may be useful to perform a cognitive assessment prior to initiation of a cognitive-based therapy, although extensive cognitive testing may not be practical or may be contraindicated because of fatigue. A brief screening tool such as the Montreal Cognitive Assessment or the Mini-Mental State Examinationmay be helpful.^{56, 57}

Prolonged exposure has been reported by many clinicians to be effective in older adults with PTSD; however, due consideration should be given to the needs of individuals, as many have functioned for decades by suppressing memories. Cognitive impairment may be important, as cognitive resources may have been utilized to cope with earlier traumas, and there may be a recrudescence or exacerbation of PTSD symptoms as these resources are compromised. There may therefore be a reemergence of symptoms that are more amenable to an exposure-based treatment. Veterans with PTSD and dementia can present particularly difficult treatment dilemmas because with progression of the dementia, standard PTSD treatments, including exposure-based treatments, may cease to be viable. Instead, the focus of intervention may need to be on specific environmental triggers and behavioral approaches that may also be designed to aid caregivers.

Apart from the treatment needs for specific PTSD symptoms, the decades-long effects of poor sleep, irritability, hypervigilance, and dissociation also have social consequences for patients, including marital discord and divorce, and social and family isolation that should be addressed in therapy when appropriate. In addition, many Korean War veterans, like all veterans, sought postmilitary employment in professions that are associated with higher rates of exposure to psychological trauma, such as police or fire departments, and this may have an exacerbating effect on PTSD.⁵⁸

Pharmacotherapy

There is very little empirical evidence guiding pharmacologic approaches to PTSD in older veterans. This population is at increased risk for many comorbidities, and pharmacologic treatments many require dosage adjustments, as is the case for any geriatric patient. Selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) medications have been proposed for some cases of PTSD.^59,60 Health care providers may consider the SSRIs escitalopram or sertraline preferentially given their decreased potential for drug-drug interactions, anticholinergic effects, or cardiac toxicity compared with that of other drugs in this class.^60,61 As venlafaxine can increase blood pressure, especially at higher doses, prescribers may choose duloxetine as an alternative if a SNRI is indicated.⁶⁰ For veterans when prazosin is being considered for nightmare control, monitoring for hypotension, orthostasis, and the administration of other antihypertensives or prostatic hypertrophy medications is necessary.⁶¹ The use of benzodiazepines, while not recommended for PTSD, should be viewed with even greater trepidation in a geriatric population given enhanced risk of falls and confusion in the geriatric veteran population.^60,62

Conclusions

Many of the oldest veterans (aged > 80 years) are from the Korean War era. The harsh and unique nature of the war, as well as the differences in context and support from the US public, and the outcome of the war, may have all contributed to and elevation of “combat fatigue” and PTSD among combat veterans from the Korean War. As the “forgotten war” cohort also has been forgotten by researchers, relatively little is known about posttraumatic stress sequelae of these veterans in the decades following the war.

From available evidence, we can readily surmise that problems were underrecognized and suboptimally diagnosed and treated. There is tentative evidence supporting the use of standard interviews and rating scales, such as the CAPS, M-PTSD, and PCL, but lower cut-scores than applied with Vietnam and later veteran cohorts are generally recommended to avoid excessive false negative errors. In terms of psychotherapy treatment, there is again a stark paucity of systematic research, but the limited evidence from studies of PTSD treatment in older adults from the general population tentatively support the acceptability and potential efficacy of recognized evidence-based trauma-focused psychotherapies for PTSD. Research on medication treatment is similarly lacking, but the general recommendations for the use of SSRI or SNRI medications seem to be valid, at least in our clinical experience, and the general rules for geriatric psychopharmacology definitely apply here—start low, go slow.

There are several important avenues for future research. Most pressing among these are establishing the effectiveness of existing treatments, and the modifications that may be needed in the broader context of the above factors, as well as the physical and cognitive changes associated with advanced age. Further research on the phenomenologic aspects of PTSD among Korean War and subsequent cohorts are also needed, as the information obtained will not only guide more effective personalized treatment of the Korean War veterans who remain with us, but also inform future generations of care in terms of the degree and dimensions of variability that may present between cohorts and within cohorts over the life span.

To the Editor: We read with interest the editorial on the clinical use of intranasal esketamine in treatment-resistant depression by Editor-in-Chief Cynthia Geppert in the October 2019 issue of Federal Practitioner.¹ A recent case report published in your journal illustrated the success of IV ketamine in alleviating refractory chronic pain caused by a rare disease.² Ketamine has been well established as an appropriate adjuvant as well as an alternative to opioids in attenuating acute postoperative pain and in certain chronic pain syndromes.³ We write out of concern for the rapidity of adoption of intranasal esketamine without considering the merits of IV ketamine.

When adopting new treatments or extending established drugs for newer indications, clinicians must balance beneficence and nonmaleficence. There is an urgent need for better treatment options for depression, suicidality, posttraumatic stress disorder (PTSD), and chronic pain in the veteran population. However, one must proceed with caution before wide adoption of a treatment that lacks real-world data on sustained or long-term benefits.⁴ Enthusiasm for this drug must also be tempered by the documented adverse effect (AE) of hepatic injury and the lack of data tracking this AE from repeated, long-term use.⁵ With these considerations in mind, reliable dosing and predictable pharmacokinetics are of great importance.

In addition to outpatient esketamine, outpatient IV administration of racemic ketamine remains an advantageous option with unique benefits compared with esketamine. Pharmacokinetically, IV ketamine is superior to intranasal esketamine. The bioavailability of intranasal esketamine is likely to be variable. A patient with a poor intranasal application or poor absorption might be falsely labeled an esketamine nonresponder. Increasing intranasal esketamine dosage to avoid false nonresponders may place other patients at risk for overdose and undesired AEs, including dysphoria and hallucinations. The variable bioavailability of intranasal ketamine adds complexity to the examination of its clinical effectiveness. IV ketamine should provide a predictable drug level and more reliable data. One might retort that esketamine is not the same as ketamine. True, esketamine is the S-enantiomer of ketamine, whereas ketamine is a racemic mixture of S- and R-ketamine. However, there is no clear evidence of clinically relevant differences between these formulations.⁵

Psychomimetic effects and cardiovascular changes are the most common short-term AEs resulting from ketamine.⁵ An IV infusion allows the treating physician to slowly titrate the administered ketamine to reach an effective concentration at the target site. Unlike an all-or-none intranasal administration, an infusion can be stopped at the first appearance of an AE. Psychomimetic effects, such as hallucinations, visual disturbances, and dysphoria are thought to occur in a dose-dependent fashion and remit once a ketamine infusion is stopped.⁵ Furthermore, cardiovascular AEs, such as hypertension and tachycardia, are commonly in patients with a body mass index > 30, with IV administration on a mg/kg basis. This suggests that calculated ideal body weight is a safer denominator, and reliable dosing is important to mitigating AEs.⁶

We urge caution with the widespread adoption of intranasal esketamine and suggest the advantages of the IV route, which offers predictability of AEs and titratability of dose. Questions remain regarding the appropriate dose and formulation of ketamine, rate of infusion, and route of administration for chronic pain and psychiatric indications.^5,7 It is our responsibility to further study the long-term safety profile of ketamine and determine an appropriate dose of ketamine. The IV route allows many veterans to be helped in a safe and controllable manner.

Eugene Raggi, MD; and Srikantha L. Rao, MD, MS, FAS

To the Editor: We read with interest the editorial on the clinical use of intranasal esketamine in treatment-resistant depression by Editor-in-Chief Cynthia Geppert in the October 2019 issue of Federal Practitioner.¹ A recent case report published in your journal illustrated the success of IV ketamine in alleviating refractory chronic pain caused by a rare disease.² Ketamine has been well established as an appropriate adjuvant as well as an alternative to opioids in attenuating acute postoperative pain and in certain chronic pain syndromes.³ We write out of concern for the rapidity of adoption of intranasal esketamine without considering the merits of IV ketamine.

When adopting new treatments or extending established drugs for newer indications, clinicians must balance beneficence and nonmaleficence. There is an urgent need for better treatment options for depression, suicidality, posttraumatic stress disorder (PTSD), and chronic pain in the veteran population. However, one must proceed with caution before wide adoption of a treatment that lacks real-world data on sustained or long-term benefits.⁴ Enthusiasm for this drug must also be tempered by the documented adverse effect (AE) of hepatic injury and the lack of data tracking this AE from repeated, long-term use.⁵ With these considerations in mind, reliable dosing and predictable pharmacokinetics are of great importance.

In addition to outpatient esketamine, outpatient IV administration of racemic ketamine remains an advantageous option with unique benefits compared with esketamine. Pharmacokinetically, IV ketamine is superior to intranasal esketamine. The bioavailability of intranasal esketamine is likely to be variable. A patient with a poor intranasal application or poor absorption might be falsely labeled an esketamine nonresponder. Increasing intranasal esketamine dosage to avoid false nonresponders may place other patients at risk for overdose and undesired AEs, including dysphoria and hallucinations. The variable bioavailability of intranasal ketamine adds complexity to the examination of its clinical effectiveness. IV ketamine should provide a predictable drug level and more reliable data. One might retort that esketamine is not the same as ketamine. True, esketamine is the S-enantiomer of ketamine, whereas ketamine is a racemic mixture of S- and R-ketamine. However, there is no clear evidence of clinically relevant differences between these formulations.⁵

Psychomimetic effects and cardiovascular changes are the most common short-term AEs resulting from ketamine.⁵ An IV infusion allows the treating physician to slowly titrate the administered ketamine to reach an effective concentration at the target site. Unlike an all-or-none intranasal administration, an infusion can be stopped at the first appearance of an AE. Psychomimetic effects, such as hallucinations, visual disturbances, and dysphoria are thought to occur in a dose-dependent fashion and remit once a ketamine infusion is stopped.⁵ Furthermore, cardiovascular AEs, such as hypertension and tachycardia, are commonly in patients with a body mass index > 30, with IV administration on a mg/kg basis. This suggests that calculated ideal body weight is a safer denominator, and reliable dosing is important to mitigating AEs.⁶

We urge caution with the widespread adoption of intranasal esketamine and suggest the advantages of the IV route, which offers predictability of AEs and titratability of dose. Questions remain regarding the appropriate dose and formulation of ketamine, rate of infusion, and route of administration for chronic pain and psychiatric indications.^5,7 It is our responsibility to further study the long-term safety profile of ketamine and determine an appropriate dose of ketamine. The IV route allows many veterans to be helped in a safe and controllable manner.

Eugene Raggi, MD; and Srikantha L. Rao, MD, MS, FAS

To the Editor: We read with interest the editorial on the clinical use of intranasal esketamine in treatment-resistant depression by Editor-in-Chief Cynthia Geppert in the October 2019 issue of Federal Practitioner.¹ A recent case report published in your journal illustrated the success of IV ketamine in alleviating refractory chronic pain caused by a rare disease.² Ketamine has been well established as an appropriate adjuvant as well as an alternative to opioids in attenuating acute postoperative pain and in certain chronic pain syndromes.³ We write out of concern for the rapidity of adoption of intranasal esketamine without considering the merits of IV ketamine.

When adopting new treatments or extending established drugs for newer indications, clinicians must balance beneficence and nonmaleficence. There is an urgent need for better treatment options for depression, suicidality, posttraumatic stress disorder (PTSD), and chronic pain in the veteran population. However, one must proceed with caution before wide adoption of a treatment that lacks real-world data on sustained or long-term benefits.⁴ Enthusiasm for this drug must also be tempered by the documented adverse effect (AE) of hepatic injury and the lack of data tracking this AE from repeated, long-term use.⁵ With these considerations in mind, reliable dosing and predictable pharmacokinetics are of great importance.

In addition to outpatient esketamine, outpatient IV administration of racemic ketamine remains an advantageous option with unique benefits compared with esketamine. Pharmacokinetically, IV ketamine is superior to intranasal esketamine. The bioavailability of intranasal esketamine is likely to be variable. A patient with a poor intranasal application or poor absorption might be falsely labeled an esketamine nonresponder. Increasing intranasal esketamine dosage to avoid false nonresponders may place other patients at risk for overdose and undesired AEs, including dysphoria and hallucinations. The variable bioavailability of intranasal ketamine adds complexity to the examination of its clinical effectiveness. IV ketamine should provide a predictable drug level and more reliable data. One might retort that esketamine is not the same as ketamine. True, esketamine is the S-enantiomer of ketamine, whereas ketamine is a racemic mixture of S- and R-ketamine. However, there is no clear evidence of clinically relevant differences between these formulations.⁵

Psychomimetic effects and cardiovascular changes are the most common short-term AEs resulting from ketamine.⁵ An IV infusion allows the treating physician to slowly titrate the administered ketamine to reach an effective concentration at the target site. Unlike an all-or-none intranasal administration, an infusion can be stopped at the first appearance of an AE. Psychomimetic effects, such as hallucinations, visual disturbances, and dysphoria are thought to occur in a dose-dependent fashion and remit once a ketamine infusion is stopped.⁵ Furthermore, cardiovascular AEs, such as hypertension and tachycardia, are commonly in patients with a body mass index > 30, with IV administration on a mg/kg basis. This suggests that calculated ideal body weight is a safer denominator, and reliable dosing is important to mitigating AEs.⁶

We urge caution with the widespread adoption of intranasal esketamine and suggest the advantages of the IV route, which offers predictability of AEs and titratability of dose. Questions remain regarding the appropriate dose and formulation of ketamine, rate of infusion, and route of administration for chronic pain and psychiatric indications.^5,7 It is our responsibility to further study the long-term safety profile of ketamine and determine an appropriate dose of ketamine. The IV route allows many veterans to be helped in a safe and controllable manner.

Eugene Raggi, MD; and Srikantha L. Rao, MD, MS, FAS

Readers may recall that at the end of each calendar as opposed to fiscal year—I know it is hard to believe time exists outside the Federal system—Federal Practitioner publishes my ethics-focused version of the familiar year-end roundup. This year I am reversing the typical order of most annual rankings by putting the worst first for 2 morally salient reasons.

The first is that, sadly, it is almost always easier to identify multiple incidents that compete ignominiously for the “worst” of federal health care. Even more disappointing, it is comparatively difficult to find stories for the “best” that are of the same scale and scope as the bad news. This is not to say that every day there are not individual narratives of courage and compassion reported in US Department of Defense, US Public Health Service, and US Department of Veterans Affairs (VA), and hundreds more unsung heroes.

The second reason is that as human beings our psychology is such that we gravitate toward the worst things more powerfully and persistently than we do the best. This is in part why it is more difficult to find uplifting stories and why the demoralizing ones affect us so strongly. In an exhaustive review of the subject, psychologists Roy Baumeister and colleagues conclude that,

When equal measures of good and bad are present, however, the psychological effects of bad ones outweigh those of the good ones. This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaptation of each individual to the exigencies of daily life.²

I am thus saving the best for last in the hope that it will be more memorable and impactful than the worst.

Unique to this year’s look-back, both the negative and the positive accounts come from the domain of end-of-life care. And unlike prior reviews where the lack of administrative vigilance and professional competence affected hundreds of patients, families, and staff, each of this year’s incidents involve a single patient.

An incident that occurred in September 2019 at a VA Community Living Center (CLC) in Georgia stood out in infamy apart from all others. It was the report of a veteran in a VA nursing home who had been bitten more than 100 times by ants crawling all over his room. He died shortly afterward. In a scene out of a horror movie tapping into the most primeval human fears, his daughter Laquana Ross described her father, a Vietnam Air Force veteran with cancer, to media and VA officials in graphic terms. “I understand mistakes happen,” she said. “I’ve had ants. But he was bit by ants two days in a row. They feasted on him.”³

In this new era of holding its senior executive service accountable, the outraged chair of the Senate Veterans Affairs Committee demanded that heads roll, and the VA acted rapidly to comply.⁴ The VA Central Office placed the network director on administrative leave, reassigned the chief medical officer, and initiated quality and safety reviews as well as an administrative investigative board to scrutinize how the parent Atlanta VA medical center managed the situation. In total, 9 officials connected to the incident were placed on leave. The VA apologized, with VA Secretary Robert Wilke zeroing in on the core values involved in the tragedy, “This is about basic humanity and dignity,” he said. “I don’t care what steps were taken to address the issues. We did not treat a vet with the dignity that he and his family deserved.”⁵ Yet it was the veteran’s daughter, with unbelievable charity, who asked the most crucial question that must be answered within the framework of a just culture if similar tragedies are not to occur in the future, “I know the staff, without a shadow of doubt, respected my dad and even loved him,” Ross said. “But what’s their ability to assess situations and fix things?”³

To begin to give Ms. Ross the answer she deserves, we must understand that the antithesis of love is not hate but indifference; of compassion, it is not cruelty but coldness. A true just culture reserves individual blame for those who have ill-will and adopts a systems perspective of organizational improvement toward most other types of errors.⁶ This means that the deplorable conditions in the CLC cannot be charged to the failure of a single staff member to fulfil their obligations but to collective collapse at many levels of the organization. Just culture is ethically laudable and far superior to the history in federal service of capricious punishment or institutional apathy that far too often were the default reactions to media exposures or congressional ire. Justice, though necessary, is not sufficient to achieve virtue. Those who work in health care also must be inspired to offer mercy, kindness, and compassion, especially in our most sacred privilege to provide care of the dying.

The best of 2019 illustrates this distinction movingly. This account also involves a Vietnam veteran, this time a Marine also dying of cancer, which happened just about a month after the earlier report. To be transparent it occurred at my home VA medical center in New Mexico. I was peripherally involved in the case as a consultant but had no role in the wondrous things that transpired. The last wish of a patient dying in the hospice unit on campus was to see his beloved dog who had been taken to the local city animal shelter when he was hospitalized because he had no friends or family to look after the companion animal. A social worker on the palliative care team called the animal shelter and explained the patient did not have much time left but wanted to see his dog before he died. Working together with support from facility leadership, shelter workers brought the dog to visit with the patient for an entire day while hospice staff cried with joy and sadness.⁷

As the epigraph for this editorial from Dame Cicely Saunders, the founder of the modern hospice movement, says, the difference between unspeakable pain and meaningful suffering can be measured in the depth of compassion caregivers show to the dying. It is this quality of mercy that in one case condemns, and in the other praises, us all as health care and administrative professionals in the service of our country. Baumeister and colleagues suggest that the human tendency to magnify the bad and minimize the good in everyday myopia may in a wider vision actually be a reason for hope:

It may be that humans and animals show heightened awareness of and responded more quickly to negative information because it signals a need for change. Hence, the adaptiveness of self-regulation partly lies in the organism’s ability to detect when response modifications are necessary and when they are unnecessary. Moreover, the lessons learned from bad events should ideally be retained permanently so that the same dangers or costs are not encountered repeatedly. Meanwhile, good events (such as those that provide a feeling of satisfaction and contentment) should ideally wear off so that the organism is motivated to continue searching for more and better outcomes.²

Let us all take this lesson into our work in 2020 so that when it comes time to write this column next year in the chilling cold of late autumn there will be more stories of light than darkness from which to choose.

Readers may recall that at the end of each calendar as opposed to fiscal year—I know it is hard to believe time exists outside the Federal system—Federal Practitioner publishes my ethics-focused version of the familiar year-end roundup. This year I am reversing the typical order of most annual rankings by putting the worst first for 2 morally salient reasons.

The first is that, sadly, it is almost always easier to identify multiple incidents that compete ignominiously for the “worst” of federal health care. Even more disappointing, it is comparatively difficult to find stories for the “best” that are of the same scale and scope as the bad news. This is not to say that every day there are not individual narratives of courage and compassion reported in US Department of Defense, US Public Health Service, and US Department of Veterans Affairs (VA), and hundreds more unsung heroes.

The second reason is that as human beings our psychology is such that we gravitate toward the worst things more powerfully and persistently than we do the best. This is in part why it is more difficult to find uplifting stories and why the demoralizing ones affect us so strongly. In an exhaustive review of the subject, psychologists Roy Baumeister and colleagues conclude that,

When equal measures of good and bad are present, however, the psychological effects of bad ones outweigh those of the good ones. This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaptation of each individual to the exigencies of daily life.²

I am thus saving the best for last in the hope that it will be more memorable and impactful than the worst.

Unique to this year’s look-back, both the negative and the positive accounts come from the domain of end-of-life care. And unlike prior reviews where the lack of administrative vigilance and professional competence affected hundreds of patients, families, and staff, each of this year’s incidents involve a single patient.

An incident that occurred in September 2019 at a VA Community Living Center (CLC) in Georgia stood out in infamy apart from all others. It was the report of a veteran in a VA nursing home who had been bitten more than 100 times by ants crawling all over his room. He died shortly afterward. In a scene out of a horror movie tapping into the most primeval human fears, his daughter Laquana Ross described her father, a Vietnam Air Force veteran with cancer, to media and VA officials in graphic terms. “I understand mistakes happen,” she said. “I’ve had ants. But he was bit by ants two days in a row. They feasted on him.”³

In this new era of holding its senior executive service accountable, the outraged chair of the Senate Veterans Affairs Committee demanded that heads roll, and the VA acted rapidly to comply.⁴ The VA Central Office placed the network director on administrative leave, reassigned the chief medical officer, and initiated quality and safety reviews as well as an administrative investigative board to scrutinize how the parent Atlanta VA medical center managed the situation. In total, 9 officials connected to the incident were placed on leave. The VA apologized, with VA Secretary Robert Wilke zeroing in on the core values involved in the tragedy, “This is about basic humanity and dignity,” he said. “I don’t care what steps were taken to address the issues. We did not treat a vet with the dignity that he and his family deserved.”⁵ Yet it was the veteran’s daughter, with unbelievable charity, who asked the most crucial question that must be answered within the framework of a just culture if similar tragedies are not to occur in the future, “I know the staff, without a shadow of doubt, respected my dad and even loved him,” Ross said. “But what’s their ability to assess situations and fix things?”³

To begin to give Ms. Ross the answer she deserves, we must understand that the antithesis of love is not hate but indifference; of compassion, it is not cruelty but coldness. A true just culture reserves individual blame for those who have ill-will and adopts a systems perspective of organizational improvement toward most other types of errors.⁶ This means that the deplorable conditions in the CLC cannot be charged to the failure of a single staff member to fulfil their obligations but to collective collapse at many levels of the organization. Just culture is ethically laudable and far superior to the history in federal service of capricious punishment or institutional apathy that far too often were the default reactions to media exposures or congressional ire. Justice, though necessary, is not sufficient to achieve virtue. Those who work in health care also must be inspired to offer mercy, kindness, and compassion, especially in our most sacred privilege to provide care of the dying.

The best of 2019 illustrates this distinction movingly. This account also involves a Vietnam veteran, this time a Marine also dying of cancer, which happened just about a month after the earlier report. To be transparent it occurred at my home VA medical center in New Mexico. I was peripherally involved in the case as a consultant but had no role in the wondrous things that transpired. The last wish of a patient dying in the hospice unit on campus was to see his beloved dog who had been taken to the local city animal shelter when he was hospitalized because he had no friends or family to look after the companion animal. A social worker on the palliative care team called the animal shelter and explained the patient did not have much time left but wanted to see his dog before he died. Working together with support from facility leadership, shelter workers brought the dog to visit with the patient for an entire day while hospice staff cried with joy and sadness.⁷

As the epigraph for this editorial from Dame Cicely Saunders, the founder of the modern hospice movement, says, the difference between unspeakable pain and meaningful suffering can be measured in the depth of compassion caregivers show to the dying. It is this quality of mercy that in one case condemns, and in the other praises, us all as health care and administrative professionals in the service of our country. Baumeister and colleagues suggest that the human tendency to magnify the bad and minimize the good in everyday myopia may in a wider vision actually be a reason for hope:

It may be that humans and animals show heightened awareness of and responded more quickly to negative information because it signals a need for change. Hence, the adaptiveness of self-regulation partly lies in the organism’s ability to detect when response modifications are necessary and when they are unnecessary. Moreover, the lessons learned from bad events should ideally be retained permanently so that the same dangers or costs are not encountered repeatedly. Meanwhile, good events (such as those that provide a feeling of satisfaction and contentment) should ideally wear off so that the organism is motivated to continue searching for more and better outcomes.²

Let us all take this lesson into our work in 2020 so that when it comes time to write this column next year in the chilling cold of late autumn there will be more stories of light than darkness from which to choose.

Readers may recall that at the end of each calendar as opposed to fiscal year—I know it is hard to believe time exists outside the Federal system—Federal Practitioner publishes my ethics-focused version of the familiar year-end roundup. This year I am reversing the typical order of most annual rankings by putting the worst first for 2 morally salient reasons.

The first is that, sadly, it is almost always easier to identify multiple incidents that compete ignominiously for the “worst” of federal health care. Even more disappointing, it is comparatively difficult to find stories for the “best” that are of the same scale and scope as the bad news. This is not to say that every day there are not individual narratives of courage and compassion reported in US Department of Defense, US Public Health Service, and US Department of Veterans Affairs (VA), and hundreds more unsung heroes.

The second reason is that as human beings our psychology is such that we gravitate toward the worst things more powerfully and persistently than we do the best. This is in part why it is more difficult to find uplifting stories and why the demoralizing ones affect us so strongly. In an exhaustive review of the subject, psychologists Roy Baumeister and colleagues conclude that,

When equal measures of good and bad are present, however, the psychological effects of bad ones outweigh those of the good ones. This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaptation of each individual to the exigencies of daily life.²

I am thus saving the best for last in the hope that it will be more memorable and impactful than the worst.

Unique to this year’s look-back, both the negative and the positive accounts come from the domain of end-of-life care. And unlike prior reviews where the lack of administrative vigilance and professional competence affected hundreds of patients, families, and staff, each of this year’s incidents involve a single patient.

An incident that occurred in September 2019 at a VA Community Living Center (CLC) in Georgia stood out in infamy apart from all others. It was the report of a veteran in a VA nursing home who had been bitten more than 100 times by ants crawling all over his room. He died shortly afterward. In a scene out of a horror movie tapping into the most primeval human fears, his daughter Laquana Ross described her father, a Vietnam Air Force veteran with cancer, to media and VA officials in graphic terms. “I understand mistakes happen,” she said. “I’ve had ants. But he was bit by ants two days in a row. They feasted on him.”³

In this new era of holding its senior executive service accountable, the outraged chair of the Senate Veterans Affairs Committee demanded that heads roll, and the VA acted rapidly to comply.⁴ The VA Central Office placed the network director on administrative leave, reassigned the chief medical officer, and initiated quality and safety reviews as well as an administrative investigative board to scrutinize how the parent Atlanta VA medical center managed the situation. In total, 9 officials connected to the incident were placed on leave. The VA apologized, with VA Secretary Robert Wilke zeroing in on the core values involved in the tragedy, “This is about basic humanity and dignity,” he said. “I don’t care what steps were taken to address the issues. We did not treat a vet with the dignity that he and his family deserved.”⁵ Yet it was the veteran’s daughter, with unbelievable charity, who asked the most crucial question that must be answered within the framework of a just culture if similar tragedies are not to occur in the future, “I know the staff, without a shadow of doubt, respected my dad and even loved him,” Ross said. “But what’s their ability to assess situations and fix things?”³

To begin to give Ms. Ross the answer she deserves, we must understand that the antithesis of love is not hate but indifference; of compassion, it is not cruelty but coldness. A true just culture reserves individual blame for those who have ill-will and adopts a systems perspective of organizational improvement toward most other types of errors.⁶ This means that the deplorable conditions in the CLC cannot be charged to the failure of a single staff member to fulfil their obligations but to collective collapse at many levels of the organization. Just culture is ethically laudable and far superior to the history in federal service of capricious punishment or institutional apathy that far too often were the default reactions to media exposures or congressional ire. Justice, though necessary, is not sufficient to achieve virtue. Those who work in health care also must be inspired to offer mercy, kindness, and compassion, especially in our most sacred privilege to provide care of the dying.

The best of 2019 illustrates this distinction movingly. This account also involves a Vietnam veteran, this time a Marine also dying of cancer, which happened just about a month after the earlier report. To be transparent it occurred at my home VA medical center in New Mexico. I was peripherally involved in the case as a consultant but had no role in the wondrous things that transpired. The last wish of a patient dying in the hospice unit on campus was to see his beloved dog who had been taken to the local city animal shelter when he was hospitalized because he had no friends or family to look after the companion animal. A social worker on the palliative care team called the animal shelter and explained the patient did not have much time left but wanted to see his dog before he died. Working together with support from facility leadership, shelter workers brought the dog to visit with the patient for an entire day while hospice staff cried with joy and sadness.⁷

As the epigraph for this editorial from Dame Cicely Saunders, the founder of the modern hospice movement, says, the difference between unspeakable pain and meaningful suffering can be measured in the depth of compassion caregivers show to the dying. It is this quality of mercy that in one case condemns, and in the other praises, us all as health care and administrative professionals in the service of our country. Baumeister and colleagues suggest that the human tendency to magnify the bad and minimize the good in everyday myopia may in a wider vision actually be a reason for hope:

It may be that humans and animals show heightened awareness of and responded more quickly to negative information because it signals a need for change. Hence, the adaptiveness of self-regulation partly lies in the organism’s ability to detect when response modifications are necessary and when they are unnecessary. Moreover, the lessons learned from bad events should ideally be retained permanently so that the same dangers or costs are not encountered repeatedly. Meanwhile, good events (such as those that provide a feeling of satisfaction and contentment) should ideally wear off so that the organism is motivated to continue searching for more and better outcomes.²

Let us all take this lesson into our work in 2020 so that when it comes time to write this column next year in the chilling cold of late autumn there will be more stories of light than darkness from which to choose.

Scleromyxedema, or generalized lichen myxedematosus, is a primary cutaneous mucinosis with unknown pathogenesis characterized by generalized firm, skin-colored papules and is commonly associated with an underlying monoclonal gammopathy (usually Ig-gamma paraproteinemia).

Courtesy Rachel Fayne, BA, Dr. Yumeng Li, Dr. Fabrizio Galimberti, and Dr. Brian Morrison

Scleromyxedema may have associated internal involvement, including neurologic, gastrointestinal, pulmonary, renal, cardiovascular, ophthalmological, or musculoskeletal. Histopathology demonstrates mucin in the dermis seen with Alcian blue staining, proliferation of fibroblasts, and increased collagen deposition.

The condition is chronic and progressive. Intravenous immunoglobulin is considered first-line treatment. Thalidomide and corticosteroids have been reported to also be efficacious.

Erythema elevatum diutinum (EED) is a small-vessel vasculitis that presents with asymptomatic, symmetrical nodules or plaques on extensor surfaces. It is associated with hematologic disorders, including IgA monoclonal gammopathy, as well as myeloproliferative disorders, leukemia, infections, and inflammatory bowel disease. Although its pathophysiology is not well understood, vascular immune complex deposition, repetitive inflammation, and subsequent fibrosis may play a role. On histology, there is leukocytoclastic vasculitis with polymorphonuclear cell infiltrate and fibrin deposition in the superficial and mid-dermis and onion-skin fibrosis.

EED often self-resolves within 5-10 years, although it can become chronic and recurrent. Dapsone, niacinamide, antimalarials, NSAIDs, tetracyclines, corticosteroids, colchicine, and plasmapheresis are reported treatments. This patient’s EED was recalcitrant to prednisone and responded to colchicine.

Scleromyxedema and EED are both rare, distinct cutaneous entities associated with different underlying paraproteinemias and to the best of our knowledge, have not been previously reported to coexist in a single patient.

This case and the photos were submitted by Rachel Fayne, BA; Yumeng Li, MD, MS; Fabrizio Galimberti, MD, PhD; and Brian Morrison, MD, of the department of dermatology and cutaneous surgery at the University of Miami.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.

Scleromyxedema, or generalized lichen myxedematosus, is a primary cutaneous mucinosis with unknown pathogenesis characterized by generalized firm, skin-colored papules and is commonly associated with an underlying monoclonal gammopathy (usually Ig-gamma paraproteinemia).

Courtesy Rachel Fayne, BA, Dr. Yumeng Li, Dr. Fabrizio Galimberti, and Dr. Brian Morrison

Scleromyxedema may have associated internal involvement, including neurologic, gastrointestinal, pulmonary, renal, cardiovascular, ophthalmological, or musculoskeletal. Histopathology demonstrates mucin in the dermis seen with Alcian blue staining, proliferation of fibroblasts, and increased collagen deposition.

The condition is chronic and progressive. Intravenous immunoglobulin is considered first-line treatment. Thalidomide and corticosteroids have been reported to also be efficacious.

Erythema elevatum diutinum (EED) is a small-vessel vasculitis that presents with asymptomatic, symmetrical nodules or plaques on extensor surfaces. It is associated with hematologic disorders, including IgA monoclonal gammopathy, as well as myeloproliferative disorders, leukemia, infections, and inflammatory bowel disease. Although its pathophysiology is not well understood, vascular immune complex deposition, repetitive inflammation, and subsequent fibrosis may play a role. On histology, there is leukocytoclastic vasculitis with polymorphonuclear cell infiltrate and fibrin deposition in the superficial and mid-dermis and onion-skin fibrosis.

EED often self-resolves within 5-10 years, although it can become chronic and recurrent. Dapsone, niacinamide, antimalarials, NSAIDs, tetracyclines, corticosteroids, colchicine, and plasmapheresis are reported treatments. This patient’s EED was recalcitrant to prednisone and responded to colchicine.

Scleromyxedema and EED are both rare, distinct cutaneous entities associated with different underlying paraproteinemias and to the best of our knowledge, have not been previously reported to coexist in a single patient.

This case and the photos were submitted by Rachel Fayne, BA; Yumeng Li, MD, MS; Fabrizio Galimberti, MD, PhD; and Brian Morrison, MD, of the department of dermatology and cutaneous surgery at the University of Miami.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.

Scleromyxedema, or generalized lichen myxedematosus, is a primary cutaneous mucinosis with unknown pathogenesis characterized by generalized firm, skin-colored papules and is commonly associated with an underlying monoclonal gammopathy (usually Ig-gamma paraproteinemia).

Courtesy Rachel Fayne, BA, Dr. Yumeng Li, Dr. Fabrizio Galimberti, and Dr. Brian Morrison

Scleromyxedema may have associated internal involvement, including neurologic, gastrointestinal, pulmonary, renal, cardiovascular, ophthalmological, or musculoskeletal. Histopathology demonstrates mucin in the dermis seen with Alcian blue staining, proliferation of fibroblasts, and increased collagen deposition.

The condition is chronic and progressive. Intravenous immunoglobulin is considered first-line treatment. Thalidomide and corticosteroids have been reported to also be efficacious.

Erythema elevatum diutinum (EED) is a small-vessel vasculitis that presents with asymptomatic, symmetrical nodules or plaques on extensor surfaces. It is associated with hematologic disorders, including IgA monoclonal gammopathy, as well as myeloproliferative disorders, leukemia, infections, and inflammatory bowel disease. Although its pathophysiology is not well understood, vascular immune complex deposition, repetitive inflammation, and subsequent fibrosis may play a role. On histology, there is leukocytoclastic vasculitis with polymorphonuclear cell infiltrate and fibrin deposition in the superficial and mid-dermis and onion-skin fibrosis.

EED often self-resolves within 5-10 years, although it can become chronic and recurrent. Dapsone, niacinamide, antimalarials, NSAIDs, tetracyclines, corticosteroids, colchicine, and plasmapheresis are reported treatments. This patient’s EED was recalcitrant to prednisone and responded to colchicine.

Scleromyxedema and EED are both rare, distinct cutaneous entities associated with different underlying paraproteinemias and to the best of our knowledge, have not been previously reported to coexist in a single patient.

This case and the photos were submitted by Rachel Fayne, BA; Yumeng Li, MD, MS; Fabrizio Galimberti, MD, PhD; and Brian Morrison, MD, of the department of dermatology and cutaneous surgery at the University of Miami.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.