MADRID – Fatigue is an important symptom in patients with psoriatic arthritis but often goes unaddressed when treatment only involves disease modifying drugs.

A survey of more than 1,000 patients with psoriatic arthritis (PsA) in Denmark found that more than half had moderate or severe levels of fatigue, and a principal component analysis of the sources of fatigue found three factors responsible for the majority of reported patient fatigue: chronic inflammation, chronic pain, and chronification of the PsA, Tanja S. Jørgensen, PhD, said at the European Congress of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler
 

MADRID – Fatigue is an important symptom in patients with psoriatic arthritis but often goes unaddressed when treatment only involves disease modifying drugs.

A survey of more than 1,000 patients with psoriatic arthritis (PsA) in Denmark found that more than half had moderate or severe levels of fatigue, and a principal component analysis of the sources of fatigue found three factors responsible for the majority of reported patient fatigue: chronic inflammation, chronic pain, and chronification of the PsA, Tanja S. Jørgensen, PhD, said at the European Congress of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler
 

MADRID – Fatigue is an important symptom in patients with psoriatic arthritis but often goes unaddressed when treatment only involves disease modifying drugs.

A survey of more than 1,000 patients with psoriatic arthritis (PsA) in Denmark found that more than half had moderate or severe levels of fatigue, and a principal component analysis of the sources of fatigue found three factors responsible for the majority of reported patient fatigue: chronic inflammation, chronic pain, and chronification of the PsA, Tanja S. Jørgensen, PhD, said at the European Congress of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler
 

CHICAGO – With growing pressure to deliver higher-quality care at reduced costs, more physicians and practices are looking to join a clinically integrated network. But establishing and successfully operating such a network is sometimes easier said than done.

A clinically integrated network is defined as a collection of health providers, such as physicians, hospitals, and post-acute specialists that join together to improve care and reduce costs. Such networks generally share record systems, track data, and rely on evidence-based guidelines to provide high-quality care across participating providers.

If a group meets Federal Trade Commission compliance requirements to be considered a clinically integrated network, the government will provide a safe harbor from antitrust scrutiny. The four components that networks must meet to be considered clinically integrated include: physician leadership and commitment, development and implementation of clinical practice guidelines to improve performance, development of infrastructure and technology, and financial incentives for achieving goals.

An accountable care organization (ACO) that participates in the Medicare Shared Savings Program is deemed “clinically integrated.” The clinical integration network (CIN) is the actual legal entity/network that the physicians join. Unlike physician hospital organizations (PHOs), clinically integrated networks can jointly negotiate contractual fees as long as the primary purpose of the negotiation is to achieve care improvement, according to a summary by the Medical Group Management Association.

Clinically integrated networks can also support ACOs or patient centered medical homes as part of the clinically integrated network by serving as a mechanism for sharing infrastructure and development costs.

“For doctors, participating in a clinically integrated network is an opportunity to work as part of a group, without giving up their independence,” George Mayzell, MD, chief clinical officer for Vizient Southeast, said during a recent American Bar Association meeting. Participation in such a network also may potentially support some of the alternative payment models under the Medicare Access and CHIP Reauthorization Act (MACRA), he said.

From financial challenges to lack of collaboration to data woes, physicians can face unexpected barriers as their clinically integrated network gets off the ground. Below, experts discuss the top five roadblocks to clinically integrated networks and how doctors and hospitals can overcome them.
 

1. Contribution reluctance

Although there is no hard-and-fast level, investments of time, energy, and financial resources by all participating providers are necessary to create and maintain a clinically integrated network, according to the Federal Trade Commission. However, physicians can sometimes be wary of contributing substantially to a new network, said April E. Schweitzer, a Chicago-based health law attorney who specializes in clinical integration networks and accountable care organizations.

Some doctors feel comfortable contributing only nominal amounts or believe that the system should bear the burden of costs, Ms. Schweitzer said at an American Bar Association meeting.

2. Savings expectations

Network members often have high hopes when it comes to the savings and reimbursement bonuses they expect to see once the network launches. The reality can be disappointing, said Dr. Mayzell.

“Creating savings takes time and a high level of patience/commitment,” Dr. Mayzell said in an interview. “Even when the savings are realized early on, financial awards are often low, and if they’re spread out between all of the primary care physicians and the specialists, they are not very motivating. This must be taken into account.”

It helps to set reasonable expectations early on about reimbursement, Ms. Schweitzer said. The same goes for managing payer contract expectations.

“You want to manage expectations at the outset,” she said during the meeting. “And you really do want to be honest about what the payers in your market are looking for and are expecting.”

3. Balancing leadership

Sophisticated clinically integrated networks require significant infrastructure and IT costs, thus most are funded by a hospital or health system, Ms. Schweitzer said. As a result, the hospital or health system is likely to be the sole corporate member of the legal entity serving as the network. But because success within the network requires physicians to potentially change their practice patterns, it is important to have true physician leadership on the governing board of the clinically integrated network.

Class voting is one way to balance the need for a physician-led network with appropriate governance of a clinically integrated network, Ms. Schweitzer said in an interview. Class voting allows “physicians to comprise a majority of the governing board of a clinically integrated network [while allowing the corporate member] to retain decision-making power because the physician class gets one vote and the hospital or health system class gets one vote.”

In addition, she advised giving the hospital or health system certain reserved powers to protect the health system’s tax-exempt status. This includes:

• Ensuring that the CIN serves community and charitable purposes.
• Protecting and promoting the community benefits served by the corporate member and ensuring that the assets and income of the corporate member and the CIN are used to serve community objectives.
• Protecting the assets and income of the corporate member and the CIN by ensuring that the CIN complies with all applicable laws and regulatory requirements.

4. EHR interoperability

For a successful network, quality data must be aggregated from all providers. This can prove challenging when independent physicians each have separate electronic health record systems, Dr. Mayzell said.

“You can try to aggregate this data manually, but that is extremely challenging,” he said in an interview. “To aggregate [EHR] level data, you generally need to use additional software and organizations that connect electronically with each of their systems. This is often very expensive and cumbersome, with each system requiring a different interface and often each version of each system requiring a different interface.”

In the beginning stages of the network, survey all participating providers about the most widely used EHR systems to narrow interfacing to a manageable number, Ms. Schweitzer advised.

“This is what a lot of our clients are doing during the steering committee phase,” she said. “That’s when you’re bringing the health system and the doctors together to make decisions about how this entity will run.”

Additionally, consider alternative methods for data downloads, such as flat fees, payer downloads, or manual entries. Incorporate a long-term strategy about how many record systems the network will be using in future years, added Dr. Mayzell.

5. Resistance to data download

When it comes to data, many physicians feel that patient data are “their” data, and they are uneasy about giving access to that data when participating in a clinically integrated network, Ms. Schweitzer said. Patient privacy is also a top concern.

While these are valid concerns, networks need as much data as possible in their data warehouse to show payers that their participating physicians are providing quality care, while reducing cost, she said.

A full data download is beneficial for the network because overinclusion allows for more accurate assessment and better extrapolation in quality improvement, she said. This means each participating physician submits all their patient data, regardless of payer. Remind members that from an IT perspective, data from one doctor are merely grains of sand in a beach of data. Explain to uneasy members that the data are scrubbed of all patient identifiers and that it is the aggregate data that are most valuable to the network.

“If you’re going through one of these processes, I would encourage you to push the lawyers hard because there are answers to these questions about data privacy and you should understand that 99% of the time, the data that are going to be seen, are going to be scrubbed,” she said. “I urge you to ask tough questions if you’re in the room and discussing that particular issue.”

[email protected]

On Twitter @legal_med

CHICAGO – With growing pressure to deliver higher-quality care at reduced costs, more physicians and practices are looking to join a clinically integrated network. But establishing and successfully operating such a network is sometimes easier said than done.

A clinically integrated network is defined as a collection of health providers, such as physicians, hospitals, and post-acute specialists that join together to improve care and reduce costs. Such networks generally share record systems, track data, and rely on evidence-based guidelines to provide high-quality care across participating providers.

If a group meets Federal Trade Commission compliance requirements to be considered a clinically integrated network, the government will provide a safe harbor from antitrust scrutiny. The four components that networks must meet to be considered clinically integrated include: physician leadership and commitment, development and implementation of clinical practice guidelines to improve performance, development of infrastructure and technology, and financial incentives for achieving goals.

An accountable care organization (ACO) that participates in the Medicare Shared Savings Program is deemed “clinically integrated.” The clinical integration network (CIN) is the actual legal entity/network that the physicians join. Unlike physician hospital organizations (PHOs), clinically integrated networks can jointly negotiate contractual fees as long as the primary purpose of the negotiation is to achieve care improvement, according to a summary by the Medical Group Management Association.

Clinically integrated networks can also support ACOs or patient centered medical homes as part of the clinically integrated network by serving as a mechanism for sharing infrastructure and development costs.

“For doctors, participating in a clinically integrated network is an opportunity to work as part of a group, without giving up their independence,” George Mayzell, MD, chief clinical officer for Vizient Southeast, said during a recent American Bar Association meeting. Participation in such a network also may potentially support some of the alternative payment models under the Medicare Access and CHIP Reauthorization Act (MACRA), he said.

From financial challenges to lack of collaboration to data woes, physicians can face unexpected barriers as their clinically integrated network gets off the ground. Below, experts discuss the top five roadblocks to clinically integrated networks and how doctors and hospitals can overcome them.
 

1. Contribution reluctance

Although there is no hard-and-fast level, investments of time, energy, and financial resources by all participating providers are necessary to create and maintain a clinically integrated network, according to the Federal Trade Commission. However, physicians can sometimes be wary of contributing substantially to a new network, said April E. Schweitzer, a Chicago-based health law attorney who specializes in clinical integration networks and accountable care organizations.

Some doctors feel comfortable contributing only nominal amounts or believe that the system should bear the burden of costs, Ms. Schweitzer said at an American Bar Association meeting.

2. Savings expectations

Network members often have high hopes when it comes to the savings and reimbursement bonuses they expect to see once the network launches. The reality can be disappointing, said Dr. Mayzell.

“Creating savings takes time and a high level of patience/commitment,” Dr. Mayzell said in an interview. “Even when the savings are realized early on, financial awards are often low, and if they’re spread out between all of the primary care physicians and the specialists, they are not very motivating. This must be taken into account.”

It helps to set reasonable expectations early on about reimbursement, Ms. Schweitzer said. The same goes for managing payer contract expectations.

“You want to manage expectations at the outset,” she said during the meeting. “And you really do want to be honest about what the payers in your market are looking for and are expecting.”

3. Balancing leadership

Sophisticated clinically integrated networks require significant infrastructure and IT costs, thus most are funded by a hospital or health system, Ms. Schweitzer said. As a result, the hospital or health system is likely to be the sole corporate member of the legal entity serving as the network. But because success within the network requires physicians to potentially change their practice patterns, it is important to have true physician leadership on the governing board of the clinically integrated network.

Class voting is one way to balance the need for a physician-led network with appropriate governance of a clinically integrated network, Ms. Schweitzer said in an interview. Class voting allows “physicians to comprise a majority of the governing board of a clinically integrated network [while allowing the corporate member] to retain decision-making power because the physician class gets one vote and the hospital or health system class gets one vote.”

In addition, she advised giving the hospital or health system certain reserved powers to protect the health system’s tax-exempt status. This includes:

• Ensuring that the CIN serves community and charitable purposes.
• Protecting and promoting the community benefits served by the corporate member and ensuring that the assets and income of the corporate member and the CIN are used to serve community objectives.
• Protecting the assets and income of the corporate member and the CIN by ensuring that the CIN complies with all applicable laws and regulatory requirements.

4. EHR interoperability

For a successful network, quality data must be aggregated from all providers. This can prove challenging when independent physicians each have separate electronic health record systems, Dr. Mayzell said.

“You can try to aggregate this data manually, but that is extremely challenging,” he said in an interview. “To aggregate [EHR] level data, you generally need to use additional software and organizations that connect electronically with each of their systems. This is often very expensive and cumbersome, with each system requiring a different interface and often each version of each system requiring a different interface.”

In the beginning stages of the network, survey all participating providers about the most widely used EHR systems to narrow interfacing to a manageable number, Ms. Schweitzer advised.

“This is what a lot of our clients are doing during the steering committee phase,” she said. “That’s when you’re bringing the health system and the doctors together to make decisions about how this entity will run.”

Additionally, consider alternative methods for data downloads, such as flat fees, payer downloads, or manual entries. Incorporate a long-term strategy about how many record systems the network will be using in future years, added Dr. Mayzell.

5. Resistance to data download

When it comes to data, many physicians feel that patient data are “their” data, and they are uneasy about giving access to that data when participating in a clinically integrated network, Ms. Schweitzer said. Patient privacy is also a top concern.

While these are valid concerns, networks need as much data as possible in their data warehouse to show payers that their participating physicians are providing quality care, while reducing cost, she said.

A full data download is beneficial for the network because overinclusion allows for more accurate assessment and better extrapolation in quality improvement, she said. This means each participating physician submits all their patient data, regardless of payer. Remind members that from an IT perspective, data from one doctor are merely grains of sand in a beach of data. Explain to uneasy members that the data are scrubbed of all patient identifiers and that it is the aggregate data that are most valuable to the network.

“If you’re going through one of these processes, I would encourage you to push the lawyers hard because there are answers to these questions about data privacy and you should understand that 99% of the time, the data that are going to be seen, are going to be scrubbed,” she said. “I urge you to ask tough questions if you’re in the room and discussing that particular issue.”

[email protected]

On Twitter @legal_med

CHICAGO – With growing pressure to deliver higher-quality care at reduced costs, more physicians and practices are looking to join a clinically integrated network. But establishing and successfully operating such a network is sometimes easier said than done.

A clinically integrated network is defined as a collection of health providers, such as physicians, hospitals, and post-acute specialists that join together to improve care and reduce costs. Such networks generally share record systems, track data, and rely on evidence-based guidelines to provide high-quality care across participating providers.

If a group meets Federal Trade Commission compliance requirements to be considered a clinically integrated network, the government will provide a safe harbor from antitrust scrutiny. The four components that networks must meet to be considered clinically integrated include: physician leadership and commitment, development and implementation of clinical practice guidelines to improve performance, development of infrastructure and technology, and financial incentives for achieving goals.

An accountable care organization (ACO) that participates in the Medicare Shared Savings Program is deemed “clinically integrated.” The clinical integration network (CIN) is the actual legal entity/network that the physicians join. Unlike physician hospital organizations (PHOs), clinically integrated networks can jointly negotiate contractual fees as long as the primary purpose of the negotiation is to achieve care improvement, according to a summary by the Medical Group Management Association.

Clinically integrated networks can also support ACOs or patient centered medical homes as part of the clinically integrated network by serving as a mechanism for sharing infrastructure and development costs.

“For doctors, participating in a clinically integrated network is an opportunity to work as part of a group, without giving up their independence,” George Mayzell, MD, chief clinical officer for Vizient Southeast, said during a recent American Bar Association meeting. Participation in such a network also may potentially support some of the alternative payment models under the Medicare Access and CHIP Reauthorization Act (MACRA), he said.

From financial challenges to lack of collaboration to data woes, physicians can face unexpected barriers as their clinically integrated network gets off the ground. Below, experts discuss the top five roadblocks to clinically integrated networks and how doctors and hospitals can overcome them.
 

1. Contribution reluctance

Although there is no hard-and-fast level, investments of time, energy, and financial resources by all participating providers are necessary to create and maintain a clinically integrated network, according to the Federal Trade Commission. However, physicians can sometimes be wary of contributing substantially to a new network, said April E. Schweitzer, a Chicago-based health law attorney who specializes in clinical integration networks and accountable care organizations.

Some doctors feel comfortable contributing only nominal amounts or believe that the system should bear the burden of costs, Ms. Schweitzer said at an American Bar Association meeting.

2. Savings expectations

Network members often have high hopes when it comes to the savings and reimbursement bonuses they expect to see once the network launches. The reality can be disappointing, said Dr. Mayzell.

“Creating savings takes time and a high level of patience/commitment,” Dr. Mayzell said in an interview. “Even when the savings are realized early on, financial awards are often low, and if they’re spread out between all of the primary care physicians and the specialists, they are not very motivating. This must be taken into account.”

It helps to set reasonable expectations early on about reimbursement, Ms. Schweitzer said. The same goes for managing payer contract expectations.

“You want to manage expectations at the outset,” she said during the meeting. “And you really do want to be honest about what the payers in your market are looking for and are expecting.”

3. Balancing leadership

Sophisticated clinically integrated networks require significant infrastructure and IT costs, thus most are funded by a hospital or health system, Ms. Schweitzer said. As a result, the hospital or health system is likely to be the sole corporate member of the legal entity serving as the network. But because success within the network requires physicians to potentially change their practice patterns, it is important to have true physician leadership on the governing board of the clinically integrated network.

Class voting is one way to balance the need for a physician-led network with appropriate governance of a clinically integrated network, Ms. Schweitzer said in an interview. Class voting allows “physicians to comprise a majority of the governing board of a clinically integrated network [while allowing the corporate member] to retain decision-making power because the physician class gets one vote and the hospital or health system class gets one vote.”

In addition, she advised giving the hospital or health system certain reserved powers to protect the health system’s tax-exempt status. This includes:

• Ensuring that the CIN serves community and charitable purposes.
• Protecting and promoting the community benefits served by the corporate member and ensuring that the assets and income of the corporate member and the CIN are used to serve community objectives.
• Protecting the assets and income of the corporate member and the CIN by ensuring that the CIN complies with all applicable laws and regulatory requirements.

4. EHR interoperability

For a successful network, quality data must be aggregated from all providers. This can prove challenging when independent physicians each have separate electronic health record systems, Dr. Mayzell said.

“You can try to aggregate this data manually, but that is extremely challenging,” he said in an interview. “To aggregate [EHR] level data, you generally need to use additional software and organizations that connect electronically with each of their systems. This is often very expensive and cumbersome, with each system requiring a different interface and often each version of each system requiring a different interface.”

In the beginning stages of the network, survey all participating providers about the most widely used EHR systems to narrow interfacing to a manageable number, Ms. Schweitzer advised.

“This is what a lot of our clients are doing during the steering committee phase,” she said. “That’s when you’re bringing the health system and the doctors together to make decisions about how this entity will run.”

Additionally, consider alternative methods for data downloads, such as flat fees, payer downloads, or manual entries. Incorporate a long-term strategy about how many record systems the network will be using in future years, added Dr. Mayzell.

5. Resistance to data download

When it comes to data, many physicians feel that patient data are “their” data, and they are uneasy about giving access to that data when participating in a clinically integrated network, Ms. Schweitzer said. Patient privacy is also a top concern.

While these are valid concerns, networks need as much data as possible in their data warehouse to show payers that their participating physicians are providing quality care, while reducing cost, she said.

A full data download is beneficial for the network because overinclusion allows for more accurate assessment and better extrapolation in quality improvement, she said. This means each participating physician submits all their patient data, regardless of payer. Remind members that from an IT perspective, data from one doctor are merely grains of sand in a beach of data. Explain to uneasy members that the data are scrubbed of all patient identifiers and that it is the aggregate data that are most valuable to the network.

“If you’re going through one of these processes, I would encourage you to push the lawyers hard because there are answers to these questions about data privacy and you should understand that 99% of the time, the data that are going to be seen, are going to be scrubbed,” she said. “I urge you to ask tough questions if you’re in the room and discussing that particular issue.”

[email protected]

On Twitter @legal_med

A blood test has been found to be effective for detecting early pancreatic cancer in those at high risk, with the potential to find the deadly cancer at a time when it is more likely to be treatable with surgery, according to phase 2b findings recently published in Science Translational Medicine.

In a 337-person study, researchers found that a blood panel for the protein thrombospondin-2 (THBS2) and cancer antigen 19-9 (CA19-9), measured with a standard ELISA test, together detected pancreatic ductal adenocarcinoma (PDAC) with a specificity of 98% and a sensitivity of 87%. The test was effective at distinguishing patients with PDAC from controls and those with benign pancreatic disease across all stages of the cancer, wrote Kenneth Zaret, PhD, at the University of Pennsylvania, Philadelphia.

©Martynasfoto/Thinkstock

A blood test has been found to be effective for detecting early pancreatic cancer in those at high risk, with the potential to find the deadly cancer at a time when it is more likely to be treatable with surgery, according to phase 2b findings recently published in Science Translational Medicine.

In a 337-person study, researchers found that a blood panel for the protein thrombospondin-2 (THBS2) and cancer antigen 19-9 (CA19-9), measured with a standard ELISA test, together detected pancreatic ductal adenocarcinoma (PDAC) with a specificity of 98% and a sensitivity of 87%. The test was effective at distinguishing patients with PDAC from controls and those with benign pancreatic disease across all stages of the cancer, wrote Kenneth Zaret, PhD, at the University of Pennsylvania, Philadelphia.

©Martynasfoto/Thinkstock

A blood test has been found to be effective for detecting early pancreatic cancer in those at high risk, with the potential to find the deadly cancer at a time when it is more likely to be treatable with surgery, according to phase 2b findings recently published in Science Translational Medicine.

In a 337-person study, researchers found that a blood panel for the protein thrombospondin-2 (THBS2) and cancer antigen 19-9 (CA19-9), measured with a standard ELISA test, together detected pancreatic ductal adenocarcinoma (PDAC) with a specificity of 98% and a sensitivity of 87%. The test was effective at distinguishing patients with PDAC from controls and those with benign pancreatic disease across all stages of the cancer, wrote Kenneth Zaret, PhD, at the University of Pennsylvania, Philadelphia.

©Martynasfoto/Thinkstock

DENVER – An antiviral drug that is a key player in the recent revolution in the treatment of hepatitis C infection also blocks Zika virus replication both in vitro and in a mouse model, Alysson R. Muotri, PhD, said at the annual meeting of the Teratology Society.

Rattikankeawpun/Thinkstock

[email protected]


 

DENVER – An antiviral drug that is a key player in the recent revolution in the treatment of hepatitis C infection also blocks Zika virus replication both in vitro and in a mouse model, Alysson R. Muotri, PhD, said at the annual meeting of the Teratology Society.

Rattikankeawpun/Thinkstock

[email protected]


 

DENVER – An antiviral drug that is a key player in the recent revolution in the treatment of hepatitis C infection also blocks Zika virus replication both in vitro and in a mouse model, Alysson R. Muotri, PhD, said at the annual meeting of the Teratology Society.

Rattikankeawpun/Thinkstock

[email protected]


 

Last month’s column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. “Isn’t it true,” asked one contributor, “that most physicians tolerate marginal employees because it’s less painful than firing them?”

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. Sometimes, however, it is unavoidable if you want to preserve the efficiency and morale of your other employees, as well as your own.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as you can. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential. You must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that any of a number of their civil rights was violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age (if the employee is over 40). You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusal to take a lie detector test, and report of OSHA violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims, or for exercising a legal right, such as voting or participating in a political demonstration. You cannot fire an alcohol abuser unless he or she is caught drinking at work, but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since lawsuits are always a possibility despite all efforts to prevent them.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon (as many do), you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say, so, for what it’s worth: “I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So, today, we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”

There will, of course, be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the real story from you, not some distorted version via the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

Last month’s column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. “Isn’t it true,” asked one contributor, “that most physicians tolerate marginal employees because it’s less painful than firing them?”

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. Sometimes, however, it is unavoidable if you want to preserve the efficiency and morale of your other employees, as well as your own.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as you can. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential. You must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that any of a number of their civil rights was violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age (if the employee is over 40). You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusal to take a lie detector test, and report of OSHA violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims, or for exercising a legal right, such as voting or participating in a political demonstration. You cannot fire an alcohol abuser unless he or she is caught drinking at work, but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since lawsuits are always a possibility despite all efforts to prevent them.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon (as many do), you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say, so, for what it’s worth: “I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So, today, we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”

There will, of course, be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the real story from you, not some distorted version via the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

Last month’s column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. “Isn’t it true,” asked one contributor, “that most physicians tolerate marginal employees because it’s less painful than firing them?”

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. Sometimes, however, it is unavoidable if you want to preserve the efficiency and morale of your other employees, as well as your own.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as you can. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential. You must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that any of a number of their civil rights was violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age (if the employee is over 40). You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusal to take a lie detector test, and report of OSHA violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims, or for exercising a legal right, such as voting or participating in a political demonstration. You cannot fire an alcohol abuser unless he or she is caught drinking at work, but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since lawsuits are always a possibility despite all efforts to prevent them.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon (as many do), you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say, so, for what it’s worth: “I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So, today, we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”

There will, of course, be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the real story from you, not some distorted version via the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

An appeals court has struck down Wisconsin’s medical malpractice cap for noneconomic damages, ruling that the $750,000 limit is unconstitutional.

In a July opinion, a panel of the First District Court of Appeals wrote that the medical liability cap denies equal protection for the most severely injured patients who are awarded damages exceeding the limit. The decision reinstates a $16.5 million noneconomic damages verdict awarded to a Wisconsin women who lost her limbs after a delayed sepsis diagnosis, according to court documents.

The Wisconsin Medical Society expressed its disappointment at the decision, warning that the ruling could destabilize Wisconsin’s medical liability environment and endanger patients’ access to high-quality, affordable care.

“This decision endangers the long-term solvency of the Injured Patients and Families Compensation Fund and its ability to adequately compensate patients and incentivizes attorneys to file questionable cases in hopes of astronomical jury awards seen in other states without caps,” Noel Deep, MD, president of the Wisconsin Medical Society, said in a statement. “We look forward to further opportunities to explain the importance of the cap to the stability of Wisconsin’s medical liability environment and its benefits for all Wisconsin patients as this case progresses.”

The Wisconsin Association for Justice, an association for the plaintiffs’ bar, praised the cap’s elimination.

“The Court of Appeals, in a concise and well-reasoned opinion, took a brave step toward ensuring that injured patients in Wisconsin can achieve justice by utilizing their constitutional right to a civil jury trial,” Association President Benjamin S. Wagner said in a statement. “The data the court relied upon speaks for itself. The imposition of damage caps against a person like Ascaris Mayo has no rational relationship to controlling medical costs, nor does the verdict impose a financial hardship on the Injured Patients and Families Compensation Fund. To the contrary, the court’s decision ensures that the fund meets its dual statutory obligations to provide excess insurance to medical professionals and provide compensation to injured patients and families.”

The ruling results from a medical malpractice lawsuit filed by patient Ascaris Mayo and her family against Infinity Health Care in Milwaukee, an emergency physician, a physician assistant, ProAssurance Wisconsin Insurance, and the Wisconsin Injured Patients and Families Compensation Fund. The suit claimed that, during a visit to the emergency department at Columbia St. Mary’s Hospital in Milwaukee for abdominal pain and a high fever, health providers failed to diagnosis and treat Ms. Mayo for sepsis. The sepsis led to organ failure, dry gangrene, and, eventually, amputation of her extremities, according to court documents.

A jury awarded Ms. Mayo and her husband $9 million in economic damages and $16.5 million in noneconomic damages. After the verdict, representatives for the Wisconsin Injured Patients and Families Compensation Fund moved to reduce the noneconomic damages award to $750,000 per the state’s cap. The Mayos challenged the reduction, arguing that the cap violated their constitutional rights. A circuit court concluded that the cap was not facially unconstitutional and that it was unconstitutional as applied to the Mayos because it violated the Mayos’ rights to equal protection and due process. Both the Mayos and representatives for the compensation fund appealed.

In their decision, the appeals panel shot down the reasoning used by Wisconsin’s Legislature to enact the noneconomic damages cap, raising doubts that the limit reduces defensive medicine by physicians and prevents a doctor shortage in the state.

“The record before us does not support a finding that the legislative objectives articulated in [the statute] are promoted in any way because the amount of the noneconomic damages cap is $750,000,” the judges wrote. “Data demonstrate that many states with no caps on noneconomic damages actually have higher physician retention rates than Wisconsin. [In addition,] the record before us shows that the ability to accurately measure the financial impact of ‘defensive medicine’ practices has not improved. ... Indeed, data suggest that the existence of noneconomic damages caps may actually increase the risk to patient safety.”

The case is expected to be appealed to the Wisconsin Supreme Court.

[email protected]

On Twitter @legal_med

An appeals court has struck down Wisconsin’s medical malpractice cap for noneconomic damages, ruling that the $750,000 limit is unconstitutional.

In a July opinion, a panel of the First District Court of Appeals wrote that the medical liability cap denies equal protection for the most severely injured patients who are awarded damages exceeding the limit. The decision reinstates a $16.5 million noneconomic damages verdict awarded to a Wisconsin women who lost her limbs after a delayed sepsis diagnosis, according to court documents.

The Wisconsin Medical Society expressed its disappointment at the decision, warning that the ruling could destabilize Wisconsin’s medical liability environment and endanger patients’ access to high-quality, affordable care.

“This decision endangers the long-term solvency of the Injured Patients and Families Compensation Fund and its ability to adequately compensate patients and incentivizes attorneys to file questionable cases in hopes of astronomical jury awards seen in other states without caps,” Noel Deep, MD, president of the Wisconsin Medical Society, said in a statement. “We look forward to further opportunities to explain the importance of the cap to the stability of Wisconsin’s medical liability environment and its benefits for all Wisconsin patients as this case progresses.”

The Wisconsin Association for Justice, an association for the plaintiffs’ bar, praised the cap’s elimination.

“The Court of Appeals, in a concise and well-reasoned opinion, took a brave step toward ensuring that injured patients in Wisconsin can achieve justice by utilizing their constitutional right to a civil jury trial,” Association President Benjamin S. Wagner said in a statement. “The data the court relied upon speaks for itself. The imposition of damage caps against a person like Ascaris Mayo has no rational relationship to controlling medical costs, nor does the verdict impose a financial hardship on the Injured Patients and Families Compensation Fund. To the contrary, the court’s decision ensures that the fund meets its dual statutory obligations to provide excess insurance to medical professionals and provide compensation to injured patients and families.”

The ruling results from a medical malpractice lawsuit filed by patient Ascaris Mayo and her family against Infinity Health Care in Milwaukee, an emergency physician, a physician assistant, ProAssurance Wisconsin Insurance, and the Wisconsin Injured Patients and Families Compensation Fund. The suit claimed that, during a visit to the emergency department at Columbia St. Mary’s Hospital in Milwaukee for abdominal pain and a high fever, health providers failed to diagnosis and treat Ms. Mayo for sepsis. The sepsis led to organ failure, dry gangrene, and, eventually, amputation of her extremities, according to court documents.

A jury awarded Ms. Mayo and her husband $9 million in economic damages and $16.5 million in noneconomic damages. After the verdict, representatives for the Wisconsin Injured Patients and Families Compensation Fund moved to reduce the noneconomic damages award to $750,000 per the state’s cap. The Mayos challenged the reduction, arguing that the cap violated their constitutional rights. A circuit court concluded that the cap was not facially unconstitutional and that it was unconstitutional as applied to the Mayos because it violated the Mayos’ rights to equal protection and due process. Both the Mayos and representatives for the compensation fund appealed.

In their decision, the appeals panel shot down the reasoning used by Wisconsin’s Legislature to enact the noneconomic damages cap, raising doubts that the limit reduces defensive medicine by physicians and prevents a doctor shortage in the state.

“The record before us does not support a finding that the legislative objectives articulated in [the statute] are promoted in any way because the amount of the noneconomic damages cap is $750,000,” the judges wrote. “Data demonstrate that many states with no caps on noneconomic damages actually have higher physician retention rates than Wisconsin. [In addition,] the record before us shows that the ability to accurately measure the financial impact of ‘defensive medicine’ practices has not improved. ... Indeed, data suggest that the existence of noneconomic damages caps may actually increase the risk to patient safety.”

The case is expected to be appealed to the Wisconsin Supreme Court.

[email protected]

On Twitter @legal_med

An appeals court has struck down Wisconsin’s medical malpractice cap for noneconomic damages, ruling that the $750,000 limit is unconstitutional.

In a July opinion, a panel of the First District Court of Appeals wrote that the medical liability cap denies equal protection for the most severely injured patients who are awarded damages exceeding the limit. The decision reinstates a $16.5 million noneconomic damages verdict awarded to a Wisconsin women who lost her limbs after a delayed sepsis diagnosis, according to court documents.

The Wisconsin Medical Society expressed its disappointment at the decision, warning that the ruling could destabilize Wisconsin’s medical liability environment and endanger patients’ access to high-quality, affordable care.

“This decision endangers the long-term solvency of the Injured Patients and Families Compensation Fund and its ability to adequately compensate patients and incentivizes attorneys to file questionable cases in hopes of astronomical jury awards seen in other states without caps,” Noel Deep, MD, president of the Wisconsin Medical Society, said in a statement. “We look forward to further opportunities to explain the importance of the cap to the stability of Wisconsin’s medical liability environment and its benefits for all Wisconsin patients as this case progresses.”

The Wisconsin Association for Justice, an association for the plaintiffs’ bar, praised the cap’s elimination.

“The Court of Appeals, in a concise and well-reasoned opinion, took a brave step toward ensuring that injured patients in Wisconsin can achieve justice by utilizing their constitutional right to a civil jury trial,” Association President Benjamin S. Wagner said in a statement. “The data the court relied upon speaks for itself. The imposition of damage caps against a person like Ascaris Mayo has no rational relationship to controlling medical costs, nor does the verdict impose a financial hardship on the Injured Patients and Families Compensation Fund. To the contrary, the court’s decision ensures that the fund meets its dual statutory obligations to provide excess insurance to medical professionals and provide compensation to injured patients and families.”

The ruling results from a medical malpractice lawsuit filed by patient Ascaris Mayo and her family against Infinity Health Care in Milwaukee, an emergency physician, a physician assistant, ProAssurance Wisconsin Insurance, and the Wisconsin Injured Patients and Families Compensation Fund. The suit claimed that, during a visit to the emergency department at Columbia St. Mary’s Hospital in Milwaukee for abdominal pain and a high fever, health providers failed to diagnosis and treat Ms. Mayo for sepsis. The sepsis led to organ failure, dry gangrene, and, eventually, amputation of her extremities, according to court documents.

A jury awarded Ms. Mayo and her husband $9 million in economic damages and $16.5 million in noneconomic damages. After the verdict, representatives for the Wisconsin Injured Patients and Families Compensation Fund moved to reduce the noneconomic damages award to $750,000 per the state’s cap. The Mayos challenged the reduction, arguing that the cap violated their constitutional rights. A circuit court concluded that the cap was not facially unconstitutional and that it was unconstitutional as applied to the Mayos because it violated the Mayos’ rights to equal protection and due process. Both the Mayos and representatives for the compensation fund appealed.

In their decision, the appeals panel shot down the reasoning used by Wisconsin’s Legislature to enact the noneconomic damages cap, raising doubts that the limit reduces defensive medicine by physicians and prevents a doctor shortage in the state.

“The record before us does not support a finding that the legislative objectives articulated in [the statute] are promoted in any way because the amount of the noneconomic damages cap is $750,000,” the judges wrote. “Data demonstrate that many states with no caps on noneconomic damages actually have higher physician retention rates than Wisconsin. [In addition,] the record before us shows that the ability to accurately measure the financial impact of ‘defensive medicine’ practices has not improved. ... Indeed, data suggest that the existence of noneconomic damages caps may actually increase the risk to patient safety.”

The case is expected to be appealed to the Wisconsin Supreme Court.

[email protected]

On Twitter @legal_med

MADRID – Treatment with the dual interleukin (IL) 1 blocker ABT-981 did not improve pain scores or erosive joint damage in patients with hand osteoarthritis (OA) in a phase 2a trial reported at the European Congress of Rheumatology.

The disappointing findings suggest that IL-1 may not be an effective target in erosive hand OA, said Margreet Kloppenburg, MD, of Leiden (the Netherlands) University Medical Center, even though the investigators obtained adequate pharmacodynamic results that suggested it was effectively blocking both IL-1 alpha and IL-1 beta.

Sara Freeman/Frontline Medical News

Disappointing results with cytokine targeting

Hand OA affects around 11% of the OA population and erosive hand OA is a very painful phenotype that affects multiple joints, Xavier Chevalier, MD, of Henri-Mondor Hospital, Paris XII University (France), said during a separate session at the congress.

While there is a rationale for using anti-inflammatory drugs for erosive hand OA, so far there just have not been many, if any, real successes. “The effect sizes are small,” Dr. Chevalier said. “There are not a lot of drugs when compared to hip and knee OA,” he observed.

Sara Freeman/Frontline Medical News

[email protected]

On Twitter @rheumnews1

MADRID – Treatment with the dual interleukin (IL) 1 blocker ABT-981 did not improve pain scores or erosive joint damage in patients with hand osteoarthritis (OA) in a phase 2a trial reported at the European Congress of Rheumatology.

The disappointing findings suggest that IL-1 may not be an effective target in erosive hand OA, said Margreet Kloppenburg, MD, of Leiden (the Netherlands) University Medical Center, even though the investigators obtained adequate pharmacodynamic results that suggested it was effectively blocking both IL-1 alpha and IL-1 beta.

Sara Freeman/Frontline Medical News

Disappointing results with cytokine targeting

Hand OA affects around 11% of the OA population and erosive hand OA is a very painful phenotype that affects multiple joints, Xavier Chevalier, MD, of Henri-Mondor Hospital, Paris XII University (France), said during a separate session at the congress.

While there is a rationale for using anti-inflammatory drugs for erosive hand OA, so far there just have not been many, if any, real successes. “The effect sizes are small,” Dr. Chevalier said. “There are not a lot of drugs when compared to hip and knee OA,” he observed.

Sara Freeman/Frontline Medical News

[email protected]

On Twitter @rheumnews1

MADRID – Treatment with the dual interleukin (IL) 1 blocker ABT-981 did not improve pain scores or erosive joint damage in patients with hand osteoarthritis (OA) in a phase 2a trial reported at the European Congress of Rheumatology.

The disappointing findings suggest that IL-1 may not be an effective target in erosive hand OA, said Margreet Kloppenburg, MD, of Leiden (the Netherlands) University Medical Center, even though the investigators obtained adequate pharmacodynamic results that suggested it was effectively blocking both IL-1 alpha and IL-1 beta.

Sara Freeman/Frontline Medical News

Disappointing results with cytokine targeting

Hand OA affects around 11% of the OA population and erosive hand OA is a very painful phenotype that affects multiple joints, Xavier Chevalier, MD, of Henri-Mondor Hospital, Paris XII University (France), said during a separate session at the congress.

While there is a rationale for using anti-inflammatory drugs for erosive hand OA, so far there just have not been many, if any, real successes. “The effect sizes are small,” Dr. Chevalier said. “There are not a lot of drugs when compared to hip and knee OA,” he observed.

Sara Freeman/Frontline Medical News

[email protected]

On Twitter @rheumnews1

SAN FRANCISCO – Teens may express feelings that indicate an increased risk for depression and give you an opportunity for early intervention and prevention if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.

“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”

AlexRaths/Thinkstock

• Feeling stressed, sad, or down, often involving crying and interfering with their lives.

• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”

• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”

• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.

“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”

For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”

The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.

The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.

“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”

The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.

SAN FRANCISCO – Teens may express feelings that indicate an increased risk for depression and give you an opportunity for early intervention and prevention if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.

“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”

AlexRaths/Thinkstock

• Feeling stressed, sad, or down, often involving crying and interfering with their lives.

• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”

• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”

• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.

“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”

For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”

The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.

The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.

“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”

The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.

SAN FRANCISCO – Teens may express feelings that indicate an increased risk for depression and give you an opportunity for early intervention and prevention if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.

“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”

AlexRaths/Thinkstock

• Feeling stressed, sad, or down, often involving crying and interfering with their lives.

• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”

• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”

• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.

“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”

For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”

The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.

The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.

“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”

The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.

MIAMI – Not all researchers are clinicians, but what if all clinicians were researchers? Clinical studies would yield more relevant data, resulting in better patient care, according to an expert.

“The clinical research enterprise is broken,” Andrew A. Nierenberg, MD, said during a keynote plenary session dedicated to serving diverse populations, at a meeting of the American Society of Clinical Psychopharmacology, formerly known as the New Clinical Drug Evaluation Unit meeting. “It’s a problem, because it really does not have an impact on the actual care we give, and it doesn’t answer the types of questions that patients care about.”

One persistent problem, Dr. Nierenberg said, is that often those who enroll in trials have unclear motives for doing so, but those motives usually are tied to incentives such as cash. “Who goes into these trials and why is absolutely critical to the signal,” he said.

[email protected]

On Twitter @whitneymcknight

MIAMI – Not all researchers are clinicians, but what if all clinicians were researchers? Clinical studies would yield more relevant data, resulting in better patient care, according to an expert.

“The clinical research enterprise is broken,” Andrew A. Nierenberg, MD, said during a keynote plenary session dedicated to serving diverse populations, at a meeting of the American Society of Clinical Psychopharmacology, formerly known as the New Clinical Drug Evaluation Unit meeting. “It’s a problem, because it really does not have an impact on the actual care we give, and it doesn’t answer the types of questions that patients care about.”

One persistent problem, Dr. Nierenberg said, is that often those who enroll in trials have unclear motives for doing so, but those motives usually are tied to incentives such as cash. “Who goes into these trials and why is absolutely critical to the signal,” he said.

[email protected]

On Twitter @whitneymcknight

MIAMI – Not all researchers are clinicians, but what if all clinicians were researchers? Clinical studies would yield more relevant data, resulting in better patient care, according to an expert.

“The clinical research enterprise is broken,” Andrew A. Nierenberg, MD, said during a keynote plenary session dedicated to serving diverse populations, at a meeting of the American Society of Clinical Psychopharmacology, formerly known as the New Clinical Drug Evaluation Unit meeting. “It’s a problem, because it really does not have an impact on the actual care we give, and it doesn’t answer the types of questions that patients care about.”

One persistent problem, Dr. Nierenberg said, is that often those who enroll in trials have unclear motives for doing so, but those motives usually are tied to incentives such as cash. “Who goes into these trials and why is absolutely critical to the signal,” he said.

[email protected]

On Twitter @whitneymcknight

DENVER – Prevention of Zika virus infection in pregnancy is critical, given the lack of an effective treatment or vaccine, but it’s easier said than done.

“The particular mosquito that transmits Zika is really difficult because it tends to be indoors and live under the coffee table in your living room rather than outside. It bites in the day, as well as night, so it’s hard to prevent. Trying to consistently have repellent on [and] wear long-sleeved shirts and long pants, even when you’re indoors, in places that are typically quite warm – it’s challenging,” Margaret Honein, PhD, said at the annual meeting of the Teratology Society.

©DamrongpanThongwat/thinkstockphotos.com

[email protected]

DENVER – Prevention of Zika virus infection in pregnancy is critical, given the lack of an effective treatment or vaccine, but it’s easier said than done.

“The particular mosquito that transmits Zika is really difficult because it tends to be indoors and live under the coffee table in your living room rather than outside. It bites in the day, as well as night, so it’s hard to prevent. Trying to consistently have repellent on [and] wear long-sleeved shirts and long pants, even when you’re indoors, in places that are typically quite warm – it’s challenging,” Margaret Honein, PhD, said at the annual meeting of the Teratology Society.

©DamrongpanThongwat/thinkstockphotos.com

[email protected]

DENVER – Prevention of Zika virus infection in pregnancy is critical, given the lack of an effective treatment or vaccine, but it’s easier said than done.

“The particular mosquito that transmits Zika is really difficult because it tends to be indoors and live under the coffee table in your living room rather than outside. It bites in the day, as well as night, so it’s hard to prevent. Trying to consistently have repellent on [and] wear long-sleeved shirts and long pants, even when you’re indoors, in places that are typically quite warm – it’s challenging,” Margaret Honein, PhD, said at the annual meeting of the Teratology Society.

©DamrongpanThongwat/thinkstockphotos.com

[email protected]