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Neurosurgeon memoir illuminates the journey through cancer treatment and acceptance of mortality
Dr. Paul Kalanithi, a neurosurgeon who had just completed his residency at the Stanford (Calif.) University, died of metastatic lung cancer last year, but he left a memoir of his experiences as a physician, a patient, and a dying man that was published on Jan. 12. His book, “When Breath Becomes Air” (New York: Random House, 2016), recounts the many years of working to exhaustion and deferring of life experiences and pleasures that are necessary to complete medical training.
In a review of the book, Janet Maslin wrote, “One of the most poignant things about Dr. Kalanithi’s story is that he had postponed learning how to live while pursuing his career in neurosurgery. By the time he was ready to enjoy a life outside the operating room, what he needed to learn was how to die.”
Dr. Kalanithi reflected on the profound grief and sense of loss that comes with a diagnosis that he knew meant imminent death. The memoir also reveals his search for meaning and joy, and finally, his acceptance of mortality. He opted for palliative care and his memoir, along with the epilogue written by his wife, Dr. Lucy Kalanithi, gives insight into the value of the palliative path to patients and their families in dire medical crises.
Dr. Paul Kalanithi, a neurosurgeon who had just completed his residency at the Stanford (Calif.) University, died of metastatic lung cancer last year, but he left a memoir of his experiences as a physician, a patient, and a dying man that was published on Jan. 12. His book, “When Breath Becomes Air” (New York: Random House, 2016), recounts the many years of working to exhaustion and deferring of life experiences and pleasures that are necessary to complete medical training.
In a review of the book, Janet Maslin wrote, “One of the most poignant things about Dr. Kalanithi’s story is that he had postponed learning how to live while pursuing his career in neurosurgery. By the time he was ready to enjoy a life outside the operating room, what he needed to learn was how to die.”
Dr. Kalanithi reflected on the profound grief and sense of loss that comes with a diagnosis that he knew meant imminent death. The memoir also reveals his search for meaning and joy, and finally, his acceptance of mortality. He opted for palliative care and his memoir, along with the epilogue written by his wife, Dr. Lucy Kalanithi, gives insight into the value of the palliative path to patients and their families in dire medical crises.
Dr. Paul Kalanithi, a neurosurgeon who had just completed his residency at the Stanford (Calif.) University, died of metastatic lung cancer last year, but he left a memoir of his experiences as a physician, a patient, and a dying man that was published on Jan. 12. His book, “When Breath Becomes Air” (New York: Random House, 2016), recounts the many years of working to exhaustion and deferring of life experiences and pleasures that are necessary to complete medical training.
In a review of the book, Janet Maslin wrote, “One of the most poignant things about Dr. Kalanithi’s story is that he had postponed learning how to live while pursuing his career in neurosurgery. By the time he was ready to enjoy a life outside the operating room, what he needed to learn was how to die.”
Dr. Kalanithi reflected on the profound grief and sense of loss that comes with a diagnosis that he knew meant imminent death. The memoir also reveals his search for meaning and joy, and finally, his acceptance of mortality. He opted for palliative care and his memoir, along with the epilogue written by his wife, Dr. Lucy Kalanithi, gives insight into the value of the palliative path to patients and their families in dire medical crises.
David Bowie’s death inspires blog on palliative care
The death of David Bowie, iconic musician and artist, on Jan. 10 inspired palliative care specialist Dr. Mark Taubert to write a blog about end-of-life scenarios and the importance of advance care planning. The blog, which begins by thanking Mr. Bowie for his many artistic contributions, continues by suggesting that his planned death at home will inspire many people in similar health crises to consider palliative care. The palliative care conversation between a doctor and a patient facing death can be challenging but can lead to what Dr. Taubert called “a good death” at home with symptoms managed and loved ones nearby. Mr. Bowie’s son, Duncan Jones, tweeted a link to the blog in the days after his father’s death.
Dr. Taubert found himself speaking with a patient who was facing probable death in the near future, and both doctor and patient found inspiration in Mr. Bowie’s final music project and his death at home with his family. Dr. Taubert and his patient were able to have the conversation about palliative care at end-of-life in part because they were both impressed with what Mr. Bowie was able to achieve in his last months. “Your story became a way for us to communicate very openly about death, something many doctors and nurses struggle to introduce as a topic of conversation,” he wrote.
Dr. Taubert of the Velindre NHS Trust in Cardiff, Wales, noted that, although palliative care is a highly developed skill with many resources to help patients at the end of life, “this essential part of training is not always available for junior healthcare professionals, including doctors and nurses, and is sometimes overlooked or under-prioritized by those who plan their education. I think if you [David Bowie] were ever to return (as Lazarus did), you would be a firm advocate for good palliative care training being available everywhere.”
The death of David Bowie, iconic musician and artist, on Jan. 10 inspired palliative care specialist Dr. Mark Taubert to write a blog about end-of-life scenarios and the importance of advance care planning. The blog, which begins by thanking Mr. Bowie for his many artistic contributions, continues by suggesting that his planned death at home will inspire many people in similar health crises to consider palliative care. The palliative care conversation between a doctor and a patient facing death can be challenging but can lead to what Dr. Taubert called “a good death” at home with symptoms managed and loved ones nearby. Mr. Bowie’s son, Duncan Jones, tweeted a link to the blog in the days after his father’s death.
Dr. Taubert found himself speaking with a patient who was facing probable death in the near future, and both doctor and patient found inspiration in Mr. Bowie’s final music project and his death at home with his family. Dr. Taubert and his patient were able to have the conversation about palliative care at end-of-life in part because they were both impressed with what Mr. Bowie was able to achieve in his last months. “Your story became a way for us to communicate very openly about death, something many doctors and nurses struggle to introduce as a topic of conversation,” he wrote.
Dr. Taubert of the Velindre NHS Trust in Cardiff, Wales, noted that, although palliative care is a highly developed skill with many resources to help patients at the end of life, “this essential part of training is not always available for junior healthcare professionals, including doctors and nurses, and is sometimes overlooked or under-prioritized by those who plan their education. I think if you [David Bowie] were ever to return (as Lazarus did), you would be a firm advocate for good palliative care training being available everywhere.”
The death of David Bowie, iconic musician and artist, on Jan. 10 inspired palliative care specialist Dr. Mark Taubert to write a blog about end-of-life scenarios and the importance of advance care planning. The blog, which begins by thanking Mr. Bowie for his many artistic contributions, continues by suggesting that his planned death at home will inspire many people in similar health crises to consider palliative care. The palliative care conversation between a doctor and a patient facing death can be challenging but can lead to what Dr. Taubert called “a good death” at home with symptoms managed and loved ones nearby. Mr. Bowie’s son, Duncan Jones, tweeted a link to the blog in the days after his father’s death.
Dr. Taubert found himself speaking with a patient who was facing probable death in the near future, and both doctor and patient found inspiration in Mr. Bowie’s final music project and his death at home with his family. Dr. Taubert and his patient were able to have the conversation about palliative care at end-of-life in part because they were both impressed with what Mr. Bowie was able to achieve in his last months. “Your story became a way for us to communicate very openly about death, something many doctors and nurses struggle to introduce as a topic of conversation,” he wrote.
Dr. Taubert of the Velindre NHS Trust in Cardiff, Wales, noted that, although palliative care is a highly developed skill with many resources to help patients at the end of life, “this essential part of training is not always available for junior healthcare professionals, including doctors and nurses, and is sometimes overlooked or under-prioritized by those who plan their education. I think if you [David Bowie] were ever to return (as Lazarus did), you would be a firm advocate for good palliative care training being available everywhere.”
Families perceive few benefits from aggressive end-of-life care
Bereaved families were substantially more satisfied with end-of-life cancer care when patients did not die in hospital, received more than 3 days of hospice care, and did not enter the ICU within 30 days of dying, according to a multicenter, prospective study published online Jan. 19 in JAMA.
The analysis is one of the first of its type to assess these end-of-life care indicators, said Dr. Alexi Wright of Harvard Medical School, Boston, and her associates. The findings could affect health policy as electronic health records expand under the Health Information Technology for Economic and Clinical Health Act, they said.
End-of-life cancer care has become increasingly aggressive, belying evidence that this approach does not improve patient outcomes, quality of life, or caregiver bereavement. To explore alternatives, the researchers analyzed 1,146 interviews of family members of Medicare patients who died of lung or colorectal cancer by 2011. Their data source was the multiregional, prospective, observational Cancer Care Outcomes Research and Surveillance (CanCORS) study (JAMA 2016;315:284-92).
Family members described end-of-life care as “excellent” 59% of the time when hospice care lasted more 3 days, but 43% of the time otherwise (95% confidence interval for adjusted difference, 11% to 22%). Notably, 73% of patients who received more than 3 days of hospice care died in their preferred location, compared with 40% of patients who received less or no hospice care. Care was rated as excellent 52% of the time when ICU admission was avoided within 30 days of death, and 57% of the time when patients died outside the hospital, compared with 45% and 42% of the time otherwise.
The results support “advance care planning consistent with the preferences of patients,” said the investigators. They recommended more extensive counseling of cancer patients and families, earlier palliative care referrals, and an audit and feedback system to monitor the use of aggressive end-of-life care.
The National Cancer Institute and the Cancer Care Outcomes Research and Surveillance Consortium funded the study. One coinvestigator reported financial relationships with the American Academy of Hospice and Palliative Medicine, National Institute of Nursing Research, National Institute on Aging, Retirement Research Retirement Foundation, California Healthcare Foundation, Commonwealth Fund, West Health Institute, University of Wisconsin, and UpToDate.com. Senior author Dr. Mary Landrum, also of Harvard Medical School, reported grant funding from Pfizer and personal fees from McKinsey and Company and Greylock McKinnon Associates. The other authors had no disclosures.
Bereaved families were substantially more satisfied with end-of-life cancer care when patients did not die in hospital, received more than 3 days of hospice care, and did not enter the ICU within 30 days of dying, according to a multicenter, prospective study published online Jan. 19 in JAMA.
The analysis is one of the first of its type to assess these end-of-life care indicators, said Dr. Alexi Wright of Harvard Medical School, Boston, and her associates. The findings could affect health policy as electronic health records expand under the Health Information Technology for Economic and Clinical Health Act, they said.
End-of-life cancer care has become increasingly aggressive, belying evidence that this approach does not improve patient outcomes, quality of life, or caregiver bereavement. To explore alternatives, the researchers analyzed 1,146 interviews of family members of Medicare patients who died of lung or colorectal cancer by 2011. Their data source was the multiregional, prospective, observational Cancer Care Outcomes Research and Surveillance (CanCORS) study (JAMA 2016;315:284-92).
Family members described end-of-life care as “excellent” 59% of the time when hospice care lasted more 3 days, but 43% of the time otherwise (95% confidence interval for adjusted difference, 11% to 22%). Notably, 73% of patients who received more than 3 days of hospice care died in their preferred location, compared with 40% of patients who received less or no hospice care. Care was rated as excellent 52% of the time when ICU admission was avoided within 30 days of death, and 57% of the time when patients died outside the hospital, compared with 45% and 42% of the time otherwise.
The results support “advance care planning consistent with the preferences of patients,” said the investigators. They recommended more extensive counseling of cancer patients and families, earlier palliative care referrals, and an audit and feedback system to monitor the use of aggressive end-of-life care.
The National Cancer Institute and the Cancer Care Outcomes Research and Surveillance Consortium funded the study. One coinvestigator reported financial relationships with the American Academy of Hospice and Palliative Medicine, National Institute of Nursing Research, National Institute on Aging, Retirement Research Retirement Foundation, California Healthcare Foundation, Commonwealth Fund, West Health Institute, University of Wisconsin, and UpToDate.com. Senior author Dr. Mary Landrum, also of Harvard Medical School, reported grant funding from Pfizer and personal fees from McKinsey and Company and Greylock McKinnon Associates. The other authors had no disclosures.
Bereaved families were substantially more satisfied with end-of-life cancer care when patients did not die in hospital, received more than 3 days of hospice care, and did not enter the ICU within 30 days of dying, according to a multicenter, prospective study published online Jan. 19 in JAMA.
The analysis is one of the first of its type to assess these end-of-life care indicators, said Dr. Alexi Wright of Harvard Medical School, Boston, and her associates. The findings could affect health policy as electronic health records expand under the Health Information Technology for Economic and Clinical Health Act, they said.
End-of-life cancer care has become increasingly aggressive, belying evidence that this approach does not improve patient outcomes, quality of life, or caregiver bereavement. To explore alternatives, the researchers analyzed 1,146 interviews of family members of Medicare patients who died of lung or colorectal cancer by 2011. Their data source was the multiregional, prospective, observational Cancer Care Outcomes Research and Surveillance (CanCORS) study (JAMA 2016;315:284-92).
Family members described end-of-life care as “excellent” 59% of the time when hospice care lasted more 3 days, but 43% of the time otherwise (95% confidence interval for adjusted difference, 11% to 22%). Notably, 73% of patients who received more than 3 days of hospice care died in their preferred location, compared with 40% of patients who received less or no hospice care. Care was rated as excellent 52% of the time when ICU admission was avoided within 30 days of death, and 57% of the time when patients died outside the hospital, compared with 45% and 42% of the time otherwise.
The results support “advance care planning consistent with the preferences of patients,” said the investigators. They recommended more extensive counseling of cancer patients and families, earlier palliative care referrals, and an audit and feedback system to monitor the use of aggressive end-of-life care.
The National Cancer Institute and the Cancer Care Outcomes Research and Surveillance Consortium funded the study. One coinvestigator reported financial relationships with the American Academy of Hospice and Palliative Medicine, National Institute of Nursing Research, National Institute on Aging, Retirement Research Retirement Foundation, California Healthcare Foundation, Commonwealth Fund, West Health Institute, University of Wisconsin, and UpToDate.com. Senior author Dr. Mary Landrum, also of Harvard Medical School, reported grant funding from Pfizer and personal fees from McKinsey and Company and Greylock McKinnon Associates. The other authors had no disclosures.
FROM JAMA
Key clinical point: Bereaved family members were more satisfied with end-of-life cancer care when patients spent more than 3 days in hospice, died outside the hospital, and were not admitted to the ICU within 30 days of dying.
Major finding: Care was described as “excellent” about 9%-17% more often when these end-of-life quality indicators were met.
Data source: A multicenter, prospective, observational study of 1,146 family members of patients who died of lung or colorectal cancer.
Disclosures: The National Cancer Institute and the Cancer Care Outcomes Research and Surveillance Consortium funded the analysis. One coinvestigator reported financial relationships with the American Academy of Hospice and Palliative Medicine, National Institute of Nursing Research, National Institute on Aging, Retirement Research Retirement Foundation, California Healthcare Foundation, Commonwealth Fund, West Health Institute, University of Wisconsin, and UpToDate.com. Senior author Dr. Mary Landrum reported grant funding from Pfizer and personal fees from McKinsey and Company and Greylock McKinnon Associates. The other authors had no disclosures.
Law & Medicine: Health care costs and defensive medicine
Question: Which of the following choices is best?
A. Controversy exists over whether defensive medicine is widely practiced and whether it raises health care costs.
B. Everyone agrees that defensive medicine is widely practiced.
C. Doctors who spend more for their hospitalized patients have been reported to face a lower malpractice risk.
D. A and C.
E. B and C.
Answer: D. Virtually all doctors admit they practice defensive medicine, which describes medical care specifically directed to attenuate the threat of malpractice liability rather than for a proper medical indication. Survey studies generally put the prevalence at greater than 90%, but what separates true defensive medicine from careful practice or patient expectation/demand remains controversial.
A mail survey of 824 physicians in high-risk specialties in Pennsylvania, a state where doctors pay high malpractice premiums, revealed that nearly all reported practicing defensive medicine. The respondents admitted to both assurance behavior – such as ordering more tests, especially imaging studies – as well as avoidance behavior – that is, restricting or eliminating complex procedures or perceived litigious patients.1
In another study, emergency physicians in the upper third of “malpractice fear” used more diagnostic tests and were more likely to hospitalize patients at low risk for coronary artery disease.2
On the other hand, a report using simulated clinical scenarios concluded that the extent of defensive medicine was at most 8%, and another found no correlation between individual malpractice claims experience and resource use, physician concern about malpractice, tolerance for uncertainty, or perception of risk.3
Another area of contention is whether some of our soaring health care costs may reflect defensive medicine at play.
A recent survey of 2,000 U.S. orthopedic surgeons found that 96% admitted practicing defensive medicine, with 24% of all ordered tests being for defensive reasons. The authors estimated that this amounted to about $100,000 per surgeon per year, or a total annual sum of $2 billion for the 20,400 orthopedic surgeons in the U.S.4
By correlating professional liability insurance with cost of services, the AMA estimated that in the 1980s, defensive medicine cost $12.1 billion to $13.7 billion each year.5 In an oft-cited study by Kessler and McClellan, the authors measured the effects of malpractice liability reforms using data from elderly Medicare beneficiaries treated for serious heart disease.6 They found that reforms that directly reduced provider liability pressure led to reductions of 5%-9% in medical expenditures. If such Medicare savings, which amounted to $600 million per year for cardiac disease, were extrapolated across the health care system, the annual savings would total $50 billion.
A more conservative study estimated that systemwide savings from aggressive malpractice reform would approach $41 billion over 5 years.7
Dr. Anupam B. Jena and his coauthors are the latest investigators seeking to clarify the correlation between defensive medicine and health care costs.8 Using Florida hospital admission data from 2000-2009, which covered some 24,000 physicians in seven separate specialties, the authors found that higher spending by physicians was associated with reduced malpractice claims the following year. This pattern held true for six of the seven specialties, family practitioners being the sole exception.
For example, among internists, the malpractice risk probability was reduced from 1.5% in the bottom spending fifth ($19,725 per admission) to 0.3% in the top fifth ($39,379 per admission). Among obstetricians, a separate subgroup analysis of cesarean-section rates revealed that malpractice claims were approximately halved among obstetricians with rates in the highest fifth, compared with the lowest fifth. These results comport with previous reports of higher C-section rates in obstetricians who perceived themselves at higher malpractice risk, although other studies have found no correlation or an actual lower rate.
In concluding that higher resource use by physicians was associated with fewer malpractice claims, the authors acknowledged that a principal limitation of the study was the lack of information on illness severity. Importantly, they were unable to state whether higher spending was defensively motivated. A companion editorial questioned whether increased resource expenditure was a bona fide reflection of defensive medicine or may simply have resulted in fewer errors and adverse events.9
Unfortunately, the past malpractice experience of the doctors, which could provide insight into more defensive postures, better communication, etc., was not measured in the study. In addition, claims made just 1 year after an incident may not accurately reflect the real-world situation, where the filing of a lawsuit may lag any alleged negligence by a much longer period, especially in obstetric cases.
Worryingly, the results of this timely study may be used to imply that the more doctors spend, the less likely they are to be sued – a troubling notion in our current race to stem rising health care costs.
References
1. JAMA. 2005 Jun 1;293(21):2609-17.
2. Ann Emerg Med. 2005 Dec;46(6):525-33.
3. J Health Polit Policy Law. 1996 Summer;21(2):267-88.
4. Am J Orthop (Belle Mead NJ). 2012 Feb;41(2):69-73.
5. JAMA. 1987 May 22-29;257(20):2776-81.
6. Q J Econ. 1996 May; 111(2):353-90.
7. J Am Health Policy. 1994 Jul-Aug;4(4):7-15.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: Which of the following choices is best?
A. Controversy exists over whether defensive medicine is widely practiced and whether it raises health care costs.
B. Everyone agrees that defensive medicine is widely practiced.
C. Doctors who spend more for their hospitalized patients have been reported to face a lower malpractice risk.
D. A and C.
E. B and C.
Answer: D. Virtually all doctors admit they practice defensive medicine, which describes medical care specifically directed to attenuate the threat of malpractice liability rather than for a proper medical indication. Survey studies generally put the prevalence at greater than 90%, but what separates true defensive medicine from careful practice or patient expectation/demand remains controversial.
A mail survey of 824 physicians in high-risk specialties in Pennsylvania, a state where doctors pay high malpractice premiums, revealed that nearly all reported practicing defensive medicine. The respondents admitted to both assurance behavior – such as ordering more tests, especially imaging studies – as well as avoidance behavior – that is, restricting or eliminating complex procedures or perceived litigious patients.1
In another study, emergency physicians in the upper third of “malpractice fear” used more diagnostic tests and were more likely to hospitalize patients at low risk for coronary artery disease.2
On the other hand, a report using simulated clinical scenarios concluded that the extent of defensive medicine was at most 8%, and another found no correlation between individual malpractice claims experience and resource use, physician concern about malpractice, tolerance for uncertainty, or perception of risk.3
Another area of contention is whether some of our soaring health care costs may reflect defensive medicine at play.
A recent survey of 2,000 U.S. orthopedic surgeons found that 96% admitted practicing defensive medicine, with 24% of all ordered tests being for defensive reasons. The authors estimated that this amounted to about $100,000 per surgeon per year, or a total annual sum of $2 billion for the 20,400 orthopedic surgeons in the U.S.4
By correlating professional liability insurance with cost of services, the AMA estimated that in the 1980s, defensive medicine cost $12.1 billion to $13.7 billion each year.5 In an oft-cited study by Kessler and McClellan, the authors measured the effects of malpractice liability reforms using data from elderly Medicare beneficiaries treated for serious heart disease.6 They found that reforms that directly reduced provider liability pressure led to reductions of 5%-9% in medical expenditures. If such Medicare savings, which amounted to $600 million per year for cardiac disease, were extrapolated across the health care system, the annual savings would total $50 billion.
A more conservative study estimated that systemwide savings from aggressive malpractice reform would approach $41 billion over 5 years.7
Dr. Anupam B. Jena and his coauthors are the latest investigators seeking to clarify the correlation between defensive medicine and health care costs.8 Using Florida hospital admission data from 2000-2009, which covered some 24,000 physicians in seven separate specialties, the authors found that higher spending by physicians was associated with reduced malpractice claims the following year. This pattern held true for six of the seven specialties, family practitioners being the sole exception.
For example, among internists, the malpractice risk probability was reduced from 1.5% in the bottom spending fifth ($19,725 per admission) to 0.3% in the top fifth ($39,379 per admission). Among obstetricians, a separate subgroup analysis of cesarean-section rates revealed that malpractice claims were approximately halved among obstetricians with rates in the highest fifth, compared with the lowest fifth. These results comport with previous reports of higher C-section rates in obstetricians who perceived themselves at higher malpractice risk, although other studies have found no correlation or an actual lower rate.
In concluding that higher resource use by physicians was associated with fewer malpractice claims, the authors acknowledged that a principal limitation of the study was the lack of information on illness severity. Importantly, they were unable to state whether higher spending was defensively motivated. A companion editorial questioned whether increased resource expenditure was a bona fide reflection of defensive medicine or may simply have resulted in fewer errors and adverse events.9
Unfortunately, the past malpractice experience of the doctors, which could provide insight into more defensive postures, better communication, etc., was not measured in the study. In addition, claims made just 1 year after an incident may not accurately reflect the real-world situation, where the filing of a lawsuit may lag any alleged negligence by a much longer period, especially in obstetric cases.
Worryingly, the results of this timely study may be used to imply that the more doctors spend, the less likely they are to be sued – a troubling notion in our current race to stem rising health care costs.
References
1. JAMA. 2005 Jun 1;293(21):2609-17.
2. Ann Emerg Med. 2005 Dec;46(6):525-33.
3. J Health Polit Policy Law. 1996 Summer;21(2):267-88.
4. Am J Orthop (Belle Mead NJ). 2012 Feb;41(2):69-73.
5. JAMA. 1987 May 22-29;257(20):2776-81.
6. Q J Econ. 1996 May; 111(2):353-90.
7. J Am Health Policy. 1994 Jul-Aug;4(4):7-15.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: Which of the following choices is best?
A. Controversy exists over whether defensive medicine is widely practiced and whether it raises health care costs.
B. Everyone agrees that defensive medicine is widely practiced.
C. Doctors who spend more for their hospitalized patients have been reported to face a lower malpractice risk.
D. A and C.
E. B and C.
Answer: D. Virtually all doctors admit they practice defensive medicine, which describes medical care specifically directed to attenuate the threat of malpractice liability rather than for a proper medical indication. Survey studies generally put the prevalence at greater than 90%, but what separates true defensive medicine from careful practice or patient expectation/demand remains controversial.
A mail survey of 824 physicians in high-risk specialties in Pennsylvania, a state where doctors pay high malpractice premiums, revealed that nearly all reported practicing defensive medicine. The respondents admitted to both assurance behavior – such as ordering more tests, especially imaging studies – as well as avoidance behavior – that is, restricting or eliminating complex procedures or perceived litigious patients.1
In another study, emergency physicians in the upper third of “malpractice fear” used more diagnostic tests and were more likely to hospitalize patients at low risk for coronary artery disease.2
On the other hand, a report using simulated clinical scenarios concluded that the extent of defensive medicine was at most 8%, and another found no correlation between individual malpractice claims experience and resource use, physician concern about malpractice, tolerance for uncertainty, or perception of risk.3
Another area of contention is whether some of our soaring health care costs may reflect defensive medicine at play.
A recent survey of 2,000 U.S. orthopedic surgeons found that 96% admitted practicing defensive medicine, with 24% of all ordered tests being for defensive reasons. The authors estimated that this amounted to about $100,000 per surgeon per year, or a total annual sum of $2 billion for the 20,400 orthopedic surgeons in the U.S.4
By correlating professional liability insurance with cost of services, the AMA estimated that in the 1980s, defensive medicine cost $12.1 billion to $13.7 billion each year.5 In an oft-cited study by Kessler and McClellan, the authors measured the effects of malpractice liability reforms using data from elderly Medicare beneficiaries treated for serious heart disease.6 They found that reforms that directly reduced provider liability pressure led to reductions of 5%-9% in medical expenditures. If such Medicare savings, which amounted to $600 million per year for cardiac disease, were extrapolated across the health care system, the annual savings would total $50 billion.
A more conservative study estimated that systemwide savings from aggressive malpractice reform would approach $41 billion over 5 years.7
Dr. Anupam B. Jena and his coauthors are the latest investigators seeking to clarify the correlation between defensive medicine and health care costs.8 Using Florida hospital admission data from 2000-2009, which covered some 24,000 physicians in seven separate specialties, the authors found that higher spending by physicians was associated with reduced malpractice claims the following year. This pattern held true for six of the seven specialties, family practitioners being the sole exception.
For example, among internists, the malpractice risk probability was reduced from 1.5% in the bottom spending fifth ($19,725 per admission) to 0.3% in the top fifth ($39,379 per admission). Among obstetricians, a separate subgroup analysis of cesarean-section rates revealed that malpractice claims were approximately halved among obstetricians with rates in the highest fifth, compared with the lowest fifth. These results comport with previous reports of higher C-section rates in obstetricians who perceived themselves at higher malpractice risk, although other studies have found no correlation or an actual lower rate.
In concluding that higher resource use by physicians was associated with fewer malpractice claims, the authors acknowledged that a principal limitation of the study was the lack of information on illness severity. Importantly, they were unable to state whether higher spending was defensively motivated. A companion editorial questioned whether increased resource expenditure was a bona fide reflection of defensive medicine or may simply have resulted in fewer errors and adverse events.9
Unfortunately, the past malpractice experience of the doctors, which could provide insight into more defensive postures, better communication, etc., was not measured in the study. In addition, claims made just 1 year after an incident may not accurately reflect the real-world situation, where the filing of a lawsuit may lag any alleged negligence by a much longer period, especially in obstetric cases.
Worryingly, the results of this timely study may be used to imply that the more doctors spend, the less likely they are to be sued – a troubling notion in our current race to stem rising health care costs.
References
1. JAMA. 2005 Jun 1;293(21):2609-17.
2. Ann Emerg Med. 2005 Dec;46(6):525-33.
3. J Health Polit Policy Law. 1996 Summer;21(2):267-88.
4. Am J Orthop (Belle Mead NJ). 2012 Feb;41(2):69-73.
5. JAMA. 1987 May 22-29;257(20):2776-81.
6. Q J Econ. 1996 May; 111(2):353-90.
7. J Am Health Policy. 1994 Jul-Aug;4(4):7-15.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Alternative payment models: MedPAC says keep it simple
WASHINGTON – A federal advisory panel has straightforward advice for the government as it shifts towards value-based health care: Keep it simple.
At the Jan. 15 meeting of the Medicare Payment Advisory Commission (MedPAC), Commissioner Warner Thomas said, “I think one of our first principles should be to try to simplify this because it’s very complicated for a provider to try to understand what path to take and how to play in these situations. We want providers to engage in this and I think there is a lot of aversion because folks don’t understand it, and they’re not sure where to play or where not to play.”
Officials at the Centers for Medicare & Medicaid Services are drafting the regulations needed to implement the Medicare Access & CHIP Reauthorization Act (MACRA); the proposed regulations are expected in the Spring.
MedPAC staff offered a number of principles they hope to see incorporated into the final design for alternative payment models (APMs) under the law, including:
• Incentive payments to providers should be distributed only if the entities they are a part of are able to successfully control cost, improve quality, or both.
• Entities should have enough beneficiaries to detect changes in spending and quality.
• Entities should be at risk for total Part A and Part B spending; in the future, Part D also might be measured.
• Entities should be allowed to share savings with beneficiaries.
• Regulatory relief should be possible.
Several MedPAC commissioners focused on how physicians are viewing the risk they will be asked to assume in an APM.
APMs are “an attempt to sort of jump start a movement in the direction of risk taking from a group that I don’t think is very thrilled about taking financial risk and has shown it by their actual practice in the face of efforts at least to nudge them in this direction,” said Commissioner Bill Gradison Jr., a former congressman from Ohio who served on the House Committee on Ways and Means. “Having said that, I wish I had a better understanding of the motivation of physicians in terms of what might move them in this direction. The assumption here is that the money will move them, and maybe it’s that simple, but I am not too sure about that.”
Commissioner Jack Hoadley, Ph.D., of the Health Policy Institute at Georgetown University, Washington, noted that the if there is too little risk involved, there tends to be little movement in changing the behavior.
Dr. Hoadley suggested that CMS could consider “looking at some of the models by which risk can be structured so it puts plenty of money on the line but it doesn’t do it in a way that’s going to get complicated in terms of physicians owing money back.”
Commissioners also recommended a tight threshold, at least early on, to show that cost containment and/or quality improvement are well established before an entity can move into an APM and receive a financial incentive.
“Let’s keep the initial round and definition tight and actually demand a track record before we qualify something as an alternative payment mechanism,” said Commissioner Kathy Buto, a U.S. and international health policy consultant and former deputy executive secretary in the U.S. Health & Human Services Department. “Once you open this up, you can’t close it down. You cannot walk it back. We are talking about paying a lot more money, 5% more and if the definition is too loose and too many entities get into it, you can never walk it back and you will be just adding to the expenditures.”
WASHINGTON – A federal advisory panel has straightforward advice for the government as it shifts towards value-based health care: Keep it simple.
At the Jan. 15 meeting of the Medicare Payment Advisory Commission (MedPAC), Commissioner Warner Thomas said, “I think one of our first principles should be to try to simplify this because it’s very complicated for a provider to try to understand what path to take and how to play in these situations. We want providers to engage in this and I think there is a lot of aversion because folks don’t understand it, and they’re not sure where to play or where not to play.”
Officials at the Centers for Medicare & Medicaid Services are drafting the regulations needed to implement the Medicare Access & CHIP Reauthorization Act (MACRA); the proposed regulations are expected in the Spring.
MedPAC staff offered a number of principles they hope to see incorporated into the final design for alternative payment models (APMs) under the law, including:
• Incentive payments to providers should be distributed only if the entities they are a part of are able to successfully control cost, improve quality, or both.
• Entities should have enough beneficiaries to detect changes in spending and quality.
• Entities should be at risk for total Part A and Part B spending; in the future, Part D also might be measured.
• Entities should be allowed to share savings with beneficiaries.
• Regulatory relief should be possible.
Several MedPAC commissioners focused on how physicians are viewing the risk they will be asked to assume in an APM.
APMs are “an attempt to sort of jump start a movement in the direction of risk taking from a group that I don’t think is very thrilled about taking financial risk and has shown it by their actual practice in the face of efforts at least to nudge them in this direction,” said Commissioner Bill Gradison Jr., a former congressman from Ohio who served on the House Committee on Ways and Means. “Having said that, I wish I had a better understanding of the motivation of physicians in terms of what might move them in this direction. The assumption here is that the money will move them, and maybe it’s that simple, but I am not too sure about that.”
Commissioner Jack Hoadley, Ph.D., of the Health Policy Institute at Georgetown University, Washington, noted that the if there is too little risk involved, there tends to be little movement in changing the behavior.
Dr. Hoadley suggested that CMS could consider “looking at some of the models by which risk can be structured so it puts plenty of money on the line but it doesn’t do it in a way that’s going to get complicated in terms of physicians owing money back.”
Commissioners also recommended a tight threshold, at least early on, to show that cost containment and/or quality improvement are well established before an entity can move into an APM and receive a financial incentive.
“Let’s keep the initial round and definition tight and actually demand a track record before we qualify something as an alternative payment mechanism,” said Commissioner Kathy Buto, a U.S. and international health policy consultant and former deputy executive secretary in the U.S. Health & Human Services Department. “Once you open this up, you can’t close it down. You cannot walk it back. We are talking about paying a lot more money, 5% more and if the definition is too loose and too many entities get into it, you can never walk it back and you will be just adding to the expenditures.”
WASHINGTON – A federal advisory panel has straightforward advice for the government as it shifts towards value-based health care: Keep it simple.
At the Jan. 15 meeting of the Medicare Payment Advisory Commission (MedPAC), Commissioner Warner Thomas said, “I think one of our first principles should be to try to simplify this because it’s very complicated for a provider to try to understand what path to take and how to play in these situations. We want providers to engage in this and I think there is a lot of aversion because folks don’t understand it, and they’re not sure where to play or where not to play.”
Officials at the Centers for Medicare & Medicaid Services are drafting the regulations needed to implement the Medicare Access & CHIP Reauthorization Act (MACRA); the proposed regulations are expected in the Spring.
MedPAC staff offered a number of principles they hope to see incorporated into the final design for alternative payment models (APMs) under the law, including:
• Incentive payments to providers should be distributed only if the entities they are a part of are able to successfully control cost, improve quality, or both.
• Entities should have enough beneficiaries to detect changes in spending and quality.
• Entities should be at risk for total Part A and Part B spending; in the future, Part D also might be measured.
• Entities should be allowed to share savings with beneficiaries.
• Regulatory relief should be possible.
Several MedPAC commissioners focused on how physicians are viewing the risk they will be asked to assume in an APM.
APMs are “an attempt to sort of jump start a movement in the direction of risk taking from a group that I don’t think is very thrilled about taking financial risk and has shown it by their actual practice in the face of efforts at least to nudge them in this direction,” said Commissioner Bill Gradison Jr., a former congressman from Ohio who served on the House Committee on Ways and Means. “Having said that, I wish I had a better understanding of the motivation of physicians in terms of what might move them in this direction. The assumption here is that the money will move them, and maybe it’s that simple, but I am not too sure about that.”
Commissioner Jack Hoadley, Ph.D., of the Health Policy Institute at Georgetown University, Washington, noted that the if there is too little risk involved, there tends to be little movement in changing the behavior.
Dr. Hoadley suggested that CMS could consider “looking at some of the models by which risk can be structured so it puts plenty of money on the line but it doesn’t do it in a way that’s going to get complicated in terms of physicians owing money back.”
Commissioners also recommended a tight threshold, at least early on, to show that cost containment and/or quality improvement are well established before an entity can move into an APM and receive a financial incentive.
“Let’s keep the initial round and definition tight and actually demand a track record before we qualify something as an alternative payment mechanism,” said Commissioner Kathy Buto, a U.S. and international health policy consultant and former deputy executive secretary in the U.S. Health & Human Services Department. “Once you open this up, you can’t close it down. You cannot walk it back. We are talking about paying a lot more money, 5% more and if the definition is too loose and too many entities get into it, you can never walk it back and you will be just adding to the expenditures.”
AT A MEDPAC MEETING
New year brings reduced flu activity
Influenza-like illness (ILI) activity was down during the first full week in January – a not-so-unlucky week 13 of the 2015-2016 flu season, the Centers for Disease Control and Prevention reported.
South Carolina was at level 8, making it the only state in the “high” range of activity for the week ending Jan. 9. Puerto Rico was also at level 8, but there was no state in the “moderate” range and only seven states in the “low” range: Arizona and Maryland at level 5 and Connecticut, Illinois, Pennsylvania, Texas, and Virginia at level 4. There were 18 states at level 2 or higher, compared with 24 the previous week, according to data from the CDC’s Outpatient Influenza-like Illness Surveillance Network.
The proportion of outpatient visits for ILI was 2% for week 13, which was down from 2.8% in week 12 and below the national baseline of 2.1%, the CDC said. ILI is defined as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.
One ILI-related pediatric death was reported during week 13, although it actually occurred in December. So far, there have been seven pediatric deaths reported during the 2015-2016 flu season, the CDC report noted.
Since Oct. 1, 2015, there have been 423 laboratory-confirmed influenza-associated hospitalizations reported in the 13 states – including California, New York, and Ohio – of the CDC’s Influenza Hospitalization Surveillance Network, for an overall hospitalization rate of 1.5 per 100,000 population. That rate, however, is “likely to be an underestimate as influenza-related hospitalizations can be missed, either because testing is not performed, or because cases may be attributed to other causes of pneumonia or other common influenza-related complications,” the CDC said.
Influenza-like illness (ILI) activity was down during the first full week in January – a not-so-unlucky week 13 of the 2015-2016 flu season, the Centers for Disease Control and Prevention reported.
South Carolina was at level 8, making it the only state in the “high” range of activity for the week ending Jan. 9. Puerto Rico was also at level 8, but there was no state in the “moderate” range and only seven states in the “low” range: Arizona and Maryland at level 5 and Connecticut, Illinois, Pennsylvania, Texas, and Virginia at level 4. There were 18 states at level 2 or higher, compared with 24 the previous week, according to data from the CDC’s Outpatient Influenza-like Illness Surveillance Network.
The proportion of outpatient visits for ILI was 2% for week 13, which was down from 2.8% in week 12 and below the national baseline of 2.1%, the CDC said. ILI is defined as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.
One ILI-related pediatric death was reported during week 13, although it actually occurred in December. So far, there have been seven pediatric deaths reported during the 2015-2016 flu season, the CDC report noted.
Since Oct. 1, 2015, there have been 423 laboratory-confirmed influenza-associated hospitalizations reported in the 13 states – including California, New York, and Ohio – of the CDC’s Influenza Hospitalization Surveillance Network, for an overall hospitalization rate of 1.5 per 100,000 population. That rate, however, is “likely to be an underestimate as influenza-related hospitalizations can be missed, either because testing is not performed, or because cases may be attributed to other causes of pneumonia or other common influenza-related complications,” the CDC said.
Influenza-like illness (ILI) activity was down during the first full week in January – a not-so-unlucky week 13 of the 2015-2016 flu season, the Centers for Disease Control and Prevention reported.
South Carolina was at level 8, making it the only state in the “high” range of activity for the week ending Jan. 9. Puerto Rico was also at level 8, but there was no state in the “moderate” range and only seven states in the “low” range: Arizona and Maryland at level 5 and Connecticut, Illinois, Pennsylvania, Texas, and Virginia at level 4. There were 18 states at level 2 or higher, compared with 24 the previous week, according to data from the CDC’s Outpatient Influenza-like Illness Surveillance Network.
The proportion of outpatient visits for ILI was 2% for week 13, which was down from 2.8% in week 12 and below the national baseline of 2.1%, the CDC said. ILI is defined as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.
One ILI-related pediatric death was reported during week 13, although it actually occurred in December. So far, there have been seven pediatric deaths reported during the 2015-2016 flu season, the CDC report noted.
Since Oct. 1, 2015, there have been 423 laboratory-confirmed influenza-associated hospitalizations reported in the 13 states – including California, New York, and Ohio – of the CDC’s Influenza Hospitalization Surveillance Network, for an overall hospitalization rate of 1.5 per 100,000 population. That rate, however, is “likely to be an underestimate as influenza-related hospitalizations can be missed, either because testing is not performed, or because cases may be attributed to other causes of pneumonia or other common influenza-related complications,” the CDC said.
2016: Celebrating 20 Years of Hospital Medicine and Looking Toward a Bright Future
For hospitalists who were practicing medicine in 1996, it may seem like just a few years ago; however, that was when the term “hospitalist” was first used by Bob Wachter, MD, MHM, and Lee Goldman, MD, in a New England Journal of Medicine article. And for those who started their hospitalist careers since then, it may be inconceivable that there was a time before hospitalists were widely known.
In either case, 20 years later, the term has stuck and now identifies more than 44,000 hospitalists nationwide.
SHM will be commemorating the specialty’s milestone all year, referring to 2016 as the “Year of the Hospitalist.”
In addition to yearlong recognition of hospitalists, SHM will celebrate the Year of the Hospitalist in front of thousands at a plenary session at HM16 in San Diego. There, SHM co-founders John Nelson, MD, MHM, and Win Whitcomb, MD, MHM, will offer their own perspective on the specialty after just 20 years—and what’s to come.
“When Win Whitcomb and I began talking about forming a medical society, we wanted to make sure it would serve as a forum for exchange of ideas about the most effective ways to approach our work,” Dr. Nelson recalls. “It is really gratifying to see all the ways SHM has done that and to think about how it will be increasingly important for all in hospital medicine to have a way to stay connected given the ever-increasing pace of change in hospital care and healthcare generally.”
Dr. Whitcomb shares Dr. Nelson’s awe at the growth and influence of the specialty in a relatively short amount of time.
“A lot has changed in 20 years. Back then, we were surprised to observe that hospitalists, yet unnamed, could reliably decrease cost and length of stay,” Dr. Whitcomb says. “Then, in 1999, hospital medicine was transformed as patient safety emerged as a bona fide discipline.”
However, the transitions are not over for hospitalists, he says.
“As we see healthcare in the midst of a generational transition to alternative payment models like ACOs and bundled payment, hospitalists will once again reinvent themselves, this time to influence care over not just the inpatient stay but also patients’ transition out of the hospital and back into the primary care system,” Dr. Whitcomb says. TH
Brendon Shank is SHM’s associate vice president of communications.
For hospitalists who were practicing medicine in 1996, it may seem like just a few years ago; however, that was when the term “hospitalist” was first used by Bob Wachter, MD, MHM, and Lee Goldman, MD, in a New England Journal of Medicine article. And for those who started their hospitalist careers since then, it may be inconceivable that there was a time before hospitalists were widely known.
In either case, 20 years later, the term has stuck and now identifies more than 44,000 hospitalists nationwide.
SHM will be commemorating the specialty’s milestone all year, referring to 2016 as the “Year of the Hospitalist.”
In addition to yearlong recognition of hospitalists, SHM will celebrate the Year of the Hospitalist in front of thousands at a plenary session at HM16 in San Diego. There, SHM co-founders John Nelson, MD, MHM, and Win Whitcomb, MD, MHM, will offer their own perspective on the specialty after just 20 years—and what’s to come.
“When Win Whitcomb and I began talking about forming a medical society, we wanted to make sure it would serve as a forum for exchange of ideas about the most effective ways to approach our work,” Dr. Nelson recalls. “It is really gratifying to see all the ways SHM has done that and to think about how it will be increasingly important for all in hospital medicine to have a way to stay connected given the ever-increasing pace of change in hospital care and healthcare generally.”
Dr. Whitcomb shares Dr. Nelson’s awe at the growth and influence of the specialty in a relatively short amount of time.
“A lot has changed in 20 years. Back then, we were surprised to observe that hospitalists, yet unnamed, could reliably decrease cost and length of stay,” Dr. Whitcomb says. “Then, in 1999, hospital medicine was transformed as patient safety emerged as a bona fide discipline.”
However, the transitions are not over for hospitalists, he says.
“As we see healthcare in the midst of a generational transition to alternative payment models like ACOs and bundled payment, hospitalists will once again reinvent themselves, this time to influence care over not just the inpatient stay but also patients’ transition out of the hospital and back into the primary care system,” Dr. Whitcomb says. TH
Brendon Shank is SHM’s associate vice president of communications.
For hospitalists who were practicing medicine in 1996, it may seem like just a few years ago; however, that was when the term “hospitalist” was first used by Bob Wachter, MD, MHM, and Lee Goldman, MD, in a New England Journal of Medicine article. And for those who started their hospitalist careers since then, it may be inconceivable that there was a time before hospitalists were widely known.
In either case, 20 years later, the term has stuck and now identifies more than 44,000 hospitalists nationwide.
SHM will be commemorating the specialty’s milestone all year, referring to 2016 as the “Year of the Hospitalist.”
In addition to yearlong recognition of hospitalists, SHM will celebrate the Year of the Hospitalist in front of thousands at a plenary session at HM16 in San Diego. There, SHM co-founders John Nelson, MD, MHM, and Win Whitcomb, MD, MHM, will offer their own perspective on the specialty after just 20 years—and what’s to come.
“When Win Whitcomb and I began talking about forming a medical society, we wanted to make sure it would serve as a forum for exchange of ideas about the most effective ways to approach our work,” Dr. Nelson recalls. “It is really gratifying to see all the ways SHM has done that and to think about how it will be increasingly important for all in hospital medicine to have a way to stay connected given the ever-increasing pace of change in hospital care and healthcare generally.”
Dr. Whitcomb shares Dr. Nelson’s awe at the growth and influence of the specialty in a relatively short amount of time.
“A lot has changed in 20 years. Back then, we were surprised to observe that hospitalists, yet unnamed, could reliably decrease cost and length of stay,” Dr. Whitcomb says. “Then, in 1999, hospital medicine was transformed as patient safety emerged as a bona fide discipline.”
However, the transitions are not over for hospitalists, he says.
“As we see healthcare in the midst of a generational transition to alternative payment models like ACOs and bundled payment, hospitalists will once again reinvent themselves, this time to influence care over not just the inpatient stay but also patients’ transition out of the hospital and back into the primary care system,” Dr. Whitcomb says. TH
Brendon Shank is SHM’s associate vice president of communications.
Melissa Mattison, MD, SFHM, Offers Inside Scoop on HM16 Educational Offerings
HM16 course director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School in Boston, took some time out of her busy schedule to chat with The Hospitalist about how the annual meeting program comes together, the continued relevance of SHM meetings, resisting the lure of San Diego beaches, and more.
Read more about what's new at HM16
Question: There’s a lot packed into just a few days at every annual meeting. What is the process for determining what makes it into the program?
Answer: The annual meeting committee starts meeting in the spring, basically around 12 to 13 months before the annual meeting. So even as the current annual meeting is going on, the next one is well under way in terms of planning.
The annual meeting committee then meets every single week, if not more frequently, by conference call to map out and assign jobs and whatnot to the group. We usually start by reviewing workshops. The workshop proposals are received by SHM through an open-access submission process, whereby pretty much anyone can submit a proposal for a workshop. The annual meeting committee reviews all of the workshops. This year, we had 160 or 170 workshop submissions. We were only able to accept 16, I believe. …
Listen to more of our interview with Dr. Mattison.
At the same time the workshops are being selected, we work with the leaders of practice management, the leaders of the academic and research committees, and the leaders of quality and pediatrics committees to have them help us identify content for their various tracks, suggest speakers and talks. After all of that’s done, we move on to the remaining didactic sessions, and we look at what things were popular in previous years, what things had good reviews, which speakers were highly regarded, etc., and spend some time thinking deliberately about tracks that we feel we ought to include again, like the “Young Hospitalists” track and tracks that we think deserve to be included that haven’t previously been included—those that warrant some sort of attention because of widespread appeal and usefulness to the attendee of SHM.
Q: It’s very easy for hospitalists to stream videos of talks, access literature online, and talk about important topics in online chat rooms. In this day and age, what is the advantage to physically taking part in an annual meeting in an actual brick-and-mortar building?
A: The content itself is enough to draw someone. It’s packed content in terms of topics that would be of interest and benefit to the average hospitalist; pretty much any hospitalist who’s practicing medicine will find multiple, multiple sessions of interest and value. And you don’t have to go far for them. You don’t have to go hunting for them. They’re all there. …
Aside from actual didactics and content of the annual meeting, there’s the value of networking and of collaboration and meeting and talking to hospitalists from around the country and around the world. I mean, I think that one of the biggest values I’ve had is just meeting other people who are facing challenges in their work environment that I have [and learning] how they solve their challenges.
I think the [special interest] groups that meet Monday evening at 4:30 p.m. … those are great opportunities to go and meet people who have interests that are similar to yours or concerns that are similar to yours.
Q: Technology has a presence in the program this year. Why is it so important to highlight this?
A: The challenge of healthcare and incorporating technology into providing care to patients in a way that is efficient and helpful is there. That is a challenge that has been written about by many, many folks. Dr. Bob Wachter gave a whole keynote on it last year. And we’re all seeking ways to work with the technology that we have and identify opportunities to improve the care we’re providing using and harnessing the technology that’s available to us.
So whether that’s with new apps or with figuring out ways to embed decision support into our local systems of care, we need to do that. I think hospitalists are, time and time again, looked at as leaders at their institutions in this domain. It’s going to be 2016, this is the world we live in, and to ignore technology would be foolhardy.
Q: One of the new tracks is focused on post-acute care. Is the importance of the post-acute setting a sign that hospital medicine is, in some ways, reinventing itself?
A: I wouldn’t say reinventing. I think that hospitalists and internists that have become hospitalists have filled the gap in care over the past 20 years. It’s been 20 years since the name “hospitalist” was used in the New England Journal of Medicine. And in that time, the breadth and depth of care that hospitalists provide across the continuum in the acute-care setting has grown. …
Our older patients are often discharged from the acute-care setting but unable to return directly to their home environment safely. [They] require a period of a week or two, or sometimes longer, in a post-acute-care setting to continue to receive both the medical and the physical rehabilitation care that they need. And we know that there are not enough geriatricians in the world, and hospitalists are really sort of stepping up to provide this post-acute care. And it makes sense because the patients are coming from the hospital directly, and a lot of folks would say they’re sicker than ever in the post-acute-care setting. You don’t stay in the hospital for long anymore, and when you get to the post-acute-care setting, often the illness is ongoing but stabilized, and the patient is on the mend from whatever has befallen them. But they still require a fair amount of medical management. So it makes sense that hospitalists are going into that sphere.
Q: How will you go about resisting the temptation to stealthily leave the convention center during the day and hit the beach? Or will you be able to resist?
A: [Laughter.] I do like that question. I think that … I think that the conference, while it’s busy, there’s some time in the evening to go out and have a nice meal or [to] the beach and see friends. And then the last day, if you have time, if you don’t need to race off, you have a good half a day where you could go to the beach, or you could come early and come a day before or stay an extra couple of days and enjoy San Diego.
But I think if you skip the conference for the beach, you’re not doing yourself a service. You’re going to miss out on the opportunity to learn new clinical information, new strategies for communication. You’re also going to miss out on opportunities to network with your colleagues from across the country. TH
Thomas R. Collins is a freelance writer in South Florida.
HM16 course director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School in Boston, took some time out of her busy schedule to chat with The Hospitalist about how the annual meeting program comes together, the continued relevance of SHM meetings, resisting the lure of San Diego beaches, and more.
Read more about what's new at HM16
Question: There’s a lot packed into just a few days at every annual meeting. What is the process for determining what makes it into the program?
Answer: The annual meeting committee starts meeting in the spring, basically around 12 to 13 months before the annual meeting. So even as the current annual meeting is going on, the next one is well under way in terms of planning.
The annual meeting committee then meets every single week, if not more frequently, by conference call to map out and assign jobs and whatnot to the group. We usually start by reviewing workshops. The workshop proposals are received by SHM through an open-access submission process, whereby pretty much anyone can submit a proposal for a workshop. The annual meeting committee reviews all of the workshops. This year, we had 160 or 170 workshop submissions. We were only able to accept 16, I believe. …
Listen to more of our interview with Dr. Mattison.
At the same time the workshops are being selected, we work with the leaders of practice management, the leaders of the academic and research committees, and the leaders of quality and pediatrics committees to have them help us identify content for their various tracks, suggest speakers and talks. After all of that’s done, we move on to the remaining didactic sessions, and we look at what things were popular in previous years, what things had good reviews, which speakers were highly regarded, etc., and spend some time thinking deliberately about tracks that we feel we ought to include again, like the “Young Hospitalists” track and tracks that we think deserve to be included that haven’t previously been included—those that warrant some sort of attention because of widespread appeal and usefulness to the attendee of SHM.
Q: It’s very easy for hospitalists to stream videos of talks, access literature online, and talk about important topics in online chat rooms. In this day and age, what is the advantage to physically taking part in an annual meeting in an actual brick-and-mortar building?
A: The content itself is enough to draw someone. It’s packed content in terms of topics that would be of interest and benefit to the average hospitalist; pretty much any hospitalist who’s practicing medicine will find multiple, multiple sessions of interest and value. And you don’t have to go far for them. You don’t have to go hunting for them. They’re all there. …
Aside from actual didactics and content of the annual meeting, there’s the value of networking and of collaboration and meeting and talking to hospitalists from around the country and around the world. I mean, I think that one of the biggest values I’ve had is just meeting other people who are facing challenges in their work environment that I have [and learning] how they solve their challenges.
I think the [special interest] groups that meet Monday evening at 4:30 p.m. … those are great opportunities to go and meet people who have interests that are similar to yours or concerns that are similar to yours.
Q: Technology has a presence in the program this year. Why is it so important to highlight this?
A: The challenge of healthcare and incorporating technology into providing care to patients in a way that is efficient and helpful is there. That is a challenge that has been written about by many, many folks. Dr. Bob Wachter gave a whole keynote on it last year. And we’re all seeking ways to work with the technology that we have and identify opportunities to improve the care we’re providing using and harnessing the technology that’s available to us.
So whether that’s with new apps or with figuring out ways to embed decision support into our local systems of care, we need to do that. I think hospitalists are, time and time again, looked at as leaders at their institutions in this domain. It’s going to be 2016, this is the world we live in, and to ignore technology would be foolhardy.
Q: One of the new tracks is focused on post-acute care. Is the importance of the post-acute setting a sign that hospital medicine is, in some ways, reinventing itself?
A: I wouldn’t say reinventing. I think that hospitalists and internists that have become hospitalists have filled the gap in care over the past 20 years. It’s been 20 years since the name “hospitalist” was used in the New England Journal of Medicine. And in that time, the breadth and depth of care that hospitalists provide across the continuum in the acute-care setting has grown. …
Our older patients are often discharged from the acute-care setting but unable to return directly to their home environment safely. [They] require a period of a week or two, or sometimes longer, in a post-acute-care setting to continue to receive both the medical and the physical rehabilitation care that they need. And we know that there are not enough geriatricians in the world, and hospitalists are really sort of stepping up to provide this post-acute care. And it makes sense because the patients are coming from the hospital directly, and a lot of folks would say they’re sicker than ever in the post-acute-care setting. You don’t stay in the hospital for long anymore, and when you get to the post-acute-care setting, often the illness is ongoing but stabilized, and the patient is on the mend from whatever has befallen them. But they still require a fair amount of medical management. So it makes sense that hospitalists are going into that sphere.
Q: How will you go about resisting the temptation to stealthily leave the convention center during the day and hit the beach? Or will you be able to resist?
A: [Laughter.] I do like that question. I think that … I think that the conference, while it’s busy, there’s some time in the evening to go out and have a nice meal or [to] the beach and see friends. And then the last day, if you have time, if you don’t need to race off, you have a good half a day where you could go to the beach, or you could come early and come a day before or stay an extra couple of days and enjoy San Diego.
But I think if you skip the conference for the beach, you’re not doing yourself a service. You’re going to miss out on the opportunity to learn new clinical information, new strategies for communication. You’re also going to miss out on opportunities to network with your colleagues from across the country. TH
Thomas R. Collins is a freelance writer in South Florida.
HM16 course director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School in Boston, took some time out of her busy schedule to chat with The Hospitalist about how the annual meeting program comes together, the continued relevance of SHM meetings, resisting the lure of San Diego beaches, and more.
Read more about what's new at HM16
Question: There’s a lot packed into just a few days at every annual meeting. What is the process for determining what makes it into the program?
Answer: The annual meeting committee starts meeting in the spring, basically around 12 to 13 months before the annual meeting. So even as the current annual meeting is going on, the next one is well under way in terms of planning.
The annual meeting committee then meets every single week, if not more frequently, by conference call to map out and assign jobs and whatnot to the group. We usually start by reviewing workshops. The workshop proposals are received by SHM through an open-access submission process, whereby pretty much anyone can submit a proposal for a workshop. The annual meeting committee reviews all of the workshops. This year, we had 160 or 170 workshop submissions. We were only able to accept 16, I believe. …
Listen to more of our interview with Dr. Mattison.
At the same time the workshops are being selected, we work with the leaders of practice management, the leaders of the academic and research committees, and the leaders of quality and pediatrics committees to have them help us identify content for their various tracks, suggest speakers and talks. After all of that’s done, we move on to the remaining didactic sessions, and we look at what things were popular in previous years, what things had good reviews, which speakers were highly regarded, etc., and spend some time thinking deliberately about tracks that we feel we ought to include again, like the “Young Hospitalists” track and tracks that we think deserve to be included that haven’t previously been included—those that warrant some sort of attention because of widespread appeal and usefulness to the attendee of SHM.
Q: It’s very easy for hospitalists to stream videos of talks, access literature online, and talk about important topics in online chat rooms. In this day and age, what is the advantage to physically taking part in an annual meeting in an actual brick-and-mortar building?
A: The content itself is enough to draw someone. It’s packed content in terms of topics that would be of interest and benefit to the average hospitalist; pretty much any hospitalist who’s practicing medicine will find multiple, multiple sessions of interest and value. And you don’t have to go far for them. You don’t have to go hunting for them. They’re all there. …
Aside from actual didactics and content of the annual meeting, there’s the value of networking and of collaboration and meeting and talking to hospitalists from around the country and around the world. I mean, I think that one of the biggest values I’ve had is just meeting other people who are facing challenges in their work environment that I have [and learning] how they solve their challenges.
I think the [special interest] groups that meet Monday evening at 4:30 p.m. … those are great opportunities to go and meet people who have interests that are similar to yours or concerns that are similar to yours.
Q: Technology has a presence in the program this year. Why is it so important to highlight this?
A: The challenge of healthcare and incorporating technology into providing care to patients in a way that is efficient and helpful is there. That is a challenge that has been written about by many, many folks. Dr. Bob Wachter gave a whole keynote on it last year. And we’re all seeking ways to work with the technology that we have and identify opportunities to improve the care we’re providing using and harnessing the technology that’s available to us.
So whether that’s with new apps or with figuring out ways to embed decision support into our local systems of care, we need to do that. I think hospitalists are, time and time again, looked at as leaders at their institutions in this domain. It’s going to be 2016, this is the world we live in, and to ignore technology would be foolhardy.
Q: One of the new tracks is focused on post-acute care. Is the importance of the post-acute setting a sign that hospital medicine is, in some ways, reinventing itself?
A: I wouldn’t say reinventing. I think that hospitalists and internists that have become hospitalists have filled the gap in care over the past 20 years. It’s been 20 years since the name “hospitalist” was used in the New England Journal of Medicine. And in that time, the breadth and depth of care that hospitalists provide across the continuum in the acute-care setting has grown. …
Our older patients are often discharged from the acute-care setting but unable to return directly to their home environment safely. [They] require a period of a week or two, or sometimes longer, in a post-acute-care setting to continue to receive both the medical and the physical rehabilitation care that they need. And we know that there are not enough geriatricians in the world, and hospitalists are really sort of stepping up to provide this post-acute care. And it makes sense because the patients are coming from the hospital directly, and a lot of folks would say they’re sicker than ever in the post-acute-care setting. You don’t stay in the hospital for long anymore, and when you get to the post-acute-care setting, often the illness is ongoing but stabilized, and the patient is on the mend from whatever has befallen them. But they still require a fair amount of medical management. So it makes sense that hospitalists are going into that sphere.
Q: How will you go about resisting the temptation to stealthily leave the convention center during the day and hit the beach? Or will you be able to resist?
A: [Laughter.] I do like that question. I think that … I think that the conference, while it’s busy, there’s some time in the evening to go out and have a nice meal or [to] the beach and see friends. And then the last day, if you have time, if you don’t need to race off, you have a good half a day where you could go to the beach, or you could come early and come a day before or stay an extra couple of days and enjoy San Diego.
But I think if you skip the conference for the beach, you’re not doing yourself a service. You’re going to miss out on the opportunity to learn new clinical information, new strategies for communication. You’re also going to miss out on opportunities to network with your colleagues from across the country. TH
Thomas R. Collins is a freelance writer in South Florida.
CIPN persists in female cancer survivors
Photo courtesy of NIH
SAN FRANCISCO—A study of female cancer survivors indicates that many still have chemotherapy-induced peripheral neuropathy (CIPN) symptoms years after completing cancer treatment.
In addition, CIPN was associated with worse physical functioning, poorer mobility, and a higher risk of falls.
Although more research is needed, investigators believe these findings may inform rehabilitation and fall prevention interventions for people with CIPN.
The findings were presented at the 2016 Cancer Survivorship Symposium (abstract 130*).
“We can’t dismiss neuropathy as a treatment side effect that goes away because symptoms persist for years in nearly half of women,” said Kerri M. Winters-Stone, PhD, of Oregon Health and Science University in Portland.
“While there are no effective treatments for this side effect, rehabilitative exercise programs may preserve physical functioning and mobility in the presence of neuropathy to help prevent falls and resulting injuries.”
For this study, Dr Winters-Stone and her colleagues assessed data from 512 women enrolled in exercise intervention trials designed to address fractures and falls in female cancer survivors. Most of the women had breast cancer, but there were also cases of lung, colorectal, ovarian, and hematologic cancers.
At an average of 6 years post-cancer diagnosis, 46% of the women (n=238) still reported some symptoms of CIPN, such as loss of feeling in their hands and feet.
The investigators noted significant relationships (P<0.01) between CIPN severity and gait speed, Physical Performance Battery score, self-reported physical functioning, and self-reported disability.
The team also compared measures of physical functioning in the women with CIPN to measures in women without CIPN (n=274). This analysis was adjusted for cancer type and time since diagnosis.
There was a significant difference (P<0.01) between the groups in one measure of lower-extremity fitness but not another. Namely, it took CIPN-positive women significantly longer to rise out of a chair (tested 5 times each). But women in both groups fared similarly on a test measuring maximal leg press strength.
The investigators also tested the women on mobility and physical functioning. The CIPN-positive women fared significantly worse than CIPN-negative women (P<0.01) when it came to walking speed, step number, stride length, percentage of gait cycle in double support, and Physical Performance Battery score. However, there was no significant difference between the groups with regard to base of support.
Finally, CIPN-positive women were significantly more likely than CIPN-negative women to report poor physical function and disability (P<0.01 for both). And CIPN-positive women had a higher rate of falls in the last year (P<0.01).
The investigators said women with CIPN have specific underlying impairments that put them at risk for falls, which may be different from the impairments that occur with other conditions or old age.
For example, CIPN does not cause muscle weakness, but it has a distinct effect on movement and gait patterns.
The team noted that the women with CIPN had difficulty rising from a chair, possibly because their brains do not get enough information from their feet about how quickly or forcefully to stand up.
Based on these findings, the investigators argued that commonly recommended exercise, such as walking, may be safer for women with CIPN when done on a treadmill with handrails because their altered gait puts them at an increased risk of falling.
The team also said that machine-based resistance training may not be beneficial because neuropathy does not appear to decrease leg strength. Instead, rehabilitation efforts should focus on improving balance during upright movement and specific gait training.
Furthermore, the investigators believe that, if the symptoms of CIPN are detected early, cancer treatments could potentially be changed to prevent these debilitating problems or early rehabilitation interventions could be started.
In addition, Dr Winters-Stone and her research team are developing a smartphone-driven device that patients can use to detect and quantify symptoms of neuropathy, such as gait and balance impairments. 
*Data in the abstract differ from the presentation.
Photo courtesy of NIH
SAN FRANCISCO—A study of female cancer survivors indicates that many still have chemotherapy-induced peripheral neuropathy (CIPN) symptoms years after completing cancer treatment.
In addition, CIPN was associated with worse physical functioning, poorer mobility, and a higher risk of falls.
Although more research is needed, investigators believe these findings may inform rehabilitation and fall prevention interventions for people with CIPN.
The findings were presented at the 2016 Cancer Survivorship Symposium (abstract 130*).
“We can’t dismiss neuropathy as a treatment side effect that goes away because symptoms persist for years in nearly half of women,” said Kerri M. Winters-Stone, PhD, of Oregon Health and Science University in Portland.
“While there are no effective treatments for this side effect, rehabilitative exercise programs may preserve physical functioning and mobility in the presence of neuropathy to help prevent falls and resulting injuries.”
For this study, Dr Winters-Stone and her colleagues assessed data from 512 women enrolled in exercise intervention trials designed to address fractures and falls in female cancer survivors. Most of the women had breast cancer, but there were also cases of lung, colorectal, ovarian, and hematologic cancers.
At an average of 6 years post-cancer diagnosis, 46% of the women (n=238) still reported some symptoms of CIPN, such as loss of feeling in their hands and feet.
The investigators noted significant relationships (P<0.01) between CIPN severity and gait speed, Physical Performance Battery score, self-reported physical functioning, and self-reported disability.
The team also compared measures of physical functioning in the women with CIPN to measures in women without CIPN (n=274). This analysis was adjusted for cancer type and time since diagnosis.
There was a significant difference (P<0.01) between the groups in one measure of lower-extremity fitness but not another. Namely, it took CIPN-positive women significantly longer to rise out of a chair (tested 5 times each). But women in both groups fared similarly on a test measuring maximal leg press strength.
The investigators also tested the women on mobility and physical functioning. The CIPN-positive women fared significantly worse than CIPN-negative women (P<0.01) when it came to walking speed, step number, stride length, percentage of gait cycle in double support, and Physical Performance Battery score. However, there was no significant difference between the groups with regard to base of support.
Finally, CIPN-positive women were significantly more likely than CIPN-negative women to report poor physical function and disability (P<0.01 for both). And CIPN-positive women had a higher rate of falls in the last year (P<0.01).
The investigators said women with CIPN have specific underlying impairments that put them at risk for falls, which may be different from the impairments that occur with other conditions or old age.
For example, CIPN does not cause muscle weakness, but it has a distinct effect on movement and gait patterns.
The team noted that the women with CIPN had difficulty rising from a chair, possibly because their brains do not get enough information from their feet about how quickly or forcefully to stand up.
Based on these findings, the investigators argued that commonly recommended exercise, such as walking, may be safer for women with CIPN when done on a treadmill with handrails because their altered gait puts them at an increased risk of falling.
The team also said that machine-based resistance training may not be beneficial because neuropathy does not appear to decrease leg strength. Instead, rehabilitation efforts should focus on improving balance during upright movement and specific gait training.
Furthermore, the investigators believe that, if the symptoms of CIPN are detected early, cancer treatments could potentially be changed to prevent these debilitating problems or early rehabilitation interventions could be started.
In addition, Dr Winters-Stone and her research team are developing a smartphone-driven device that patients can use to detect and quantify symptoms of neuropathy, such as gait and balance impairments.
*Data in the abstract differ from the presentation.
Photo courtesy of NIH
SAN FRANCISCO—A study of female cancer survivors indicates that many still have chemotherapy-induced peripheral neuropathy (CIPN) symptoms years after completing cancer treatment.
In addition, CIPN was associated with worse physical functioning, poorer mobility, and a higher risk of falls.
Although more research is needed, investigators believe these findings may inform rehabilitation and fall prevention interventions for people with CIPN.
The findings were presented at the 2016 Cancer Survivorship Symposium (abstract 130*).
“We can’t dismiss neuropathy as a treatment side effect that goes away because symptoms persist for years in nearly half of women,” said Kerri M. Winters-Stone, PhD, of Oregon Health and Science University in Portland.
“While there are no effective treatments for this side effect, rehabilitative exercise programs may preserve physical functioning and mobility in the presence of neuropathy to help prevent falls and resulting injuries.”
For this study, Dr Winters-Stone and her colleagues assessed data from 512 women enrolled in exercise intervention trials designed to address fractures and falls in female cancer survivors. Most of the women had breast cancer, but there were also cases of lung, colorectal, ovarian, and hematologic cancers.
At an average of 6 years post-cancer diagnosis, 46% of the women (n=238) still reported some symptoms of CIPN, such as loss of feeling in their hands and feet.
The investigators noted significant relationships (P<0.01) between CIPN severity and gait speed, Physical Performance Battery score, self-reported physical functioning, and self-reported disability.
The team also compared measures of physical functioning in the women with CIPN to measures in women without CIPN (n=274). This analysis was adjusted for cancer type and time since diagnosis.
There was a significant difference (P<0.01) between the groups in one measure of lower-extremity fitness but not another. Namely, it took CIPN-positive women significantly longer to rise out of a chair (tested 5 times each). But women in both groups fared similarly on a test measuring maximal leg press strength.
The investigators also tested the women on mobility and physical functioning. The CIPN-positive women fared significantly worse than CIPN-negative women (P<0.01) when it came to walking speed, step number, stride length, percentage of gait cycle in double support, and Physical Performance Battery score. However, there was no significant difference between the groups with regard to base of support.
Finally, CIPN-positive women were significantly more likely than CIPN-negative women to report poor physical function and disability (P<0.01 for both). And CIPN-positive women had a higher rate of falls in the last year (P<0.01).
The investigators said women with CIPN have specific underlying impairments that put them at risk for falls, which may be different from the impairments that occur with other conditions or old age.
For example, CIPN does not cause muscle weakness, but it has a distinct effect on movement and gait patterns.
The team noted that the women with CIPN had difficulty rising from a chair, possibly because their brains do not get enough information from their feet about how quickly or forcefully to stand up.
Based on these findings, the investigators argued that commonly recommended exercise, such as walking, may be safer for women with CIPN when done on a treadmill with handrails because their altered gait puts them at an increased risk of falling.
The team also said that machine-based resistance training may not be beneficial because neuropathy does not appear to decrease leg strength. Instead, rehabilitation efforts should focus on improving balance during upright movement and specific gait training.
Furthermore, the investigators believe that, if the symptoms of CIPN are detected early, cancer treatments could potentially be changed to prevent these debilitating problems or early rehabilitation interventions could be started.
In addition, Dr Winters-Stone and her research team are developing a smartphone-driven device that patients can use to detect and quantify symptoms of neuropathy, such as gait and balance impairments.
*Data in the abstract differ from the presentation.
Acupuncture no better than sham for relief of hot flashes
Chinese medicine needle acupuncture was about as effective as a sham blunt needle treatment in the relief of hot flashes, although women reported a 40% drop in symptoms with both treatments.
The findings, published online Jan. 18 in Annals of Internal Medicine, add to a growing, but conflicting body of evidence about the benefits of acupuncture in the treatment of menopause symptoms.
Prior to this study, two trials had demonstrated the effectiveness of acupuncture, compared with self care. And a pilot study had shown the effectiveness of acupuncture, compared with a noninsertive sham control. However, a Cochrane review found that acupuncture was more effective, compared with no treatment, and it had a moderate effect size, but was not effective when compared with a sham control (Cochrane Database Syst Rev. 2013 Jul 30;7:CD007410. doi:10.1002/14651858.CD007410.pub2).
The current trial, conducted at multiple sites in Australia, sought to add to the evidence with an adequately powered trial involving a sham control. But Carolyn Ee and her associates at the University of Melbourne noted that their study did not control for the nonspecific effects of acupuncture, such as regular interaction with a therapist.
The researchers randomly assigned 327 women aged older than 40 years who were in late menopause transition or postmenopause and experiencing at least seven moderate daily hot flashes to receive either a standardized Chinese medicine acupuncture treatment or a noninsertive, blunt needle sham acupuncture treatment. Patients received 10 treatments over 8 weeks, and they were assessed at 4 weeks, at the end of treatment, and at 3 and 6 months after treatment (Ann Intern Med. 2016; Jan 18. doi:10.7326/M15-1380.).
Both groups had about a 40% improvement in their hot flashes at the end of treatment, compared with their mean baseline hot flash score. The improvement was sustained at 3 and 6 months after the trial. In the acupuncture group, the mean hot flash scores at the end of treatment were 15.36, compared with 15.04 in the sham group, which was not statistically different. The researchers also found no advantage for acupuncture in quality of life, anxiety, or depression.
“Unless further high-quality evidence emerges, we cannot recommend skin-penetrating acupuncture as an efficacious treatment of this indication; the effects, if any, of acupuncture on these symptoms seem to be unrelated to needling,” the researchers wrote.
Some of the researchers reported receiving grant, scholarship, or fellowship support from the National Health and Medical Research Council of Australia, which funded the study.
On Twitter @maryellenny
Chinese medicine needle acupuncture was about as effective as a sham blunt needle treatment in the relief of hot flashes, although women reported a 40% drop in symptoms with both treatments.
The findings, published online Jan. 18 in Annals of Internal Medicine, add to a growing, but conflicting body of evidence about the benefits of acupuncture in the treatment of menopause symptoms.
Prior to this study, two trials had demonstrated the effectiveness of acupuncture, compared with self care. And a pilot study had shown the effectiveness of acupuncture, compared with a noninsertive sham control. However, a Cochrane review found that acupuncture was more effective, compared with no treatment, and it had a moderate effect size, but was not effective when compared with a sham control (Cochrane Database Syst Rev. 2013 Jul 30;7:CD007410. doi:10.1002/14651858.CD007410.pub2).
The current trial, conducted at multiple sites in Australia, sought to add to the evidence with an adequately powered trial involving a sham control. But Carolyn Ee and her associates at the University of Melbourne noted that their study did not control for the nonspecific effects of acupuncture, such as regular interaction with a therapist.
The researchers randomly assigned 327 women aged older than 40 years who were in late menopause transition or postmenopause and experiencing at least seven moderate daily hot flashes to receive either a standardized Chinese medicine acupuncture treatment or a noninsertive, blunt needle sham acupuncture treatment. Patients received 10 treatments over 8 weeks, and they were assessed at 4 weeks, at the end of treatment, and at 3 and 6 months after treatment (Ann Intern Med. 2016; Jan 18. doi:10.7326/M15-1380.).
Both groups had about a 40% improvement in their hot flashes at the end of treatment, compared with their mean baseline hot flash score. The improvement was sustained at 3 and 6 months after the trial. In the acupuncture group, the mean hot flash scores at the end of treatment were 15.36, compared with 15.04 in the sham group, which was not statistically different. The researchers also found no advantage for acupuncture in quality of life, anxiety, or depression.
“Unless further high-quality evidence emerges, we cannot recommend skin-penetrating acupuncture as an efficacious treatment of this indication; the effects, if any, of acupuncture on these symptoms seem to be unrelated to needling,” the researchers wrote.
Some of the researchers reported receiving grant, scholarship, or fellowship support from the National Health and Medical Research Council of Australia, which funded the study.
On Twitter @maryellenny
Chinese medicine needle acupuncture was about as effective as a sham blunt needle treatment in the relief of hot flashes, although women reported a 40% drop in symptoms with both treatments.
The findings, published online Jan. 18 in Annals of Internal Medicine, add to a growing, but conflicting body of evidence about the benefits of acupuncture in the treatment of menopause symptoms.
Prior to this study, two trials had demonstrated the effectiveness of acupuncture, compared with self care. And a pilot study had shown the effectiveness of acupuncture, compared with a noninsertive sham control. However, a Cochrane review found that acupuncture was more effective, compared with no treatment, and it had a moderate effect size, but was not effective when compared with a sham control (Cochrane Database Syst Rev. 2013 Jul 30;7:CD007410. doi:10.1002/14651858.CD007410.pub2).
The current trial, conducted at multiple sites in Australia, sought to add to the evidence with an adequately powered trial involving a sham control. But Carolyn Ee and her associates at the University of Melbourne noted that their study did not control for the nonspecific effects of acupuncture, such as regular interaction with a therapist.
The researchers randomly assigned 327 women aged older than 40 years who were in late menopause transition or postmenopause and experiencing at least seven moderate daily hot flashes to receive either a standardized Chinese medicine acupuncture treatment or a noninsertive, blunt needle sham acupuncture treatment. Patients received 10 treatments over 8 weeks, and they were assessed at 4 weeks, at the end of treatment, and at 3 and 6 months after treatment (Ann Intern Med. 2016; Jan 18. doi:10.7326/M15-1380.).
Both groups had about a 40% improvement in their hot flashes at the end of treatment, compared with their mean baseline hot flash score. The improvement was sustained at 3 and 6 months after the trial. In the acupuncture group, the mean hot flash scores at the end of treatment were 15.36, compared with 15.04 in the sham group, which was not statistically different. The researchers also found no advantage for acupuncture in quality of life, anxiety, or depression.
“Unless further high-quality evidence emerges, we cannot recommend skin-penetrating acupuncture as an efficacious treatment of this indication; the effects, if any, of acupuncture on these symptoms seem to be unrelated to needling,” the researchers wrote.
Some of the researchers reported receiving grant, scholarship, or fellowship support from the National Health and Medical Research Council of Australia, which funded the study.
On Twitter @maryellenny
FROM ANNALS OF INTERNAL MEDICINE
Key clinical point: Chinese medicine acupuncture was no better than a sham treatment for the relief of hot flashes.
Major finding: After 8 weeks of treatment, mean hot flash scores were 15.36 in the acupuncture group and 15.04 in the sham treatment group, which was not a statistically significant difference.
Data source: A stratified, blind, parallel, randomized, sham-controlled trial of 327 women in late menopause transition or postmenopause.
Disclosures: Some of the researchers reported receiving grant, scholarship, or fellowship support from the National Health and Medical Research Council of Australia, which funded the study.
