Much has been written of the widespread concern among America’s physicians over upcoming changes in our health care system. Dire predictions of impending doom have prompted many to consider early retirement.

I do not share such concerns, for what that is worth; but if you do, and you are serious about retiring sooner than planned, now would be a great time to take a close look at your financial situation.

Many doctors have a false sense of security about their money; most of us save too little. We either miscalculate or underestimate how much we’ll need to last through retirement.

We tend to live longer than we think we will, and as such we run the risk of outliving our savings. And we don’t face facts about long-term care. Not nearly enough of us have long-term care insurance, or the means to self-fund an extended long-term care situation.

Many people lack a clear idea of where their retirement income will come from, and even when they do, they don’t know how to manage their savings correctly. Doctors in particular are notorious for not understanding investments. Many attempt to manage their practice’s retirement plans with inadequate knowledge of how the investments within their plans work.

So how will you know if you can safely retire before Obamacare gets up to speed? Of course, as with everything else, it depends. But to arrive at any sort of reliable ballpark figure, you’ll need to know three things: (1) how much you realistically expect to spend annually after retirement; (2) how much principal you will need to generate that annual income; and (3) how far your present savings are from that target figure.

An oft-quoted rule of thumb is that in retirement you should plan to spend about 70% of what you are spending now. In my opinion, that’s nonsense. While a few significant expenses, such as disability and malpractice insurance premiums, will be eliminated, other expenses, such as travel, recreation, and medical care (including long-term care insurance, which no one should be without), will increase. My wife and I are assuming we will spend about the same in retirement as we spend now, and I suggest you do too.

Once you know how much money you will spend per year, you can calculate how much money – in interest- and dividend-producing assets – will be needed to generate that amount.

Ideally, you will want to spend only the interest and dividends; by leaving the principal untouched you will never run short, even if you retire at an unusually young age, or longevity runs in your family (or both). Most financial advisers use the 5% rule: You can safely assume a minimum average of 5% annual return on your nest egg. So if you want to spend $100,000 per year, you will need $2 million in assets; for $200,000, you’ll need $4 million.

This is where you may discover – if your present savings are a long way from your target figure – that early retirement is not a realistic option. Better, though, to make that unpleasant discovery now, rather than face the frightening prospect of running out of money at an advanced age. Don’t be tempted to close a wide gap in a hurry with high-return/high-risk investments, which often backfire, leaving you further than ever from retirement.

Of course, it goes without saying that debt can destroy the best-laid retirement plans. If you carry significant debt, pay it off as soon as possible, and certainly before you retire.

Even if you have no plans to retire in the immediate future, it is never too soon to think about retirement. Young physicians often defer contributing to their retirement plans because they want to save for a new house, or college for their children. But there are tangible tax benefits that you get now, because your contributions usually reduce your taxable income, and your investment grows tax-free until you take it out.

For long-term planning, the most foolproof strategy – seldom employed, because it’s boring – is to sock away a fixed amount per month (after your retirement plan has been funded) in a mutual fund. For example, $1,000 per month for 25 years with the market earning 10% overall comes to almost $2 million, with the power of compounded interest working for you.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Much has been written of the widespread concern among America’s physicians over upcoming changes in our health care system. Dire predictions of impending doom have prompted many to consider early retirement.

I do not share such concerns, for what that is worth; but if you do, and you are serious about retiring sooner than planned, now would be a great time to take a close look at your financial situation.

Many doctors have a false sense of security about their money; most of us save too little. We either miscalculate or underestimate how much we’ll need to last through retirement.

We tend to live longer than we think we will, and as such we run the risk of outliving our savings. And we don’t face facts about long-term care. Not nearly enough of us have long-term care insurance, or the means to self-fund an extended long-term care situation.

Many people lack a clear idea of where their retirement income will come from, and even when they do, they don’t know how to manage their savings correctly. Doctors in particular are notorious for not understanding investments. Many attempt to manage their practice’s retirement plans with inadequate knowledge of how the investments within their plans work.

So how will you know if you can safely retire before Obamacare gets up to speed? Of course, as with everything else, it depends. But to arrive at any sort of reliable ballpark figure, you’ll need to know three things: (1) how much you realistically expect to spend annually after retirement; (2) how much principal you will need to generate that annual income; and (3) how far your present savings are from that target figure.

An oft-quoted rule of thumb is that in retirement you should plan to spend about 70% of what you are spending now. In my opinion, that’s nonsense. While a few significant expenses, such as disability and malpractice insurance premiums, will be eliminated, other expenses, such as travel, recreation, and medical care (including long-term care insurance, which no one should be without), will increase. My wife and I are assuming we will spend about the same in retirement as we spend now, and I suggest you do too.

Once you know how much money you will spend per year, you can calculate how much money – in interest- and dividend-producing assets – will be needed to generate that amount.

Ideally, you will want to spend only the interest and dividends; by leaving the principal untouched you will never run short, even if you retire at an unusually young age, or longevity runs in your family (or both). Most financial advisers use the 5% rule: You can safely assume a minimum average of 5% annual return on your nest egg. So if you want to spend $100,000 per year, you will need $2 million in assets; for $200,000, you’ll need $4 million.

This is where you may discover – if your present savings are a long way from your target figure – that early retirement is not a realistic option. Better, though, to make that unpleasant discovery now, rather than face the frightening prospect of running out of money at an advanced age. Don’t be tempted to close a wide gap in a hurry with high-return/high-risk investments, which often backfire, leaving you further than ever from retirement.

Of course, it goes without saying that debt can destroy the best-laid retirement plans. If you carry significant debt, pay it off as soon as possible, and certainly before you retire.

Even if you have no plans to retire in the immediate future, it is never too soon to think about retirement. Young physicians often defer contributing to their retirement plans because they want to save for a new house, or college for their children. But there are tangible tax benefits that you get now, because your contributions usually reduce your taxable income, and your investment grows tax-free until you take it out.

For long-term planning, the most foolproof strategy – seldom employed, because it’s boring – is to sock away a fixed amount per month (after your retirement plan has been funded) in a mutual fund. For example, $1,000 per month for 25 years with the market earning 10% overall comes to almost $2 million, with the power of compounded interest working for you.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Much has been written of the widespread concern among America’s physicians over upcoming changes in our health care system. Dire predictions of impending doom have prompted many to consider early retirement.

I do not share such concerns, for what that is worth; but if you do, and you are serious about retiring sooner than planned, now would be a great time to take a close look at your financial situation.

Many doctors have a false sense of security about their money; most of us save too little. We either miscalculate or underestimate how much we’ll need to last through retirement.

We tend to live longer than we think we will, and as such we run the risk of outliving our savings. And we don’t face facts about long-term care. Not nearly enough of us have long-term care insurance, or the means to self-fund an extended long-term care situation.

Many people lack a clear idea of where their retirement income will come from, and even when they do, they don’t know how to manage their savings correctly. Doctors in particular are notorious for not understanding investments. Many attempt to manage their practice’s retirement plans with inadequate knowledge of how the investments within their plans work.

So how will you know if you can safely retire before Obamacare gets up to speed? Of course, as with everything else, it depends. But to arrive at any sort of reliable ballpark figure, you’ll need to know three things: (1) how much you realistically expect to spend annually after retirement; (2) how much principal you will need to generate that annual income; and (3) how far your present savings are from that target figure.

An oft-quoted rule of thumb is that in retirement you should plan to spend about 70% of what you are spending now. In my opinion, that’s nonsense. While a few significant expenses, such as disability and malpractice insurance premiums, will be eliminated, other expenses, such as travel, recreation, and medical care (including long-term care insurance, which no one should be without), will increase. My wife and I are assuming we will spend about the same in retirement as we spend now, and I suggest you do too.

Once you know how much money you will spend per year, you can calculate how much money – in interest- and dividend-producing assets – will be needed to generate that amount.

Ideally, you will want to spend only the interest and dividends; by leaving the principal untouched you will never run short, even if you retire at an unusually young age, or longevity runs in your family (or both). Most financial advisers use the 5% rule: You can safely assume a minimum average of 5% annual return on your nest egg. So if you want to spend $100,000 per year, you will need $2 million in assets; for $200,000, you’ll need $4 million.

This is where you may discover – if your present savings are a long way from your target figure – that early retirement is not a realistic option. Better, though, to make that unpleasant discovery now, rather than face the frightening prospect of running out of money at an advanced age. Don’t be tempted to close a wide gap in a hurry with high-return/high-risk investments, which often backfire, leaving you further than ever from retirement.

Of course, it goes without saying that debt can destroy the best-laid retirement plans. If you carry significant debt, pay it off as soon as possible, and certainly before you retire.

Even if you have no plans to retire in the immediate future, it is never too soon to think about retirement. Young physicians often defer contributing to their retirement plans because they want to save for a new house, or college for their children. But there are tangible tax benefits that you get now, because your contributions usually reduce your taxable income, and your investment grows tax-free until you take it out.

For long-term planning, the most foolproof strategy – seldom employed, because it’s boring – is to sock away a fixed amount per month (after your retirement plan has been funded) in a mutual fund. For example, $1,000 per month for 25 years with the market earning 10% overall comes to almost $2 million, with the power of compounded interest working for you.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.

She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.

Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).

Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.

He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.

In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.

Measuring relational functioning briefly

In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.

The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.

The BMAS demonstrated acceptable reliability, especially for such a brief measure. It also demonstrated concurrent and convergent validity with a much longer commonly used clinical outcome scale. The BMAS is a useful assessment tool for patients with any clinical condition for which it is desirable to track how the patient is experiencing his or her life situation at a given point in time and when there is a desire to monitor change over time. Notably, BMAS includes health relationships as a measure of good clinical outcome.

A daughter’s documentary about her father

One media workshop slated for the APA meeting will be offered by three members of the Association of Family Psychiatrists: Dr. Michael S. Ascher, Dr. Ira Glick, and Dr. Igor Galynker. They will present a film, "Unlisted: A Story of Schizophrenia." This is a soul-searching examination of responsibility – of parents and children, physicians and patients, and of society and citizens – toward those afflicted with severe mental illness. The film was made by Dr. Delaney Ruston, a Seattle general physician who documents the rebuilding of her relationship with her father. "Unlisted" examines the challenging family dynamics that are present when schizophrenia occurs. Dr. Ruston works hard to overcome the obstacles in accessing appropriate treatment for her father, and her documentary exposes the many failings of the American mental health system as experienced by the families. Dr. Ruston traces the progression of her father’s illness. She studies his medical files and narrates from his autobiographical surrealist novel. In beautifully portrayed scenes, "Unlisted" enters the inner life of Richard Ruston with a clarity and affection missing from many films about people with mental illness.

In summary, family-oriented patient care can be delivered in many ways, from focusing on relational improvement in individual work, to being aware of how to assess and measure relational functioning briefly at each visit, to being able to listen to the accounts of family members and invite them into the treatment room.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.

She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.

Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).

Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.

He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.

In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.

Measuring relational functioning briefly

In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.

The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.

The BMAS demonstrated acceptable reliability, especially for such a brief measure. It also demonstrated concurrent and convergent validity with a much longer commonly used clinical outcome scale. The BMAS is a useful assessment tool for patients with any clinical condition for which it is desirable to track how the patient is experiencing his or her life situation at a given point in time and when there is a desire to monitor change over time. Notably, BMAS includes health relationships as a measure of good clinical outcome.

A daughter’s documentary about her father

One media workshop slated for the APA meeting will be offered by three members of the Association of Family Psychiatrists: Dr. Michael S. Ascher, Dr. Ira Glick, and Dr. Igor Galynker. They will present a film, "Unlisted: A Story of Schizophrenia." This is a soul-searching examination of responsibility – of parents and children, physicians and patients, and of society and citizens – toward those afflicted with severe mental illness. The film was made by Dr. Delaney Ruston, a Seattle general physician who documents the rebuilding of her relationship with her father. "Unlisted" examines the challenging family dynamics that are present when schizophrenia occurs. Dr. Ruston works hard to overcome the obstacles in accessing appropriate treatment for her father, and her documentary exposes the many failings of the American mental health system as experienced by the families. Dr. Ruston traces the progression of her father’s illness. She studies his medical files and narrates from his autobiographical surrealist novel. In beautifully portrayed scenes, "Unlisted" enters the inner life of Richard Ruston with a clarity and affection missing from many films about people with mental illness.

In summary, family-oriented patient care can be delivered in many ways, from focusing on relational improvement in individual work, to being aware of how to assess and measure relational functioning briefly at each visit, to being able to listen to the accounts of family members and invite them into the treatment room.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

Diana looked at her pill bottles and wondered why she was on all these medications when she did not feel any better. She looked at the five bottles: bupropion, paroxetine, diazepam, alprazolam, and zolpidem. She thought about the side effects she was experiencing.

She had been taking this cocktail, in various dosages, for the best part of a year now. Her depression remained unchanged. She made a decision that she would tell her psychiatrist that she wanted off the medications at her next visit. She would then ask for other treatments. She had found many therapies offered on the Internet for treatment of depression, and she hoped her psychiatrist would be able to help her decide which therapies might be best suited for her. Perhaps she would agree to stay on one medication as a compromise as she knew her psychiatrist thought treatment of depression with medication to be important.

Up to 30% of patients with depression do not respond to multiple treatment trials and are considered to have treatment-resistant depression. Most treatment trials for these patients focus on symptom reduction as a goal. This emphasis on symptom reduction often leads to tunnel vision, where other evidence-based treatments become marginalized by psychiatrists. Thus, patients like Diana end up on multiple medications, without an integrated approach to assessment or discussion of combined treatments (medications and psychotherapy).

Dr. Gabor Keitner, who practices in Providence, R.I., and is a member of the Association of Family Psychiatrists, offers a new program aimed at helping patients manage their depression. His philosophical stance is that depression is a chronic illness and that expecting symptoms to be cured with medications is, for most patients, a false hope perpetuated by a consumer society, where the pharmaceutical industry has dominated the education of patients, their families, and the psychiatric profession. He conceptualizes depression, like other chronic medical illnesses, such as diabetes or hypertension, with a similar range of severity. Therefore, the assessment and treatment of depression requires a more nuanced approach.

He is scheduled to present his Management of Depression (MOD) program at this year’s American Psychiatric Association meeting in San Francisco. His MOD program focuses on how a patient such as Diana can build a satisfying life with meaningful goals and relationships – even if her depressive symptoms persist.

In his pilot study, 30 patients with treatment-resistant depression were randomized to treatment as usual (TAU, n = 13) or the MOD program (n = 17) for 12 weeks. The patients in the MOD group had significant improvement in perception of social support (P < .034) and purpose in life (P < .038) scores, in contrast to the TAU group. The MOD group participated in nine adjunctive sessions of disease management focused therapy. The Scales of Psychological Well-Being measured purpose in life, life goals, and meaning. Social support was measured with the Multidimensional Scale of Perceived Social Support. Depression severity was measured by the Montgomery-Åsberg Depression Rating Scale. Patients were assessed at baseline and week 12. Both groups of patients had significant improvements in their depressive symptoms (TAU 35.46 to 25.9 P < .010; MOD 31.88 to 22.41 P < .001) but continued to experience moderate levels of depression. Adjunctive treatment focusing on functioning, life meaning, and relationships, as opposed to symptom reduction, will help Diana to have a more satisfying life, despite her symptoms of depression.

Measuring relational functioning briefly

In another session, Dr. Keitner is slated to present "The Brief Multidimensional Assessment Scale (BMAS): A Mental Health Check Up," coauthored with Abigail K. Mansfield Maraccio, Ph.D., and Joan Kelley. This scale evaluates global mental health outcomes, including quality of life, symptoms, functioning, and relationships. This measure can be used to assess the clinical status of patients at every health encounter and over the course of an illness. Most available scales are either too long for routine clinical use, focus on a narrow range of symptoms, or focus on specific diagnostic groups. Best of all, this new scale takes less than a minute to complete.

The BMAS was tested against The Outcome Questionnaire–45 (OQ45) with 248 psychiatric outpatients as part of their standard ongoing care. Internal consistency was evaluated with Cronbach’s alpha, which was .75 for the four items. Test-retest reliability was assessed using Pearson’s r and ranged from .45 (symptom severity, which can fluctuate daily) to .79 (quality of life) for each of the BMAS items. Concurrent and convergent validity was analyzed with Pearson product moment correlations between BMAS and OQ45 scales. All correlations were significant for the relevant dimensions.

The BMAS demonstrated acceptable reliability, especially for such a brief measure. It also demonstrated concurrent and convergent validity with a much longer commonly used clinical outcome scale. The BMAS is a useful assessment tool for patients with any clinical condition for which it is desirable to track how the patient is experiencing his or her life situation at a given point in time and when there is a desire to monitor change over time. Notably, BMAS includes health relationships as a measure of good clinical outcome.

A daughter’s documentary about her father

One media workshop slated for the APA meeting will be offered by three members of the Association of Family Psychiatrists: Dr. Michael S. Ascher, Dr. Ira Glick, and Dr. Igor Galynker. They will present a film, "Unlisted: A Story of Schizophrenia." This is a soul-searching examination of responsibility – of parents and children, physicians and patients, and of society and citizens – toward those afflicted with severe mental illness. The film was made by Dr. Delaney Ruston, a Seattle general physician who documents the rebuilding of her relationship with her father. "Unlisted" examines the challenging family dynamics that are present when schizophrenia occurs. Dr. Ruston works hard to overcome the obstacles in accessing appropriate treatment for her father, and her documentary exposes the many failings of the American mental health system as experienced by the families. Dr. Ruston traces the progression of her father’s illness. She studies his medical files and narrates from his autobiographical surrealist novel. In beautifully portrayed scenes, "Unlisted" enters the inner life of Richard Ruston with a clarity and affection missing from many films about people with mental illness.

In summary, family-oriented patient care can be delivered in many ways, from focusing on relational improvement in individual work, to being aware of how to assess and measure relational functioning briefly at each visit, to being able to listen to the accounts of family members and invite them into the treatment room.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professions" (New York: Routledge, March 2013), and has been a member of the Association of Family Psychiatrists since 2002.

Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:

Only you can save America.

He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.

"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.

If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."

Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.

Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.

Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.

The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.

Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.

Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.

Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.

Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.

In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.

"You have to lead this," he explained.

No one should expect that reforming the fifth-largest economy in the world could be accomplished in just a few years, however. "It's going to take this decade," Dr. Emanuel predicted.

Dr. Emanuel reported having no financial disclosures.

[email protected]

Twitter: @sherryboschert

Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:

Only you can save America.

He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.

"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.

If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."

Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.

Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.

Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.

The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.

Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.

Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.

Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.

Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.

In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.

"You have to lead this," he explained.

No one should expect that reforming the fifth-largest economy in the world could be accomplished in just a few years, however. "It's going to take this decade," Dr. Emanuel predicted.

Dr. Emanuel reported having no financial disclosures.

[email protected]

Twitter: @sherryboschert

Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:

Only you can save America.

He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.

"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.

If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."

Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.

Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.

Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.

The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.

Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.

Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.

Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.

Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.

In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.

"You have to lead this," he explained.

No one should expect that reforming the fifth-largest economy in the world could be accomplished in just a few years, however. "It's going to take this decade," Dr. Emanuel predicted.

Dr. Emanuel reported having no financial disclosures.

[email protected]

Twitter: @sherryboschert

A new prediction model that uses a familiar phrase can help identify potentially avoidable hospital patient readmissions, according to a report in JAMA Internal Medicine.

The retrospective cohort study, "Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients," used a model dubbed HOSPITAL to create a score that targets patients most likely to benefit from pre-discharge interventions. The model is based on seven factors: hemoglobin at discharge, discharge from an oncology service, sodium levels at discharge, procedure during the index admission, index type of admission, number of admissions in the prior 12 months, and length of stay. The HOSPITAL score had fair discriminatory power (C statistic 0.71) and good calibration, the authors noted.

"By definition, these [interventions] are expensive and you really want to reserve them for the patients that are most likely to benefit," says study co-author Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospital in Boston.

The study identified 879 potentially avoidable discharges out of 10,731 eligible discharges, or 8.5%. The estimated potentially avoidable readmission risk was 18%. Dr. Schnipper says that in absolute reduction, the model could cut 2% to 3% of readmissions.

"This is an evolution of sophistication in how we think about this work," Dr. Schnipper adds. "Not all patients have a preventable readmission. Maybe some of those patients are more likely to benefit. The next step is to prove it. That's the gold standard and that’s our next study." TH

Visit our website for more information on 30-day readmissions.

A new prediction model that uses a familiar phrase can help identify potentially avoidable hospital patient readmissions, according to a report in JAMA Internal Medicine.

The retrospective cohort study, "Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients," used a model dubbed HOSPITAL to create a score that targets patients most likely to benefit from pre-discharge interventions. The model is based on seven factors: hemoglobin at discharge, discharge from an oncology service, sodium levels at discharge, procedure during the index admission, index type of admission, number of admissions in the prior 12 months, and length of stay. The HOSPITAL score had fair discriminatory power (C statistic 0.71) and good calibration, the authors noted.

"By definition, these [interventions] are expensive and you really want to reserve them for the patients that are most likely to benefit," says study co-author Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospital in Boston.

The study identified 879 potentially avoidable discharges out of 10,731 eligible discharges, or 8.5%. The estimated potentially avoidable readmission risk was 18%. Dr. Schnipper says that in absolute reduction, the model could cut 2% to 3% of readmissions.

"This is an evolution of sophistication in how we think about this work," Dr. Schnipper adds. "Not all patients have a preventable readmission. Maybe some of those patients are more likely to benefit. The next step is to prove it. That's the gold standard and that’s our next study." TH

Visit our website for more information on 30-day readmissions.

A new prediction model that uses a familiar phrase can help identify potentially avoidable hospital patient readmissions, according to a report in JAMA Internal Medicine.

The retrospective cohort study, "Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients," used a model dubbed HOSPITAL to create a score that targets patients most likely to benefit from pre-discharge interventions. The model is based on seven factors: hemoglobin at discharge, discharge from an oncology service, sodium levels at discharge, procedure during the index admission, index type of admission, number of admissions in the prior 12 months, and length of stay. The HOSPITAL score had fair discriminatory power (C statistic 0.71) and good calibration, the authors noted.

"By definition, these [interventions] are expensive and you really want to reserve them for the patients that are most likely to benefit," says study co-author Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospital in Boston.

The study identified 879 potentially avoidable discharges out of 10,731 eligible discharges, or 8.5%. The estimated potentially avoidable readmission risk was 18%. Dr. Schnipper says that in absolute reduction, the model could cut 2% to 3% of readmissions.

"This is an evolution of sophistication in how we think about this work," Dr. Schnipper adds. "Not all patients have a preventable readmission. Maybe some of those patients are more likely to benefit. The next step is to prove it. That's the gold standard and that’s our next study." TH

Visit our website for more information on 30-day readmissions.

Everyone is prone to an angry outburst from time to time, and doctors are no exception. With well-documented, negative effects on morale, nurse retention, and patient safety, it's safe to say anger issues crop up from time to time among the nearly 40,000 practicing hospitalists throughout the U.S.

A recent article in Kaiser Health News describes efforts by hospitals to deal with physicians' tirades, such as a three-day counseling program developed at Vanderbilt University in Nashville, Tenn.

"All physicians need to be aware that there should be a 'zero tolerance' attitude for disruptive behavior, hospitalists included, and that disruptive behavior undermines a culture of safety, and therefore can put patients in danger," says Danielle Scheurer, MD, MSCR, SFHM, hospitalist and chief quality officer at Medical University of South Carolina in Charleston and physician editor of The Hospitalist.

In 2009, The Joint Commission issued a sentinel alert about intimidating and disruptive behaviors by physicians and the ways in which hospitals can address the issue.

The problem is not unique to any physician specialty, including hospitalists, says Alan Rosenstein, MD, an internist and disruptive behavior researcher based in San Francisco. A physician's training or personality might contribute to angry outbursts, but excessive workloads will cause pressure, stress, and burnout, which can lead to poor behavior.

"Hospitals can no longer afford to look the other way," Dr. Rosenstein says. "I look at physicians as a precious resource. The organizations they're affiliated with need to be more proactive and empathetic, intervening before the problem reaches the stage of requiring discipline through techniques such as coaching and stress management." TH

Visit our website for more information about the impact of workloads on hospitalists.

Everyone is prone to an angry outburst from time to time, and doctors are no exception. With well-documented, negative effects on morale, nurse retention, and patient safety, it's safe to say anger issues crop up from time to time among the nearly 40,000 practicing hospitalists throughout the U.S.

A recent article in Kaiser Health News describes efforts by hospitals to deal with physicians' tirades, such as a three-day counseling program developed at Vanderbilt University in Nashville, Tenn.

"All physicians need to be aware that there should be a 'zero tolerance' attitude for disruptive behavior, hospitalists included, and that disruptive behavior undermines a culture of safety, and therefore can put patients in danger," says Danielle Scheurer, MD, MSCR, SFHM, hospitalist and chief quality officer at Medical University of South Carolina in Charleston and physician editor of The Hospitalist.

In 2009, The Joint Commission issued a sentinel alert about intimidating and disruptive behaviors by physicians and the ways in which hospitals can address the issue.

The problem is not unique to any physician specialty, including hospitalists, says Alan Rosenstein, MD, an internist and disruptive behavior researcher based in San Francisco. A physician's training or personality might contribute to angry outbursts, but excessive workloads will cause pressure, stress, and burnout, which can lead to poor behavior.

"Hospitals can no longer afford to look the other way," Dr. Rosenstein says. "I look at physicians as a precious resource. The organizations they're affiliated with need to be more proactive and empathetic, intervening before the problem reaches the stage of requiring discipline through techniques such as coaching and stress management." TH

Visit our website for more information about the impact of workloads on hospitalists.

Everyone is prone to an angry outburst from time to time, and doctors are no exception. With well-documented, negative effects on morale, nurse retention, and patient safety, it's safe to say anger issues crop up from time to time among the nearly 40,000 practicing hospitalists throughout the U.S.

A recent article in Kaiser Health News describes efforts by hospitals to deal with physicians' tirades, such as a three-day counseling program developed at Vanderbilt University in Nashville, Tenn.

"All physicians need to be aware that there should be a 'zero tolerance' attitude for disruptive behavior, hospitalists included, and that disruptive behavior undermines a culture of safety, and therefore can put patients in danger," says Danielle Scheurer, MD, MSCR, SFHM, hospitalist and chief quality officer at Medical University of South Carolina in Charleston and physician editor of The Hospitalist.

In 2009, The Joint Commission issued a sentinel alert about intimidating and disruptive behaviors by physicians and the ways in which hospitals can address the issue.

The problem is not unique to any physician specialty, including hospitalists, says Alan Rosenstein, MD, an internist and disruptive behavior researcher based in San Francisco. A physician's training or personality might contribute to angry outbursts, but excessive workloads will cause pressure, stress, and burnout, which can lead to poor behavior.

"Hospitals can no longer afford to look the other way," Dr. Rosenstein says. "I look at physicians as a precious resource. The organizations they're affiliated with need to be more proactive and empathetic, intervening before the problem reaches the stage of requiring discipline through techniques such as coaching and stress management." TH

Visit our website for more information about the impact of workloads on hospitalists.

Alstonia scholaris, a tree that grows 50-80 feet high and belongs to the Apocynaceae family, has a long history of use in traditional and homeopathic medicine, including Ayurvedic medicine in India, where it is known as sapthaparna (Integr. Cancer Ther. 2009;8:273-9), in traditional Chinese medicine (J. Ethnopharmacol. 2010;129:293-8; J. Ethnopharmacol. 2010;129:174-81), and in traditional medicine in Africa and Australia (Integr. Cancer Ther. 2010;9:261-9). The bark contains the alkaloids ditamine, echitamine (or ditaine), and echitanines; and decoctions or other preparations of the bark have been used to treat gastrointestinal conditions (Grieve M. A Modern Herbal (Vol. 1). New York, Dover Publications, 1971, p. 29). Often called the devil’s tree, the bark of A. scholaris also has been used to treat malaria, cutaneous diseases, tumors, ulcers, chronic respiratory conditions (such as asthma and bronchitis), helminthiasis, and agalactia (Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]).

In the study of A. scholaris most directly pertinent to potential dermatologic treatment, Lee et al. found that ethanolic bark extracts of A. scholaris significantly suppressed retinoid-induced skin irritation in vitro and in vivo, in human HaCat keratinocytes. The investigators identified echitamine and loganin as the primary components likely responsible for the anti-inflammatory effects.

Courtesy Wikimedia Commons/Binh Giang/Public Domain

Data showed that A. scholaris dose-dependently inhibited the all-trans retinoic acid–induced releases of the pro-inflammatory cytokines monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) in vitro. Also in vitro, A. scholaris extract potently suppressed radiation-induced increases in matrix metalloproteinase-1 (MMP-1). Importantly, in a cumulative irritation patch test, the botanical extract diminished retinol-induced skin irritation while enhancing retinoid activity in blocking MMP-1 expression, which is linked closely to cutaneous aging. The authors concluded that A. scholaris appears to have the dual benefits of decreasing irritation associated with retinoids while augmenting their antiaging impact (Evid. Based Complement. Alternat. Med. 2012;2012:190370).

The leaf extract of A. scholaris has been used to treat cold symptoms and tracheitis, and it has been prescribed in hospitals and approved for commercial over-the-counter sale by the State Food and Drugs Administration of China (SFDA) (J. Ethnopharmacol. 2010;129:293-8; J. Ethnopharmacol. 2010;129:174-81). The broad range of biological properties associated with A. scholaris has been ascribed to particular constituent categories, including alkaloids, flavonoids, and terpenoids (specifically, phenolic acids) (Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]). These properties include, but are reportedly not limited to, antioxidant, anticancer, anti-inflammatory, antistress, analgesic, antimutagenic, hepatoprotective, immunomodulatory, and chemopreventive activity (Integr. Cancer Ther. 2010;9:261-9; Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]). Antineoplastic effects have been linked directly to phytochemical constituents including echitamine, alstonine, pleiocarpamine, O-methylmacralstonine, macralstonine, and lupeol (Integr. Cancer Ther. 2010;9:261-9).

In 2006, Jagetia and Baliga investigated the anticancer activity of A. scholaris alkaloid fractions in vitro in cultured human neoplastic cell lines. They also conducted in vivo studies in tumor-bearing mice. The in vitro data in HeLa cells revealed a time-dependent rise in antineoplastic activity after 24 hours of exposure (25 mcg/mL). Further, once-daily administration of A. scholaris (240 mg/kg) to tumor-bearing mice yielded dose-dependent remissions, although there were toxic presentations at this dosage. The next-lower dose of 210 mg/kg was found to be most effective, with 20% of the mice surviving for as long as 120 days after tumor cell inoculation, compared with none of the control animals treated with saline (Phytother. Res. 2006;20:103-9).

Using an acute-restraint stress model in mice in 2009, Kulkarni and Juvekar evaluated the effects of stress and the impact of a methanolic extract of A. scholaris bark. Pretreatments with the extract of 100, 250, and 500 mg/kg for 7 days were found to exert significant antistress effects. In addition, nootropic activities were observed, with memory functions clearly enhanced in learning tasks. A. scholaris also was associated with significant antioxidant properties. The extract at 200 mcg/mL exhibited maximum scavenging of the stable radical 1,1-diphenyl-2-picrylhydrazyl at 90.11% and the nitric oxide radical at 62.77% (Indian J. Exp. Biol. 2009;47:47-52).

Later in 2009, Jahan et al. reported on their investigation of potential antioxidant and chemopreventive activity displayed by A. scholaris in a two-stage murine model. Skin carcinogenesis development was initiated in Swiss albino mice through one application of 7, 12-dimethyabenz(a)anthrecene (DMBA) and then promoted two weeks later by repeated application of croton oil three times per week through 16 weeks. The investigators found a lower incidence of tumors, tumor yield, tumor burden, and number of papillomas in mice treated with A. scholaris extract as compared to untreated controls (Integr. Cancer Ther. 2009;8:273-9).

In 2010, Shang et al. conducted multiple studies using A. scholaris. In the first published report, they assessed the anti-inflammatory and analgesic properties of the ethanolic leaf extract to validate its use in traditional Chinese medicine and modern clinical medicine. The investigators first determined that analgesic activity was conferred as the ethyl acetate and alkaloid fractions significantly diminished acetic acid-induced reactions in mice and, along with the ethanolic extract, reduced xylene-induced ear edema.

The researchers also performed in vivo and in vitro assessments of anti-inflammatory activity again on xylene-induced ear edema and carrageenan-induced air pouch formation in mice, as well as cyclooxygenase (COX)-1, -2 and 5-LOX inhibition.

In the air pouch model, A. scholaris alkaloids were found to have significantly spurred superoxide dismutase activity while lowering nitric oxide, prostaglandin E2, and malondialdehyde levels. In vitro tests, supporting evidence from animal models, showed that the three primary alkaloids isolated from A. scholaris leaves (picrinine, vallesamine, and scholaricine) inhibited the inflammatory mediators COX-1, COX-2, and 5-LOX. The researchers also noted that the in vitro anti-inflammatory assay results reinforced the notion of these alkaloids as the bioactive fraction of the plant (J. Ethnopharmacol. 2010;129:174-81).

In their second published report that year, Shang et al. investigated the antitussive and anti-asthmatic activities of the ethanolic extract, fractions, and chief alkaloids of A. scholaris leaf.

The researchers tested for antitussive effects using ammonia-induced or sulfur dioxide-induced coughing in mice and citric acid-induced coughing in guinea pigs. They evaluated anti-asthmatic activity via histamine-induced bronchoconstriction in guinea pigs. They also measured phenol red volume in murine tracheas to assess expectorant activity.

The data indicated antitussive activity, with significant alkaloid suppression of ammonia-induced coughing frequency in mice. Latency periods of sulfur dioxide-induced cough in mice and citric acid-induced cough in guinea pigs increased, and cough frequency in guinea pigs decreased.

Anti-asthmatic effects, such as suppression of convulsion, were observed in guinea pigs. In the expectorant assessment, tracheal phenol red production was increased. The researchers identified picrinine as the primary alkaloid responsible for these activities (J. Ethnopharmacol. 2010;129:293-8).

In addition, Jahan and Goyal showed that pretreatment with A. scholaris bark extract protected the bone marrow of mice against radiation-induced chromosomal damage and micronuclei induction (J Environ. Pathol. Toxicol. Oncol. 2010;29:101-11).

Conclusion

Despite the dearth of research on A. scholaris, the existing data are intriguing, particularly the findings that A. scholaris may have the capacity to amplify the anti-aging activity of retinoids while blunting their irritating effects. Although more research is needed to determine the dermatologic value of A. scholaris, the pursuit may potentially prove fruitful.

Dr. Baumann is in private practice in Miami Beach. She did not disclose any conflicts of interest. To respond to this column, or to suggest topics for future columns, write to her at [email protected].

Alstonia scholaris, a tree that grows 50-80 feet high and belongs to the Apocynaceae family, has a long history of use in traditional and homeopathic medicine, including Ayurvedic medicine in India, where it is known as sapthaparna (Integr. Cancer Ther. 2009;8:273-9), in traditional Chinese medicine (J. Ethnopharmacol. 2010;129:293-8; J. Ethnopharmacol. 2010;129:174-81), and in traditional medicine in Africa and Australia (Integr. Cancer Ther. 2010;9:261-9). The bark contains the alkaloids ditamine, echitamine (or ditaine), and echitanines; and decoctions or other preparations of the bark have been used to treat gastrointestinal conditions (Grieve M. A Modern Herbal (Vol. 1). New York, Dover Publications, 1971, p. 29). Often called the devil’s tree, the bark of A. scholaris also has been used to treat malaria, cutaneous diseases, tumors, ulcers, chronic respiratory conditions (such as asthma and bronchitis), helminthiasis, and agalactia (Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]).

In the study of A. scholaris most directly pertinent to potential dermatologic treatment, Lee et al. found that ethanolic bark extracts of A. scholaris significantly suppressed retinoid-induced skin irritation in vitro and in vivo, in human HaCat keratinocytes. The investigators identified echitamine and loganin as the primary components likely responsible for the anti-inflammatory effects.

Courtesy Wikimedia Commons/Binh Giang/Public Domain

Data showed that A. scholaris dose-dependently inhibited the all-trans retinoic acid–induced releases of the pro-inflammatory cytokines monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) in vitro. Also in vitro, A. scholaris extract potently suppressed radiation-induced increases in matrix metalloproteinase-1 (MMP-1). Importantly, in a cumulative irritation patch test, the botanical extract diminished retinol-induced skin irritation while enhancing retinoid activity in blocking MMP-1 expression, which is linked closely to cutaneous aging. The authors concluded that A. scholaris appears to have the dual benefits of decreasing irritation associated with retinoids while augmenting their antiaging impact (Evid. Based Complement. Alternat. Med. 2012;2012:190370).

The leaf extract of A. scholaris has been used to treat cold symptoms and tracheitis, and it has been prescribed in hospitals and approved for commercial over-the-counter sale by the State Food and Drugs Administration of China (SFDA) (J. Ethnopharmacol. 2010;129:293-8; J. Ethnopharmacol. 2010;129:174-81). The broad range of biological properties associated with A. scholaris has been ascribed to particular constituent categories, including alkaloids, flavonoids, and terpenoids (specifically, phenolic acids) (Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]). These properties include, but are reportedly not limited to, antioxidant, anticancer, anti-inflammatory, antistress, analgesic, antimutagenic, hepatoprotective, immunomodulatory, and chemopreventive activity (Integr. Cancer Ther. 2010;9:261-9; Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]). Antineoplastic effects have been linked directly to phytochemical constituents including echitamine, alstonine, pleiocarpamine, O-methylmacralstonine, macralstonine, and lupeol (Integr. Cancer Ther. 2010;9:261-9).

In 2006, Jagetia and Baliga investigated the anticancer activity of A. scholaris alkaloid fractions in vitro in cultured human neoplastic cell lines. They also conducted in vivo studies in tumor-bearing mice. The in vitro data in HeLa cells revealed a time-dependent rise in antineoplastic activity after 24 hours of exposure (25 mcg/mL). Further, once-daily administration of A. scholaris (240 mg/kg) to tumor-bearing mice yielded dose-dependent remissions, although there were toxic presentations at this dosage. The next-lower dose of 210 mg/kg was found to be most effective, with 20% of the mice surviving for as long as 120 days after tumor cell inoculation, compared with none of the control animals treated with saline (Phytother. Res. 2006;20:103-9).

Using an acute-restraint stress model in mice in 2009, Kulkarni and Juvekar evaluated the effects of stress and the impact of a methanolic extract of A. scholaris bark. Pretreatments with the extract of 100, 250, and 500 mg/kg for 7 days were found to exert significant antistress effects. In addition, nootropic activities were observed, with memory functions clearly enhanced in learning tasks. A. scholaris also was associated with significant antioxidant properties. The extract at 200 mcg/mL exhibited maximum scavenging of the stable radical 1,1-diphenyl-2-picrylhydrazyl at 90.11% and the nitric oxide radical at 62.77% (Indian J. Exp. Biol. 2009;47:47-52).

Later in 2009, Jahan et al. reported on their investigation of potential antioxidant and chemopreventive activity displayed by A. scholaris in a two-stage murine model. Skin carcinogenesis development was initiated in Swiss albino mice through one application of 7, 12-dimethyabenz(a)anthrecene (DMBA) and then promoted two weeks later by repeated application of croton oil three times per week through 16 weeks. The investigators found a lower incidence of tumors, tumor yield, tumor burden, and number of papillomas in mice treated with A. scholaris extract as compared to untreated controls (Integr. Cancer Ther. 2009;8:273-9).

In 2010, Shang et al. conducted multiple studies using A. scholaris. In the first published report, they assessed the anti-inflammatory and analgesic properties of the ethanolic leaf extract to validate its use in traditional Chinese medicine and modern clinical medicine. The investigators first determined that analgesic activity was conferred as the ethyl acetate and alkaloid fractions significantly diminished acetic acid-induced reactions in mice and, along with the ethanolic extract, reduced xylene-induced ear edema.

The researchers also performed in vivo and in vitro assessments of anti-inflammatory activity again on xylene-induced ear edema and carrageenan-induced air pouch formation in mice, as well as cyclooxygenase (COX)-1, -2 and 5-LOX inhibition.

In the air pouch model, A. scholaris alkaloids were found to have significantly spurred superoxide dismutase activity while lowering nitric oxide, prostaglandin E2, and malondialdehyde levels. In vitro tests, supporting evidence from animal models, showed that the three primary alkaloids isolated from A. scholaris leaves (picrinine, vallesamine, and scholaricine) inhibited the inflammatory mediators COX-1, COX-2, and 5-LOX. The researchers also noted that the in vitro anti-inflammatory assay results reinforced the notion of these alkaloids as the bioactive fraction of the plant (J. Ethnopharmacol. 2010;129:174-81).

In their second published report that year, Shang et al. investigated the antitussive and anti-asthmatic activities of the ethanolic extract, fractions, and chief alkaloids of A. scholaris leaf.

The researchers tested for antitussive effects using ammonia-induced or sulfur dioxide-induced coughing in mice and citric acid-induced coughing in guinea pigs. They evaluated anti-asthmatic activity via histamine-induced bronchoconstriction in guinea pigs. They also measured phenol red volume in murine tracheas to assess expectorant activity.

The data indicated antitussive activity, with significant alkaloid suppression of ammonia-induced coughing frequency in mice. Latency periods of sulfur dioxide-induced cough in mice and citric acid-induced cough in guinea pigs increased, and cough frequency in guinea pigs decreased.

Anti-asthmatic effects, such as suppression of convulsion, were observed in guinea pigs. In the expectorant assessment, tracheal phenol red production was increased. The researchers identified picrinine as the primary alkaloid responsible for these activities (J. Ethnopharmacol. 2010;129:293-8).

In addition, Jahan and Goyal showed that pretreatment with A. scholaris bark extract protected the bone marrow of mice against radiation-induced chromosomal damage and micronuclei induction (J Environ. Pathol. Toxicol. Oncol. 2010;29:101-11).

Conclusion

Despite the dearth of research on A. scholaris, the existing data are intriguing, particularly the findings that A. scholaris may have the capacity to amplify the anti-aging activity of retinoids while blunting their irritating effects. Although more research is needed to determine the dermatologic value of A. scholaris, the pursuit may potentially prove fruitful.

Dr. Baumann is in private practice in Miami Beach. She did not disclose any conflicts of interest. To respond to this column, or to suggest topics for future columns, write to her at [email protected].

Alstonia scholaris, a tree that grows 50-80 feet high and belongs to the Apocynaceae family, has a long history of use in traditional and homeopathic medicine, including Ayurvedic medicine in India, where it is known as sapthaparna (Integr. Cancer Ther. 2009;8:273-9), in traditional Chinese medicine (J. Ethnopharmacol. 2010;129:293-8; J. Ethnopharmacol. 2010;129:174-81), and in traditional medicine in Africa and Australia (Integr. Cancer Ther. 2010;9:261-9). The bark contains the alkaloids ditamine, echitamine (or ditaine), and echitanines; and decoctions or other preparations of the bark have been used to treat gastrointestinal conditions (Grieve M. A Modern Herbal (Vol. 1). New York, Dover Publications, 1971, p. 29). Often called the devil’s tree, the bark of A. scholaris also has been used to treat malaria, cutaneous diseases, tumors, ulcers, chronic respiratory conditions (such as asthma and bronchitis), helminthiasis, and agalactia (Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]).

In the study of A. scholaris most directly pertinent to potential dermatologic treatment, Lee et al. found that ethanolic bark extracts of A. scholaris significantly suppressed retinoid-induced skin irritation in vitro and in vivo, in human HaCat keratinocytes. The investigators identified echitamine and loganin as the primary components likely responsible for the anti-inflammatory effects.

Courtesy Wikimedia Commons/Binh Giang/Public Domain

Data showed that A. scholaris dose-dependently inhibited the all-trans retinoic acid–induced releases of the pro-inflammatory cytokines monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) in vitro. Also in vitro, A. scholaris extract potently suppressed radiation-induced increases in matrix metalloproteinase-1 (MMP-1). Importantly, in a cumulative irritation patch test, the botanical extract diminished retinol-induced skin irritation while enhancing retinoid activity in blocking MMP-1 expression, which is linked closely to cutaneous aging. The authors concluded that A. scholaris appears to have the dual benefits of decreasing irritation associated with retinoids while augmenting their antiaging impact (Evid. Based Complement. Alternat. Med. 2012;2012:190370).

The leaf extract of A. scholaris has been used to treat cold symptoms and tracheitis, and it has been prescribed in hospitals and approved for commercial over-the-counter sale by the State Food and Drugs Administration of China (SFDA) (J. Ethnopharmacol. 2010;129:293-8; J. Ethnopharmacol. 2010;129:174-81). The broad range of biological properties associated with A. scholaris has been ascribed to particular constituent categories, including alkaloids, flavonoids, and terpenoids (specifically, phenolic acids) (Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]). These properties include, but are reportedly not limited to, antioxidant, anticancer, anti-inflammatory, antistress, analgesic, antimutagenic, hepatoprotective, immunomodulatory, and chemopreventive activity (Integr. Cancer Ther. 2010;9:261-9; Chin. J. Integr. Med. 2012 Mar 28 [Epub ahead of print]). Antineoplastic effects have been linked directly to phytochemical constituents including echitamine, alstonine, pleiocarpamine, O-methylmacralstonine, macralstonine, and lupeol (Integr. Cancer Ther. 2010;9:261-9).

In 2006, Jagetia and Baliga investigated the anticancer activity of A. scholaris alkaloid fractions in vitro in cultured human neoplastic cell lines. They also conducted in vivo studies in tumor-bearing mice. The in vitro data in HeLa cells revealed a time-dependent rise in antineoplastic activity after 24 hours of exposure (25 mcg/mL). Further, once-daily administration of A. scholaris (240 mg/kg) to tumor-bearing mice yielded dose-dependent remissions, although there were toxic presentations at this dosage. The next-lower dose of 210 mg/kg was found to be most effective, with 20% of the mice surviving for as long as 120 days after tumor cell inoculation, compared with none of the control animals treated with saline (Phytother. Res. 2006;20:103-9).

Using an acute-restraint stress model in mice in 2009, Kulkarni and Juvekar evaluated the effects of stress and the impact of a methanolic extract of A. scholaris bark. Pretreatments with the extract of 100, 250, and 500 mg/kg for 7 days were found to exert significant antistress effects. In addition, nootropic activities were observed, with memory functions clearly enhanced in learning tasks. A. scholaris also was associated with significant antioxidant properties. The extract at 200 mcg/mL exhibited maximum scavenging of the stable radical 1,1-diphenyl-2-picrylhydrazyl at 90.11% and the nitric oxide radical at 62.77% (Indian J. Exp. Biol. 2009;47:47-52).

Later in 2009, Jahan et al. reported on their investigation of potential antioxidant and chemopreventive activity displayed by A. scholaris in a two-stage murine model. Skin carcinogenesis development was initiated in Swiss albino mice through one application of 7, 12-dimethyabenz(a)anthrecene (DMBA) and then promoted two weeks later by repeated application of croton oil three times per week through 16 weeks. The investigators found a lower incidence of tumors, tumor yield, tumor burden, and number of papillomas in mice treated with A. scholaris extract as compared to untreated controls (Integr. Cancer Ther. 2009;8:273-9).

In 2010, Shang et al. conducted multiple studies using A. scholaris. In the first published report, they assessed the anti-inflammatory and analgesic properties of the ethanolic leaf extract to validate its use in traditional Chinese medicine and modern clinical medicine. The investigators first determined that analgesic activity was conferred as the ethyl acetate and alkaloid fractions significantly diminished acetic acid-induced reactions in mice and, along with the ethanolic extract, reduced xylene-induced ear edema.

The researchers also performed in vivo and in vitro assessments of anti-inflammatory activity again on xylene-induced ear edema and carrageenan-induced air pouch formation in mice, as well as cyclooxygenase (COX)-1, -2 and 5-LOX inhibition.

In the air pouch model, A. scholaris alkaloids were found to have significantly spurred superoxide dismutase activity while lowering nitric oxide, prostaglandin E2, and malondialdehyde levels. In vitro tests, supporting evidence from animal models, showed that the three primary alkaloids isolated from A. scholaris leaves (picrinine, vallesamine, and scholaricine) inhibited the inflammatory mediators COX-1, COX-2, and 5-LOX. The researchers also noted that the in vitro anti-inflammatory assay results reinforced the notion of these alkaloids as the bioactive fraction of the plant (J. Ethnopharmacol. 2010;129:174-81).

In their second published report that year, Shang et al. investigated the antitussive and anti-asthmatic activities of the ethanolic extract, fractions, and chief alkaloids of A. scholaris leaf.

The researchers tested for antitussive effects using ammonia-induced or sulfur dioxide-induced coughing in mice and citric acid-induced coughing in guinea pigs. They evaluated anti-asthmatic activity via histamine-induced bronchoconstriction in guinea pigs. They also measured phenol red volume in murine tracheas to assess expectorant activity.

The data indicated antitussive activity, with significant alkaloid suppression of ammonia-induced coughing frequency in mice. Latency periods of sulfur dioxide-induced cough in mice and citric acid-induced cough in guinea pigs increased, and cough frequency in guinea pigs decreased.

Anti-asthmatic effects, such as suppression of convulsion, were observed in guinea pigs. In the expectorant assessment, tracheal phenol red production was increased. The researchers identified picrinine as the primary alkaloid responsible for these activities (J. Ethnopharmacol. 2010;129:293-8).

In addition, Jahan and Goyal showed that pretreatment with A. scholaris bark extract protected the bone marrow of mice against radiation-induced chromosomal damage and micronuclei induction (J Environ. Pathol. Toxicol. Oncol. 2010;29:101-11).

Conclusion

Despite the dearth of research on A. scholaris, the existing data are intriguing, particularly the findings that A. scholaris may have the capacity to amplify the anti-aging activity of retinoids while blunting their irritating effects. Although more research is needed to determine the dermatologic value of A. scholaris, the pursuit may potentially prove fruitful.

Dr. Baumann is in private practice in Miami Beach. She did not disclose any conflicts of interest. To respond to this column, or to suggest topics for future columns, write to her at [email protected].

Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, sounds like a football coach when he says the best way to fight carbapenem-resistant Enterobacteriaceae (CRE) infections is with a good defense. Hospitalists and others should focus on contact precautions, hand hygiene, removing gowns and gloves before entering new rooms, and even suggest better room cleanings when trying to prevent the spread of CRE, he says. In fact, he has worked with SHM leadership for years to engage hospitalists about the “critical necessity of antimicrobial stewardship.”

“They’re all critical to prevent transmission,” says Dr. Fishman, who chairs the CDC’s Health Infection Control Practices Advisory Committee. “That’s part of the things that can be done in the here and now to try to prevent people from getting infected with these organisms. It’s what the CDC calls ‘detect and prevent.’”

Dr. Fishman’s suggestions echo findings in a new CDC report that shows a threefold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem in the past decade. The data, in the CDC’s Morbidity and Mortality Weekly Report, showed the proportion of reported Enterobacteriacae that were CRE infections jumped to 4.2% in 2011 from 1.2% in

“It is a very serious public health threat,” says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC’s Division of Healthcare Quality Promotion. “Maybe it’s not that common now, but with no action, it has the potential to become much more common—like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission.”

Part of the problem, Dr. Fishman says, is a lack of antibiotic options. Polymyxins briefly showed success against the bacteria, but performance is waning. Dr. Fishman estimates it will be up to eight years before a new antibiotic to combat the infection is in widespread use.

Listen to Dr. Fishman discuss the history of treating CRE infections and importance of antimicrobial stewardship.

Both he and Dr. Kallen say hospitalists can help reduce the spread of CRE through antibiotic stewardship, review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene.

Dr. Kallen notes hospitalists also can play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions (i.e. skilled nursing or assisted-living facilities). Part of being that leader is refusing to dismiss possible CRE cases.

“If you’re a place that doesn’t see this very often, and you see one, that’s a big deal,” Dr. Kallen says. “It needs to be acted on aggressively. Being proactive is much more effective than waiting until it’s common and then trying to intervene.” TH

Richard Quinn is a freelance writer in New Jersey.

Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, sounds like a football coach when he says the best way to fight carbapenem-resistant Enterobacteriaceae (CRE) infections is with a good defense. Hospitalists and others should focus on contact precautions, hand hygiene, removing gowns and gloves before entering new rooms, and even suggest better room cleanings when trying to prevent the spread of CRE, he says. In fact, he has worked with SHM leadership for years to engage hospitalists about the “critical necessity of antimicrobial stewardship.”

“They’re all critical to prevent transmission,” says Dr. Fishman, who chairs the CDC’s Health Infection Control Practices Advisory Committee. “That’s part of the things that can be done in the here and now to try to prevent people from getting infected with these organisms. It’s what the CDC calls ‘detect and prevent.’”

Dr. Fishman’s suggestions echo findings in a new CDC report that shows a threefold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem in the past decade. The data, in the CDC’s Morbidity and Mortality Weekly Report, showed the proportion of reported Enterobacteriacae that were CRE infections jumped to 4.2% in 2011 from 1.2% in

“It is a very serious public health threat,” says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC’s Division of Healthcare Quality Promotion. “Maybe it’s not that common now, but with no action, it has the potential to become much more common—like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission.”

Part of the problem, Dr. Fishman says, is a lack of antibiotic options. Polymyxins briefly showed success against the bacteria, but performance is waning. Dr. Fishman estimates it will be up to eight years before a new antibiotic to combat the infection is in widespread use.

Listen to Dr. Fishman discuss the history of treating CRE infections and importance of antimicrobial stewardship.

Both he and Dr. Kallen say hospitalists can help reduce the spread of CRE through antibiotic stewardship, review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene.

Dr. Kallen notes hospitalists also can play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions (i.e. skilled nursing or assisted-living facilities). Part of being that leader is refusing to dismiss possible CRE cases.

“If you’re a place that doesn’t see this very often, and you see one, that’s a big deal,” Dr. Kallen says. “It needs to be acted on aggressively. Being proactive is much more effective than waiting until it’s common and then trying to intervene.” TH

Richard Quinn is a freelance writer in New Jersey.

Neil Fishman, MD, associate chief medical officer at the University of Pennsylvania Health System in Philadelphia, sounds like a football coach when he says the best way to fight carbapenem-resistant Enterobacteriaceae (CRE) infections is with a good defense. Hospitalists and others should focus on contact precautions, hand hygiene, removing gowns and gloves before entering new rooms, and even suggest better room cleanings when trying to prevent the spread of CRE, he says. In fact, he has worked with SHM leadership for years to engage hospitalists about the “critical necessity of antimicrobial stewardship.”

“They’re all critical to prevent transmission,” says Dr. Fishman, who chairs the CDC’s Health Infection Control Practices Advisory Committee. “That’s part of the things that can be done in the here and now to try to prevent people from getting infected with these organisms. It’s what the CDC calls ‘detect and prevent.’”

Dr. Fishman’s suggestions echo findings in a new CDC report that shows a threefold increase in the proportion of Enterobacteriaceae bugs that proved resistant to carbapenem in the past decade. The data, in the CDC’s Morbidity and Mortality Weekly Report, showed the proportion of reported Enterobacteriacae that were CRE infections jumped to 4.2% in 2011 from 1.2% in

“It is a very serious public health threat,” says co-author Alex Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC’s Division of Healthcare Quality Promotion. “Maybe it’s not that common now, but with no action, it has the potential to become much more common—like a lot of the other MDROs [multidrug-resistant organisms] that hospitalists see regularly. [Hospitalists] have a lot of control over some of the things that could potentially lead to increased transmission.”

Part of the problem, Dr. Fishman says, is a lack of antibiotic options. Polymyxins briefly showed success against the bacteria, but performance is waning. Dr. Fishman estimates it will be up to eight years before a new antibiotic to combat the infection is in widespread use.

Listen to Dr. Fishman discuss the history of treating CRE infections and importance of antimicrobial stewardship.

Both he and Dr. Kallen say hospitalists can help reduce the spread of CRE through antibiotic stewardship, review of detailed patient histories to ferret out risk factors, and dedication to contact precautions and hand hygiene.

Dr. Kallen notes hospitalists also can play a leadership role in coordinating efforts for patients transferring between hospitals and other institutions (i.e. skilled nursing or assisted-living facilities). Part of being that leader is refusing to dismiss possible CRE cases.

“If you’re a place that doesn’t see this very often, and you see one, that’s a big deal,” Dr. Kallen says. “It needs to be acted on aggressively. Being proactive is much more effective than waiting until it’s common and then trying to intervene.” TH

Richard Quinn is a freelance writer in New Jersey.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.