Perspectives

As I look back, there have been many changes during my 25 years of clinical practice. I always assumed there would be advancements in medical research during my career. I expected those advancements to produce progress rather than a random walk.

One area of positive change has been the recommendations for safe sleep practices for young infants. The Back to Sleep program of the mid 1990s reversed prior advice. It recommended that babies should sleep on their backs to avoid accidental suffocation. Prior advice had been that they should sleep on their stomachs to avoid aspiration. The new advice cut infant deaths by 50%.

Over the years, treatment of gastroesophageal reflux has significantly changed. Polysomnograms are ordered much less frequently. Medications to reduce stomach acid have been associated with side effects and now are discouraged. Raising the head of the crib was common advice in 2000s that was contradicted in the 2010s. For 2 decades I wrote orders in the hospital to elevate the head of the crib. More frequently, the nurses did it without my orders whenever they found a spitty baby.

In May 2019, there was a product recall of inclined infant sleepers. The Fisher-Price Rock ‘n Play was one product recalled; 4.7 million of these were sold in the United States in the past 10 years. Because they are used only by infants, and because there are about 4 million births per year in the United States, there are enough of these items stored in basements and garages for every infant to have one.

Investigative reporting by the Washington Post yielded an article highly critical of the product and the way it was originally created and designed. There is outrage in the author’s description of events. Because I have degrees in both engineering and pediatric medicine, I reviewed his assertions and tried to compare his ideal of the medical research world with my reality.

There are 3,600 infant deaths per year in the United States attributed to SUID/SIDS (sudden unexplained infant death/sudden infant death syndrome). From that perspective, I don’t know what 30 deaths in a decade associated with the sleeper really means. There is a high potential for recall bias and confirmation bias. It doesn’t surprise me that there was a delay in assigning blame to an ubiquitous consumer product. The article assumes that medical opinion is monolithic and synchronized rather than undergoing a diffusion of innovation, as described by Everett M. Rogers. Sorting out who knew what and when they knew it will take the courts many years.

Some of my columns earlier this year have appraised medical information in social media, and particularly on Facebook, as being harmfully unreliable. I find when I appraise the quality of medical information in peer-reviewed articles in reputable journals, its reliability isn’t good either.

An example of the unreliability of modern medical research was documented in an article in Hospital Pediatrics in July 2019.

The authors were performing a meta-analysis to determine whether the use of respiratory viral (RV) detection tests are helpful in reducing length of stay or reducing unnecessary antibiotic use. To me, that is a much simpler issue, scientifically, than safe sleep practices. The authors found 23 relevant studies that met their criteria for inclusion. Their overall conclusion was that the quality of the studies, the heterogeneity of the studies, and the statistically significant but contradictory results between the studies made it impossible to prove RV testing is beneficial. However, as I read the article, they cannot – for a litany of reasons – rule out such a benefit. Twenty three published articles in total yielded no reliable medical knowledge.

RV testing already has been widely adopted, particularly in emergency rooms. It is expensive. Clinical guidelines discourage RV testing but those guidelines are based on RV testing in the 2003-2006 time frame, which is obsolete technology. The author of the article on the infant sleepers expressed shock at what he considered to be inadequate medical research supporting the development of the inclined infant sleeper. RV testing is a product in widespread use, with lots of research, and has no better proof of efficacy or safety.

I expected, when I first started practice, that when I was older and grayer I would look back and recall many advances. I anticipated my recall would be of fond memories and of many patients helped. What I didn’t expect was so much of the advice that I provided to be wrong. Perhaps my medical education and parts of the academic research system should be subject to a product recall.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

As I look back, there have been many changes during my 25 years of clinical practice. I always assumed there would be advancements in medical research during my career. I expected those advancements to produce progress rather than a random walk.

One area of positive change has been the recommendations for safe sleep practices for young infants. The Back to Sleep program of the mid 1990s reversed prior advice. It recommended that babies should sleep on their backs to avoid accidental suffocation. Prior advice had been that they should sleep on their stomachs to avoid aspiration. The new advice cut infant deaths by 50%.

Over the years, treatment of gastroesophageal reflux has significantly changed. Polysomnograms are ordered much less frequently. Medications to reduce stomach acid have been associated with side effects and now are discouraged. Raising the head of the crib was common advice in 2000s that was contradicted in the 2010s. For 2 decades I wrote orders in the hospital to elevate the head of the crib. More frequently, the nurses did it without my orders whenever they found a spitty baby.

In May 2019, there was a product recall of inclined infant sleepers. The Fisher-Price Rock ‘n Play was one product recalled; 4.7 million of these were sold in the United States in the past 10 years. Because they are used only by infants, and because there are about 4 million births per year in the United States, there are enough of these items stored in basements and garages for every infant to have one.

Investigative reporting by the Washington Post yielded an article highly critical of the product and the way it was originally created and designed. There is outrage in the author’s description of events. Because I have degrees in both engineering and pediatric medicine, I reviewed his assertions and tried to compare his ideal of the medical research world with my reality.

There are 3,600 infant deaths per year in the United States attributed to SUID/SIDS (sudden unexplained infant death/sudden infant death syndrome). From that perspective, I don’t know what 30 deaths in a decade associated with the sleeper really means. There is a high potential for recall bias and confirmation bias. It doesn’t surprise me that there was a delay in assigning blame to an ubiquitous consumer product. The article assumes that medical opinion is monolithic and synchronized rather than undergoing a diffusion of innovation, as described by Everett M. Rogers. Sorting out who knew what and when they knew it will take the courts many years.

Some of my columns earlier this year have appraised medical information in social media, and particularly on Facebook, as being harmfully unreliable. I find when I appraise the quality of medical information in peer-reviewed articles in reputable journals, its reliability isn’t good either.

An example of the unreliability of modern medical research was documented in an article in Hospital Pediatrics in July 2019.

The authors were performing a meta-analysis to determine whether the use of respiratory viral (RV) detection tests are helpful in reducing length of stay or reducing unnecessary antibiotic use. To me, that is a much simpler issue, scientifically, than safe sleep practices. The authors found 23 relevant studies that met their criteria for inclusion. Their overall conclusion was that the quality of the studies, the heterogeneity of the studies, and the statistically significant but contradictory results between the studies made it impossible to prove RV testing is beneficial. However, as I read the article, they cannot – for a litany of reasons – rule out such a benefit. Twenty three published articles in total yielded no reliable medical knowledge.

RV testing already has been widely adopted, particularly in emergency rooms. It is expensive. Clinical guidelines discourage RV testing but those guidelines are based on RV testing in the 2003-2006 time frame, which is obsolete technology. The author of the article on the infant sleepers expressed shock at what he considered to be inadequate medical research supporting the development of the inclined infant sleeper. RV testing is a product in widespread use, with lots of research, and has no better proof of efficacy or safety.

I expected, when I first started practice, that when I was older and grayer I would look back and recall many advances. I anticipated my recall would be of fond memories and of many patients helped. What I didn’t expect was so much of the advice that I provided to be wrong. Perhaps my medical education and parts of the academic research system should be subject to a product recall.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

As I look back, there have been many changes during my 25 years of clinical practice. I always assumed there would be advancements in medical research during my career. I expected those advancements to produce progress rather than a random walk.

One area of positive change has been the recommendations for safe sleep practices for young infants. The Back to Sleep program of the mid 1990s reversed prior advice. It recommended that babies should sleep on their backs to avoid accidental suffocation. Prior advice had been that they should sleep on their stomachs to avoid aspiration. The new advice cut infant deaths by 50%.

Over the years, treatment of gastroesophageal reflux has significantly changed. Polysomnograms are ordered much less frequently. Medications to reduce stomach acid have been associated with side effects and now are discouraged. Raising the head of the crib was common advice in 2000s that was contradicted in the 2010s. For 2 decades I wrote orders in the hospital to elevate the head of the crib. More frequently, the nurses did it without my orders whenever they found a spitty baby.

In May 2019, there was a product recall of inclined infant sleepers. The Fisher-Price Rock ‘n Play was one product recalled; 4.7 million of these were sold in the United States in the past 10 years. Because they are used only by infants, and because there are about 4 million births per year in the United States, there are enough of these items stored in basements and garages for every infant to have one.

Investigative reporting by the Washington Post yielded an article highly critical of the product and the way it was originally created and designed. There is outrage in the author’s description of events. Because I have degrees in both engineering and pediatric medicine, I reviewed his assertions and tried to compare his ideal of the medical research world with my reality.

There are 3,600 infant deaths per year in the United States attributed to SUID/SIDS (sudden unexplained infant death/sudden infant death syndrome). From that perspective, I don’t know what 30 deaths in a decade associated with the sleeper really means. There is a high potential for recall bias and confirmation bias. It doesn’t surprise me that there was a delay in assigning blame to an ubiquitous consumer product. The article assumes that medical opinion is monolithic and synchronized rather than undergoing a diffusion of innovation, as described by Everett M. Rogers. Sorting out who knew what and when they knew it will take the courts many years.

Some of my columns earlier this year have appraised medical information in social media, and particularly on Facebook, as being harmfully unreliable. I find when I appraise the quality of medical information in peer-reviewed articles in reputable journals, its reliability isn’t good either.

An example of the unreliability of modern medical research was documented in an article in Hospital Pediatrics in July 2019.

The authors were performing a meta-analysis to determine whether the use of respiratory viral (RV) detection tests are helpful in reducing length of stay or reducing unnecessary antibiotic use. To me, that is a much simpler issue, scientifically, than safe sleep practices. The authors found 23 relevant studies that met their criteria for inclusion. Their overall conclusion was that the quality of the studies, the heterogeneity of the studies, and the statistically significant but contradictory results between the studies made it impossible to prove RV testing is beneficial. However, as I read the article, they cannot – for a litany of reasons – rule out such a benefit. Twenty three published articles in total yielded no reliable medical knowledge.

RV testing already has been widely adopted, particularly in emergency rooms. It is expensive. Clinical guidelines discourage RV testing but those guidelines are based on RV testing in the 2003-2006 time frame, which is obsolete technology. The author of the article on the infant sleepers expressed shock at what he considered to be inadequate medical research supporting the development of the inclined infant sleeper. RV testing is a product in widespread use, with lots of research, and has no better proof of efficacy or safety.

I expected, when I first started practice, that when I was older and grayer I would look back and recall many advances. I anticipated my recall would be of fond memories and of many patients helped. What I didn’t expect was so much of the advice that I provided to be wrong. Perhaps my medical education and parts of the academic research system should be subject to a product recall.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Nausea and vomiting of pregnancy (NVP) affects up to 80% of pregnant women, most commonly between 5 and 18 weeks of gestation. In addition, its extreme form, hyperemesis gravidarum, affects less than 3% of pregnancies.¹ Certainly with hyperemesis gravidarum, and oftentimes with less severe NVP, pharmacologic treatment is desired or required. One of the choices for such treatment has been ondansetron, a 5-HT₃ receptor antagonist, which has been used off label for NVP and is now available in generic form. However, there have been concerns raised regarding the fetal safety of this medication, last reviewed in Ob.Gyn. News by Gideon Koren, MD, in a commentary published in 2013.

Since then, the escalating use of ondansetron in the United States has been described using a large dataset covering 2.3 million, predominantly commercially insured, pregnancies that resulted in live births from 2001 to 2015.¹ Over that period of time, any outpatient pharmacy dispensing of an antiemetic in pregnancy increased from 17.0% in 2001 to 27.2% in 2014. That increase was entirely accounted for by a dramatic rise in oral ondansetron use beginning in 2006. By 2014, 22.4% of pregnancies in the database had received a prescription for ondansetron.

There have been two studies that have suggested an increased risk in specific major birth defects with first-trimester ondansetron use. The first, published in 2012, used data from the National Birth Defects Prevention case control study from 1997 to 2004 to examine risks with NVP and its treatments for the most common noncardiac defects in the dataset. These included cleft lip with or without cleft palate, cleft palate alone, neural tube defects, and hypospadias. NVP itself was not associated with any increased risks for the selected defects. In contrast, ondansetron was associated with an increased risk for cleft palate alone based on seven exposed cases (adjusted odds ratio, 2.37; 95% confidence interval, 1.18-4.76).²

A second study published in 2014 used data from the Swedish Medical Birth Register from 1998 to 2012 to identify 1,349 infants whose mothers reported taking ondansetron in early pregnancy. While no overall increased risk of major birth defects was found with early pregnancy ondansetron use, compared with no such use, there was a significant increased risk noted for cardiovascular defects, particularly cardiac septum defects (any cardiac defect OR, 1.62; 95% CI, 1.04-2.14; cardiac septum defects risk ratio, 2.05; 95% CI, 1.19-3.28).³ No cases of cleft palate were reported among exposed cases in that study.

In contrast, in another study, Danish National Birth Cohort data on 608,385 pregnancies from 2004 to 2011 were used to compare major birth defect outcomes among 1,233 women exposed to ondansetron in the first trimester with those of 4,392 unexposed women.⁴ The birth prevalence of any major birth defect was identical (2.9%) in both exposed and unexposed groups (adjusted prevalence OR, 1.12; 95% CI, 0.69-1.82). No cases of cleft palate were reported among exposed cases and the crude OR for any cardiac defect approximated the null (1.04; 95% CI, 0.52-1.95). Two other smaller or less well-designed studies did not support an increased risk for major birth defects overall (Fejzo et al. 2016 Jul;62:87-91; Einarson et al. 2004Aug 23. doi: 10.1111/j.1471-0528.2004.00236.x).

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is also director of MotherToBaby California, a past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no conflicts of interest to disclose related to this column.

References:

1. Taylor LG et al. Antiemetic use among pregnant women in the United States: the escalating use of ondansetron. Pharmacoepidemiol Drug Saf. 2017 May;26(5):592-6.

2. Anderka M et al. Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects. Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):22-30.

3. Danielsson B et al. Use of ondansetron during pregnancy and congenital malformations in the infant. Reprod Toxicol. 2014 Dec;50:134-7.

4. Pasternak B et al. Ondansetron in pregnancy and risk of adverse fetal outcomes. N Engl J Med. 2013 Feb 28;368(9):814-23.

Nausea and vomiting of pregnancy (NVP) affects up to 80% of pregnant women, most commonly between 5 and 18 weeks of gestation. In addition, its extreme form, hyperemesis gravidarum, affects less than 3% of pregnancies.¹ Certainly with hyperemesis gravidarum, and oftentimes with less severe NVP, pharmacologic treatment is desired or required. One of the choices for such treatment has been ondansetron, a 5-HT₃ receptor antagonist, which has been used off label for NVP and is now available in generic form. However, there have been concerns raised regarding the fetal safety of this medication, last reviewed in Ob.Gyn. News by Gideon Koren, MD, in a commentary published in 2013.

Since then, the escalating use of ondansetron in the United States has been described using a large dataset covering 2.3 million, predominantly commercially insured, pregnancies that resulted in live births from 2001 to 2015.¹ Over that period of time, any outpatient pharmacy dispensing of an antiemetic in pregnancy increased from 17.0% in 2001 to 27.2% in 2014. That increase was entirely accounted for by a dramatic rise in oral ondansetron use beginning in 2006. By 2014, 22.4% of pregnancies in the database had received a prescription for ondansetron.

There have been two studies that have suggested an increased risk in specific major birth defects with first-trimester ondansetron use. The first, published in 2012, used data from the National Birth Defects Prevention case control study from 1997 to 2004 to examine risks with NVP and its treatments for the most common noncardiac defects in the dataset. These included cleft lip with or without cleft palate, cleft palate alone, neural tube defects, and hypospadias. NVP itself was not associated with any increased risks for the selected defects. In contrast, ondansetron was associated with an increased risk for cleft palate alone based on seven exposed cases (adjusted odds ratio, 2.37; 95% confidence interval, 1.18-4.76).²

A second study published in 2014 used data from the Swedish Medical Birth Register from 1998 to 2012 to identify 1,349 infants whose mothers reported taking ondansetron in early pregnancy. While no overall increased risk of major birth defects was found with early pregnancy ondansetron use, compared with no such use, there was a significant increased risk noted for cardiovascular defects, particularly cardiac septum defects (any cardiac defect OR, 1.62; 95% CI, 1.04-2.14; cardiac septum defects risk ratio, 2.05; 95% CI, 1.19-3.28).³ No cases of cleft palate were reported among exposed cases in that study.

In contrast, in another study, Danish National Birth Cohort data on 608,385 pregnancies from 2004 to 2011 were used to compare major birth defect outcomes among 1,233 women exposed to ondansetron in the first trimester with those of 4,392 unexposed women.⁴ The birth prevalence of any major birth defect was identical (2.9%) in both exposed and unexposed groups (adjusted prevalence OR, 1.12; 95% CI, 0.69-1.82). No cases of cleft palate were reported among exposed cases and the crude OR for any cardiac defect approximated the null (1.04; 95% CI, 0.52-1.95). Two other smaller or less well-designed studies did not support an increased risk for major birth defects overall (Fejzo et al. 2016 Jul;62:87-91; Einarson et al. 2004Aug 23. doi: 10.1111/j.1471-0528.2004.00236.x).

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is also director of MotherToBaby California, a past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no conflicts of interest to disclose related to this column.

References:

1. Taylor LG et al. Antiemetic use among pregnant women in the United States: the escalating use of ondansetron. Pharmacoepidemiol Drug Saf. 2017 May;26(5):592-6.

2. Anderka M et al. Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects. Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):22-30.

3. Danielsson B et al. Use of ondansetron during pregnancy and congenital malformations in the infant. Reprod Toxicol. 2014 Dec;50:134-7.

4. Pasternak B et al. Ondansetron in pregnancy and risk of adverse fetal outcomes. N Engl J Med. 2013 Feb 28;368(9):814-23.

Nausea and vomiting of pregnancy (NVP) affects up to 80% of pregnant women, most commonly between 5 and 18 weeks of gestation. In addition, its extreme form, hyperemesis gravidarum, affects less than 3% of pregnancies.¹ Certainly with hyperemesis gravidarum, and oftentimes with less severe NVP, pharmacologic treatment is desired or required. One of the choices for such treatment has been ondansetron, a 5-HT₃ receptor antagonist, which has been used off label for NVP and is now available in generic form. However, there have been concerns raised regarding the fetal safety of this medication, last reviewed in Ob.Gyn. News by Gideon Koren, MD, in a commentary published in 2013.

Since then, the escalating use of ondansetron in the United States has been described using a large dataset covering 2.3 million, predominantly commercially insured, pregnancies that resulted in live births from 2001 to 2015.¹ Over that period of time, any outpatient pharmacy dispensing of an antiemetic in pregnancy increased from 17.0% in 2001 to 27.2% in 2014. That increase was entirely accounted for by a dramatic rise in oral ondansetron use beginning in 2006. By 2014, 22.4% of pregnancies in the database had received a prescription for ondansetron.

There have been two studies that have suggested an increased risk in specific major birth defects with first-trimester ondansetron use. The first, published in 2012, used data from the National Birth Defects Prevention case control study from 1997 to 2004 to examine risks with NVP and its treatments for the most common noncardiac defects in the dataset. These included cleft lip with or without cleft palate, cleft palate alone, neural tube defects, and hypospadias. NVP itself was not associated with any increased risks for the selected defects. In contrast, ondansetron was associated with an increased risk for cleft palate alone based on seven exposed cases (adjusted odds ratio, 2.37; 95% confidence interval, 1.18-4.76).²

A second study published in 2014 used data from the Swedish Medical Birth Register from 1998 to 2012 to identify 1,349 infants whose mothers reported taking ondansetron in early pregnancy. While no overall increased risk of major birth defects was found with early pregnancy ondansetron use, compared with no such use, there was a significant increased risk noted for cardiovascular defects, particularly cardiac septum defects (any cardiac defect OR, 1.62; 95% CI, 1.04-2.14; cardiac septum defects risk ratio, 2.05; 95% CI, 1.19-3.28).³ No cases of cleft palate were reported among exposed cases in that study.

In contrast, in another study, Danish National Birth Cohort data on 608,385 pregnancies from 2004 to 2011 were used to compare major birth defect outcomes among 1,233 women exposed to ondansetron in the first trimester with those of 4,392 unexposed women.⁴ The birth prevalence of any major birth defect was identical (2.9%) in both exposed and unexposed groups (adjusted prevalence OR, 1.12; 95% CI, 0.69-1.82). No cases of cleft palate were reported among exposed cases and the crude OR for any cardiac defect approximated the null (1.04; 95% CI, 0.52-1.95). Two other smaller or less well-designed studies did not support an increased risk for major birth defects overall (Fejzo et al. 2016 Jul;62:87-91; Einarson et al. 2004Aug 23. doi: 10.1111/j.1471-0528.2004.00236.x).

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is also director of MotherToBaby California, a past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no conflicts of interest to disclose related to this column.

References:

1. Taylor LG et al. Antiemetic use among pregnant women in the United States: the escalating use of ondansetron. Pharmacoepidemiol Drug Saf. 2017 May;26(5):592-6.

2. Anderka M et al. Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects. Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):22-30.

3. Danielsson B et al. Use of ondansetron during pregnancy and congenital malformations in the infant. Reprod Toxicol. 2014 Dec;50:134-7.

4. Pasternak B et al. Ondansetron in pregnancy and risk of adverse fetal outcomes. N Engl J Med. 2013 Feb 28;368(9):814-23.

It goes without saying that as a physician, it’s essential to keep your knowledge and skills current. But too many private practitioners overlook the similar needs of their employees.

Continuing education is as important for your staff as for you. Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

But there are lots of other good reasons to invest in ongoing staff training. It’s a win-win strategy for you, your staff, and for your practice.

The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. And the better their skills and the greater their confidence, the less supervision they need from you, and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees’ competence makes them feel valued and appreciated. This leads to reduced turnover – which, alone, often pays for the training.

You probably already do some ongoing education: You do your yearly OSHA training because the law requires it, you run HIPAA updates as necessary, and you have everyone recertified periodically in basic or advanced CPR (I hope). But I’m talking about going beyond the basic stuff, which may satisfy legal requirements, but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses – or at the very least, online refreshers – so they are always current on the latest third-party changes. The use of outdated or obsolete codes can cost you thousands of dollars every month. Other opportunities include keyboarding and computer courses for staff who work with your computers, and Excel and QuickBooks updates for your bookkeepers.

Continuing education does not have to be costly, and in some cases it can be free. For example, pharmaceutical representatives will be happy to run an in-service for your staff on a new medication or procedure or instrument, or refresh their memories on an established one. Be sure to make clear to the rep that the presentation must be as objective and impartial as possible, given the obvious potential conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators and Managers. It holds annual meetings at the same time and in the same city as the American Academy of Dermatology winter meetings, with a good selection of refresher courses and lots of opportunities for networking with other managers, both personally or virtually.

Many other venues are available for employee education, in the cloud and in conventional classrooms. Courses are offered in many relevant subjects; a quick Google search turns up an eclectic mix, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far the most common question I receive on this issue is, “What if I pay for all that training, and then the employees leave?”

My reply: “What if you don’t, and they stay?”

Well-trained employees are vastly preferable to untrained ones. I suppose there is some risk of an occasional staffer accepting training and then moving on; but in 38 years, it has never happened in my office. In my experience, well-trained employees will stay. Education fosters loyalty. Employees who know you care enough about them to advance their skills will sense that they have a stake in the practice, and thus will be less likely to want to leave. Furthermore, continuing education will always be cheaper than training new employees from scratch.

In any case, everyone will benefit from a well-trained staff – you, your employees, your practice, and most importantly your patients.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

It goes without saying that as a physician, it’s essential to keep your knowledge and skills current. But too many private practitioners overlook the similar needs of their employees.

Continuing education is as important for your staff as for you. Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

But there are lots of other good reasons to invest in ongoing staff training. It’s a win-win strategy for you, your staff, and for your practice.

The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. And the better their skills and the greater their confidence, the less supervision they need from you, and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees’ competence makes them feel valued and appreciated. This leads to reduced turnover – which, alone, often pays for the training.

You probably already do some ongoing education: You do your yearly OSHA training because the law requires it, you run HIPAA updates as necessary, and you have everyone recertified periodically in basic or advanced CPR (I hope). But I’m talking about going beyond the basic stuff, which may satisfy legal requirements, but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses – or at the very least, online refreshers – so they are always current on the latest third-party changes. The use of outdated or obsolete codes can cost you thousands of dollars every month. Other opportunities include keyboarding and computer courses for staff who work with your computers, and Excel and QuickBooks updates for your bookkeepers.

Continuing education does not have to be costly, and in some cases it can be free. For example, pharmaceutical representatives will be happy to run an in-service for your staff on a new medication or procedure or instrument, or refresh their memories on an established one. Be sure to make clear to the rep that the presentation must be as objective and impartial as possible, given the obvious potential conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators and Managers. It holds annual meetings at the same time and in the same city as the American Academy of Dermatology winter meetings, with a good selection of refresher courses and lots of opportunities for networking with other managers, both personally or virtually.

Many other venues are available for employee education, in the cloud and in conventional classrooms. Courses are offered in many relevant subjects; a quick Google search turns up an eclectic mix, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far the most common question I receive on this issue is, “What if I pay for all that training, and then the employees leave?”

My reply: “What if you don’t, and they stay?”

Well-trained employees are vastly preferable to untrained ones. I suppose there is some risk of an occasional staffer accepting training and then moving on; but in 38 years, it has never happened in my office. In my experience, well-trained employees will stay. Education fosters loyalty. Employees who know you care enough about them to advance their skills will sense that they have a stake in the practice, and thus will be less likely to want to leave. Furthermore, continuing education will always be cheaper than training new employees from scratch.

In any case, everyone will benefit from a well-trained staff – you, your employees, your practice, and most importantly your patients.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

It goes without saying that as a physician, it’s essential to keep your knowledge and skills current. But too many private practitioners overlook the similar needs of their employees.

Continuing education is as important for your staff as for you. Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

But there are lots of other good reasons to invest in ongoing staff training. It’s a win-win strategy for you, your staff, and for your practice.

The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. And the better their skills and the greater their confidence, the less supervision they need from you, and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees’ competence makes them feel valued and appreciated. This leads to reduced turnover – which, alone, often pays for the training.

You probably already do some ongoing education: You do your yearly OSHA training because the law requires it, you run HIPAA updates as necessary, and you have everyone recertified periodically in basic or advanced CPR (I hope). But I’m talking about going beyond the basic stuff, which may satisfy legal requirements, but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses – or at the very least, online refreshers – so they are always current on the latest third-party changes. The use of outdated or obsolete codes can cost you thousands of dollars every month. Other opportunities include keyboarding and computer courses for staff who work with your computers, and Excel and QuickBooks updates for your bookkeepers.

Continuing education does not have to be costly, and in some cases it can be free. For example, pharmaceutical representatives will be happy to run an in-service for your staff on a new medication or procedure or instrument, or refresh their memories on an established one. Be sure to make clear to the rep that the presentation must be as objective and impartial as possible, given the obvious potential conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators and Managers. It holds annual meetings at the same time and in the same city as the American Academy of Dermatology winter meetings, with a good selection of refresher courses and lots of opportunities for networking with other managers, both personally or virtually.

Many other venues are available for employee education, in the cloud and in conventional classrooms. Courses are offered in many relevant subjects; a quick Google search turns up an eclectic mix, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far the most common question I receive on this issue is, “What if I pay for all that training, and then the employees leave?”

My reply: “What if you don’t, and they stay?”

Well-trained employees are vastly preferable to untrained ones. I suppose there is some risk of an occasional staffer accepting training and then moving on; but in 38 years, it has never happened in my office. In my experience, well-trained employees will stay. Education fosters loyalty. Employees who know you care enough about them to advance their skills will sense that they have a stake in the practice, and thus will be less likely to want to leave. Furthermore, continuing education will always be cheaper than training new employees from scratch.

In any case, everyone will benefit from a well-trained staff – you, your employees, your practice, and most importantly your patients.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The patient grabbed my attention as I glanced through our clinic schedule. It was his age: He was 99 years old and scheduled for eye surgery. The plastic surgery resident’s note read: “Patient understands that this would involve surgery under general anesthesia and is agreeable to moving forward...Extremely high risk of anesthesia emphasized.”

I reviewed the patient’s history. At baseline, he had severe pulmonary hypertension, severe aortic stenosis (AS), diastolic heart failure, chronic atrial fibrillation, chronic kidney disease (estimated glomerular filtration rate of 26 mL/min [normal is > 60 mL/min]), anemia (hematocrit 26%), and a standing do not resuscitate (DNR) order. His maximal daily exercise was walking slowly across a room, primarily limited by joint pain. Recent geropsychiatry notes indicated mild cognitive impairment. The anesthesia record from an urgent hip fracture repair 7 months before under general anesthesia was unremarkable.

I phoned the attending plastic surgeon. Our conversation was as follows:

“Hi, I’m about to see a 99-year-old patient with a DNR who is scheduled for resection of an eyelid tumor. His medical history makes me nervous. Are you sure this is a good idea?”“Hmmm, 99-year-old…okay, that’s right,” he responded. “He has an invasive squamous that could become a big problem. The actual procedure is under 10 minutes. Waiting for the pathology report will be the longest part of the procedure.”

“Can it be done under local?” I asked.

“Yes,” he replied.

“Okay, I’ll talk to him and call you back.”

I found the patient in the waiting room, flanked by his 2 daughters and invited them into the clinic room. After introductions, I began asking whether they had any questions about the anesthesia. By midsentence a daughter was prompting him to discuss what happened “last time.” He described a history of posttraumatic stress disorder (PTSD) stemming from his hip surgery, which he blamed squarely on the anesthesia. His emotion was evident in the gathering pauses. “I hate that I am so emotional since they kept me awake during my surgery.”

Through the fog of multiple accounts, it became clear that he was traumatized by the loss of control during the administration of and emergence from the anesthesia.

“They told me it was only oxygen,” he said. “They lied. There was a taste to it…I was awake and skinned alive…They said I was a monster when I woke up thrashing.” He went on, explaining that in the recovery room “there were 2 people bothering me, man-handling me, asking me questions.”

One of his daughters showed me pictures of bruises on his face from ripping off the mask and pulling out the breathing tube. They were visibly upset by the memory of his postoperative combativeness and paranoia. The note written by the orthopedic surgery resident on the day after surgery stated succinctly, “Doing well, had some delirium from anesthesia overnight.” Subsequent geropsychiatry home visits attested to intrusive thoughts, flashbacks, and nightmares from his time as a combat soldier in World War II, 65 years in the past.

“It took me months…months to recover,” he said.

He was in the mood to reminisce, however, perhaps a willful distraction. He had the floor for at least 30 minutes, during which I spoke about 5 sentences. With every sad story he told there was a happy, humorous one, such as meeting his future wife while on leave in New Zealand during the war, recalled down to exact dates. And another story:
 

There we were in New Caledonia. All our supplies went out to replace what sank on [USS] Coolidge, including a lot of food. Well, there were deer on the island. So we took out a truck and a rifle and wouldn’t you know we came upon a roadblock in the form of a big steer. We figured it looked enough like a deer. My buddy shot it dead with one shot. We dressed it and loaded it into the jeep. Hardly before we even got back to the mess hall, the officers’ cook came sniffing around. He and our captain agreed it was easily the biggest deer they’d ever seen and appropriated it to the officers’ mess. Next day the CO [commanding officer] of the whole outfit came by and announced it was the best tasting ‘venison’ he’d ever had. I heard the farmer got paid a pretty penny for that steer. I didn’t get a damn bite.

He delivered this last bit with relish.

When the conversation returned to anesthesia, I read them the record of his hip fracture repair. I explained that on the face of it, the report seemed uneventful. One daughter asked astute questions about his awareness. I explained that although awareness during general anesthesia is possible, it seemed from the record, he’d had plenty of anesthesia during the case and that there is always less at the beginning and end, the periods that apparently had caused him distress. I also explained that most studies report the incidence of true awareness as at most 1 out of thousands of events and that he had none of the established risk factors for it, such as female gender, young age, chronic substance abuse, cardiac and obstetric surgery, and history of awareness.¹

The other daughter wondered why he was so agitated afterward. I recited data on the frequency of postoperative delirium in elderly patients but explained that the range is wide, depending on the study and population, from about 1% in elderly patients undergoing ambulatory surgery to 65% for open aortic surgery.^2,3 I added that their father had 2 of the strongest risk factors for delirium, advanced age and cognitive impairment.³ Only after airing each question about the hip surgery in detail were they ready to discuss the eye surgery.

He started that conversation with the right question: “Do I really need it?”

I quoted my surgical colleague’s concern. I told him that, should he opt to undergo the surgery, I was confident that this time around his experience would be different from the last.

“If you’re okay with it, all you need is some numbing medicine from the surgeon; you won’t need any anesthesia from me.”

I walked step-by-step through what they could expect on the day of surgery. Maintaining control was of obvious importance to him. He felt comfortable going forward. His daughters intuited that less would be more for a quick recovery.

We then addressed the DNR directive. I acknowledged his absolute right to self-determination and explained that the need for resuscitation is, at times, a consequence of the surgery and anesthesia. I reassured them that our plan made resuscitation and intubation highly unlikely. They also asked to use any interventions necessary to restart his heart if it should stop beating. I documented their decision in my notes and communicated it to the surgical team. We had talked for 90 minutes.

I met the patient and his daughters on the day of surgery in the preoperative holding area. I inserted an IV, applied electrocardiography leads, and affixed a pulse oximeter and a noninvasive blood pressure cuff. In the operating room (OR) we took time to place his 99-year-old joints into, as he said, the “least worst” position. He tolerated the injection of the local by the surgeon perfectly well. We were in the OR for 3 hours, during which he taught me a fair amount about boating and outboard engines among other things. Pathology reported clean margins. He was discharged home soon after and had an uneventful recovery.

Patient-First Approach

A core competency of the Accreditation Council for Graduate Medical Education for an anesthesia residency is the Interpersonal and Communication Skills program. A comprehensive discussion of communication is far beyond the scope here. But not surprisingly, deficient communication between physicians and patients can cause emotional distress, significant dissatisfaction among family members, and negative patient judgment of how well we communicate.^4-6 These observations are particularly true in our increasingly elderly surgical population, in which both surgeons and anesthesiologists often feel unequal to the task of discussing concepts such as code status.^7,8

In our practice and in residency training, the preoperative clinic often is the location where patient/provider communication occurs. Here we consider the latest American College of Cardiology/American Heart Association guidelines, examine airways, review electrocardiograms, and formulate plans agreeable to and understood by our anxious patients and their families. The potent anxiolytic effect of a preoperative visit by an anesthesiologist is well established.⁹ Anxiety about surgery is a risk factor for impaired decision making before surgery.¹⁰ And surgery is traumatic—as many as 7.6% of postoperative patients experience symptoms consistent with PTSD attributable to the surgery, placing it on a par with being mugged (8.0%).^11,12

The patient in this case presented several communication challenges even absent his revelation of prior traumatic experience with anesthesia. He was elderly, anxious, and had multiple comorbidities. He had mild cognitive impairment and required a code status discussion. There also were the clinical challenges—navigating a 99-year-old with severe aortic stenosis and a right ventricular systolic pressure > 90 mm Hg through a general anesthetic gave me a sinking feeling.

He was fortunate that the procedure could be done with local anesthesia, mitigating his risk of cognitive dysfunction, including delirium. He also was fortunate in that his anesthesiologist and surgeon had created a collaborative, patient-first approach and that his US Department of Veterans Affairs (VA) clinic had the time, space, and staffing to accommodate an unexpected 90-minute visit. A big investment in communication, mainly my keeping quiet, made the intraoperative management simple. Such is life in an integrated health care system without financial incentives for high-volume care—and another reminder that VA physicians are blessed to guide patients through some of the most vulnerable and distressing moments of their lives.

Postscript

During the preparation of this manuscript, the patient passed away at the age of 100. His obituary was consistent with what I had learned about him and his family during our 2 encounters: a long successful career in local industry; extensive involvement in his community; an avid sportsman; and nearly 30 grandchildren, great-grandchildren, and great-great grandchildren. But there was one more detail that never came up during my extensive discussion with him and his daughters: He was awarded the Purple Heart for his service in World War II.

The patient grabbed my attention as I glanced through our clinic schedule. It was his age: He was 99 years old and scheduled for eye surgery. The plastic surgery resident’s note read: “Patient understands that this would involve surgery under general anesthesia and is agreeable to moving forward...Extremely high risk of anesthesia emphasized.”

I reviewed the patient’s history. At baseline, he had severe pulmonary hypertension, severe aortic stenosis (AS), diastolic heart failure, chronic atrial fibrillation, chronic kidney disease (estimated glomerular filtration rate of 26 mL/min [normal is > 60 mL/min]), anemia (hematocrit 26%), and a standing do not resuscitate (DNR) order. His maximal daily exercise was walking slowly across a room, primarily limited by joint pain. Recent geropsychiatry notes indicated mild cognitive impairment. The anesthesia record from an urgent hip fracture repair 7 months before under general anesthesia was unremarkable.

I phoned the attending plastic surgeon. Our conversation was as follows:

“Hi, I’m about to see a 99-year-old patient with a DNR who is scheduled for resection of an eyelid tumor. His medical history makes me nervous. Are you sure this is a good idea?”“Hmmm, 99-year-old…okay, that’s right,” he responded. “He has an invasive squamous that could become a big problem. The actual procedure is under 10 minutes. Waiting for the pathology report will be the longest part of the procedure.”

“Can it be done under local?” I asked.

“Yes,” he replied.

“Okay, I’ll talk to him and call you back.”

I found the patient in the waiting room, flanked by his 2 daughters and invited them into the clinic room. After introductions, I began asking whether they had any questions about the anesthesia. By midsentence a daughter was prompting him to discuss what happened “last time.” He described a history of posttraumatic stress disorder (PTSD) stemming from his hip surgery, which he blamed squarely on the anesthesia. His emotion was evident in the gathering pauses. “I hate that I am so emotional since they kept me awake during my surgery.”

Through the fog of multiple accounts, it became clear that he was traumatized by the loss of control during the administration of and emergence from the anesthesia.

“They told me it was only oxygen,” he said. “They lied. There was a taste to it…I was awake and skinned alive…They said I was a monster when I woke up thrashing.” He went on, explaining that in the recovery room “there were 2 people bothering me, man-handling me, asking me questions.”

One of his daughters showed me pictures of bruises on his face from ripping off the mask and pulling out the breathing tube. They were visibly upset by the memory of his postoperative combativeness and paranoia. The note written by the orthopedic surgery resident on the day after surgery stated succinctly, “Doing well, had some delirium from anesthesia overnight.” Subsequent geropsychiatry home visits attested to intrusive thoughts, flashbacks, and nightmares from his time as a combat soldier in World War II, 65 years in the past.

“It took me months…months to recover,” he said.

He was in the mood to reminisce, however, perhaps a willful distraction. He had the floor for at least 30 minutes, during which I spoke about 5 sentences. With every sad story he told there was a happy, humorous one, such as meeting his future wife while on leave in New Zealand during the war, recalled down to exact dates. And another story:
 

There we were in New Caledonia. All our supplies went out to replace what sank on [USS] Coolidge, including a lot of food. Well, there were deer on the island. So we took out a truck and a rifle and wouldn’t you know we came upon a roadblock in the form of a big steer. We figured it looked enough like a deer. My buddy shot it dead with one shot. We dressed it and loaded it into the jeep. Hardly before we even got back to the mess hall, the officers’ cook came sniffing around. He and our captain agreed it was easily the biggest deer they’d ever seen and appropriated it to the officers’ mess. Next day the CO [commanding officer] of the whole outfit came by and announced it was the best tasting ‘venison’ he’d ever had. I heard the farmer got paid a pretty penny for that steer. I didn’t get a damn bite.

He delivered this last bit with relish.

When the conversation returned to anesthesia, I read them the record of his hip fracture repair. I explained that on the face of it, the report seemed uneventful. One daughter asked astute questions about his awareness. I explained that although awareness during general anesthesia is possible, it seemed from the record, he’d had plenty of anesthesia during the case and that there is always less at the beginning and end, the periods that apparently had caused him distress. I also explained that most studies report the incidence of true awareness as at most 1 out of thousands of events and that he had none of the established risk factors for it, such as female gender, young age, chronic substance abuse, cardiac and obstetric surgery, and history of awareness.¹

The other daughter wondered why he was so agitated afterward. I recited data on the frequency of postoperative delirium in elderly patients but explained that the range is wide, depending on the study and population, from about 1% in elderly patients undergoing ambulatory surgery to 65% for open aortic surgery.^2,3 I added that their father had 2 of the strongest risk factors for delirium, advanced age and cognitive impairment.³ Only after airing each question about the hip surgery in detail were they ready to discuss the eye surgery.

He started that conversation with the right question: “Do I really need it?”

I quoted my surgical colleague’s concern. I told him that, should he opt to undergo the surgery, I was confident that this time around his experience would be different from the last.

“If you’re okay with it, all you need is some numbing medicine from the surgeon; you won’t need any anesthesia from me.”

I walked step-by-step through what they could expect on the day of surgery. Maintaining control was of obvious importance to him. He felt comfortable going forward. His daughters intuited that less would be more for a quick recovery.

We then addressed the DNR directive. I acknowledged his absolute right to self-determination and explained that the need for resuscitation is, at times, a consequence of the surgery and anesthesia. I reassured them that our plan made resuscitation and intubation highly unlikely. They also asked to use any interventions necessary to restart his heart if it should stop beating. I documented their decision in my notes and communicated it to the surgical team. We had talked for 90 minutes.

I met the patient and his daughters on the day of surgery in the preoperative holding area. I inserted an IV, applied electrocardiography leads, and affixed a pulse oximeter and a noninvasive blood pressure cuff. In the operating room (OR) we took time to place his 99-year-old joints into, as he said, the “least worst” position. He tolerated the injection of the local by the surgeon perfectly well. We were in the OR for 3 hours, during which he taught me a fair amount about boating and outboard engines among other things. Pathology reported clean margins. He was discharged home soon after and had an uneventful recovery.

Patient-First Approach

A core competency of the Accreditation Council for Graduate Medical Education for an anesthesia residency is the Interpersonal and Communication Skills program. A comprehensive discussion of communication is far beyond the scope here. But not surprisingly, deficient communication between physicians and patients can cause emotional distress, significant dissatisfaction among family members, and negative patient judgment of how well we communicate.^4-6 These observations are particularly true in our increasingly elderly surgical population, in which both surgeons and anesthesiologists often feel unequal to the task of discussing concepts such as code status.^7,8

In our practice and in residency training, the preoperative clinic often is the location where patient/provider communication occurs. Here we consider the latest American College of Cardiology/American Heart Association guidelines, examine airways, review electrocardiograms, and formulate plans agreeable to and understood by our anxious patients and their families. The potent anxiolytic effect of a preoperative visit by an anesthesiologist is well established.⁹ Anxiety about surgery is a risk factor for impaired decision making before surgery.¹⁰ And surgery is traumatic—as many as 7.6% of postoperative patients experience symptoms consistent with PTSD attributable to the surgery, placing it on a par with being mugged (8.0%).^11,12

The patient in this case presented several communication challenges even absent his revelation of prior traumatic experience with anesthesia. He was elderly, anxious, and had multiple comorbidities. He had mild cognitive impairment and required a code status discussion. There also were the clinical challenges—navigating a 99-year-old with severe aortic stenosis and a right ventricular systolic pressure > 90 mm Hg through a general anesthetic gave me a sinking feeling.

He was fortunate that the procedure could be done with local anesthesia, mitigating his risk of cognitive dysfunction, including delirium. He also was fortunate in that his anesthesiologist and surgeon had created a collaborative, patient-first approach and that his US Department of Veterans Affairs (VA) clinic had the time, space, and staffing to accommodate an unexpected 90-minute visit. A big investment in communication, mainly my keeping quiet, made the intraoperative management simple. Such is life in an integrated health care system without financial incentives for high-volume care—and another reminder that VA physicians are blessed to guide patients through some of the most vulnerable and distressing moments of their lives.

Postscript

During the preparation of this manuscript, the patient passed away at the age of 100. His obituary was consistent with what I had learned about him and his family during our 2 encounters: a long successful career in local industry; extensive involvement in his community; an avid sportsman; and nearly 30 grandchildren, great-grandchildren, and great-great grandchildren. But there was one more detail that never came up during my extensive discussion with him and his daughters: He was awarded the Purple Heart for his service in World War II.

The patient grabbed my attention as I glanced through our clinic schedule. It was his age: He was 99 years old and scheduled for eye surgery. The plastic surgery resident’s note read: “Patient understands that this would involve surgery under general anesthesia and is agreeable to moving forward...Extremely high risk of anesthesia emphasized.”

I reviewed the patient’s history. At baseline, he had severe pulmonary hypertension, severe aortic stenosis (AS), diastolic heart failure, chronic atrial fibrillation, chronic kidney disease (estimated glomerular filtration rate of 26 mL/min [normal is > 60 mL/min]), anemia (hematocrit 26%), and a standing do not resuscitate (DNR) order. His maximal daily exercise was walking slowly across a room, primarily limited by joint pain. Recent geropsychiatry notes indicated mild cognitive impairment. The anesthesia record from an urgent hip fracture repair 7 months before under general anesthesia was unremarkable.

I phoned the attending plastic surgeon. Our conversation was as follows:

“Hi, I’m about to see a 99-year-old patient with a DNR who is scheduled for resection of an eyelid tumor. His medical history makes me nervous. Are you sure this is a good idea?”“Hmmm, 99-year-old…okay, that’s right,” he responded. “He has an invasive squamous that could become a big problem. The actual procedure is under 10 minutes. Waiting for the pathology report will be the longest part of the procedure.”

“Can it be done under local?” I asked.

“Yes,” he replied.

“Okay, I’ll talk to him and call you back.”

I found the patient in the waiting room, flanked by his 2 daughters and invited them into the clinic room. After introductions, I began asking whether they had any questions about the anesthesia. By midsentence a daughter was prompting him to discuss what happened “last time.” He described a history of posttraumatic stress disorder (PTSD) stemming from his hip surgery, which he blamed squarely on the anesthesia. His emotion was evident in the gathering pauses. “I hate that I am so emotional since they kept me awake during my surgery.”

Through the fog of multiple accounts, it became clear that he was traumatized by the loss of control during the administration of and emergence from the anesthesia.

“They told me it was only oxygen,” he said. “They lied. There was a taste to it…I was awake and skinned alive…They said I was a monster when I woke up thrashing.” He went on, explaining that in the recovery room “there were 2 people bothering me, man-handling me, asking me questions.”

One of his daughters showed me pictures of bruises on his face from ripping off the mask and pulling out the breathing tube. They were visibly upset by the memory of his postoperative combativeness and paranoia. The note written by the orthopedic surgery resident on the day after surgery stated succinctly, “Doing well, had some delirium from anesthesia overnight.” Subsequent geropsychiatry home visits attested to intrusive thoughts, flashbacks, and nightmares from his time as a combat soldier in World War II, 65 years in the past.

“It took me months…months to recover,” he said.

He was in the mood to reminisce, however, perhaps a willful distraction. He had the floor for at least 30 minutes, during which I spoke about 5 sentences. With every sad story he told there was a happy, humorous one, such as meeting his future wife while on leave in New Zealand during the war, recalled down to exact dates. And another story:
 

There we were in New Caledonia. All our supplies went out to replace what sank on [USS] Coolidge, including a lot of food. Well, there were deer on the island. So we took out a truck and a rifle and wouldn’t you know we came upon a roadblock in the form of a big steer. We figured it looked enough like a deer. My buddy shot it dead with one shot. We dressed it and loaded it into the jeep. Hardly before we even got back to the mess hall, the officers’ cook came sniffing around. He and our captain agreed it was easily the biggest deer they’d ever seen and appropriated it to the officers’ mess. Next day the CO [commanding officer] of the whole outfit came by and announced it was the best tasting ‘venison’ he’d ever had. I heard the farmer got paid a pretty penny for that steer. I didn’t get a damn bite.

He delivered this last bit with relish.

When the conversation returned to anesthesia, I read them the record of his hip fracture repair. I explained that on the face of it, the report seemed uneventful. One daughter asked astute questions about his awareness. I explained that although awareness during general anesthesia is possible, it seemed from the record, he’d had plenty of anesthesia during the case and that there is always less at the beginning and end, the periods that apparently had caused him distress. I also explained that most studies report the incidence of true awareness as at most 1 out of thousands of events and that he had none of the established risk factors for it, such as female gender, young age, chronic substance abuse, cardiac and obstetric surgery, and history of awareness.¹

The other daughter wondered why he was so agitated afterward. I recited data on the frequency of postoperative delirium in elderly patients but explained that the range is wide, depending on the study and population, from about 1% in elderly patients undergoing ambulatory surgery to 65% for open aortic surgery.^2,3 I added that their father had 2 of the strongest risk factors for delirium, advanced age and cognitive impairment.³ Only after airing each question about the hip surgery in detail were they ready to discuss the eye surgery.

He started that conversation with the right question: “Do I really need it?”

I quoted my surgical colleague’s concern. I told him that, should he opt to undergo the surgery, I was confident that this time around his experience would be different from the last.

“If you’re okay with it, all you need is some numbing medicine from the surgeon; you won’t need any anesthesia from me.”

I walked step-by-step through what they could expect on the day of surgery. Maintaining control was of obvious importance to him. He felt comfortable going forward. His daughters intuited that less would be more for a quick recovery.

We then addressed the DNR directive. I acknowledged his absolute right to self-determination and explained that the need for resuscitation is, at times, a consequence of the surgery and anesthesia. I reassured them that our plan made resuscitation and intubation highly unlikely. They also asked to use any interventions necessary to restart his heart if it should stop beating. I documented their decision in my notes and communicated it to the surgical team. We had talked for 90 minutes.

I met the patient and his daughters on the day of surgery in the preoperative holding area. I inserted an IV, applied electrocardiography leads, and affixed a pulse oximeter and a noninvasive blood pressure cuff. In the operating room (OR) we took time to place his 99-year-old joints into, as he said, the “least worst” position. He tolerated the injection of the local by the surgeon perfectly well. We were in the OR for 3 hours, during which he taught me a fair amount about boating and outboard engines among other things. Pathology reported clean margins. He was discharged home soon after and had an uneventful recovery.

Patient-First Approach

A core competency of the Accreditation Council for Graduate Medical Education for an anesthesia residency is the Interpersonal and Communication Skills program. A comprehensive discussion of communication is far beyond the scope here. But not surprisingly, deficient communication between physicians and patients can cause emotional distress, significant dissatisfaction among family members, and negative patient judgment of how well we communicate.^4-6 These observations are particularly true in our increasingly elderly surgical population, in which both surgeons and anesthesiologists often feel unequal to the task of discussing concepts such as code status.^7,8

In our practice and in residency training, the preoperative clinic often is the location where patient/provider communication occurs. Here we consider the latest American College of Cardiology/American Heart Association guidelines, examine airways, review electrocardiograms, and formulate plans agreeable to and understood by our anxious patients and their families. The potent anxiolytic effect of a preoperative visit by an anesthesiologist is well established.⁹ Anxiety about surgery is a risk factor for impaired decision making before surgery.¹⁰ And surgery is traumatic—as many as 7.6% of postoperative patients experience symptoms consistent with PTSD attributable to the surgery, placing it on a par with being mugged (8.0%).^11,12

The patient in this case presented several communication challenges even absent his revelation of prior traumatic experience with anesthesia. He was elderly, anxious, and had multiple comorbidities. He had mild cognitive impairment and required a code status discussion. There also were the clinical challenges—navigating a 99-year-old with severe aortic stenosis and a right ventricular systolic pressure > 90 mm Hg through a general anesthetic gave me a sinking feeling.

He was fortunate that the procedure could be done with local anesthesia, mitigating his risk of cognitive dysfunction, including delirium. He also was fortunate in that his anesthesiologist and surgeon had created a collaborative, patient-first approach and that his US Department of Veterans Affairs (VA) clinic had the time, space, and staffing to accommodate an unexpected 90-minute visit. A big investment in communication, mainly my keeping quiet, made the intraoperative management simple. Such is life in an integrated health care system without financial incentives for high-volume care—and another reminder that VA physicians are blessed to guide patients through some of the most vulnerable and distressing moments of their lives.

Postscript

During the preparation of this manuscript, the patient passed away at the age of 100. His obituary was consistent with what I had learned about him and his family during our 2 encounters: a long successful career in local industry; extensive involvement in his community; an avid sportsman; and nearly 30 grandchildren, great-grandchildren, and great-great grandchildren. But there was one more detail that never came up during my extensive discussion with him and his daughters: He was awarded the Purple Heart for his service in World War II.

There is probably no area where human contact is more important than in the area of counseling and psychotherapy. Or so most of us have thought. It turns out that, even in behavioral medicine, technology has made fantastic inroads in helping patients achieve real improvement in troublesome behavioral symptoms. There is good evidence that digital interfaces for cognitive behavioral therapy (CBT) can help in the treatment of anxiety and depression. We will not go over that evidence in this column, other than to say that the evidence is there, but rather we will review some of the best apps that those of us in primary care can utilize in the care of our patients. It is our opinion that these apps are best used in conjunction with our care to supplement the counseling we are giving our patients in the office. Many of the apps listed may be used for both anxiety and depression, as well as in areas related to problem solving, self-esteem, anger management, creating lifestyle changes, and coping with uncertainty.

MoodKit

MoodKit is a CBT app with four main tools: a collection of activities focused on coping self-efficacy (a person’s belief in success in specific situations) that includes individual productivity, social relationships, physical activity, and healthy habits; a thought checker; mood tracker; and journal. MoodKit is accessed in an unstructured way and can be used as an unguided self-help app. It is useful in patient interactions to access interventions in areas such as social engagement and options for choosing a healthy lifestyle. It is available in Apple’s App Store, and it costs $4.99.

Moodnotes

Based on CBT and positive psychology, Moodnotes assists in recognizing and learning about “traps” in thinking, as well as emphasizing healthier thinking habits. Traps in thinking include “catastrophic thinking” where patients with depression may think that a small error or behavioral indiscretion may lead to a consequence that far exceeds what is likely, or “mind-reading” where a person assumes that others are critical of them without actually having evidence that this is the case. Moodnotes tracks mood over a period of time while identifying factors that influence it. It is helpful in between visits to aid clinicians in gaining perspective on mood patterns. It is available in the App Store; it costs $4.99.

MoodMission

This app recommends strategies based in CBT after input of low moods or feelings of anxiety. MoodMission provides five “missions” to engage in that promote confidence in handling stressors and promotes coping self-efficacy. The app learns what style works best and tailors techniques according to when a patient uses it most frequently. Rewards in the app are used to promote motivation and to increase pleasure and self-confidence. It is useful for patients who could use a lift in mood or decrease in symptoms of anxiety and depression. It available in the App Store and Google Play, and it’s free.

What’s Up

In line with its development based on principles from CBT and Acceptance and Commitment Therapy (ACT), What’s Up identifies common negative thinking patterns and methods to overcome them with useful metaphors, a catastrophe scale, grounding techniques, and breathing exercises. What’s Up syncs data across multiple devices and uses a unique passcode to protect this information. One of the abilities that separates it from other apps is that it can become active in forums where people discuss similar feelings and strategies that have been useful for them. It is available in the App Store and Google Play, and it’s free.

Moodpath

Moodpath uses daily screenings to create better understanding of thoughts, feelings, and emotions. If needed, it provides a discussion guide to talking with a medical professional based on answers to its daily screenings. Included in the app are over 150 psychological exercises and videos to promote and strengthen overall mental health. It is useful in introducing how to discuss mental health with a professional. It is available in the App Store and Google Play free of cost.

MindShift CBT

Designed to assist youth and young adults in coping with anxiety, MindShift constructs an individualized toolbox to help individuals deal with test anxiety, perfectionism, social anxiety, worry, panic, and conflict. The app includes directions on how to construct “belief experiments” to test common beliefs that fuel anxiety, guided relaxation, as well as tools and tips to help set and accomplish goals. It is useful in helping teens and young adults learn about helpful and unhelpful anxiety, as well as to overcome fears by gradually facing them in manageable steps. It is available in the App Store and Google Play for free.

CBT-i Coach

CBT-i Coach, based on principles of cognitive behavioral therapy for insomnia (CBT-i), is a structured program to learn about sleep, develop positive sleep routines, and improve sleep environment. The CBT methods used attempt to change behaviors, which in turn provides confidence that patients will sleep better on a regular basis. It useful as a first-line intervention in treating symptoms of insomnia. It is available in the App Store and Google Play for no cost.

Getselfhelp.co.uk

This website provides free self-help and therapy resources grounded in methods that teach the change agents in CBT that can influence negative and destructive thought patterns. Negative thought patterns include thinking in terms of all or nothing: “Nothing ever works out for me,” fortune telling: “I shouldn’t even try,” and overgeneralization: “This didn’t work so this will not either.” Getselfhelp.co.uk provides handouts on a wide array of symptoms related to anxiety, depression, low self-esteem, panic attacks, social disorder, and more. The solution section of the website supplies interventions that can be printed and saved for future use. It is helpful for clinicians and patients in identifying an area of need and creating an action plan. It is also useful for clinicians to have as an augmented supplement for counseling and is free of cost.

The bottom line

When used correctly the resources that we have reviewed can essentially be deployed in a manner similar to how we use finger-stick blood sugar monitoring in the treatment of diabetes. Each of these technologies works best when combined with clinician input and periodic review. When used to supplement clinician counseling, the apps may help sustain motivation and provide insights and exercises that improve patient engagement and supplement the effect of counseling and/or medications that are prescribed in the office.

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.

There is probably no area where human contact is more important than in the area of counseling and psychotherapy. Or so most of us have thought. It turns out that, even in behavioral medicine, technology has made fantastic inroads in helping patients achieve real improvement in troublesome behavioral symptoms. There is good evidence that digital interfaces for cognitive behavioral therapy (CBT) can help in the treatment of anxiety and depression. We will not go over that evidence in this column, other than to say that the evidence is there, but rather we will review some of the best apps that those of us in primary care can utilize in the care of our patients. It is our opinion that these apps are best used in conjunction with our care to supplement the counseling we are giving our patients in the office. Many of the apps listed may be used for both anxiety and depression, as well as in areas related to problem solving, self-esteem, anger management, creating lifestyle changes, and coping with uncertainty.

MoodKit

MoodKit is a CBT app with four main tools: a collection of activities focused on coping self-efficacy (a person’s belief in success in specific situations) that includes individual productivity, social relationships, physical activity, and healthy habits; a thought checker; mood tracker; and journal. MoodKit is accessed in an unstructured way and can be used as an unguided self-help app. It is useful in patient interactions to access interventions in areas such as social engagement and options for choosing a healthy lifestyle. It is available in Apple’s App Store, and it costs $4.99.

Moodnotes

Based on CBT and positive psychology, Moodnotes assists in recognizing and learning about “traps” in thinking, as well as emphasizing healthier thinking habits. Traps in thinking include “catastrophic thinking” where patients with depression may think that a small error or behavioral indiscretion may lead to a consequence that far exceeds what is likely, or “mind-reading” where a person assumes that others are critical of them without actually having evidence that this is the case. Moodnotes tracks mood over a period of time while identifying factors that influence it. It is helpful in between visits to aid clinicians in gaining perspective on mood patterns. It is available in the App Store; it costs $4.99.

MoodMission

This app recommends strategies based in CBT after input of low moods or feelings of anxiety. MoodMission provides five “missions” to engage in that promote confidence in handling stressors and promotes coping self-efficacy. The app learns what style works best and tailors techniques according to when a patient uses it most frequently. Rewards in the app are used to promote motivation and to increase pleasure and self-confidence. It is useful for patients who could use a lift in mood or decrease in symptoms of anxiety and depression. It available in the App Store and Google Play, and it’s free.

What’s Up

In line with its development based on principles from CBT and Acceptance and Commitment Therapy (ACT), What’s Up identifies common negative thinking patterns and methods to overcome them with useful metaphors, a catastrophe scale, grounding techniques, and breathing exercises. What’s Up syncs data across multiple devices and uses a unique passcode to protect this information. One of the abilities that separates it from other apps is that it can become active in forums where people discuss similar feelings and strategies that have been useful for them. It is available in the App Store and Google Play, and it’s free.

Moodpath

Moodpath uses daily screenings to create better understanding of thoughts, feelings, and emotions. If needed, it provides a discussion guide to talking with a medical professional based on answers to its daily screenings. Included in the app are over 150 psychological exercises and videos to promote and strengthen overall mental health. It is useful in introducing how to discuss mental health with a professional. It is available in the App Store and Google Play free of cost.

MindShift CBT

Designed to assist youth and young adults in coping with anxiety, MindShift constructs an individualized toolbox to help individuals deal with test anxiety, perfectionism, social anxiety, worry, panic, and conflict. The app includes directions on how to construct “belief experiments” to test common beliefs that fuel anxiety, guided relaxation, as well as tools and tips to help set and accomplish goals. It is useful in helping teens and young adults learn about helpful and unhelpful anxiety, as well as to overcome fears by gradually facing them in manageable steps. It is available in the App Store and Google Play for free.

CBT-i Coach

CBT-i Coach, based on principles of cognitive behavioral therapy for insomnia (CBT-i), is a structured program to learn about sleep, develop positive sleep routines, and improve sleep environment. The CBT methods used attempt to change behaviors, which in turn provides confidence that patients will sleep better on a regular basis. It useful as a first-line intervention in treating symptoms of insomnia. It is available in the App Store and Google Play for no cost.

Getselfhelp.co.uk

This website provides free self-help and therapy resources grounded in methods that teach the change agents in CBT that can influence negative and destructive thought patterns. Negative thought patterns include thinking in terms of all or nothing: “Nothing ever works out for me,” fortune telling: “I shouldn’t even try,” and overgeneralization: “This didn’t work so this will not either.” Getselfhelp.co.uk provides handouts on a wide array of symptoms related to anxiety, depression, low self-esteem, panic attacks, social disorder, and more. The solution section of the website supplies interventions that can be printed and saved for future use. It is helpful for clinicians and patients in identifying an area of need and creating an action plan. It is also useful for clinicians to have as an augmented supplement for counseling and is free of cost.

The bottom line

When used correctly the resources that we have reviewed can essentially be deployed in a manner similar to how we use finger-stick blood sugar monitoring in the treatment of diabetes. Each of these technologies works best when combined with clinician input and periodic review. When used to supplement clinician counseling, the apps may help sustain motivation and provide insights and exercises that improve patient engagement and supplement the effect of counseling and/or medications that are prescribed in the office.

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.

There is probably no area where human contact is more important than in the area of counseling and psychotherapy. Or so most of us have thought. It turns out that, even in behavioral medicine, technology has made fantastic inroads in helping patients achieve real improvement in troublesome behavioral symptoms. There is good evidence that digital interfaces for cognitive behavioral therapy (CBT) can help in the treatment of anxiety and depression. We will not go over that evidence in this column, other than to say that the evidence is there, but rather we will review some of the best apps that those of us in primary care can utilize in the care of our patients. It is our opinion that these apps are best used in conjunction with our care to supplement the counseling we are giving our patients in the office. Many of the apps listed may be used for both anxiety and depression, as well as in areas related to problem solving, self-esteem, anger management, creating lifestyle changes, and coping with uncertainty.

MoodKit

MoodKit is a CBT app with four main tools: a collection of activities focused on coping self-efficacy (a person’s belief in success in specific situations) that includes individual productivity, social relationships, physical activity, and healthy habits; a thought checker; mood tracker; and journal. MoodKit is accessed in an unstructured way and can be used as an unguided self-help app. It is useful in patient interactions to access interventions in areas such as social engagement and options for choosing a healthy lifestyle. It is available in Apple’s App Store, and it costs $4.99.

Moodnotes

Based on CBT and positive psychology, Moodnotes assists in recognizing and learning about “traps” in thinking, as well as emphasizing healthier thinking habits. Traps in thinking include “catastrophic thinking” where patients with depression may think that a small error or behavioral indiscretion may lead to a consequence that far exceeds what is likely, or “mind-reading” where a person assumes that others are critical of them without actually having evidence that this is the case. Moodnotes tracks mood over a period of time while identifying factors that influence it. It is helpful in between visits to aid clinicians in gaining perspective on mood patterns. It is available in the App Store; it costs $4.99.

MoodMission

This app recommends strategies based in CBT after input of low moods or feelings of anxiety. MoodMission provides five “missions” to engage in that promote confidence in handling stressors and promotes coping self-efficacy. The app learns what style works best and tailors techniques according to when a patient uses it most frequently. Rewards in the app are used to promote motivation and to increase pleasure and self-confidence. It is useful for patients who could use a lift in mood or decrease in symptoms of anxiety and depression. It available in the App Store and Google Play, and it’s free.

What’s Up

In line with its development based on principles from CBT and Acceptance and Commitment Therapy (ACT), What’s Up identifies common negative thinking patterns and methods to overcome them with useful metaphors, a catastrophe scale, grounding techniques, and breathing exercises. What’s Up syncs data across multiple devices and uses a unique passcode to protect this information. One of the abilities that separates it from other apps is that it can become active in forums where people discuss similar feelings and strategies that have been useful for them. It is available in the App Store and Google Play, and it’s free.

Moodpath

Moodpath uses daily screenings to create better understanding of thoughts, feelings, and emotions. If needed, it provides a discussion guide to talking with a medical professional based on answers to its daily screenings. Included in the app are over 150 psychological exercises and videos to promote and strengthen overall mental health. It is useful in introducing how to discuss mental health with a professional. It is available in the App Store and Google Play free of cost.

MindShift CBT

Designed to assist youth and young adults in coping with anxiety, MindShift constructs an individualized toolbox to help individuals deal with test anxiety, perfectionism, social anxiety, worry, panic, and conflict. The app includes directions on how to construct “belief experiments” to test common beliefs that fuel anxiety, guided relaxation, as well as tools and tips to help set and accomplish goals. It is useful in helping teens and young adults learn about helpful and unhelpful anxiety, as well as to overcome fears by gradually facing them in manageable steps. It is available in the App Store and Google Play for free.

CBT-i Coach

CBT-i Coach, based on principles of cognitive behavioral therapy for insomnia (CBT-i), is a structured program to learn about sleep, develop positive sleep routines, and improve sleep environment. The CBT methods used attempt to change behaviors, which in turn provides confidence that patients will sleep better on a regular basis. It useful as a first-line intervention in treating symptoms of insomnia. It is available in the App Store and Google Play for no cost.

Getselfhelp.co.uk

This website provides free self-help and therapy resources grounded in methods that teach the change agents in CBT that can influence negative and destructive thought patterns. Negative thought patterns include thinking in terms of all or nothing: “Nothing ever works out for me,” fortune telling: “I shouldn’t even try,” and overgeneralization: “This didn’t work so this will not either.” Getselfhelp.co.uk provides handouts on a wide array of symptoms related to anxiety, depression, low self-esteem, panic attacks, social disorder, and more. The solution section of the website supplies interventions that can be printed and saved for future use. It is helpful for clinicians and patients in identifying an area of need and creating an action plan. It is also useful for clinicians to have as an augmented supplement for counseling and is free of cost.

The bottom line

When used correctly the resources that we have reviewed can essentially be deployed in a manner similar to how we use finger-stick blood sugar monitoring in the treatment of diabetes. Each of these technologies works best when combined with clinician input and periodic review. When used to supplement clinician counseling, the apps may help sustain motivation and provide insights and exercises that improve patient engagement and supplement the effect of counseling and/or medications that are prescribed in the office.

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.

In this edition of “How I will treat my next patient,” I take a look at two phase 2 trials in stage IV non–small cell lung cancer (NSCLC) patients that appeared recently in JAMA Oncology. One summarizes a trial in stage IV NSCLC with four or fewer sites of metastasis (oligometastatic disease or OM), in which pembrolizumab is added to locally ablative therapy (LAT). The other examines whether LAT potentiates the response to immuno-oncology (I/O) in distant sites that were unexposed to LAT.

©Sergey Nivens/thinkstockphotos

I/O added to LAT in OM-NSCLC

Joshua M. Bauml, MD, of the University of Pennsylvania, Philadelphia, and colleagues, published findings from a nonrandomized phase 2 trial in OM-NSCLC in which patients could receive LAT by any technique (JAMA Oncol. 2019 Jul 11. doi: 10.1001/jamaoncol.2019.1449). Patients could have synchronous or metachronous OM-NSCLC, any histology, and any PD-L1 tumor proportion score. Patients with more than four sites of metastatic disease that regressed to OM-NSCLC after prior therapy (i.e., “oligoremnant NSCLC”) were excluded.

They reported on 51 patients who received conventional-dose pembrolizumab for eight cycles after LAT. Patients without toxicity or progression were allowed to receive up to eight additional cycles of pembrolizumab. The median progression-free survival (PFS) was 19.1 months (95% confidence interval, 9.4-28.7 months), significantly longer than the historical comparison group (median PFS, 6.6 months; P = .005). Additionally, the 24-month overall survival (OS) was 77.5%. With respect to safety, no quality of life decrement or new safety signals were seen.
 

What this means in practice

As Dr. Bauml and colleagues suggest, there is strong theoretical rationale for believing that OM-NSCLC represents a special, potentially curable, population of stage IV NSCLC patients. Like the recently published work of Daniel R. Gomez, MD, of the University of Texas MD Anderson Cancer Center, Houston, and colleagues (J Clin Oncol. 2019 Jun 20;37[18]:1558-65), who studied LAT in comparison with consolidative/maintenance chemotherapy in a slightly different population of OM-NSCLC patients, the current trial moves clinical research forward.

Practically, this study has limitations that should temper a clinician’s enthusiasm for adopting the strategy of LAT, followed by I/O, as standard practice: small patient numbers, most with only one site of OM-NSCLC; comparison with historical controls; and no meaningful information about patient subsets who benefit from I/O and who do not. As the authors suggest, this study provides a strong rationale for a phase 3 trial with stratification for variables that could influence outcome. It does not inform clinical practice at the present time.
 

LAT added to I/O in stage IV NSCLC

We have limited ability to identify (the majority of) patients with metastatic NSCLC who will not benefit from I/O and no proven interventions to augment benefit in (the majority of) patients with low PD-L1 tumor proportion scores and/or low tumor mutation burden. However, the PEMBRO-RT study was designed to investigate whether LAT with stereotactic body radiation therapy (SBRT) could exploit the hypothesized increase in tumor antigen release and antigen presentation that could lead to better responses to I/O in untreated sites of disease among all patients with stage IV NSCLC.

As reported by Willemijn S.M.E. Theelen, MD, of the Netherlands Cancer Institute in Amsterdam and colleagues, the PEMBRO-RT study randomized 76 patients with stage IV NSCLC to pembro following SBRT to a single metastatic site (the experimental arm of the trial) or pembrolizumab alone. Pembrolizumab was given in a conventional dose and schedule in both arms of the trial and was administered within 7 days after SBRT on the experimental arm (JAMA Oncol. 2019 Jul 11. doi: 10.1001/jamaoncol.2019.1478).

The primary outcome was the overall response rate (ORR) at 12 weeks. Among patients on the experimental versus control arms, the ORR was 36% and 18%, respectively (P = .07). This did not meet the prespecified endpoint of improving ORR from 20% to 50% at 12 weeks. Additionally, although improved on the pembro plus SBRT arm of the trial, the median PFS and OS did not meet statistical criteria for improvement over the control arm, except among the 47 patients in the PD-L1 negative subset.

What this means in practice

There are a lot of potentially relevant variables in this small, randomized phase 2 study. As the authors discuss, if there is a dose and schedule of RT that facilitates antigen release and presentation and or an ideal latent period after radiotherapy that promotes an “abscopal effect” from I/O, it is unclear whether the ideal schema was used in the PEMBRO-RT trial.

At present, if a patient with stage IV NSCLC requires LAT for clinical reasons during I/O treatment, the patient can receive it safely, but without the expectation that the LAT will augment overall benefit from I/O. Additional preclinical work will need to help guide us about a rational way to design the next trial to test the concept of supra-additive benefit from these modalities. Not only is this combination “not ready for prime time” in clinical care, but it’s not ready for the large numbers of patients in a phase 3 clinical trial.
 

Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.

In this edition of “How I will treat my next patient,” I take a look at two phase 2 trials in stage IV non–small cell lung cancer (NSCLC) patients that appeared recently in JAMA Oncology. One summarizes a trial in stage IV NSCLC with four or fewer sites of metastasis (oligometastatic disease or OM), in which pembrolizumab is added to locally ablative therapy (LAT). The other examines whether LAT potentiates the response to immuno-oncology (I/O) in distant sites that were unexposed to LAT.

©Sergey Nivens/thinkstockphotos

I/O added to LAT in OM-NSCLC

Joshua M. Bauml, MD, of the University of Pennsylvania, Philadelphia, and colleagues, published findings from a nonrandomized phase 2 trial in OM-NSCLC in which patients could receive LAT by any technique (JAMA Oncol. 2019 Jul 11. doi: 10.1001/jamaoncol.2019.1449). Patients could have synchronous or metachronous OM-NSCLC, any histology, and any PD-L1 tumor proportion score. Patients with more than four sites of metastatic disease that regressed to OM-NSCLC after prior therapy (i.e., “oligoremnant NSCLC”) were excluded.

They reported on 51 patients who received conventional-dose pembrolizumab for eight cycles after LAT. Patients without toxicity or progression were allowed to receive up to eight additional cycles of pembrolizumab. The median progression-free survival (PFS) was 19.1 months (95% confidence interval, 9.4-28.7 months), significantly longer than the historical comparison group (median PFS, 6.6 months; P = .005). Additionally, the 24-month overall survival (OS) was 77.5%. With respect to safety, no quality of life decrement or new safety signals were seen.
 

What this means in practice

As Dr. Bauml and colleagues suggest, there is strong theoretical rationale for believing that OM-NSCLC represents a special, potentially curable, population of stage IV NSCLC patients. Like the recently published work of Daniel R. Gomez, MD, of the University of Texas MD Anderson Cancer Center, Houston, and colleagues (J Clin Oncol. 2019 Jun 20;37[18]:1558-65), who studied LAT in comparison with consolidative/maintenance chemotherapy in a slightly different population of OM-NSCLC patients, the current trial moves clinical research forward.

Practically, this study has limitations that should temper a clinician’s enthusiasm for adopting the strategy of LAT, followed by I/O, as standard practice: small patient numbers, most with only one site of OM-NSCLC; comparison with historical controls; and no meaningful information about patient subsets who benefit from I/O and who do not. As the authors suggest, this study provides a strong rationale for a phase 3 trial with stratification for variables that could influence outcome. It does not inform clinical practice at the present time.
 

LAT added to I/O in stage IV NSCLC

We have limited ability to identify (the majority of) patients with metastatic NSCLC who will not benefit from I/O and no proven interventions to augment benefit in (the majority of) patients with low PD-L1 tumor proportion scores and/or low tumor mutation burden. However, the PEMBRO-RT study was designed to investigate whether LAT with stereotactic body radiation therapy (SBRT) could exploit the hypothesized increase in tumor antigen release and antigen presentation that could lead to better responses to I/O in untreated sites of disease among all patients with stage IV NSCLC.

As reported by Willemijn S.M.E. Theelen, MD, of the Netherlands Cancer Institute in Amsterdam and colleagues, the PEMBRO-RT study randomized 76 patients with stage IV NSCLC to pembro following SBRT to a single metastatic site (the experimental arm of the trial) or pembrolizumab alone. Pembrolizumab was given in a conventional dose and schedule in both arms of the trial and was administered within 7 days after SBRT on the experimental arm (JAMA Oncol. 2019 Jul 11. doi: 10.1001/jamaoncol.2019.1478).

The primary outcome was the overall response rate (ORR) at 12 weeks. Among patients on the experimental versus control arms, the ORR was 36% and 18%, respectively (P = .07). This did not meet the prespecified endpoint of improving ORR from 20% to 50% at 12 weeks. Additionally, although improved on the pembro plus SBRT arm of the trial, the median PFS and OS did not meet statistical criteria for improvement over the control arm, except among the 47 patients in the PD-L1 negative subset.

What this means in practice

There are a lot of potentially relevant variables in this small, randomized phase 2 study. As the authors discuss, if there is a dose and schedule of RT that facilitates antigen release and presentation and or an ideal latent period after radiotherapy that promotes an “abscopal effect” from I/O, it is unclear whether the ideal schema was used in the PEMBRO-RT trial.

At present, if a patient with stage IV NSCLC requires LAT for clinical reasons during I/O treatment, the patient can receive it safely, but without the expectation that the LAT will augment overall benefit from I/O. Additional preclinical work will need to help guide us about a rational way to design the next trial to test the concept of supra-additive benefit from these modalities. Not only is this combination “not ready for prime time” in clinical care, but it’s not ready for the large numbers of patients in a phase 3 clinical trial.
 

Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.

In this edition of “How I will treat my next patient,” I take a look at two phase 2 trials in stage IV non–small cell lung cancer (NSCLC) patients that appeared recently in JAMA Oncology. One summarizes a trial in stage IV NSCLC with four or fewer sites of metastasis (oligometastatic disease or OM), in which pembrolizumab is added to locally ablative therapy (LAT). The other examines whether LAT potentiates the response to immuno-oncology (I/O) in distant sites that were unexposed to LAT.

©Sergey Nivens/thinkstockphotos

I/O added to LAT in OM-NSCLC

Joshua M. Bauml, MD, of the University of Pennsylvania, Philadelphia, and colleagues, published findings from a nonrandomized phase 2 trial in OM-NSCLC in which patients could receive LAT by any technique (JAMA Oncol. 2019 Jul 11. doi: 10.1001/jamaoncol.2019.1449). Patients could have synchronous or metachronous OM-NSCLC, any histology, and any PD-L1 tumor proportion score. Patients with more than four sites of metastatic disease that regressed to OM-NSCLC after prior therapy (i.e., “oligoremnant NSCLC”) were excluded.

They reported on 51 patients who received conventional-dose pembrolizumab for eight cycles after LAT. Patients without toxicity or progression were allowed to receive up to eight additional cycles of pembrolizumab. The median progression-free survival (PFS) was 19.1 months (95% confidence interval, 9.4-28.7 months), significantly longer than the historical comparison group (median PFS, 6.6 months; P = .005). Additionally, the 24-month overall survival (OS) was 77.5%. With respect to safety, no quality of life decrement or new safety signals were seen.
 

What this means in practice

As Dr. Bauml and colleagues suggest, there is strong theoretical rationale for believing that OM-NSCLC represents a special, potentially curable, population of stage IV NSCLC patients. Like the recently published work of Daniel R. Gomez, MD, of the University of Texas MD Anderson Cancer Center, Houston, and colleagues (J Clin Oncol. 2019 Jun 20;37[18]:1558-65), who studied LAT in comparison with consolidative/maintenance chemotherapy in a slightly different population of OM-NSCLC patients, the current trial moves clinical research forward.

Practically, this study has limitations that should temper a clinician’s enthusiasm for adopting the strategy of LAT, followed by I/O, as standard practice: small patient numbers, most with only one site of OM-NSCLC; comparison with historical controls; and no meaningful information about patient subsets who benefit from I/O and who do not. As the authors suggest, this study provides a strong rationale for a phase 3 trial with stratification for variables that could influence outcome. It does not inform clinical practice at the present time.
 

LAT added to I/O in stage IV NSCLC

We have limited ability to identify (the majority of) patients with metastatic NSCLC who will not benefit from I/O and no proven interventions to augment benefit in (the majority of) patients with low PD-L1 tumor proportion scores and/or low tumor mutation burden. However, the PEMBRO-RT study was designed to investigate whether LAT with stereotactic body radiation therapy (SBRT) could exploit the hypothesized increase in tumor antigen release and antigen presentation that could lead to better responses to I/O in untreated sites of disease among all patients with stage IV NSCLC.

As reported by Willemijn S.M.E. Theelen, MD, of the Netherlands Cancer Institute in Amsterdam and colleagues, the PEMBRO-RT study randomized 76 patients with stage IV NSCLC to pembro following SBRT to a single metastatic site (the experimental arm of the trial) or pembrolizumab alone. Pembrolizumab was given in a conventional dose and schedule in both arms of the trial and was administered within 7 days after SBRT on the experimental arm (JAMA Oncol. 2019 Jul 11. doi: 10.1001/jamaoncol.2019.1478).

The primary outcome was the overall response rate (ORR) at 12 weeks. Among patients on the experimental versus control arms, the ORR was 36% and 18%, respectively (P = .07). This did not meet the prespecified endpoint of improving ORR from 20% to 50% at 12 weeks. Additionally, although improved on the pembro plus SBRT arm of the trial, the median PFS and OS did not meet statistical criteria for improvement over the control arm, except among the 47 patients in the PD-L1 negative subset.

What this means in practice

There are a lot of potentially relevant variables in this small, randomized phase 2 study. As the authors discuss, if there is a dose and schedule of RT that facilitates antigen release and presentation and or an ideal latent period after radiotherapy that promotes an “abscopal effect” from I/O, it is unclear whether the ideal schema was used in the PEMBRO-RT trial.

At present, if a patient with stage IV NSCLC requires LAT for clinical reasons during I/O treatment, the patient can receive it safely, but without the expectation that the LAT will augment overall benefit from I/O. Additional preclinical work will need to help guide us about a rational way to design the next trial to test the concept of supra-additive benefit from these modalities. Not only is this combination “not ready for prime time” in clinical care, but it’s not ready for the large numbers of patients in a phase 3 clinical trial.
 

Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.

Mr. M wanted a second opinion. He was almost 80 years old and had been healthy his entire life. But recent abdominal discomfort prompted a CT scan, which prompted a biopsy. It appeared the tumor had started in his pancreas and then spread to the lymph nodes and the wall of his abdomen.

He asked his doctor to “give it to him straight,” and she did. She told him that it was incurable, but that chemotherapy might slow it down. He asked how long he had, and she said less than a year.

He wanted a straight answer, but that wasn’t the answer he wanted. Who would? So he did some reading and decided to come to a large academic hospital an hour away for a second opinion.

I interviewed him and then scrolled through his CT scans outside the room. There were a few things we could do, the attending and I discussed. We would send his tumor for genetic testing to see if there were any cancer mutations that could be targeted with drugs more specific than standard chemotherapy. We would also refer him to our cancer genetics clinic to get his blood tested for inherited mutations.

But mostly, all of that would likely turn up negative. Mostly, we agreed with his local oncologist.

We went back in the room. Explaining the genetic testing took the length of the visit because this is not a straightforward concept. We explained the difference between tumor mutations and inherited mutations. We wrote down a list of genetic variations we could discover. We discussed treatment options that could go along with each.

Do you have any questions?

He broke down. He reached for the tissue box sitting on the exam room table. “I feel so much better,” he said. “This is why I came here.” He felt safe, reassured, and hopeful.

I was happy to be helpful, but later, as I wrote my clinic note about him, I felt uneasy about the visit.

Everything we said was true. But somehow, it still felt as though we left him with an overly optimistic view of his illness. Did our emphasis on what could be done overshadow that it was unlikely to change the big picture? Did our in-depth discussion of slim possibilities mask that his prognosis was, in fact, still grim?

Working at a large academic medical center, I see many patients who come for a second opinion. I’m incredibly fortunate to learn at a place that is not just up to date in the most cutting-edge treatments but often leading in innovation.

And so we offer patients these options. They sound novel and exciting. They fill patients with hope because they fill the field with hope. I, too, get enraptured with the possibilities – circulating tumor DNA and clinical trials and targeted therapies.

At big cancer meetings every year, oncologists come together and speak about cancer therapies with enthusiasm and hope. Advances have exploded; it’s an exciting time to be learning and practicing.

And yet, the reality for many patients is very different. We are still discussing hospice after one line of chemotherapy has failed. We are still gently holding hands and saying that we have no more options to treat their aggressive cancers.

How can both of these worlds coexist? How can both be true?

A few years ago, a friend was diagnosed with a devastating neurologic condition. I went to a clinical trials website and typed in her disease. Immediately, hundreds of options popped up. I felt hopeful. The field is moving forward, I thought. There are options.

But in the exam room, there were none. When I asked about what I had read, the neurologist explained how many of these possibilities were being investigated. But in the end, my friend really had no good options.

After my visit with Mr. M, I thought about how commonly this story plays out in my field of hematology and oncology. Yes, there are instances in which we find a mutation that drastically changes management. It’s wonderful to witness: patients handed an ominous diagnosis and then living their normal lives, in remission or with stable disease, years later.

We all hope for that. But we rarely get it. The challenge comes when we spend 95% of a visit talking about something with a 1% chance of working. The numbers don’t add up – it’s an equation that easily results in false understanding. Cancer can be glossed with a veneer of innovative options, obscuring the reality that none are likely to work.

Weaving both truths into the conversation is a difficult skill, but one I decided to be more cognizant of after my encounter with Mr. M.

At our next visit, we were still waiting on the test results. But I decided to speak with him candidly. It’s important to have a plan B, I said, and asked what would be important to him if his time were limited. He nodded, thinking about this. “I’ve just been holding out hope for the mutation,” he admitted.

The next week his genetic testing came back negative, and he decided to get palliative chemotherapy closer to home. He had no reason to come to a large academic hospital anymore. With nothing special to offer him, I never saw him again.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.

Mr. M wanted a second opinion. He was almost 80 years old and had been healthy his entire life. But recent abdominal discomfort prompted a CT scan, which prompted a biopsy. It appeared the tumor had started in his pancreas and then spread to the lymph nodes and the wall of his abdomen.

He asked his doctor to “give it to him straight,” and she did. She told him that it was incurable, but that chemotherapy might slow it down. He asked how long he had, and she said less than a year.

He wanted a straight answer, but that wasn’t the answer he wanted. Who would? So he did some reading and decided to come to a large academic hospital an hour away for a second opinion.

I interviewed him and then scrolled through his CT scans outside the room. There were a few things we could do, the attending and I discussed. We would send his tumor for genetic testing to see if there were any cancer mutations that could be targeted with drugs more specific than standard chemotherapy. We would also refer him to our cancer genetics clinic to get his blood tested for inherited mutations.

But mostly, all of that would likely turn up negative. Mostly, we agreed with his local oncologist.

We went back in the room. Explaining the genetic testing took the length of the visit because this is not a straightforward concept. We explained the difference between tumor mutations and inherited mutations. We wrote down a list of genetic variations we could discover. We discussed treatment options that could go along with each.

Do you have any questions?

He broke down. He reached for the tissue box sitting on the exam room table. “I feel so much better,” he said. “This is why I came here.” He felt safe, reassured, and hopeful.

I was happy to be helpful, but later, as I wrote my clinic note about him, I felt uneasy about the visit.

Everything we said was true. But somehow, it still felt as though we left him with an overly optimistic view of his illness. Did our emphasis on what could be done overshadow that it was unlikely to change the big picture? Did our in-depth discussion of slim possibilities mask that his prognosis was, in fact, still grim?

Working at a large academic medical center, I see many patients who come for a second opinion. I’m incredibly fortunate to learn at a place that is not just up to date in the most cutting-edge treatments but often leading in innovation.

And so we offer patients these options. They sound novel and exciting. They fill patients with hope because they fill the field with hope. I, too, get enraptured with the possibilities – circulating tumor DNA and clinical trials and targeted therapies.

At big cancer meetings every year, oncologists come together and speak about cancer therapies with enthusiasm and hope. Advances have exploded; it’s an exciting time to be learning and practicing.

And yet, the reality for many patients is very different. We are still discussing hospice after one line of chemotherapy has failed. We are still gently holding hands and saying that we have no more options to treat their aggressive cancers.

How can both of these worlds coexist? How can both be true?

A few years ago, a friend was diagnosed with a devastating neurologic condition. I went to a clinical trials website and typed in her disease. Immediately, hundreds of options popped up. I felt hopeful. The field is moving forward, I thought. There are options.

But in the exam room, there were none. When I asked about what I had read, the neurologist explained how many of these possibilities were being investigated. But in the end, my friend really had no good options.

After my visit with Mr. M, I thought about how commonly this story plays out in my field of hematology and oncology. Yes, there are instances in which we find a mutation that drastically changes management. It’s wonderful to witness: patients handed an ominous diagnosis and then living their normal lives, in remission or with stable disease, years later.

We all hope for that. But we rarely get it. The challenge comes when we spend 95% of a visit talking about something with a 1% chance of working. The numbers don’t add up – it’s an equation that easily results in false understanding. Cancer can be glossed with a veneer of innovative options, obscuring the reality that none are likely to work.

Weaving both truths into the conversation is a difficult skill, but one I decided to be more cognizant of after my encounter with Mr. M.

At our next visit, we were still waiting on the test results. But I decided to speak with him candidly. It’s important to have a plan B, I said, and asked what would be important to him if his time were limited. He nodded, thinking about this. “I’ve just been holding out hope for the mutation,” he admitted.

The next week his genetic testing came back negative, and he decided to get palliative chemotherapy closer to home. He had no reason to come to a large academic hospital anymore. With nothing special to offer him, I never saw him again.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.

Mr. M wanted a second opinion. He was almost 80 years old and had been healthy his entire life. But recent abdominal discomfort prompted a CT scan, which prompted a biopsy. It appeared the tumor had started in his pancreas and then spread to the lymph nodes and the wall of his abdomen.

He asked his doctor to “give it to him straight,” and she did. She told him that it was incurable, but that chemotherapy might slow it down. He asked how long he had, and she said less than a year.

He wanted a straight answer, but that wasn’t the answer he wanted. Who would? So he did some reading and decided to come to a large academic hospital an hour away for a second opinion.

I interviewed him and then scrolled through his CT scans outside the room. There were a few things we could do, the attending and I discussed. We would send his tumor for genetic testing to see if there were any cancer mutations that could be targeted with drugs more specific than standard chemotherapy. We would also refer him to our cancer genetics clinic to get his blood tested for inherited mutations.

But mostly, all of that would likely turn up negative. Mostly, we agreed with his local oncologist.

We went back in the room. Explaining the genetic testing took the length of the visit because this is not a straightforward concept. We explained the difference between tumor mutations and inherited mutations. We wrote down a list of genetic variations we could discover. We discussed treatment options that could go along with each.

Do you have any questions?

He broke down. He reached for the tissue box sitting on the exam room table. “I feel so much better,” he said. “This is why I came here.” He felt safe, reassured, and hopeful.

I was happy to be helpful, but later, as I wrote my clinic note about him, I felt uneasy about the visit.

Everything we said was true. But somehow, it still felt as though we left him with an overly optimistic view of his illness. Did our emphasis on what could be done overshadow that it was unlikely to change the big picture? Did our in-depth discussion of slim possibilities mask that his prognosis was, in fact, still grim?

Working at a large academic medical center, I see many patients who come for a second opinion. I’m incredibly fortunate to learn at a place that is not just up to date in the most cutting-edge treatments but often leading in innovation.

And so we offer patients these options. They sound novel and exciting. They fill patients with hope because they fill the field with hope. I, too, get enraptured with the possibilities – circulating tumor DNA and clinical trials and targeted therapies.

At big cancer meetings every year, oncologists come together and speak about cancer therapies with enthusiasm and hope. Advances have exploded; it’s an exciting time to be learning and practicing.

And yet, the reality for many patients is very different. We are still discussing hospice after one line of chemotherapy has failed. We are still gently holding hands and saying that we have no more options to treat their aggressive cancers.

How can both of these worlds coexist? How can both be true?

A few years ago, a friend was diagnosed with a devastating neurologic condition. I went to a clinical trials website and typed in her disease. Immediately, hundreds of options popped up. I felt hopeful. The field is moving forward, I thought. There are options.

But in the exam room, there were none. When I asked about what I had read, the neurologist explained how many of these possibilities were being investigated. But in the end, my friend really had no good options.

After my visit with Mr. M, I thought about how commonly this story plays out in my field of hematology and oncology. Yes, there are instances in which we find a mutation that drastically changes management. It’s wonderful to witness: patients handed an ominous diagnosis and then living their normal lives, in remission or with stable disease, years later.

We all hope for that. But we rarely get it. The challenge comes when we spend 95% of a visit talking about something with a 1% chance of working. The numbers don’t add up – it’s an equation that easily results in false understanding. Cancer can be glossed with a veneer of innovative options, obscuring the reality that none are likely to work.

Weaving both truths into the conversation is a difficult skill, but one I decided to be more cognizant of after my encounter with Mr. M.

At our next visit, we were still waiting on the test results. But I decided to speak with him candidly. It’s important to have a plan B, I said, and asked what would be important to him if his time were limited. He nodded, thinking about this. “I’ve just been holding out hope for the mutation,” he admitted.

The next week his genetic testing came back negative, and he decided to get palliative chemotherapy closer to home. He had no reason to come to a large academic hospital anymore. With nothing special to offer him, I never saw him again.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.

Narcissism has an evil reputation. But is it justified? A modicum of narcissism is actually healthy. It can bolster self-confidence, assertiveness, and success in business and in the sociobiology of mating. Perhaps that’s why narcissism as a trait has a survival value from an evolutionary perspective.

Taking an excessive number of “selfies” with a smartphone is probably the most common and relatively benign form of mild narcissism (and not in DSM-5, yet). Narcissistic personality disorder (NPD), with a prevalence of 1%, is on the extreme end of the narcissism continuum. It has become tainted with such an intensely negative halo that it has become a despised trait, an insult, and even a vile epithet, like a 4-letter word. But as psychiatrists and other mental health professionals, we clinically relate to patients with NPD as being afflicted with a serious neuropsychiatric disorder, not as despicable individuals. Many people outside the mental health profession abhor persons with NPD because of their gargantuan hubris, insufferable selfishness, self-aggrandizement, emotional abuse of others, and irremediable vanity. Narcissistic personality disorder deprives its sufferers of the prosocial capacity for empathy, which leads them to belittle others or treat competent individuals with disdain, never as equals. They also seem to be incapable of experiencing shame as they inflate their self-importance and megalomania at the expense of those they degrade. They cannot tolerate any success by others because it threatens to overshadow their own exaggerated achievements. They can be mercilessly harsh towards their underlings. They are incapable of fostering warm, long-term loving relationships, where bidirectional respect is essential. Their lives often are replete with brief, broken-up relationships because they emotionally, physically, or sexually abuse their intimate partners.

Primary NPD has been shown in twin studies to be highly genetic, and more strongly heritable than 17 other personality dimensions.¹ It is also resistant to any effective psychotherapeutic, pharmacologic, or somatic treatments. This is particularly relevant given the proclivity of individuals with NPD to experience a crushing disappointment, commonly known as “narcissistic injury,” following a real or imagined failure. This could lead to a painful depression or an outburst of “narcissistic rage” directed at anyone perceived as undermining them, and may even lead to violent behavior.²

Apart from heritable narcissism, there is also another form of narcissism that can develop in some individuals following life events. That hazardous condition, known as “acquired narcissism,” is most often associated with achieving the coveted status of an exalted celebrity. At risk for this acquired personality affliction are famous actors, singers, movie directors, TV anchors, or politicians (although some politicians are natural-born narcissists, driven to seek the powers of public office), and less frequently physicians (perhaps because the practice of medicine is not done in front of spectators) or scientists (because research, no matter how momentous, rarely procures the glamour or public adulation of the entertainment industry). The ardent fans of those “celebs” shower them with such intense attention and adulation that it malignantly transforms previously “normal” individuals into narcissists who start believing they are indeed “very special” and superior to the rest of us mortals (especially as their earning power balloons into the millions after growing up with humble social or economic roots).

Social media has become a catalyst for acquired narcissism, with millions of followers on Twitter, Facebook, or YouTube. Cable TV also caters to politicians, some of whom morph into narcissists, intoxicated with their newfound eminence and stature among their partisan followers, and become genuinely convinced that they have supreme power or influence over the masses. They get carried away with their own exaggerated self-importance as oracles of the “truth,” regardless of how extreme their views may be. Celebrity, politics, social media, and cable TV have converged into a combustible mix, a crucible for acquired narcissism.

An interesting feature of acquired narcissism is “collective narcissism,” in which celebrities coalesce to consolidate their imagined superhuman attributes that go beyond the technical skills of their professions such as acting, singing, sports, or politics. Thus, entertainers or star athletes believe they can enunciate radical statements about contemporary social, political, or environmental issues (at both ends of the debate) as though their artistic success renders them wise arbiters of the truth. What complicates matters is their delirious fans, who revere and mimic whatever their idols say (and their fashion or their tattoos), which further intensifies the grandiosity and megalomania of acquired narcissism. Celebrity triggers mindless idolatry, fueling the narcissism of individuals who are blessed (or cursed?) with runaway personal success. Neuroscientists should conduct research into how the brain is neurobiologically altered by fame, but there are many more urgent questions that demand their attention. It would be important to know if it is reversible or enduring, even as fame inevitably dims.

Continue to: The pursuit of wealth and fame...

The pursuit of wealth and fame is widely prevalent and can be healthy if it is not all-consuming. But if achieved beyond the aspirer’s wildest dreams, he/she may reach an inflection point conducive to a pathologic degree of acquired narcissism. That’s what the French refer to as “les risques du métier” (ie, occupational hazard). I recall reading about celebrities who became enraged when a policeman “dared” to stop their car for some driving violation, confronting the officer with “Do you know who I am?” That question may be a clinical biomarker of acquired narcissism.

Interestingly, several years ago, when the American Psychiatry Association last revised the DSM—sometimes referred to as the “bible” of psychiatric nosology—it came close to dropping NPD from its listed disorders, but then reverted and kept it as one of the 275 diagnostic categories included in DSM-5.³ Had the NPD diagnosis been discarded, one wonders if the mythical god of narcissism would have suffered a transcendental “narcissistic injury”…

Narcissism has an evil reputation. But is it justified? A modicum of narcissism is actually healthy. It can bolster self-confidence, assertiveness, and success in business and in the sociobiology of mating. Perhaps that’s why narcissism as a trait has a survival value from an evolutionary perspective.

Taking an excessive number of “selfies” with a smartphone is probably the most common and relatively benign form of mild narcissism (and not in DSM-5, yet). Narcissistic personality disorder (NPD), with a prevalence of 1%, is on the extreme end of the narcissism continuum. It has become tainted with such an intensely negative halo that it has become a despised trait, an insult, and even a vile epithet, like a 4-letter word. But as psychiatrists and other mental health professionals, we clinically relate to patients with NPD as being afflicted with a serious neuropsychiatric disorder, not as despicable individuals. Many people outside the mental health profession abhor persons with NPD because of their gargantuan hubris, insufferable selfishness, self-aggrandizement, emotional abuse of others, and irremediable vanity. Narcissistic personality disorder deprives its sufferers of the prosocial capacity for empathy, which leads them to belittle others or treat competent individuals with disdain, never as equals. They also seem to be incapable of experiencing shame as they inflate their self-importance and megalomania at the expense of those they degrade. They cannot tolerate any success by others because it threatens to overshadow their own exaggerated achievements. They can be mercilessly harsh towards their underlings. They are incapable of fostering warm, long-term loving relationships, where bidirectional respect is essential. Their lives often are replete with brief, broken-up relationships because they emotionally, physically, or sexually abuse their intimate partners.

Primary NPD has been shown in twin studies to be highly genetic, and more strongly heritable than 17 other personality dimensions.¹ It is also resistant to any effective psychotherapeutic, pharmacologic, or somatic treatments. This is particularly relevant given the proclivity of individuals with NPD to experience a crushing disappointment, commonly known as “narcissistic injury,” following a real or imagined failure. This could lead to a painful depression or an outburst of “narcissistic rage” directed at anyone perceived as undermining them, and may even lead to violent behavior.²

Apart from heritable narcissism, there is also another form of narcissism that can develop in some individuals following life events. That hazardous condition, known as “acquired narcissism,” is most often associated with achieving the coveted status of an exalted celebrity. At risk for this acquired personality affliction are famous actors, singers, movie directors, TV anchors, or politicians (although some politicians are natural-born narcissists, driven to seek the powers of public office), and less frequently physicians (perhaps because the practice of medicine is not done in front of spectators) or scientists (because research, no matter how momentous, rarely procures the glamour or public adulation of the entertainment industry). The ardent fans of those “celebs” shower them with such intense attention and adulation that it malignantly transforms previously “normal” individuals into narcissists who start believing they are indeed “very special” and superior to the rest of us mortals (especially as their earning power balloons into the millions after growing up with humble social or economic roots).

Social media has become a catalyst for acquired narcissism, with millions of followers on Twitter, Facebook, or YouTube. Cable TV also caters to politicians, some of whom morph into narcissists, intoxicated with their newfound eminence and stature among their partisan followers, and become genuinely convinced that they have supreme power or influence over the masses. They get carried away with their own exaggerated self-importance as oracles of the “truth,” regardless of how extreme their views may be. Celebrity, politics, social media, and cable TV have converged into a combustible mix, a crucible for acquired narcissism.

An interesting feature of acquired narcissism is “collective narcissism,” in which celebrities coalesce to consolidate their imagined superhuman attributes that go beyond the technical skills of their professions such as acting, singing, sports, or politics. Thus, entertainers or star athletes believe they can enunciate radical statements about contemporary social, political, or environmental issues (at both ends of the debate) as though their artistic success renders them wise arbiters of the truth. What complicates matters is their delirious fans, who revere and mimic whatever their idols say (and their fashion or their tattoos), which further intensifies the grandiosity and megalomania of acquired narcissism. Celebrity triggers mindless idolatry, fueling the narcissism of individuals who are blessed (or cursed?) with runaway personal success. Neuroscientists should conduct research into how the brain is neurobiologically altered by fame, but there are many more urgent questions that demand their attention. It would be important to know if it is reversible or enduring, even as fame inevitably dims.

Continue to: The pursuit of wealth and fame...

The pursuit of wealth and fame is widely prevalent and can be healthy if it is not all-consuming. But if achieved beyond the aspirer’s wildest dreams, he/she may reach an inflection point conducive to a pathologic degree of acquired narcissism. That’s what the French refer to as “les risques du métier” (ie, occupational hazard). I recall reading about celebrities who became enraged when a policeman “dared” to stop their car for some driving violation, confronting the officer with “Do you know who I am?” That question may be a clinical biomarker of acquired narcissism.

Interestingly, several years ago, when the American Psychiatry Association last revised the DSM—sometimes referred to as the “bible” of psychiatric nosology—it came close to dropping NPD from its listed disorders, but then reverted and kept it as one of the 275 diagnostic categories included in DSM-5.³ Had the NPD diagnosis been discarded, one wonders if the mythical god of narcissism would have suffered a transcendental “narcissistic injury”…

Narcissism has an evil reputation. But is it justified? A modicum of narcissism is actually healthy. It can bolster self-confidence, assertiveness, and success in business and in the sociobiology of mating. Perhaps that’s why narcissism as a trait has a survival value from an evolutionary perspective.

Taking an excessive number of “selfies” with a smartphone is probably the most common and relatively benign form of mild narcissism (and not in DSM-5, yet). Narcissistic personality disorder (NPD), with a prevalence of 1%, is on the extreme end of the narcissism continuum. It has become tainted with such an intensely negative halo that it has become a despised trait, an insult, and even a vile epithet, like a 4-letter word. But as psychiatrists and other mental health professionals, we clinically relate to patients with NPD as being afflicted with a serious neuropsychiatric disorder, not as despicable individuals. Many people outside the mental health profession abhor persons with NPD because of their gargantuan hubris, insufferable selfishness, self-aggrandizement, emotional abuse of others, and irremediable vanity. Narcissistic personality disorder deprives its sufferers of the prosocial capacity for empathy, which leads them to belittle others or treat competent individuals with disdain, never as equals. They also seem to be incapable of experiencing shame as they inflate their self-importance and megalomania at the expense of those they degrade. They cannot tolerate any success by others because it threatens to overshadow their own exaggerated achievements. They can be mercilessly harsh towards their underlings. They are incapable of fostering warm, long-term loving relationships, where bidirectional respect is essential. Their lives often are replete with brief, broken-up relationships because they emotionally, physically, or sexually abuse their intimate partners.

Primary NPD has been shown in twin studies to be highly genetic, and more strongly heritable than 17 other personality dimensions.¹ It is also resistant to any effective psychotherapeutic, pharmacologic, or somatic treatments. This is particularly relevant given the proclivity of individuals with NPD to experience a crushing disappointment, commonly known as “narcissistic injury,” following a real or imagined failure. This could lead to a painful depression or an outburst of “narcissistic rage” directed at anyone perceived as undermining them, and may even lead to violent behavior.²

Apart from heritable narcissism, there is also another form of narcissism that can develop in some individuals following life events. That hazardous condition, known as “acquired narcissism,” is most often associated with achieving the coveted status of an exalted celebrity. At risk for this acquired personality affliction are famous actors, singers, movie directors, TV anchors, or politicians (although some politicians are natural-born narcissists, driven to seek the powers of public office), and less frequently physicians (perhaps because the practice of medicine is not done in front of spectators) or scientists (because research, no matter how momentous, rarely procures the glamour or public adulation of the entertainment industry). The ardent fans of those “celebs” shower them with such intense attention and adulation that it malignantly transforms previously “normal” individuals into narcissists who start believing they are indeed “very special” and superior to the rest of us mortals (especially as their earning power balloons into the millions after growing up with humble social or economic roots).

Social media has become a catalyst for acquired narcissism, with millions of followers on Twitter, Facebook, or YouTube. Cable TV also caters to politicians, some of whom morph into narcissists, intoxicated with their newfound eminence and stature among their partisan followers, and become genuinely convinced that they have supreme power or influence over the masses. They get carried away with their own exaggerated self-importance as oracles of the “truth,” regardless of how extreme their views may be. Celebrity, politics, social media, and cable TV have converged into a combustible mix, a crucible for acquired narcissism.

An interesting feature of acquired narcissism is “collective narcissism,” in which celebrities coalesce to consolidate their imagined superhuman attributes that go beyond the technical skills of their professions such as acting, singing, sports, or politics. Thus, entertainers or star athletes believe they can enunciate radical statements about contemporary social, political, or environmental issues (at both ends of the debate) as though their artistic success renders them wise arbiters of the truth. What complicates matters is their delirious fans, who revere and mimic whatever their idols say (and their fashion or their tattoos), which further intensifies the grandiosity and megalomania of acquired narcissism. Celebrity triggers mindless idolatry, fueling the narcissism of individuals who are blessed (or cursed?) with runaway personal success. Neuroscientists should conduct research into how the brain is neurobiologically altered by fame, but there are many more urgent questions that demand their attention. It would be important to know if it is reversible or enduring, even as fame inevitably dims.

Continue to: The pursuit of wealth and fame...

The pursuit of wealth and fame is widely prevalent and can be healthy if it is not all-consuming. But if achieved beyond the aspirer’s wildest dreams, he/she may reach an inflection point conducive to a pathologic degree of acquired narcissism. That’s what the French refer to as “les risques du métier” (ie, occupational hazard). I recall reading about celebrities who became enraged when a policeman “dared” to stop their car for some driving violation, confronting the officer with “Do you know who I am?” That question may be a clinical biomarker of acquired narcissism.

Interestingly, several years ago, when the American Psychiatry Association last revised the DSM—sometimes referred to as the “bible” of psychiatric nosology—it came close to dropping NPD from its listed disorders, but then reverted and kept it as one of the 275 diagnostic categories included in DSM-5.³ Had the NPD diagnosis been discarded, one wonders if the mythical god of narcissism would have suffered a transcendental “narcissistic injury”…

I strongly disagree with the editorial by Ahmed A. Aboraya, MD, DrPH, and Henry A. Nasrallah, MD, (“It’s time to implement measurement-based care in psychiatric practice,” From the Editor, Current Psychiatry. June 2019, p. 6-8). I am 76 years old and recently retired. I have seen many attempts to “objectify” medicine. These have all failed, but each has taken a piece of medicine with it to the grave.

We do not have much more to lose before it’s a checklist, vital signs, and a script. I now refer to our profession as “McMedicine.” If you don’t have what is on the menu, you cannot get served. Diseases are rarely treated, symptoms are treated. This is not the profession of medicine. We are not fixing much; we are mostly providing consumers for pharmaceutical companies.

Few psychiatric disorders have been subjected to more measurement than depression. Quite a while ago, someone tried to compare depression scales. They correlated scale scores with the results of evaluations by board-certified psychiatrists. The best scale was a single question: “Are you depressed?” This had been included as a control. Can you do better?

Furthermore, the “paper and numbers” people can’t wait to get an “objective” wrench to tighten the screws and apply the principles of the industrial revolution to squeeze more money out of the system. They will find some way to turn patients into standardized products.

John L. Schenkel, MD
Retired psychiatrist
Peru, NY

I disagree with Drs. Aboraya and Nasrallah regarding implementing rating scales in psychiatry. Frankly, medicine has become awash in details—mounds and mounds of details.

With the use of an electronic medical record, what should be a simple 1-page note is transformed into a 5-page note of details. Doctors no longer attend to their patients but rather to their computers. Has this raised consciousness—the most important metric, according to Dr. David Hawkins? I doubt it.

In the words of my great professor, Dr. James Gustafson, I will continue to start my interview with what concerns the patient. Most of the time, they implicitly know.

Our focus should instead be on bringing down the cost of health care. This is what angers our patients most, and yet we do not make it a priority.

Mike Primc, MD
Psychiatrist
Glenbeigh Hospital
Rock Creek, Ohio
Signature Health
Ashtabula, Ohio
Behavioral Wellness Group
Mentor, Ohio

Continue to: The authors respond

We appreciate Drs. Schenkel’s and Primc’s comments on our editorial regarding measurement-based care (MBC). However, MBC will not increase the workload of psychiatrists; rather, it will streamline the evaluation of patients and measure the severity of their symptoms or adverse effects as well as the degree of their improvement. The proper use of scales with the appropriate patient populations may actually help clinicians to reduce the extensive amount of details that go into medical records.

The following quote, an excerpt from another article we wrote on MBC,¹ speaks to Dr. Primc’s concerns:

“…measures in psychiatry could be considered the equivalent of a thermometer and a stethoscope to a physician. No measure, scale, or diagnostic interview will ever replace a seasoned, experienced clinician who has been evaluating and treating real patients for years. MBC is not intended to replace clinical judgment and cannot substitute for an observant and caring clinician. Just as thermometers, stethoscopes, and lab tests help other types of physicians reach accurate diagnoses and provide appropriate management, the use of MBC by psychiatrists has the potential to improve the accuracy of diagnoses and improve the outcomes of care.”

Ahmed A. Aboraya, MD, DrPH
Assistant Professor
Department of Behavioral Medicine and Psychiatry
Chief of Psychiatry
Sharpe Hospital West Virginia University
Weston, West Virginia

Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri

Reference
1. Aboraya A, Nasrallah HA, Elswick DE, et al. Measurement-based care in psychiatry-past, present, and future. Innov Clin Neurosci. 2018;15(11-12):13-26.

I strongly disagree with the editorial by Ahmed A. Aboraya, MD, DrPH, and Henry A. Nasrallah, MD, (“It’s time to implement measurement-based care in psychiatric practice,” From the Editor, Current Psychiatry. June 2019, p. 6-8). I am 76 years old and recently retired. I have seen many attempts to “objectify” medicine. These have all failed, but each has taken a piece of medicine with it to the grave.

We do not have much more to lose before it’s a checklist, vital signs, and a script. I now refer to our profession as “McMedicine.” If you don’t have what is on the menu, you cannot get served. Diseases are rarely treated, symptoms are treated. This is not the profession of medicine. We are not fixing much; we are mostly providing consumers for pharmaceutical companies.

Few psychiatric disorders have been subjected to more measurement than depression. Quite a while ago, someone tried to compare depression scales. They correlated scale scores with the results of evaluations by board-certified psychiatrists. The best scale was a single question: “Are you depressed?” This had been included as a control. Can you do better?

Furthermore, the “paper and numbers” people can’t wait to get an “objective” wrench to tighten the screws and apply the principles of the industrial revolution to squeeze more money out of the system. They will find some way to turn patients into standardized products.

John L. Schenkel, MD
Retired psychiatrist
Peru, NY

I disagree with Drs. Aboraya and Nasrallah regarding implementing rating scales in psychiatry. Frankly, medicine has become awash in details—mounds and mounds of details.

With the use of an electronic medical record, what should be a simple 1-page note is transformed into a 5-page note of details. Doctors no longer attend to their patients but rather to their computers. Has this raised consciousness—the most important metric, according to Dr. David Hawkins? I doubt it.

In the words of my great professor, Dr. James Gustafson, I will continue to start my interview with what concerns the patient. Most of the time, they implicitly know.

Our focus should instead be on bringing down the cost of health care. This is what angers our patients most, and yet we do not make it a priority.

Mike Primc, MD
Psychiatrist
Glenbeigh Hospital
Rock Creek, Ohio
Signature Health
Ashtabula, Ohio
Behavioral Wellness Group
Mentor, Ohio

Continue to: The authors respond

We appreciate Drs. Schenkel’s and Primc’s comments on our editorial regarding measurement-based care (MBC). However, MBC will not increase the workload of psychiatrists; rather, it will streamline the evaluation of patients and measure the severity of their symptoms or adverse effects as well as the degree of their improvement. The proper use of scales with the appropriate patient populations may actually help clinicians to reduce the extensive amount of details that go into medical records.

The following quote, an excerpt from another article we wrote on MBC,¹ speaks to Dr. Primc’s concerns:

“…measures in psychiatry could be considered the equivalent of a thermometer and a stethoscope to a physician. No measure, scale, or diagnostic interview will ever replace a seasoned, experienced clinician who has been evaluating and treating real patients for years. MBC is not intended to replace clinical judgment and cannot substitute for an observant and caring clinician. Just as thermometers, stethoscopes, and lab tests help other types of physicians reach accurate diagnoses and provide appropriate management, the use of MBC by psychiatrists has the potential to improve the accuracy of diagnoses and improve the outcomes of care.”

Ahmed A. Aboraya, MD, DrPH
Assistant Professor
Department of Behavioral Medicine and Psychiatry
Chief of Psychiatry
Sharpe Hospital West Virginia University
Weston, West Virginia

Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri

Reference
1. Aboraya A, Nasrallah HA, Elswick DE, et al. Measurement-based care in psychiatry-past, present, and future. Innov Clin Neurosci. 2018;15(11-12):13-26.

I strongly disagree with the editorial by Ahmed A. Aboraya, MD, DrPH, and Henry A. Nasrallah, MD, (“It’s time to implement measurement-based care in psychiatric practice,” From the Editor, Current Psychiatry. June 2019, p. 6-8). I am 76 years old and recently retired. I have seen many attempts to “objectify” medicine. These have all failed, but each has taken a piece of medicine with it to the grave.

We do not have much more to lose before it’s a checklist, vital signs, and a script. I now refer to our profession as “McMedicine.” If you don’t have what is on the menu, you cannot get served. Diseases are rarely treated, symptoms are treated. This is not the profession of medicine. We are not fixing much; we are mostly providing consumers for pharmaceutical companies.

Few psychiatric disorders have been subjected to more measurement than depression. Quite a while ago, someone tried to compare depression scales. They correlated scale scores with the results of evaluations by board-certified psychiatrists. The best scale was a single question: “Are you depressed?” This had been included as a control. Can you do better?

Furthermore, the “paper and numbers” people can’t wait to get an “objective” wrench to tighten the screws and apply the principles of the industrial revolution to squeeze more money out of the system. They will find some way to turn patients into standardized products.

John L. Schenkel, MD
Retired psychiatrist
Peru, NY

I disagree with Drs. Aboraya and Nasrallah regarding implementing rating scales in psychiatry. Frankly, medicine has become awash in details—mounds and mounds of details.

With the use of an electronic medical record, what should be a simple 1-page note is transformed into a 5-page note of details. Doctors no longer attend to their patients but rather to their computers. Has this raised consciousness—the most important metric, according to Dr. David Hawkins? I doubt it.

In the words of my great professor, Dr. James Gustafson, I will continue to start my interview with what concerns the patient. Most of the time, they implicitly know.

Our focus should instead be on bringing down the cost of health care. This is what angers our patients most, and yet we do not make it a priority.

Mike Primc, MD
Psychiatrist
Glenbeigh Hospital
Rock Creek, Ohio
Signature Health
Ashtabula, Ohio
Behavioral Wellness Group
Mentor, Ohio

Continue to: The authors respond

We appreciate Drs. Schenkel’s and Primc’s comments on our editorial regarding measurement-based care (MBC). However, MBC will not increase the workload of psychiatrists; rather, it will streamline the evaluation of patients and measure the severity of their symptoms or adverse effects as well as the degree of their improvement. The proper use of scales with the appropriate patient populations may actually help clinicians to reduce the extensive amount of details that go into medical records.

The following quote, an excerpt from another article we wrote on MBC,¹ speaks to Dr. Primc’s concerns:

“…measures in psychiatry could be considered the equivalent of a thermometer and a stethoscope to a physician. No measure, scale, or diagnostic interview will ever replace a seasoned, experienced clinician who has been evaluating and treating real patients for years. MBC is not intended to replace clinical judgment and cannot substitute for an observant and caring clinician. Just as thermometers, stethoscopes, and lab tests help other types of physicians reach accurate diagnoses and provide appropriate management, the use of MBC by psychiatrists has the potential to improve the accuracy of diagnoses and improve the outcomes of care.”

Ahmed A. Aboraya, MD, DrPH
Assistant Professor
Department of Behavioral Medicine and Psychiatry
Chief of Psychiatry
Sharpe Hospital West Virginia University
Weston, West Virginia

Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri

Reference
1. Aboraya A, Nasrallah HA, Elswick DE, et al. Measurement-based care in psychiatry-past, present, and future. Innov Clin Neurosci. 2018;15(11-12):13-26.

An estimated 1-1.8 million sport-related concussions (SRC) occur per year in patients younger than 18 years of age. Concussion is defined as “a traumatically induced transient disturbance of brain function.” More than 50% of concussions among high school youth are not related to organized sports and between 2% and 15% of athletes in organized sports will sustain a concussion during a season of play.

©s-c-s/Thinkstock

In its position statement on concussion in sports, the American Medical Society for Sports Medicine recommends that student athletes receive specific evaluations, which will be described in this article. The guidelines include recommendations for imaging, treatment, and decision making regarding when as well as whether to return to play. Here is a brief summary of those recommendations.


Preseason: Preseason evaluation includes a preparticipation physical evaluation and discussion of concussion history as well as risk factors associated with prolonged concussion recovery. Neurocognitive tests are available for baseline evaluation. While these may assist with diagnosis and return-to-play decisions, there can be considerable variation in an individual’s baseline score as well as the possibility of changes in that baseline over time. Because of this potential for variability, these tests are not required or accepted as the standard of care.

Sideline assessment: Familiarity with the athlete is the best way to detect subtle changes in personality or performance. Looking at symptoms is still the most sensitive way to diagnose a concussion. Loss of consciousness, seizure, tonic posturing, lack of motor coordination, confusion, amnesia, difficulty with balance, or any cognitive difficulty should prompt removal from play for possible concussion. Once a potential injury is identified, how the athlete responds to the elements of orientation, memory, concentration, speech pattern, and balance should be evaluated. If an athlete has a probable or definite concussion, the athlete needs to be removed from play and cannot return to same-day play, and a more detailed evaluation needs to be done.

Office assessment: It is not unusual for symptoms and testing to normalize by the time an office visit occurs. If this is the case, the visit should focus on recommendations for safe return to school and sport. A standard office evaluation should include taking a history with details of the mechanism of injury and preexisting conditions – such as depression and prior concussion – that can affect concussion recovery. The history should focus on detecting symptoms that typically cause impairment from concussion: headache, ocular-vestibular issues leading to problems with balance, and cognitive issues with difficulty concentrating and remembering, as well as fatigue and mood issues such as anxiety, irritability, and depression. The physical exam should include assessment of ocular and vestibular function, gait, and balance in addition to a neurological exam.

Imaging: Head CT or MRI are rarely indicated. Intracranial bleeds are rare in the context of SRC but can occur. If there is concern for a bleed, then CT scan is the imaging test of choice. MRI may have value for evaluation for atypical or prolonged recovery.

Recovery time: The large majority (80%-90%) of concussed older adolescents and adults return to preinjury levels of function within 2 weeks; in younger athletes, clinical recovery may take up to 4 weeks. The best predictor of recovery from SRC is the number and severity of symptoms.

Treatment: For decades, cognitive and physical rest has been the standard of treatment. However, this is no longer the “gold standard” as it has been shown that strict rest (“cocoon therapy”) after SRC slows recovery and leads to an increased chance of prolonged symptoms. Current consensus guidelines support 24-48 hours of symptom-limited rest, both cognitive and physical, followed by a gradual increase in activity, staying below symptom-exacerbation thresholds. Activity, along with good sleep hygiene, appears to be helpful in facilitating recovery from SRC. In athletes with persistent post concussive symptoms that continue beyond the expected recovery time frame, activities of daily living, school, and exercise that do not significantly exacerbate symptoms are recommended.

Return to learning/play: A concussion can cause temporary deficits in attention, cognitive processing, short-term memory, and executive functioning. School personnel should be informed of the injury and assist in employing an individualized return to learn plan, including academic accommodations. Ultimately, return to sports activities should follow a successful return to the classroom. Return to play involves a stepwise increase in physical demands/activity without symptoms before a student is allowed to participate in full contact play.

Concussion-related risks: Continuing to participate in sports before resolution of concussion can worsen and prolong symptoms of SRC. Returning too early after concussion, before full recovery, increases the risk of recurrent SRC. During the initial post-injury period, returning to sports too early increases the risk for a rare but devastating possibility of second impact syndrome that can be a life-threatening repeat head injury. Studies of long-term mental health diagnoses are conflicting and inconsistent. Chronic traumatic encephalopathy has been described in athletes with a long history of concussions and repetitive sub-symptom head impacts. The degree of exposure needed appears to be variable and dependent on the individual.

Disqualification from play: Because each athlete is individually assessed after SRC, there are no evidence-based studies indicating how many concussions are “safe” for an athlete to have in a lifetime. The decision to stop playing sports is both serious and difficult for most athletes and requires shared decision making between clinician, the athlete, and the athlete’s parents. Factors to consider when determining if disqualification from play is warranted include:

• The total number of concussions experienced by a patient.
• Whether a patient has sustained subsequent concussions with progressively less forceful blows to the head.
• If a patient has sustained multiple concussions,whether the time to complete a full recovery after each concussion event increased.

The bottom line: “Cocoon therapy” is no longer recommended. Consensus guidelines endorse 24-48 hours of symptom-limited cognitive and physical rest followed by a gradual increase in activity, including noncontact physical activity that does not provoke symptoms.

Dr. Belogorodsky is a second-year resident and Dr. Fidler is an associate director in the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

Reference

Harmon KG et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019;53:213-25.

An estimated 1-1.8 million sport-related concussions (SRC) occur per year in patients younger than 18 years of age. Concussion is defined as “a traumatically induced transient disturbance of brain function.” More than 50% of concussions among high school youth are not related to organized sports and between 2% and 15% of athletes in organized sports will sustain a concussion during a season of play.

©s-c-s/Thinkstock

In its position statement on concussion in sports, the American Medical Society for Sports Medicine recommends that student athletes receive specific evaluations, which will be described in this article. The guidelines include recommendations for imaging, treatment, and decision making regarding when as well as whether to return to play. Here is a brief summary of those recommendations.


Preseason: Preseason evaluation includes a preparticipation physical evaluation and discussion of concussion history as well as risk factors associated with prolonged concussion recovery. Neurocognitive tests are available for baseline evaluation. While these may assist with diagnosis and return-to-play decisions, there can be considerable variation in an individual’s baseline score as well as the possibility of changes in that baseline over time. Because of this potential for variability, these tests are not required or accepted as the standard of care.

Sideline assessment: Familiarity with the athlete is the best way to detect subtle changes in personality or performance. Looking at symptoms is still the most sensitive way to diagnose a concussion. Loss of consciousness, seizure, tonic posturing, lack of motor coordination, confusion, amnesia, difficulty with balance, or any cognitive difficulty should prompt removal from play for possible concussion. Once a potential injury is identified, how the athlete responds to the elements of orientation, memory, concentration, speech pattern, and balance should be evaluated. If an athlete has a probable or definite concussion, the athlete needs to be removed from play and cannot return to same-day play, and a more detailed evaluation needs to be done.

Office assessment: It is not unusual for symptoms and testing to normalize by the time an office visit occurs. If this is the case, the visit should focus on recommendations for safe return to school and sport. A standard office evaluation should include taking a history with details of the mechanism of injury and preexisting conditions – such as depression and prior concussion – that can affect concussion recovery. The history should focus on detecting symptoms that typically cause impairment from concussion: headache, ocular-vestibular issues leading to problems with balance, and cognitive issues with difficulty concentrating and remembering, as well as fatigue and mood issues such as anxiety, irritability, and depression. The physical exam should include assessment of ocular and vestibular function, gait, and balance in addition to a neurological exam.

Imaging: Head CT or MRI are rarely indicated. Intracranial bleeds are rare in the context of SRC but can occur. If there is concern for a bleed, then CT scan is the imaging test of choice. MRI may have value for evaluation for atypical or prolonged recovery.

Recovery time: The large majority (80%-90%) of concussed older adolescents and adults return to preinjury levels of function within 2 weeks; in younger athletes, clinical recovery may take up to 4 weeks. The best predictor of recovery from SRC is the number and severity of symptoms.

Treatment: For decades, cognitive and physical rest has been the standard of treatment. However, this is no longer the “gold standard” as it has been shown that strict rest (“cocoon therapy”) after SRC slows recovery and leads to an increased chance of prolonged symptoms. Current consensus guidelines support 24-48 hours of symptom-limited rest, both cognitive and physical, followed by a gradual increase in activity, staying below symptom-exacerbation thresholds. Activity, along with good sleep hygiene, appears to be helpful in facilitating recovery from SRC. In athletes with persistent post concussive symptoms that continue beyond the expected recovery time frame, activities of daily living, school, and exercise that do not significantly exacerbate symptoms are recommended.

Return to learning/play: A concussion can cause temporary deficits in attention, cognitive processing, short-term memory, and executive functioning. School personnel should be informed of the injury and assist in employing an individualized return to learn plan, including academic accommodations. Ultimately, return to sports activities should follow a successful return to the classroom. Return to play involves a stepwise increase in physical demands/activity without symptoms before a student is allowed to participate in full contact play.

Concussion-related risks: Continuing to participate in sports before resolution of concussion can worsen and prolong symptoms of SRC. Returning too early after concussion, before full recovery, increases the risk of recurrent SRC. During the initial post-injury period, returning to sports too early increases the risk for a rare but devastating possibility of second impact syndrome that can be a life-threatening repeat head injury. Studies of long-term mental health diagnoses are conflicting and inconsistent. Chronic traumatic encephalopathy has been described in athletes with a long history of concussions and repetitive sub-symptom head impacts. The degree of exposure needed appears to be variable and dependent on the individual.

Disqualification from play: Because each athlete is individually assessed after SRC, there are no evidence-based studies indicating how many concussions are “safe” for an athlete to have in a lifetime. The decision to stop playing sports is both serious and difficult for most athletes and requires shared decision making between clinician, the athlete, and the athlete’s parents. Factors to consider when determining if disqualification from play is warranted include:

• The total number of concussions experienced by a patient.
• Whether a patient has sustained subsequent concussions with progressively less forceful blows to the head.
• If a patient has sustained multiple concussions,whether the time to complete a full recovery after each concussion event increased.

The bottom line: “Cocoon therapy” is no longer recommended. Consensus guidelines endorse 24-48 hours of symptom-limited cognitive and physical rest followed by a gradual increase in activity, including noncontact physical activity that does not provoke symptoms.

Dr. Belogorodsky is a second-year resident and Dr. Fidler is an associate director in the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

Reference

Harmon KG et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019;53:213-25.

An estimated 1-1.8 million sport-related concussions (SRC) occur per year in patients younger than 18 years of age. Concussion is defined as “a traumatically induced transient disturbance of brain function.” More than 50% of concussions among high school youth are not related to organized sports and between 2% and 15% of athletes in organized sports will sustain a concussion during a season of play.

©s-c-s/Thinkstock

In its position statement on concussion in sports, the American Medical Society for Sports Medicine recommends that student athletes receive specific evaluations, which will be described in this article. The guidelines include recommendations for imaging, treatment, and decision making regarding when as well as whether to return to play. Here is a brief summary of those recommendations.


Preseason: Preseason evaluation includes a preparticipation physical evaluation and discussion of concussion history as well as risk factors associated with prolonged concussion recovery. Neurocognitive tests are available for baseline evaluation. While these may assist with diagnosis and return-to-play decisions, there can be considerable variation in an individual’s baseline score as well as the possibility of changes in that baseline over time. Because of this potential for variability, these tests are not required or accepted as the standard of care.

Sideline assessment: Familiarity with the athlete is the best way to detect subtle changes in personality or performance. Looking at symptoms is still the most sensitive way to diagnose a concussion. Loss of consciousness, seizure, tonic posturing, lack of motor coordination, confusion, amnesia, difficulty with balance, or any cognitive difficulty should prompt removal from play for possible concussion. Once a potential injury is identified, how the athlete responds to the elements of orientation, memory, concentration, speech pattern, and balance should be evaluated. If an athlete has a probable or definite concussion, the athlete needs to be removed from play and cannot return to same-day play, and a more detailed evaluation needs to be done.

Office assessment: It is not unusual for symptoms and testing to normalize by the time an office visit occurs. If this is the case, the visit should focus on recommendations for safe return to school and sport. A standard office evaluation should include taking a history with details of the mechanism of injury and preexisting conditions – such as depression and prior concussion – that can affect concussion recovery. The history should focus on detecting symptoms that typically cause impairment from concussion: headache, ocular-vestibular issues leading to problems with balance, and cognitive issues with difficulty concentrating and remembering, as well as fatigue and mood issues such as anxiety, irritability, and depression. The physical exam should include assessment of ocular and vestibular function, gait, and balance in addition to a neurological exam.

Imaging: Head CT or MRI are rarely indicated. Intracranial bleeds are rare in the context of SRC but can occur. If there is concern for a bleed, then CT scan is the imaging test of choice. MRI may have value for evaluation for atypical or prolonged recovery.

Recovery time: The large majority (80%-90%) of concussed older adolescents and adults return to preinjury levels of function within 2 weeks; in younger athletes, clinical recovery may take up to 4 weeks. The best predictor of recovery from SRC is the number and severity of symptoms.

Treatment: For decades, cognitive and physical rest has been the standard of treatment. However, this is no longer the “gold standard” as it has been shown that strict rest (“cocoon therapy”) after SRC slows recovery and leads to an increased chance of prolonged symptoms. Current consensus guidelines support 24-48 hours of symptom-limited rest, both cognitive and physical, followed by a gradual increase in activity, staying below symptom-exacerbation thresholds. Activity, along with good sleep hygiene, appears to be helpful in facilitating recovery from SRC. In athletes with persistent post concussive symptoms that continue beyond the expected recovery time frame, activities of daily living, school, and exercise that do not significantly exacerbate symptoms are recommended.

Return to learning/play: A concussion can cause temporary deficits in attention, cognitive processing, short-term memory, and executive functioning. School personnel should be informed of the injury and assist in employing an individualized return to learn plan, including academic accommodations. Ultimately, return to sports activities should follow a successful return to the classroom. Return to play involves a stepwise increase in physical demands/activity without symptoms before a student is allowed to participate in full contact play.

Concussion-related risks: Continuing to participate in sports before resolution of concussion can worsen and prolong symptoms of SRC. Returning too early after concussion, before full recovery, increases the risk of recurrent SRC. During the initial post-injury period, returning to sports too early increases the risk for a rare but devastating possibility of second impact syndrome that can be a life-threatening repeat head injury. Studies of long-term mental health diagnoses are conflicting and inconsistent. Chronic traumatic encephalopathy has been described in athletes with a long history of concussions and repetitive sub-symptom head impacts. The degree of exposure needed appears to be variable and dependent on the individual.

Disqualification from play: Because each athlete is individually assessed after SRC, there are no evidence-based studies indicating how many concussions are “safe” for an athlete to have in a lifetime. The decision to stop playing sports is both serious and difficult for most athletes and requires shared decision making between clinician, the athlete, and the athlete’s parents. Factors to consider when determining if disqualification from play is warranted include:

• The total number of concussions experienced by a patient.
• Whether a patient has sustained subsequent concussions with progressively less forceful blows to the head.
• If a patient has sustained multiple concussions,whether the time to complete a full recovery after each concussion event increased.

The bottom line: “Cocoon therapy” is no longer recommended. Consensus guidelines endorse 24-48 hours of symptom-limited cognitive and physical rest followed by a gradual increase in activity, including noncontact physical activity that does not provoke symptoms.

Dr. Belogorodsky is a second-year resident and Dr. Fidler is an associate director in the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.

Reference

Harmon KG et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019;53:213-25.