Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

— Kerri Wachter

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

— Kerri Wachter

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

— Kerri Wachter

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Median compensation for adult hospitalists rose to $233,855 in 2011, a 6% increase from the year prior, while productivity remained nearly static, according to recently released data. This latest uptick in HM compensation means that hospitalist pay has jumped more than 27% since 2008, when unadjusted figures pegged median hospitalist compensation at $183,900 nationwide.

The data, which excludes academic hospitalists, were reported in the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. The rise comes despite little movement in the number of work relative-value units (wRVUs) hospitalists are producing. In 2011, the median physician wRVU rate was 4,159, a 0.17% drop from the year prior.

"Over time, the industry has recognized there is a strong demand and there is a need for these types of practitioners," says Todd Evenson, MGMA director of data solutions. Evenson says he sees no immediate hurdles to the continued growth of hospitalist compensation, as hospitalists have established themselves as major players in most hospitals.

Although wRVUs might appear stable—they've ticked up 1.26% since 2010—the measure might not be as closely tied to compensation as healthcare reform redefines payment and reimbursement models, Evenson says. For example, bundled payments tied to quality of care and outcomes could have a limited impact on wRVUs but be a major driver of compensation.

Just how high compensation can climb, Evenson says, will depend on "the payment mechanisms that we start to see fall out of the legislation that occurs. ... As that evolves, I can't say I know the ceiling."

The report compiled data on 3,192 full-time hospitalists nationwide. Slightly more than 54% of the respondents worked in hospital-owned practices, while 27% are in physician-owned groups. The rest reported "other" practice models.

The MGMA survey data will be incorporated into SHM's State of Hospital Medicine report, due out later next month. In addition to information on individual physicians collected by MGMA, SHM's report includes group-level data valuable to HM groups, including financial data (subsidies and CPT code distribution) and staffing and scheduling.

Median compensation for adult hospitalists rose to $233,855 in 2011, a 6% increase from the year prior, while productivity remained nearly static, according to recently released data. This latest uptick in HM compensation means that hospitalist pay has jumped more than 27% since 2008, when unadjusted figures pegged median hospitalist compensation at $183,900 nationwide.

The data, which excludes academic hospitalists, were reported in the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. The rise comes despite little movement in the number of work relative-value units (wRVUs) hospitalists are producing. In 2011, the median physician wRVU rate was 4,159, a 0.17% drop from the year prior.

"Over time, the industry has recognized there is a strong demand and there is a need for these types of practitioners," says Todd Evenson, MGMA director of data solutions. Evenson says he sees no immediate hurdles to the continued growth of hospitalist compensation, as hospitalists have established themselves as major players in most hospitals.

Although wRVUs might appear stable—they've ticked up 1.26% since 2010—the measure might not be as closely tied to compensation as healthcare reform redefines payment and reimbursement models, Evenson says. For example, bundled payments tied to quality of care and outcomes could have a limited impact on wRVUs but be a major driver of compensation.

Just how high compensation can climb, Evenson says, will depend on "the payment mechanisms that we start to see fall out of the legislation that occurs. ... As that evolves, I can't say I know the ceiling."

The report compiled data on 3,192 full-time hospitalists nationwide. Slightly more than 54% of the respondents worked in hospital-owned practices, while 27% are in physician-owned groups. The rest reported "other" practice models.

The MGMA survey data will be incorporated into SHM's State of Hospital Medicine report, due out later next month. In addition to information on individual physicians collected by MGMA, SHM's report includes group-level data valuable to HM groups, including financial data (subsidies and CPT code distribution) and staffing and scheduling.

Median compensation for adult hospitalists rose to $233,855 in 2011, a 6% increase from the year prior, while productivity remained nearly static, according to recently released data. This latest uptick in HM compensation means that hospitalist pay has jumped more than 27% since 2008, when unadjusted figures pegged median hospitalist compensation at $183,900 nationwide.

The data, which excludes academic hospitalists, were reported in the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. The rise comes despite little movement in the number of work relative-value units (wRVUs) hospitalists are producing. In 2011, the median physician wRVU rate was 4,159, a 0.17% drop from the year prior.

"Over time, the industry has recognized there is a strong demand and there is a need for these types of practitioners," says Todd Evenson, MGMA director of data solutions. Evenson says he sees no immediate hurdles to the continued growth of hospitalist compensation, as hospitalists have established themselves as major players in most hospitals.

Although wRVUs might appear stable—they've ticked up 1.26% since 2010—the measure might not be as closely tied to compensation as healthcare reform redefines payment and reimbursement models, Evenson says. For example, bundled payments tied to quality of care and outcomes could have a limited impact on wRVUs but be a major driver of compensation.

Just how high compensation can climb, Evenson says, will depend on "the payment mechanisms that we start to see fall out of the legislation that occurs. ... As that evolves, I can't say I know the ceiling."

The report compiled data on 3,192 full-time hospitalists nationwide. Slightly more than 54% of the respondents worked in hospital-owned practices, while 27% are in physician-owned groups. The rest reported "other" practice models.

The MGMA survey data will be incorporated into SHM's State of Hospital Medicine report, due out later next month. In addition to information on individual physicians collected by MGMA, SHM's report includes group-level data valuable to HM groups, including financial data (subsidies and CPT code distribution) and staffing and scheduling.

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

Dr. Joseph S. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email him at our editorial offices at sknews@elsevier.com.

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

Dr. Joseph S. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email him at our editorial offices at sknews@elsevier.com.

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

Dr. Joseph S. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, email him at our editorial offices at sknews@elsevier.com.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

Imagine if you will that you’re in the throes of labor (there is a point to this exercise in unplanned parenthood, so bear with me).

Between contractions, there’s a nattering in your ear about the use of local anesthesia prior to the epidural that friends swear will allow you to actually consider doing this again.

The injection is announced by someone saying either, "We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure" or "You are going to feel a big bee sting; this is the worst part of the procedure."

Not surprising, the perceived pain was found to be significantly greater after the latter statement.

German investigators highlight this experiment as part of a detailed and fascinating look at the nocebo phenomenon, or the opposite of the placebo phenomenon, in medicine.

The topic has apparently been given the short shrift by scientists and clinicians. A recent PubMed search by the Germans revealed roughly 2,200 studies penned on the placebo effect, but only 151 publications on the nocebo effect, with the vast majority of these being editorials, commentaries, and reviews, rather than empirical studies.

Dr. Winfried Häuser of the Klinikum Saarbrücken and his associates, nail the crux of the issue with a quote from cardiologist and Nobel laureate Dr. Bernard Lown that "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal."

The article touches on the neurobiological mechanisms of the nocebo effect, which like those for the placebo effect, center around conditioning and reaction to expectations – albeit in this case negative expectations.

There is a discussion about who might be at risk of nocebo responses (yes, ladies he’s speaking to us), and an amusing array of clinical studies illustrating the nocebo effect.

There’s a randomized controlled trial (RCT) of finasteride in benign prostate hyperplasia, in which sexual dysfunction was reported by 44% of patients informed of this possible side effect, compared with only 15% of those not informed.

Similarly, there’s another RCT of the beta-blocker atenolol in coronary heart disease. Rates of sexual dysfunction jumped from 3% of patients not told of the drug or side effect to 31% of those treated to complete details about both the drug and the possible sexual dysfunction

Where the review really hits its stride, however, is in the discussion of ethical problems that arise in everyday clinical practice where the nocebo phenomenon may be triggered by verbal and non-verbal communications by physicians and nurses.

The authors note that physicians are obliged to inform patients about the possible adverse events of a proposed treatment so they can make an informed decision, but also have a duty to minimize the risks of a medical intervention, including those induced by the patient briefing.

Strategies are offered to reduce this dilemma with the most obvious being patient education and communications training for medical staff.

Clinicians are also advised to focus on the proportion of patients who tolerate a procedure or drug rather than the proportion experiencing adverse events.

The most controversial suggestion is the concept of "permitted non-information." Patients agree not to receive information on mild and/or transient side effects, but must be briefed about severe and/or irreversible side effects. To respect their autonomy and preferences, patients could pick and chose what side effects they want to briefed on (or forego) from a list of categories of possible side effects for a drug or procedure.

When the German Medical Association gets round to updating its 1990 recommendations on patient briefing, the authors say there needs to be discussion on "whether it is legitimate to express a right of the patient not to know about complications and side effects of medical procedures and whether this must be respected by the physician."

There should also be debate on whether some patients might be left confused or uncertain by their inability to follow the comprehensive adverse event information found on package inserts or consent forms.

Such a strategy could be problematic in the United States, where nearly half of all adults (90 million people) have difficulty understanding and acting upon health information, according to the Institute of Medicine report "Health Literacy: A Prescription to End Confusion."

Throw in the wracking pain of childbirth, the instability of bipolarity, or the confusion of Parkinson’s, and you’ve just made the lawyers of America incandescently happy.

Dr. Häuser reports reimbursement for training and travel costs from Eli Lilly and the Falk Foundation, and lecture fees from Lilly, the Falk Foundation and Janssen-Cilag. A co-author reports research funds from Sorin, Italy.

Imagine if you will that you’re in the throes of labor (there is a point to this exercise in unplanned parenthood, so bear with me).

Between contractions, there’s a nattering in your ear about the use of local anesthesia prior to the epidural that friends swear will allow you to actually consider doing this again.

The injection is announced by someone saying either, "We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure" or "You are going to feel a big bee sting; this is the worst part of the procedure."

Not surprising, the perceived pain was found to be significantly greater after the latter statement.

German investigators highlight this experiment as part of a detailed and fascinating look at the nocebo phenomenon, or the opposite of the placebo phenomenon, in medicine.

The topic has apparently been given the short shrift by scientists and clinicians. A recent PubMed search by the Germans revealed roughly 2,200 studies penned on the placebo effect, but only 151 publications on the nocebo effect, with the vast majority of these being editorials, commentaries, and reviews, rather than empirical studies.

Dr. Winfried Häuser of the Klinikum Saarbrücken and his associates, nail the crux of the issue with a quote from cardiologist and Nobel laureate Dr. Bernard Lown that "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal."

The article touches on the neurobiological mechanisms of the nocebo effect, which like those for the placebo effect, center around conditioning and reaction to expectations – albeit in this case negative expectations.

There is a discussion about who might be at risk of nocebo responses (yes, ladies he’s speaking to us), and an amusing array of clinical studies illustrating the nocebo effect.

There’s a randomized controlled trial (RCT) of finasteride in benign prostate hyperplasia, in which sexual dysfunction was reported by 44% of patients informed of this possible side effect, compared with only 15% of those not informed.

Similarly, there’s another RCT of the beta-blocker atenolol in coronary heart disease. Rates of sexual dysfunction jumped from 3% of patients not told of the drug or side effect to 31% of those treated to complete details about both the drug and the possible sexual dysfunction

Where the review really hits its stride, however, is in the discussion of ethical problems that arise in everyday clinical practice where the nocebo phenomenon may be triggered by verbal and non-verbal communications by physicians and nurses.

The authors note that physicians are obliged to inform patients about the possible adverse events of a proposed treatment so they can make an informed decision, but also have a duty to minimize the risks of a medical intervention, including those induced by the patient briefing.

Strategies are offered to reduce this dilemma with the most obvious being patient education and communications training for medical staff.

Clinicians are also advised to focus on the proportion of patients who tolerate a procedure or drug rather than the proportion experiencing adverse events.

The most controversial suggestion is the concept of "permitted non-information." Patients agree not to receive information on mild and/or transient side effects, but must be briefed about severe and/or irreversible side effects. To respect their autonomy and preferences, patients could pick and chose what side effects they want to briefed on (or forego) from a list of categories of possible side effects for a drug or procedure.

When the German Medical Association gets round to updating its 1990 recommendations on patient briefing, the authors say there needs to be discussion on "whether it is legitimate to express a right of the patient not to know about complications and side effects of medical procedures and whether this must be respected by the physician."

There should also be debate on whether some patients might be left confused or uncertain by their inability to follow the comprehensive adverse event information found on package inserts or consent forms.

Such a strategy could be problematic in the United States, where nearly half of all adults (90 million people) have difficulty understanding and acting upon health information, according to the Institute of Medicine report "Health Literacy: A Prescription to End Confusion."

Throw in the wracking pain of childbirth, the instability of bipolarity, or the confusion of Parkinson’s, and you’ve just made the lawyers of America incandescently happy.

Dr. Häuser reports reimbursement for training and travel costs from Eli Lilly and the Falk Foundation, and lecture fees from Lilly, the Falk Foundation and Janssen-Cilag. A co-author reports research funds from Sorin, Italy.

Imagine if you will that you’re in the throes of labor (there is a point to this exercise in unplanned parenthood, so bear with me).

Between contractions, there’s a nattering in your ear about the use of local anesthesia prior to the epidural that friends swear will allow you to actually consider doing this again.

The injection is announced by someone saying either, "We are going to give you a local anesthetic that will numb the area so that you will be comfortable during the procedure" or "You are going to feel a big bee sting; this is the worst part of the procedure."

Not surprising, the perceived pain was found to be significantly greater after the latter statement.

German investigators highlight this experiment as part of a detailed and fascinating look at the nocebo phenomenon, or the opposite of the placebo phenomenon, in medicine.

The topic has apparently been given the short shrift by scientists and clinicians. A recent PubMed search by the Germans revealed roughly 2,200 studies penned on the placebo effect, but only 151 publications on the nocebo effect, with the vast majority of these being editorials, commentaries, and reviews, rather than empirical studies.

Dr. Winfried Häuser of the Klinikum Saarbrücken and his associates, nail the crux of the issue with a quote from cardiologist and Nobel laureate Dr. Bernard Lown that "Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal."

The article touches on the neurobiological mechanisms of the nocebo effect, which like those for the placebo effect, center around conditioning and reaction to expectations – albeit in this case negative expectations.

There is a discussion about who might be at risk of nocebo responses (yes, ladies he’s speaking to us), and an amusing array of clinical studies illustrating the nocebo effect.

There’s a randomized controlled trial (RCT) of finasteride in benign prostate hyperplasia, in which sexual dysfunction was reported by 44% of patients informed of this possible side effect, compared with only 15% of those not informed.

Similarly, there’s another RCT of the beta-blocker atenolol in coronary heart disease. Rates of sexual dysfunction jumped from 3% of patients not told of the drug or side effect to 31% of those treated to complete details about both the drug and the possible sexual dysfunction

Where the review really hits its stride, however, is in the discussion of ethical problems that arise in everyday clinical practice where the nocebo phenomenon may be triggered by verbal and non-verbal communications by physicians and nurses.

The authors note that physicians are obliged to inform patients about the possible adverse events of a proposed treatment so they can make an informed decision, but also have a duty to minimize the risks of a medical intervention, including those induced by the patient briefing.

Strategies are offered to reduce this dilemma with the most obvious being patient education and communications training for medical staff.

Clinicians are also advised to focus on the proportion of patients who tolerate a procedure or drug rather than the proportion experiencing adverse events.

The most controversial suggestion is the concept of "permitted non-information." Patients agree not to receive information on mild and/or transient side effects, but must be briefed about severe and/or irreversible side effects. To respect their autonomy and preferences, patients could pick and chose what side effects they want to briefed on (or forego) from a list of categories of possible side effects for a drug or procedure.

When the German Medical Association gets round to updating its 1990 recommendations on patient briefing, the authors say there needs to be discussion on "whether it is legitimate to express a right of the patient not to know about complications and side effects of medical procedures and whether this must be respected by the physician."

There should also be debate on whether some patients might be left confused or uncertain by their inability to follow the comprehensive adverse event information found on package inserts or consent forms.

Such a strategy could be problematic in the United States, where nearly half of all adults (90 million people) have difficulty understanding and acting upon health information, according to the Institute of Medicine report "Health Literacy: A Prescription to End Confusion."

Throw in the wracking pain of childbirth, the instability of bipolarity, or the confusion of Parkinson’s, and you’ve just made the lawyers of America incandescently happy.

Dr. Häuser reports reimbursement for training and travel costs from Eli Lilly and the Falk Foundation, and lecture fees from Lilly, the Falk Foundation and Janssen-Cilag. A co-author reports research funds from Sorin, Italy.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at bbobbitt@smithlaw.com.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at bbobbitt@smithlaw.com.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at bbobbitt@smithlaw.com.