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On a scale of 1-5 ... How frustrating is this?
Like most American doctors, I take a variety of insurances and insurance plans.
Some of these, particularly HMOs, require a referring physician to send me a written, insurance-approved, referral (AKA authorization) before the visit, to submit with my bill.
Medical visits of all kinds are generally billed on a scale from 1 (brief/simple issue) to 5 (lots of time needed/very complicated).
After 23 years, I’m used to this.
But recently a new wrinkle has emerged.
In the last month I’ve gotten two referrals (both from the same internist), except these state, very clearly, that charges for any visit cannot exceed level 3.
And they’re telling me this before I’ve ever seen the patients, or have any idea how complicated they are, or how long a list of questions they and/or their families will have.
No.
I faxed them back asking for a referral allowing me to bill up to level 5 if needed. I might charge less than that, but none of us know how complicated or long a visit will be until someone comes in. There’s no crystal ball in medicine.
I’m sure someone will say I’m a money-grubbing doctor who couldn’t care less about the patient.
That’s far from the truth. I’m here for the patients. I like helping them. It’s why I do this.
But I can’t help anyone if I can’t afford to keep the office lights on, either.
I never heard back from them. Maybe they decided the patients didn’t need me that much. Maybe they sent them to another neurologist and took my name off their referral list. Maybe they never even noticed my return fax.
What will happen now, I have no idea. Maybe this was something that office tried, to see if I noticed. Maybe it’s the start of the next wave of medical cutbacks. Maybe it was a staff error at the other end.
But either way, This isn’t an amusement park or thrift store. People with problems need time, and time costs money. I need to pay my staff, my rent, and my mortgage. If I can’t do those things, I won’t be able to help anyone.
That’s just, for better or worse, the way it is.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Like most American doctors, I take a variety of insurances and insurance plans.
Some of these, particularly HMOs, require a referring physician to send me a written, insurance-approved, referral (AKA authorization) before the visit, to submit with my bill.
Medical visits of all kinds are generally billed on a scale from 1 (brief/simple issue) to 5 (lots of time needed/very complicated).
After 23 years, I’m used to this.
But recently a new wrinkle has emerged.
In the last month I’ve gotten two referrals (both from the same internist), except these state, very clearly, that charges for any visit cannot exceed level 3.
And they’re telling me this before I’ve ever seen the patients, or have any idea how complicated they are, or how long a list of questions they and/or their families will have.
No.
I faxed them back asking for a referral allowing me to bill up to level 5 if needed. I might charge less than that, but none of us know how complicated or long a visit will be until someone comes in. There’s no crystal ball in medicine.
I’m sure someone will say I’m a money-grubbing doctor who couldn’t care less about the patient.
That’s far from the truth. I’m here for the patients. I like helping them. It’s why I do this.
But I can’t help anyone if I can’t afford to keep the office lights on, either.
I never heard back from them. Maybe they decided the patients didn’t need me that much. Maybe they sent them to another neurologist and took my name off their referral list. Maybe they never even noticed my return fax.
What will happen now, I have no idea. Maybe this was something that office tried, to see if I noticed. Maybe it’s the start of the next wave of medical cutbacks. Maybe it was a staff error at the other end.
But either way, This isn’t an amusement park or thrift store. People with problems need time, and time costs money. I need to pay my staff, my rent, and my mortgage. If I can’t do those things, I won’t be able to help anyone.
That’s just, for better or worse, the way it is.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Like most American doctors, I take a variety of insurances and insurance plans.
Some of these, particularly HMOs, require a referring physician to send me a written, insurance-approved, referral (AKA authorization) before the visit, to submit with my bill.
Medical visits of all kinds are generally billed on a scale from 1 (brief/simple issue) to 5 (lots of time needed/very complicated).
After 23 years, I’m used to this.
But recently a new wrinkle has emerged.
In the last month I’ve gotten two referrals (both from the same internist), except these state, very clearly, that charges for any visit cannot exceed level 3.
And they’re telling me this before I’ve ever seen the patients, or have any idea how complicated they are, or how long a list of questions they and/or their families will have.
No.
I faxed them back asking for a referral allowing me to bill up to level 5 if needed. I might charge less than that, but none of us know how complicated or long a visit will be until someone comes in. There’s no crystal ball in medicine.
I’m sure someone will say I’m a money-grubbing doctor who couldn’t care less about the patient.
That’s far from the truth. I’m here for the patients. I like helping them. It’s why I do this.
But I can’t help anyone if I can’t afford to keep the office lights on, either.
I never heard back from them. Maybe they decided the patients didn’t need me that much. Maybe they sent them to another neurologist and took my name off their referral list. Maybe they never even noticed my return fax.
What will happen now, I have no idea. Maybe this was something that office tried, to see if I noticed. Maybe it’s the start of the next wave of medical cutbacks. Maybe it was a staff error at the other end.
But either way, This isn’t an amusement park or thrift store. People with problems need time, and time costs money. I need to pay my staff, my rent, and my mortgage. If I can’t do those things, I won’t be able to help anyone.
That’s just, for better or worse, the way it is.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Lucid abductions and Candy Crush addiction
I dream of alien abductions
There he goes! It’s lunchtime and your colleague Tom is going on and on again about that time he was abducted by aliens. It sounds ridiculous, but he does make some convincing arguments. Tom thinks it was real, but could it have all just been in his head?
Lucid dreaming may help explain alleged alien abductions. During a lucid dream, people know that they’re dreaming, and can also have some control over how the dreams play out. During some dream states, a person can feel intense sensations, such as terror and paralysis, so it’s no wonder these dreams feel so real.
In a recent study, scientists encouraged 152 participants who had self-identified as lucid dreamers to dream about aliens. Many (75%) of the participants were able to dream about alien encounters, and 15% “achieved relatively realistic experiences,” the investigators reported.
So cut Tom some slack. He’s not crazy, he might just have lucid dreaming privileges. Tell him he should dream about something more fun, like a vacation in the Bahamas.
Follow your heart: Drink more coffee
It seems like the world is divided into coffee drinkers and non–coffee drinkers. Then there’s decaf and regular drinkers. Whichever camp you fall into, know this: The widespread belief that caffeine consumption has an effect on your heart is all beans.
In what is the largest investigation of its kind, researchers from the University of California, San Francisco, looked into whether drinking caffeinated coffee was linked to a risk for heart arrhythmia. They also researched whether patients with genetic variants that affect their metabolism could change that association. Almost 400,000 people with a mean age of 56 years participated in the study. More than half of the participants were women.
The investigators analyzed the participants’ self-reported coffee consumption using a technique called Mendelian randomization to leverage genetic data with the participants’ relationship with caffeine, making it an even field and not relying on the participant consumption self-reporting for outcomes as in previous studies.
What they found, after the 4-year follow up, was nothing short of myth busting.
“We found no evidence that caffeine consumption leads to a greater risk of arrhythmias,” said senior and corresponding author Gregory Marcus, MD. “Our population-based study provides reassurance that common prohibitions against caffeine to reduce arrhythmia risk are likely unwarranted.”
There was no evidence of a heightened risk of arrhythmias in participants who were genetically predisposed to metabolize caffeine differently from those who were not. And, there was a 3% reduction of arrhythmias in patients who consumed higher amounts of coffee.
We are not lobbying for Big Caffeine, but this study adds to the reported health benefits linked to coffee, which already include reduced risk for cancer, diabetes, and Parkinson’s disease, with an added bonus of anti-inflammatory benefits. So, the next time you’re hesitant to pour that second cup of Joe, just go for it. Your heart can take it.
Bored? Feeling down? Don’t play Candy Crush
Now hang on, aren’t those the perfect times to play video games? If there’s nothing else to do, why not open Candy Crush and mindlessly power through the levels?
Because, according to a study by a group of Canadian researchers, it’s actually the worst thing you can do. Well, maybe not literally, but it’s not helpful. Researchers recruited 60 Candy Crush players who were at various levels in the game. They had the participants play early levels that were far too easy or levels balanced with their gameplay abilities.
Players in the easy-level group got bored and quit far earlier than did those in the advanced-level group. The group playing to their abilities were able to access a “flow” state and focus all their attention on the game. While this is all well and good for their gaming performance, according to the researchers, it confirms the theory that playing to escape boredom or negative emotions is more likely to lead to addiction. As with all addictions, the temporary high can give way to a self-repeating loop, causing patients to ignore real life and deepen depression.
The researchers hope their findings will encourage game developers to “consider implementing responsible video gaming tools directly within their games.” Comedy gold. Perhaps Canadians’ idea of capitalism is a little different from that of those south of the border.
Hiccups and vaccine refusal
Tonight, LOTME News dives into the fetid cesspool that is international politics and comes out with … hiccups?
But first, a word from our sponsor, Fearless Boxing Club of South Etobicoke, Ontario.
Are you looking to flout public health restrictions? Do you want to spend time in an enclosed space with other people who haven’t gotten the COVID-19 vaccine? Do you “feel safer waiting until more research is done on the side effects being discovered right now”? (We are not making this up.)
Then join the Fearless Boxing Club, because we “will not be accepting any vaccinated members.” Our founders, Mohammed Abedeen and Krystal Glazier-Roscoe, are working hard to exclude “those who received the experimental COVID vaccine.” (Still not making it up.)
And now, back to the news.
Brazilian president Jair Bolsonaro was hospitalized recently for a severe case of hiccups that may have been related to a stab wound he received in 2018. [Nope, didn’t make that up, either.]
Mr. Bolsonaro had been hiccuping for 10 days, and was experiencing abdominal pain and difficulty speaking, when he entered the hospital on July 14. Since being stabbed while on the campaign trail, he has undergone several operations, which may have led to the partial intestinal obstruction that caused his latest symptoms.
His medical team advised Mr. Bolsonaro to go on a diet to aid his recovery, but when he was released on July 18 he said, “I hope in 10 days I’ll be eating barbecued ribs.” (Maybe this is all just a lucid dream. Probably shouldn’t have had ribs right before bed.)
I dream of alien abductions
There he goes! It’s lunchtime and your colleague Tom is going on and on again about that time he was abducted by aliens. It sounds ridiculous, but he does make some convincing arguments. Tom thinks it was real, but could it have all just been in his head?
Lucid dreaming may help explain alleged alien abductions. During a lucid dream, people know that they’re dreaming, and can also have some control over how the dreams play out. During some dream states, a person can feel intense sensations, such as terror and paralysis, so it’s no wonder these dreams feel so real.
In a recent study, scientists encouraged 152 participants who had self-identified as lucid dreamers to dream about aliens. Many (75%) of the participants were able to dream about alien encounters, and 15% “achieved relatively realistic experiences,” the investigators reported.
So cut Tom some slack. He’s not crazy, he might just have lucid dreaming privileges. Tell him he should dream about something more fun, like a vacation in the Bahamas.
Follow your heart: Drink more coffee
It seems like the world is divided into coffee drinkers and non–coffee drinkers. Then there’s decaf and regular drinkers. Whichever camp you fall into, know this: The widespread belief that caffeine consumption has an effect on your heart is all beans.
In what is the largest investigation of its kind, researchers from the University of California, San Francisco, looked into whether drinking caffeinated coffee was linked to a risk for heart arrhythmia. They also researched whether patients with genetic variants that affect their metabolism could change that association. Almost 400,000 people with a mean age of 56 years participated in the study. More than half of the participants were women.
The investigators analyzed the participants’ self-reported coffee consumption using a technique called Mendelian randomization to leverage genetic data with the participants’ relationship with caffeine, making it an even field and not relying on the participant consumption self-reporting for outcomes as in previous studies.
What they found, after the 4-year follow up, was nothing short of myth busting.
“We found no evidence that caffeine consumption leads to a greater risk of arrhythmias,” said senior and corresponding author Gregory Marcus, MD. “Our population-based study provides reassurance that common prohibitions against caffeine to reduce arrhythmia risk are likely unwarranted.”
There was no evidence of a heightened risk of arrhythmias in participants who were genetically predisposed to metabolize caffeine differently from those who were not. And, there was a 3% reduction of arrhythmias in patients who consumed higher amounts of coffee.
We are not lobbying for Big Caffeine, but this study adds to the reported health benefits linked to coffee, which already include reduced risk for cancer, diabetes, and Parkinson’s disease, with an added bonus of anti-inflammatory benefits. So, the next time you’re hesitant to pour that second cup of Joe, just go for it. Your heart can take it.
Bored? Feeling down? Don’t play Candy Crush
Now hang on, aren’t those the perfect times to play video games? If there’s nothing else to do, why not open Candy Crush and mindlessly power through the levels?
Because, according to a study by a group of Canadian researchers, it’s actually the worst thing you can do. Well, maybe not literally, but it’s not helpful. Researchers recruited 60 Candy Crush players who were at various levels in the game. They had the participants play early levels that were far too easy or levels balanced with their gameplay abilities.
Players in the easy-level group got bored and quit far earlier than did those in the advanced-level group. The group playing to their abilities were able to access a “flow” state and focus all their attention on the game. While this is all well and good for their gaming performance, according to the researchers, it confirms the theory that playing to escape boredom or negative emotions is more likely to lead to addiction. As with all addictions, the temporary high can give way to a self-repeating loop, causing patients to ignore real life and deepen depression.
The researchers hope their findings will encourage game developers to “consider implementing responsible video gaming tools directly within their games.” Comedy gold. Perhaps Canadians’ idea of capitalism is a little different from that of those south of the border.
Hiccups and vaccine refusal
Tonight, LOTME News dives into the fetid cesspool that is international politics and comes out with … hiccups?
But first, a word from our sponsor, Fearless Boxing Club of South Etobicoke, Ontario.
Are you looking to flout public health restrictions? Do you want to spend time in an enclosed space with other people who haven’t gotten the COVID-19 vaccine? Do you “feel safer waiting until more research is done on the side effects being discovered right now”? (We are not making this up.)
Then join the Fearless Boxing Club, because we “will not be accepting any vaccinated members.” Our founders, Mohammed Abedeen and Krystal Glazier-Roscoe, are working hard to exclude “those who received the experimental COVID vaccine.” (Still not making it up.)
And now, back to the news.
Brazilian president Jair Bolsonaro was hospitalized recently for a severe case of hiccups that may have been related to a stab wound he received in 2018. [Nope, didn’t make that up, either.]
Mr. Bolsonaro had been hiccuping for 10 days, and was experiencing abdominal pain and difficulty speaking, when he entered the hospital on July 14. Since being stabbed while on the campaign trail, he has undergone several operations, which may have led to the partial intestinal obstruction that caused his latest symptoms.
His medical team advised Mr. Bolsonaro to go on a diet to aid his recovery, but when he was released on July 18 he said, “I hope in 10 days I’ll be eating barbecued ribs.” (Maybe this is all just a lucid dream. Probably shouldn’t have had ribs right before bed.)
I dream of alien abductions
There he goes! It’s lunchtime and your colleague Tom is going on and on again about that time he was abducted by aliens. It sounds ridiculous, but he does make some convincing arguments. Tom thinks it was real, but could it have all just been in his head?
Lucid dreaming may help explain alleged alien abductions. During a lucid dream, people know that they’re dreaming, and can also have some control over how the dreams play out. During some dream states, a person can feel intense sensations, such as terror and paralysis, so it’s no wonder these dreams feel so real.
In a recent study, scientists encouraged 152 participants who had self-identified as lucid dreamers to dream about aliens. Many (75%) of the participants were able to dream about alien encounters, and 15% “achieved relatively realistic experiences,” the investigators reported.
So cut Tom some slack. He’s not crazy, he might just have lucid dreaming privileges. Tell him he should dream about something more fun, like a vacation in the Bahamas.
Follow your heart: Drink more coffee
It seems like the world is divided into coffee drinkers and non–coffee drinkers. Then there’s decaf and regular drinkers. Whichever camp you fall into, know this: The widespread belief that caffeine consumption has an effect on your heart is all beans.
In what is the largest investigation of its kind, researchers from the University of California, San Francisco, looked into whether drinking caffeinated coffee was linked to a risk for heart arrhythmia. They also researched whether patients with genetic variants that affect their metabolism could change that association. Almost 400,000 people with a mean age of 56 years participated in the study. More than half of the participants were women.
The investigators analyzed the participants’ self-reported coffee consumption using a technique called Mendelian randomization to leverage genetic data with the participants’ relationship with caffeine, making it an even field and not relying on the participant consumption self-reporting for outcomes as in previous studies.
What they found, after the 4-year follow up, was nothing short of myth busting.
“We found no evidence that caffeine consumption leads to a greater risk of arrhythmias,” said senior and corresponding author Gregory Marcus, MD. “Our population-based study provides reassurance that common prohibitions against caffeine to reduce arrhythmia risk are likely unwarranted.”
There was no evidence of a heightened risk of arrhythmias in participants who were genetically predisposed to metabolize caffeine differently from those who were not. And, there was a 3% reduction of arrhythmias in patients who consumed higher amounts of coffee.
We are not lobbying for Big Caffeine, but this study adds to the reported health benefits linked to coffee, which already include reduced risk for cancer, diabetes, and Parkinson’s disease, with an added bonus of anti-inflammatory benefits. So, the next time you’re hesitant to pour that second cup of Joe, just go for it. Your heart can take it.
Bored? Feeling down? Don’t play Candy Crush
Now hang on, aren’t those the perfect times to play video games? If there’s nothing else to do, why not open Candy Crush and mindlessly power through the levels?
Because, according to a study by a group of Canadian researchers, it’s actually the worst thing you can do. Well, maybe not literally, but it’s not helpful. Researchers recruited 60 Candy Crush players who were at various levels in the game. They had the participants play early levels that were far too easy or levels balanced with their gameplay abilities.
Players in the easy-level group got bored and quit far earlier than did those in the advanced-level group. The group playing to their abilities were able to access a “flow” state and focus all their attention on the game. While this is all well and good for their gaming performance, according to the researchers, it confirms the theory that playing to escape boredom or negative emotions is more likely to lead to addiction. As with all addictions, the temporary high can give way to a self-repeating loop, causing patients to ignore real life and deepen depression.
The researchers hope their findings will encourage game developers to “consider implementing responsible video gaming tools directly within their games.” Comedy gold. Perhaps Canadians’ idea of capitalism is a little different from that of those south of the border.
Hiccups and vaccine refusal
Tonight, LOTME News dives into the fetid cesspool that is international politics and comes out with … hiccups?
But first, a word from our sponsor, Fearless Boxing Club of South Etobicoke, Ontario.
Are you looking to flout public health restrictions? Do you want to spend time in an enclosed space with other people who haven’t gotten the COVID-19 vaccine? Do you “feel safer waiting until more research is done on the side effects being discovered right now”? (We are not making this up.)
Then join the Fearless Boxing Club, because we “will not be accepting any vaccinated members.” Our founders, Mohammed Abedeen and Krystal Glazier-Roscoe, are working hard to exclude “those who received the experimental COVID vaccine.” (Still not making it up.)
And now, back to the news.
Brazilian president Jair Bolsonaro was hospitalized recently for a severe case of hiccups that may have been related to a stab wound he received in 2018. [Nope, didn’t make that up, either.]
Mr. Bolsonaro had been hiccuping for 10 days, and was experiencing abdominal pain and difficulty speaking, when he entered the hospital on July 14. Since being stabbed while on the campaign trail, he has undergone several operations, which may have led to the partial intestinal obstruction that caused his latest symptoms.
His medical team advised Mr. Bolsonaro to go on a diet to aid his recovery, but when he was released on July 18 he said, “I hope in 10 days I’ll be eating barbecued ribs.” (Maybe this is all just a lucid dream. Probably shouldn’t have had ribs right before bed.)
Artificial intelligence wish list
Dear big-tech AI company,
I do understand, the benefits of artificial intelligence today are already profound and protean. Thanks to AI, I can translate Italian to English in real time in the same voice as an Italian speaker. I can be driven home autonomously by our Tesla. AI helps keep me safe by predicting crimes, on time by predicting traffic, and healthy by designing plant proteins that taste just like beef. I can even use AI to build a sprinkler to keep people off my new lawn.
In medicine, the AI news is so good that a frisson of excitement spreads vertically and horizontally across all health care. AI can detect pulmonary nodules, identify melanomas, develop new drugs – speed vaccine discovery! – and detect malignant cells on a biopsy slide. It can help predict who is going to crash in the ICU and recognize when someone is about to fall out of bed in the surgical unit. Even just this sampling of benefits proves how significant and impactful AI is in improving quality of life for patients and populations.
However, much of what I do every day in medicine cannot be solved with a neat quantitative analysis. The vast majority of my patients do not have a melanoma to be diagnosed or diabetic retinopathy to be scanned. What they want and need is time spent with me, their doctor. Although the schedule says I have 15 minutes (insufficient to begin with), patients are running late and are double booked, and I’ve loads of notes to type, medications to review, and messages to answer. Most days, I have only a fraction of 15 minutes to spend face to face with each patient.
Can AI please help us? How about reviewing the reams of data from my patient’s chart and presenting it to me succinctly? Rather than my tediously clicking through pathology reports, just summarize what skin cancers my patient has had and when. Rather than learning that my patient already failed Protopic a year ago, let me know that before I sign the order and promise: “Now, this ointment will work.” Even better, suggest alternative treatments that I might not be thinking of and which might do just the trick. Oh, and given my EMR has all the data required to determine billing codes, can you just drop that in for me when I’m done? Lastly, if the patient’s insurance is going to reject this claim or that medication, can AI please complete the authorization/paperwork/signed notary document/letter from U.S. senator that will be needed for it to be accepted?
I know this is possible. If we can blast a 70-year-old businessman into space on a private jet, surely you can invent an AI that gives us more time to spend with patients. Proposals postmarked by Dec. 31, 2021, please.
I’m sincerely yours,
Jeff Benabio, MD, MBA
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Dear big-tech AI company,
I do understand, the benefits of artificial intelligence today are already profound and protean. Thanks to AI, I can translate Italian to English in real time in the same voice as an Italian speaker. I can be driven home autonomously by our Tesla. AI helps keep me safe by predicting crimes, on time by predicting traffic, and healthy by designing plant proteins that taste just like beef. I can even use AI to build a sprinkler to keep people off my new lawn.
In medicine, the AI news is so good that a frisson of excitement spreads vertically and horizontally across all health care. AI can detect pulmonary nodules, identify melanomas, develop new drugs – speed vaccine discovery! – and detect malignant cells on a biopsy slide. It can help predict who is going to crash in the ICU and recognize when someone is about to fall out of bed in the surgical unit. Even just this sampling of benefits proves how significant and impactful AI is in improving quality of life for patients and populations.
However, much of what I do every day in medicine cannot be solved with a neat quantitative analysis. The vast majority of my patients do not have a melanoma to be diagnosed or diabetic retinopathy to be scanned. What they want and need is time spent with me, their doctor. Although the schedule says I have 15 minutes (insufficient to begin with), patients are running late and are double booked, and I’ve loads of notes to type, medications to review, and messages to answer. Most days, I have only a fraction of 15 minutes to spend face to face with each patient.
Can AI please help us? How about reviewing the reams of data from my patient’s chart and presenting it to me succinctly? Rather than my tediously clicking through pathology reports, just summarize what skin cancers my patient has had and when. Rather than learning that my patient already failed Protopic a year ago, let me know that before I sign the order and promise: “Now, this ointment will work.” Even better, suggest alternative treatments that I might not be thinking of and which might do just the trick. Oh, and given my EMR has all the data required to determine billing codes, can you just drop that in for me when I’m done? Lastly, if the patient’s insurance is going to reject this claim or that medication, can AI please complete the authorization/paperwork/signed notary document/letter from U.S. senator that will be needed for it to be accepted?
I know this is possible. If we can blast a 70-year-old businessman into space on a private jet, surely you can invent an AI that gives us more time to spend with patients. Proposals postmarked by Dec. 31, 2021, please.
I’m sincerely yours,
Jeff Benabio, MD, MBA
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Dear big-tech AI company,
I do understand, the benefits of artificial intelligence today are already profound and protean. Thanks to AI, I can translate Italian to English in real time in the same voice as an Italian speaker. I can be driven home autonomously by our Tesla. AI helps keep me safe by predicting crimes, on time by predicting traffic, and healthy by designing plant proteins that taste just like beef. I can even use AI to build a sprinkler to keep people off my new lawn.
In medicine, the AI news is so good that a frisson of excitement spreads vertically and horizontally across all health care. AI can detect pulmonary nodules, identify melanomas, develop new drugs – speed vaccine discovery! – and detect malignant cells on a biopsy slide. It can help predict who is going to crash in the ICU and recognize when someone is about to fall out of bed in the surgical unit. Even just this sampling of benefits proves how significant and impactful AI is in improving quality of life for patients and populations.
However, much of what I do every day in medicine cannot be solved with a neat quantitative analysis. The vast majority of my patients do not have a melanoma to be diagnosed or diabetic retinopathy to be scanned. What they want and need is time spent with me, their doctor. Although the schedule says I have 15 minutes (insufficient to begin with), patients are running late and are double booked, and I’ve loads of notes to type, medications to review, and messages to answer. Most days, I have only a fraction of 15 minutes to spend face to face with each patient.
Can AI please help us? How about reviewing the reams of data from my patient’s chart and presenting it to me succinctly? Rather than my tediously clicking through pathology reports, just summarize what skin cancers my patient has had and when. Rather than learning that my patient already failed Protopic a year ago, let me know that before I sign the order and promise: “Now, this ointment will work.” Even better, suggest alternative treatments that I might not be thinking of and which might do just the trick. Oh, and given my EMR has all the data required to determine billing codes, can you just drop that in for me when I’m done? Lastly, if the patient’s insurance is going to reject this claim or that medication, can AI please complete the authorization/paperwork/signed notary document/letter from U.S. senator that will be needed for it to be accepted?
I know this is possible. If we can blast a 70-year-old businessman into space on a private jet, surely you can invent an AI that gives us more time to spend with patients. Proposals postmarked by Dec. 31, 2021, please.
I’m sincerely yours,
Jeff Benabio, MD, MBA
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
The ADA and hearing-impaired patients
A recent claim against a New Jersey physician attracted considerable attention in both the medical and legal communities, not only because it resulted in a substantial jury award, but because that award was not covered by malpractice insurance.
It is a good reminder for the rest of us: This case involved a charge of discrimination against a hearing-impaired patient – which meant the physician not only had to fund his own defense, but was personally responsible for the $400,000 award against him.
The Americans with Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations – including, specifically, “the professional office of a health care professional.”
When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to insure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally it does not, particularly when complex medical concepts are involved; and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.
The claim involved a hearing-impaired patient with lupus erythematosus under treatment by a rheumatologist. For almost 2 years the patient’s partner and her daughter provided translation; but that arrangement was inadequate, she testified, because her partner and daughter were unfamiliar with medical terminology and she was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”
She repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and therefore exempt from ADA requirements.
But the undue-burden exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist’s annual income of $425,000 rendered the cost of an interpreter quite affordable.
The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved; and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.
In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be perfectly acceptable to one patient and unsuitable for another.
If the patient agrees to written notes and lip reading, as most do, you need to remember to speak slowly, and to write down critical information to avoid any miscommunications. And as always, it is crucial to document all communication, as well as the methods used for that communication – specifically including the fact that the patient agreed to those forms of communication. Documentation, as I’ve often said, is like garlic: There is no such thing as too much of it.
Should a patient not agree that written notes are sufficient, other alternatives can be offered: computer transcription, assistive listening devices, videotext displays (often available in hospitals), and telecommunication devices such as TTY and TDD. But if the patient rejects all of those options and continues to insist on a professional interpreter, the precedent set by the New Jersey case suggests that you need to acquiesce, even if the interpreter’s fee exceeds the visit reimbursement – and the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.
If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted or related to the patient (for HIPAA reasons). Your state may have an online registry of available interpreters, or your hospital may have a sign language interpreter on its staff that they might allow you to “borrow.”
The good news is several states have responded to this issue by introducing legislation that would require health insurance carriers to pay for the cost of interpreters, although none, as of this writing, have yet become law.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
A recent claim against a New Jersey physician attracted considerable attention in both the medical and legal communities, not only because it resulted in a substantial jury award, but because that award was not covered by malpractice insurance.
It is a good reminder for the rest of us: This case involved a charge of discrimination against a hearing-impaired patient – which meant the physician not only had to fund his own defense, but was personally responsible for the $400,000 award against him.
The Americans with Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations – including, specifically, “the professional office of a health care professional.”
When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to insure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally it does not, particularly when complex medical concepts are involved; and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.
The claim involved a hearing-impaired patient with lupus erythematosus under treatment by a rheumatologist. For almost 2 years the patient’s partner and her daughter provided translation; but that arrangement was inadequate, she testified, because her partner and daughter were unfamiliar with medical terminology and she was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”
She repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and therefore exempt from ADA requirements.
But the undue-burden exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist’s annual income of $425,000 rendered the cost of an interpreter quite affordable.
The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved; and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.
In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be perfectly acceptable to one patient and unsuitable for another.
If the patient agrees to written notes and lip reading, as most do, you need to remember to speak slowly, and to write down critical information to avoid any miscommunications. And as always, it is crucial to document all communication, as well as the methods used for that communication – specifically including the fact that the patient agreed to those forms of communication. Documentation, as I’ve often said, is like garlic: There is no such thing as too much of it.
Should a patient not agree that written notes are sufficient, other alternatives can be offered: computer transcription, assistive listening devices, videotext displays (often available in hospitals), and telecommunication devices such as TTY and TDD. But if the patient rejects all of those options and continues to insist on a professional interpreter, the precedent set by the New Jersey case suggests that you need to acquiesce, even if the interpreter’s fee exceeds the visit reimbursement – and the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.
If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted or related to the patient (for HIPAA reasons). Your state may have an online registry of available interpreters, or your hospital may have a sign language interpreter on its staff that they might allow you to “borrow.”
The good news is several states have responded to this issue by introducing legislation that would require health insurance carriers to pay for the cost of interpreters, although none, as of this writing, have yet become law.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
A recent claim against a New Jersey physician attracted considerable attention in both the medical and legal communities, not only because it resulted in a substantial jury award, but because that award was not covered by malpractice insurance.
It is a good reminder for the rest of us: This case involved a charge of discrimination against a hearing-impaired patient – which meant the physician not only had to fund his own defense, but was personally responsible for the $400,000 award against him.
The Americans with Disabilities Act (ADA) was designed to protect individuals with various disabilities against discrimination in various public situations – including, specifically, “the professional office of a health care professional.”
When the disability is impaired hearing, the law requires physicians to provide any “auxiliary aids and services” that might be necessary to insure clear communication between doctor and patient. In the vast majority of such situations, a pad and pencil will satisfy that requirement. But occasionally it does not, particularly when complex medical concepts are involved; and in such cases, as the New Jersey trial demonstrated, failure to make the necessary extra effort can be very expensive.
The claim involved a hearing-impaired patient with lupus erythematosus under treatment by a rheumatologist. For almost 2 years the patient’s partner and her daughter provided translation; but that arrangement was inadequate, she testified, because her partner and daughter were unfamiliar with medical terminology and she was “unable to understand and participate in her care,” which left her “unaware of risks and available alternatives.”
She repeatedly requested that the rheumatologist provide an American Sign Language interpreter for her office visits. He refused on grounds that the cost of an interpreter would exceed the payment he would receive for the visits, which made it an “undue financial burden,” and therefore exempt from ADA requirements.
But the undue-burden exemption is not automatic; it must be demonstrated in court. And the jury decided the rheumatologist’s annual income of $425,000 rendered the cost of an interpreter quite affordable.
The lessons are clear: Physicians must take antidiscrimination laws seriously, particularly when uninsurable issues are involved; and we must be constantly aware of the needs of disabled patients, to be sure their care is not substantially different from that of any other patient.
In the case of hearing-impaired or deaf patients, it is important to remember that forms of communication that are quite adequate for most are not appropriate for some. Lip reading, written notes, and the use of family members as interpreters may be perfectly acceptable to one patient and unsuitable for another.
If the patient agrees to written notes and lip reading, as most do, you need to remember to speak slowly, and to write down critical information to avoid any miscommunications. And as always, it is crucial to document all communication, as well as the methods used for that communication – specifically including the fact that the patient agreed to those forms of communication. Documentation, as I’ve often said, is like garlic: There is no such thing as too much of it.
Should a patient not agree that written notes are sufficient, other alternatives can be offered: computer transcription, assistive listening devices, videotext displays (often available in hospitals), and telecommunication devices such as TTY and TDD. But if the patient rejects all of those options and continues to insist on a professional interpreter, the precedent set by the New Jersey case suggests that you need to acquiesce, even if the interpreter’s fee exceeds the visit reimbursement – and the ADA prohibits you from passing your cost along to the patient. But any such cost will be far less than a noninsured judgment against you.
If you must go that route, make sure the interpreter you hire is familiar with medical terminology, and is not acquainted or related to the patient (for HIPAA reasons). Your state may have an online registry of available interpreters, or your hospital may have a sign language interpreter on its staff that they might allow you to “borrow.”
The good news is several states have responded to this issue by introducing legislation that would require health insurance carriers to pay for the cost of interpreters, although none, as of this writing, have yet become law.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
Legislative wins set groundwork for future success
I receive updates and stories every day from rheumatologists and their offices regarding the egregious behavior of various health care entities that profit off patients and harm them in the process. If you know me, you know I’m willing to tell and retell horror stories of pharmacy benefit managers (PBMs), especially of how they construct formularies for the most profit, again, harming patients in the process. It’s critical to serve as a voice to counter the PBM trade group, the Pharmaceutical Care Management Association, which continues to extol how PBMs are essentially saving our country billions ... one restrictive formulary at a time.
It does seem that we are constantly fighting against something:
- Patients arbitrarily being switched to completely different medications to “save” money. These “savings” are pocketed by the middlemen, not the patients or the employers paying for the coverage.
- Copay cards for medications that have no lower-cost alternative. These fill the coffers of the health plans without patients getting credit toward their deductible.
- Mandating that patients move from receiving their infusions under the watchful eye of their rheumatologist’s office to home infusion. This has been shown to be more dangerous for our patients.
- Wasting hours on prior authorization paperwork for needed medication. We know that these are nearly always approved, and thereby delay treatment unnecessarily.
By now you might wonder: “Where is the good news?” In spite of the daily barrage of battles that come our way, rheumatologists continue to do good and improve the lives of our patients. I would go as far as to say that we are prospering in spite of the challenges. Why? Because every day there are wins. Seeing that smile for the first time on the face of a patient who finally has answers and a treatment plan for their newly diagnosed RA. Walking out of the exam room and having patients and their parents give you a hug. Helping a dad be able to walk his daughter down the aisle with ease. On the clinical front, I don’t have to tell you: We score wins every single day.
There is good news on the advocacy side, too. In my own state of Louisiana, this legislative session, we passed a number of bills that are beneficial to our patients, including a bill to stop the aforementioned attacks on copay assistance by state regulated payers. We even blocked one that the Rheumatology Alliance of Louisiana felt would be harmful to our patients. The wins this session follow wins during the previous session, including passage of new and updated laws to put more prescribing power back in the hands of physicians when medication access is unnecessarily restricted by step therapy. While there has been some doubt as to whether these state laws actually work, I can attest that the new Louisiana step therapy law has allowed stable patients to remain on their medication in a number of specialties, including rheumatology and ophthalmology.
My own state of Louisiana is not the only one where the rheumatology community has seen legislative successes, and that speaks to the strength of the network that rheumatologists have built within their states and across the country, as well as our passion for our patients. Just 3 years after the emergence of accumulator programs, 11 states have already seen fit to curtail their use (Arizona, Arkansas, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Oklahoma, Tennessee, Virginia, and West Virginia), and over 20 states considered adopting similar legislation this year. Reforms to the use of step therapy continue their drumbeat across the country, with three more states (Arkansas, Nebraska, and Oregon) having bills signed into law this year. West Virginia took a bold step to reduce patient out-of-pocket costs at the point of sale by an amount commensurate with 100% of rebates received by a PBM. These material policy wins demonstrate how we continue to successfully chip away at the opacity of PBMs and the rebate system, which is truly at the root of so many of the issues affecting our patients’ care.
At the federal level, rheumatologists engage both with Congress and the administration to ensure that our patients’ voices are represented against very well funded and organized forces like insurers and PBMs. Rheumatologists weighed in on issues ranging from Medicaid payment policy, to copay accumulators in the exchanges, to creating transparency and fixing misaligned incentives in the pharmaceutical supply chain. We drive coalition engagement on issues of shared interest with other specialty and provider groups, such as extending a moratorium on Medicare sequestration. We also engage on narrow issues as they arise: For example, I personally testified before Congress that any proposed limitations on pharmaceutical samples must consider the fact that these samples can provide a critical bridge for patients waiting for their insurers to approve their needed medication. And, perhaps most importantly, we have defeated misguided and potentially devastating Part B payment reform models from the Innovation Center three separate times.
There is more work to be done. And to make it easier to find “Rheum for Action” in your daily work, the Coalition of State Rheumatology Organizations has tools on our website that summarize legislation and facilitate engagement with policy makers, including thank you messages to those who supported our priorities to celebrate the good news this year.
So yes, there is good news now, and more to come! I am optimistic that we will continue to see these advocacy wins, which will help to ensure that those hugs we share with our patients will continue long into the future.
Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is President of the CSRO, chair of the Alliance for Safe Biologic Medicines, and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at rhnews@mdedge.com.
I receive updates and stories every day from rheumatologists and their offices regarding the egregious behavior of various health care entities that profit off patients and harm them in the process. If you know me, you know I’m willing to tell and retell horror stories of pharmacy benefit managers (PBMs), especially of how they construct formularies for the most profit, again, harming patients in the process. It’s critical to serve as a voice to counter the PBM trade group, the Pharmaceutical Care Management Association, which continues to extol how PBMs are essentially saving our country billions ... one restrictive formulary at a time.
It does seem that we are constantly fighting against something:
- Patients arbitrarily being switched to completely different medications to “save” money. These “savings” are pocketed by the middlemen, not the patients or the employers paying for the coverage.
- Copay cards for medications that have no lower-cost alternative. These fill the coffers of the health plans without patients getting credit toward their deductible.
- Mandating that patients move from receiving their infusions under the watchful eye of their rheumatologist’s office to home infusion. This has been shown to be more dangerous for our patients.
- Wasting hours on prior authorization paperwork for needed medication. We know that these are nearly always approved, and thereby delay treatment unnecessarily.
By now you might wonder: “Where is the good news?” In spite of the daily barrage of battles that come our way, rheumatologists continue to do good and improve the lives of our patients. I would go as far as to say that we are prospering in spite of the challenges. Why? Because every day there are wins. Seeing that smile for the first time on the face of a patient who finally has answers and a treatment plan for their newly diagnosed RA. Walking out of the exam room and having patients and their parents give you a hug. Helping a dad be able to walk his daughter down the aisle with ease. On the clinical front, I don’t have to tell you: We score wins every single day.
There is good news on the advocacy side, too. In my own state of Louisiana, this legislative session, we passed a number of bills that are beneficial to our patients, including a bill to stop the aforementioned attacks on copay assistance by state regulated payers. We even blocked one that the Rheumatology Alliance of Louisiana felt would be harmful to our patients. The wins this session follow wins during the previous session, including passage of new and updated laws to put more prescribing power back in the hands of physicians when medication access is unnecessarily restricted by step therapy. While there has been some doubt as to whether these state laws actually work, I can attest that the new Louisiana step therapy law has allowed stable patients to remain on their medication in a number of specialties, including rheumatology and ophthalmology.
My own state of Louisiana is not the only one where the rheumatology community has seen legislative successes, and that speaks to the strength of the network that rheumatologists have built within their states and across the country, as well as our passion for our patients. Just 3 years after the emergence of accumulator programs, 11 states have already seen fit to curtail their use (Arizona, Arkansas, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Oklahoma, Tennessee, Virginia, and West Virginia), and over 20 states considered adopting similar legislation this year. Reforms to the use of step therapy continue their drumbeat across the country, with three more states (Arkansas, Nebraska, and Oregon) having bills signed into law this year. West Virginia took a bold step to reduce patient out-of-pocket costs at the point of sale by an amount commensurate with 100% of rebates received by a PBM. These material policy wins demonstrate how we continue to successfully chip away at the opacity of PBMs and the rebate system, which is truly at the root of so many of the issues affecting our patients’ care.
At the federal level, rheumatologists engage both with Congress and the administration to ensure that our patients’ voices are represented against very well funded and organized forces like insurers and PBMs. Rheumatologists weighed in on issues ranging from Medicaid payment policy, to copay accumulators in the exchanges, to creating transparency and fixing misaligned incentives in the pharmaceutical supply chain. We drive coalition engagement on issues of shared interest with other specialty and provider groups, such as extending a moratorium on Medicare sequestration. We also engage on narrow issues as they arise: For example, I personally testified before Congress that any proposed limitations on pharmaceutical samples must consider the fact that these samples can provide a critical bridge for patients waiting for their insurers to approve their needed medication. And, perhaps most importantly, we have defeated misguided and potentially devastating Part B payment reform models from the Innovation Center three separate times.
There is more work to be done. And to make it easier to find “Rheum for Action” in your daily work, the Coalition of State Rheumatology Organizations has tools on our website that summarize legislation and facilitate engagement with policy makers, including thank you messages to those who supported our priorities to celebrate the good news this year.
So yes, there is good news now, and more to come! I am optimistic that we will continue to see these advocacy wins, which will help to ensure that those hugs we share with our patients will continue long into the future.
Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is President of the CSRO, chair of the Alliance for Safe Biologic Medicines, and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at rhnews@mdedge.com.
I receive updates and stories every day from rheumatologists and their offices regarding the egregious behavior of various health care entities that profit off patients and harm them in the process. If you know me, you know I’m willing to tell and retell horror stories of pharmacy benefit managers (PBMs), especially of how they construct formularies for the most profit, again, harming patients in the process. It’s critical to serve as a voice to counter the PBM trade group, the Pharmaceutical Care Management Association, which continues to extol how PBMs are essentially saving our country billions ... one restrictive formulary at a time.
It does seem that we are constantly fighting against something:
- Patients arbitrarily being switched to completely different medications to “save” money. These “savings” are pocketed by the middlemen, not the patients or the employers paying for the coverage.
- Copay cards for medications that have no lower-cost alternative. These fill the coffers of the health plans without patients getting credit toward their deductible.
- Mandating that patients move from receiving their infusions under the watchful eye of their rheumatologist’s office to home infusion. This has been shown to be more dangerous for our patients.
- Wasting hours on prior authorization paperwork for needed medication. We know that these are nearly always approved, and thereby delay treatment unnecessarily.
By now you might wonder: “Where is the good news?” In spite of the daily barrage of battles that come our way, rheumatologists continue to do good and improve the lives of our patients. I would go as far as to say that we are prospering in spite of the challenges. Why? Because every day there are wins. Seeing that smile for the first time on the face of a patient who finally has answers and a treatment plan for their newly diagnosed RA. Walking out of the exam room and having patients and their parents give you a hug. Helping a dad be able to walk his daughter down the aisle with ease. On the clinical front, I don’t have to tell you: We score wins every single day.
There is good news on the advocacy side, too. In my own state of Louisiana, this legislative session, we passed a number of bills that are beneficial to our patients, including a bill to stop the aforementioned attacks on copay assistance by state regulated payers. We even blocked one that the Rheumatology Alliance of Louisiana felt would be harmful to our patients. The wins this session follow wins during the previous session, including passage of new and updated laws to put more prescribing power back in the hands of physicians when medication access is unnecessarily restricted by step therapy. While there has been some doubt as to whether these state laws actually work, I can attest that the new Louisiana step therapy law has allowed stable patients to remain on their medication in a number of specialties, including rheumatology and ophthalmology.
My own state of Louisiana is not the only one where the rheumatology community has seen legislative successes, and that speaks to the strength of the network that rheumatologists have built within their states and across the country, as well as our passion for our patients. Just 3 years after the emergence of accumulator programs, 11 states have already seen fit to curtail their use (Arizona, Arkansas, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Oklahoma, Tennessee, Virginia, and West Virginia), and over 20 states considered adopting similar legislation this year. Reforms to the use of step therapy continue their drumbeat across the country, with three more states (Arkansas, Nebraska, and Oregon) having bills signed into law this year. West Virginia took a bold step to reduce patient out-of-pocket costs at the point of sale by an amount commensurate with 100% of rebates received by a PBM. These material policy wins demonstrate how we continue to successfully chip away at the opacity of PBMs and the rebate system, which is truly at the root of so many of the issues affecting our patients’ care.
At the federal level, rheumatologists engage both with Congress and the administration to ensure that our patients’ voices are represented against very well funded and organized forces like insurers and PBMs. Rheumatologists weighed in on issues ranging from Medicaid payment policy, to copay accumulators in the exchanges, to creating transparency and fixing misaligned incentives in the pharmaceutical supply chain. We drive coalition engagement on issues of shared interest with other specialty and provider groups, such as extending a moratorium on Medicare sequestration. We also engage on narrow issues as they arise: For example, I personally testified before Congress that any proposed limitations on pharmaceutical samples must consider the fact that these samples can provide a critical bridge for patients waiting for their insurers to approve their needed medication. And, perhaps most importantly, we have defeated misguided and potentially devastating Part B payment reform models from the Innovation Center three separate times.
There is more work to be done. And to make it easier to find “Rheum for Action” in your daily work, the Coalition of State Rheumatology Organizations has tools on our website that summarize legislation and facilitate engagement with policy makers, including thank you messages to those who supported our priorities to celebrate the good news this year.
So yes, there is good news now, and more to come! I am optimistic that we will continue to see these advocacy wins, which will help to ensure that those hugs we share with our patients will continue long into the future.
Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is President of the CSRO, chair of the Alliance for Safe Biologic Medicines, and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at rhnews@mdedge.com.
Rheumatologists’ industry payments rise, primarily go to small minority
Practicing rheumatologists in the United States received more than $220 million from pharmaceutical companies during 2014-2019, with payments increasing each year, according to findings from a descriptive study of the Centers for Medicare & Medicaid Services Open Payments Database.
Rheumatologists have identified conflicts of interest as an ethical concern, but the details of industry payments to rheumatologists have not been investigated, wrote Michael Putman, MD, of the Medical College of Wisconsin, Milwaukee, and colleagues in Arthritis & Rheumatology. “Payments among rheumatologists may be of particular interest,” given their frequent prescription of expensive and primarily on-patent biologic and targeted disease-modifying antirheumatic drugs (DMARDs), the researchers said.
Over the 2014-2019 study period, 5,723 rheumatologists received a total of $221,254,966 from 1,610,668 payments. Of these, 3,416 (59%) received less than $5,000; 368 (6%) received more than $100,000, accounting for 78% of the total payments. The yearly value of the payments increased from $29,755,133 in 2014 to $46,308,926 in 2019, a 56% increase.
The payments to individual rheumatologists during the study period ranged from $8 to $5,612,254, with a median individual payment of $2,818. However, most (81%) of the payments were less than $25, and only 4% were more than $1,000.
Physicians who received more than $100,000 were significantly more likely to be paid speakers’ fees, consulting fees, and travel and lodging fees, but significantly less likely to receive payments for food and beverage than were those who received less than $100,000.
Overall, women made up 43% of the study population and received 34% of the total payments.
However, the median payment to male rheumatologists was significantly higher than the median payment to female rheumatologists ($3,732 vs. $2,084). Female rheumatologists were significantly more likely to receive payments for food and beverage and significantly less likely to receive speakers’ fees or travel and lodging coverage.
When the data were analyzed by state, California had the highest amount of total payments ($27,769,124), followed by New York and Texas, while Arizona had the highest spending per rheumatologist ($143,559). By region, based on U.S. Census divisions, the highest spending occurred in the Middle Atlantic Division ($46,327,351) and the highest per rheumatologist spending occurred in the East-South Central Division ($49,605).
“These data suggest industry payments in rheumatology have followed two distinct patterns, which have been observed in other medical subspecialties,” specifically, that many small payments are made to a large number of physicians, and large-value payments are made to a small number of physicians, the researchers noted.
The impact of small payments cannot be discounted, they said, “as even small gifts may affect behavior and are associated with prescribing patterns.” The impact of large payments on behavior and practice deserve further investigation, “but it is notable that a recent evaluation of rheumatology clinical practice guidelines identified substantial involvement from rheumatologists who had accepted large values of industry payments,” the researchers added.
Approximately half the total value of payments came from three companies: Bristol-Myers Squibb (20%), Abbvie (17%), and Pfizer (12%). Medications associated with the highest spending included Otezla, Humira, and Xeljanz.
Of note, the data showed that H.P. Acthar gel was among the top 10 agents for total payments, and “over 90% of rheumatologists who frequently prescribe H.P. Acthar gel have also received H.P. Acthar–related payments, raising the possibility that such payments have influenced prescribing behavior,” given the lack of high-quality evidence to support its use and the availability of less expensive alternatives, the researchers said.
The study findings were limited by several factors, including the focus only on general payments to rheumatologists, and the lack of external sources to verify payments, the researchers noted. “Most importantly, this was a descriptive study, and the degree to which payments have influenced physician behavior lies outside the scope of this work. Future studies should investigate the degree to which industry payments have influenced prescribing in the field of rheumatology.”
Focus on collaborations that add value
The study is important because previous data on the magnitude of payments or payment patterns from pharmaceutical companies to practicing rheumatologists were limited, lead author Dr. Putman said in an interview.
“I was most surprised by some of the medications that received high values of payments,” he said. “Many payments were linked to medications that we use commonly and that have high-quality data supporting their use. That was not surprising, and you could imagine dollars spent on [interleukin]-23 or IL-17 inhibitors being used in a way that is valuable to other physicians or to patients with rheumatic diseases. On the other hand, some medications – most notably H.P. Acthar gel – have no high-quality data supporting their use, are used by a very small cadre of physicians, and are extraordinarily expensive. At least in my opinion, there is no world where payments linked to H.P. Acthar gel provide any benefit for physicians or patients.”
Dr. Putman said he expected that the patterns and the increases observed in the study are likely to continue.
“Ultimately, I have a somewhat nuanced view of financial conflicts of interest,” he said. “Collaborations between the pharmaceutical industry and rheumatologists have provided extraordinary value to our field. I think rheumatologists should be much more involved in some areas. At the same time, I think we should be much less involved in marketing drugs that provide little value to patients and great cost to society. H.P. Acthar Gel is the classic example of this, but there are others as well. I think future research should focus on how these payments influence behavior and should seek to identify areas where they result in low-value care.” Going forward, valuable collaborations between rheumatologists and the pharmaceutical industry should be encouraged, but collaborations without value should be discouraged, he said.
Industry payments serve no useful purpose
The findings “highlight the overarching concern regarding the ability of industry payments to adversely affect care quality within the specific context of rheumatology practice,” Aaron P. Mitchell, MD, of Memorial Sloan Kettering Cancer Center, New York, wrote in an accompanying editorial.
Dr. Mitchell emphasized several points, starting with the temporal trend showing an increase in industry payments beyond the rate of inflation that has not been universal across specialties. He also emphasized the “highly skewed distribution of payments,” with a large majority going to a relatively small number of rheumatologists. “This suggests an industry strategy of targeting ‘key opinion leaders,’ or KOLs, with higher payments,” and which was not surprising, as similar patterns have been seen in other specialties. Dr. Mitchell noted that 10 drugs accounted for more than half of the payments, and that “the unifying feature of these drugs is their high cost.”
“The picture of industry strategy that emerges from Putman et al. and other similar reports is that of intense, sustained KOL-focused marketing soon after the release of a new high-margin drug,” he wrote.
Despite the descriptive nature of the study, the findings have clinical implications based on other studies of the consequences of industry payments with respect to care quality, Dr. Mitchell said. “Hypothetically, industry spending to promote drugs to physicians could increase dissemination of new, superior drugs, improving patient outcomes.” However, physicians tend to opt for game-changing drugs without added incentive; “it is the less-innovative drugs that industry has to push harder.”
The practice of industry payments for physicians becomes even more difficult to rationalize given the potential for increased out-of-pocket costs and potentially avoidable toxicities for patients, Dr. Mitchell said. “Moreover, industry payments serve no unmet need; through our professional societies and other nonprofit sources, we physicians are fully capable of staying up-to-date on new treatments without relying on industry meals and sponsored events.”
Disclosure of payments is important
The study is important because it is essential to understand how public disclosure of industry payments influences financial relationship between the biomedical industry and physicians, said Amarnath Annapureddy, MD, a clinical fellow in cardiology at Yale University, New Haven, Conn., who has studied and written about industry payments to physicians.
Dr. Annapureddy said in an interview that he was surprised by how the study findings were opposite to the assumption that public disclosure would dissuade continuation of financial ties between physicians and industry. “This study showed payments increased over time rather than decreasing due to public disclosure.”
However, Dr. Annapureddy said that he was not surprised at how few physicians received the bulk of industry payments. “These physicians are considered to be ‘key opinion leaders’ who could influence practicing patterns of other physicians. These findings are similar to payment patterns for other specialties, including cardiology.
“So far, no study has evaluated factors that drive changes in industry payment patterns,” Dr. Annapureddy said. “I anticipate the patterns noted in this study will continue at least in the short term. If health care systems mandate physicians to disclose potential conflicts of interest to the patients, it may reduce payments.”
However, “unless, there is a major health policy mandate by government, I anticipate public disclosure of payments through the open payments program will not impact industry-physician ties,” he said. “This study has not evaluated impact of payments on prescribing practices. There are overwhelming data from several studies that showed payments influence physicians practicing patterns, whether it is prescribing a medication or implanting a device.” However, as for additional research, Dr. Annapureddy said that it would interesting to see a randomized trial to show whether the way physicians disclose their financial ties with patients would impact their practicing patterns.
The study received no outside funding. Dr. Putman was supported by a Rheumatology Research grant, but he and the other researchers had no financial conflicts to disclose. Dr. Mitchell disclosed a merit award from the nonprofit Conquer Cancer Foundation, for which the Foundation received financial support from Merck. Dr. Annapureddy had no financial conflicts to disclose.
Practicing rheumatologists in the United States received more than $220 million from pharmaceutical companies during 2014-2019, with payments increasing each year, according to findings from a descriptive study of the Centers for Medicare & Medicaid Services Open Payments Database.
Rheumatologists have identified conflicts of interest as an ethical concern, but the details of industry payments to rheumatologists have not been investigated, wrote Michael Putman, MD, of the Medical College of Wisconsin, Milwaukee, and colleagues in Arthritis & Rheumatology. “Payments among rheumatologists may be of particular interest,” given their frequent prescription of expensive and primarily on-patent biologic and targeted disease-modifying antirheumatic drugs (DMARDs), the researchers said.
Over the 2014-2019 study period, 5,723 rheumatologists received a total of $221,254,966 from 1,610,668 payments. Of these, 3,416 (59%) received less than $5,000; 368 (6%) received more than $100,000, accounting for 78% of the total payments. The yearly value of the payments increased from $29,755,133 in 2014 to $46,308,926 in 2019, a 56% increase.
The payments to individual rheumatologists during the study period ranged from $8 to $5,612,254, with a median individual payment of $2,818. However, most (81%) of the payments were less than $25, and only 4% were more than $1,000.
Physicians who received more than $100,000 were significantly more likely to be paid speakers’ fees, consulting fees, and travel and lodging fees, but significantly less likely to receive payments for food and beverage than were those who received less than $100,000.
Overall, women made up 43% of the study population and received 34% of the total payments.
However, the median payment to male rheumatologists was significantly higher than the median payment to female rheumatologists ($3,732 vs. $2,084). Female rheumatologists were significantly more likely to receive payments for food and beverage and significantly less likely to receive speakers’ fees or travel and lodging coverage.
When the data were analyzed by state, California had the highest amount of total payments ($27,769,124), followed by New York and Texas, while Arizona had the highest spending per rheumatologist ($143,559). By region, based on U.S. Census divisions, the highest spending occurred in the Middle Atlantic Division ($46,327,351) and the highest per rheumatologist spending occurred in the East-South Central Division ($49,605).
“These data suggest industry payments in rheumatology have followed two distinct patterns, which have been observed in other medical subspecialties,” specifically, that many small payments are made to a large number of physicians, and large-value payments are made to a small number of physicians, the researchers noted.
The impact of small payments cannot be discounted, they said, “as even small gifts may affect behavior and are associated with prescribing patterns.” The impact of large payments on behavior and practice deserve further investigation, “but it is notable that a recent evaluation of rheumatology clinical practice guidelines identified substantial involvement from rheumatologists who had accepted large values of industry payments,” the researchers added.
Approximately half the total value of payments came from three companies: Bristol-Myers Squibb (20%), Abbvie (17%), and Pfizer (12%). Medications associated with the highest spending included Otezla, Humira, and Xeljanz.
Of note, the data showed that H.P. Acthar gel was among the top 10 agents for total payments, and “over 90% of rheumatologists who frequently prescribe H.P. Acthar gel have also received H.P. Acthar–related payments, raising the possibility that such payments have influenced prescribing behavior,” given the lack of high-quality evidence to support its use and the availability of less expensive alternatives, the researchers said.
The study findings were limited by several factors, including the focus only on general payments to rheumatologists, and the lack of external sources to verify payments, the researchers noted. “Most importantly, this was a descriptive study, and the degree to which payments have influenced physician behavior lies outside the scope of this work. Future studies should investigate the degree to which industry payments have influenced prescribing in the field of rheumatology.”
Focus on collaborations that add value
The study is important because previous data on the magnitude of payments or payment patterns from pharmaceutical companies to practicing rheumatologists were limited, lead author Dr. Putman said in an interview.
“I was most surprised by some of the medications that received high values of payments,” he said. “Many payments were linked to medications that we use commonly and that have high-quality data supporting their use. That was not surprising, and you could imagine dollars spent on [interleukin]-23 or IL-17 inhibitors being used in a way that is valuable to other physicians or to patients with rheumatic diseases. On the other hand, some medications – most notably H.P. Acthar gel – have no high-quality data supporting their use, are used by a very small cadre of physicians, and are extraordinarily expensive. At least in my opinion, there is no world where payments linked to H.P. Acthar gel provide any benefit for physicians or patients.”
Dr. Putman said he expected that the patterns and the increases observed in the study are likely to continue.
“Ultimately, I have a somewhat nuanced view of financial conflicts of interest,” he said. “Collaborations between the pharmaceutical industry and rheumatologists have provided extraordinary value to our field. I think rheumatologists should be much more involved in some areas. At the same time, I think we should be much less involved in marketing drugs that provide little value to patients and great cost to society. H.P. Acthar Gel is the classic example of this, but there are others as well. I think future research should focus on how these payments influence behavior and should seek to identify areas where they result in low-value care.” Going forward, valuable collaborations between rheumatologists and the pharmaceutical industry should be encouraged, but collaborations without value should be discouraged, he said.
Industry payments serve no useful purpose
The findings “highlight the overarching concern regarding the ability of industry payments to adversely affect care quality within the specific context of rheumatology practice,” Aaron P. Mitchell, MD, of Memorial Sloan Kettering Cancer Center, New York, wrote in an accompanying editorial.
Dr. Mitchell emphasized several points, starting with the temporal trend showing an increase in industry payments beyond the rate of inflation that has not been universal across specialties. He also emphasized the “highly skewed distribution of payments,” with a large majority going to a relatively small number of rheumatologists. “This suggests an industry strategy of targeting ‘key opinion leaders,’ or KOLs, with higher payments,” and which was not surprising, as similar patterns have been seen in other specialties. Dr. Mitchell noted that 10 drugs accounted for more than half of the payments, and that “the unifying feature of these drugs is their high cost.”
“The picture of industry strategy that emerges from Putman et al. and other similar reports is that of intense, sustained KOL-focused marketing soon after the release of a new high-margin drug,” he wrote.
Despite the descriptive nature of the study, the findings have clinical implications based on other studies of the consequences of industry payments with respect to care quality, Dr. Mitchell said. “Hypothetically, industry spending to promote drugs to physicians could increase dissemination of new, superior drugs, improving patient outcomes.” However, physicians tend to opt for game-changing drugs without added incentive; “it is the less-innovative drugs that industry has to push harder.”
The practice of industry payments for physicians becomes even more difficult to rationalize given the potential for increased out-of-pocket costs and potentially avoidable toxicities for patients, Dr. Mitchell said. “Moreover, industry payments serve no unmet need; through our professional societies and other nonprofit sources, we physicians are fully capable of staying up-to-date on new treatments without relying on industry meals and sponsored events.”
Disclosure of payments is important
The study is important because it is essential to understand how public disclosure of industry payments influences financial relationship between the biomedical industry and physicians, said Amarnath Annapureddy, MD, a clinical fellow in cardiology at Yale University, New Haven, Conn., who has studied and written about industry payments to physicians.
Dr. Annapureddy said in an interview that he was surprised by how the study findings were opposite to the assumption that public disclosure would dissuade continuation of financial ties between physicians and industry. “This study showed payments increased over time rather than decreasing due to public disclosure.”
However, Dr. Annapureddy said that he was not surprised at how few physicians received the bulk of industry payments. “These physicians are considered to be ‘key opinion leaders’ who could influence practicing patterns of other physicians. These findings are similar to payment patterns for other specialties, including cardiology.
“So far, no study has evaluated factors that drive changes in industry payment patterns,” Dr. Annapureddy said. “I anticipate the patterns noted in this study will continue at least in the short term. If health care systems mandate physicians to disclose potential conflicts of interest to the patients, it may reduce payments.”
However, “unless, there is a major health policy mandate by government, I anticipate public disclosure of payments through the open payments program will not impact industry-physician ties,” he said. “This study has not evaluated impact of payments on prescribing practices. There are overwhelming data from several studies that showed payments influence physicians practicing patterns, whether it is prescribing a medication or implanting a device.” However, as for additional research, Dr. Annapureddy said that it would interesting to see a randomized trial to show whether the way physicians disclose their financial ties with patients would impact their practicing patterns.
The study received no outside funding. Dr. Putman was supported by a Rheumatology Research grant, but he and the other researchers had no financial conflicts to disclose. Dr. Mitchell disclosed a merit award from the nonprofit Conquer Cancer Foundation, for which the Foundation received financial support from Merck. Dr. Annapureddy had no financial conflicts to disclose.
Practicing rheumatologists in the United States received more than $220 million from pharmaceutical companies during 2014-2019, with payments increasing each year, according to findings from a descriptive study of the Centers for Medicare & Medicaid Services Open Payments Database.
Rheumatologists have identified conflicts of interest as an ethical concern, but the details of industry payments to rheumatologists have not been investigated, wrote Michael Putman, MD, of the Medical College of Wisconsin, Milwaukee, and colleagues in Arthritis & Rheumatology. “Payments among rheumatologists may be of particular interest,” given their frequent prescription of expensive and primarily on-patent biologic and targeted disease-modifying antirheumatic drugs (DMARDs), the researchers said.
Over the 2014-2019 study period, 5,723 rheumatologists received a total of $221,254,966 from 1,610,668 payments. Of these, 3,416 (59%) received less than $5,000; 368 (6%) received more than $100,000, accounting for 78% of the total payments. The yearly value of the payments increased from $29,755,133 in 2014 to $46,308,926 in 2019, a 56% increase.
The payments to individual rheumatologists during the study period ranged from $8 to $5,612,254, with a median individual payment of $2,818. However, most (81%) of the payments were less than $25, and only 4% were more than $1,000.
Physicians who received more than $100,000 were significantly more likely to be paid speakers’ fees, consulting fees, and travel and lodging fees, but significantly less likely to receive payments for food and beverage than were those who received less than $100,000.
Overall, women made up 43% of the study population and received 34% of the total payments.
However, the median payment to male rheumatologists was significantly higher than the median payment to female rheumatologists ($3,732 vs. $2,084). Female rheumatologists were significantly more likely to receive payments for food and beverage and significantly less likely to receive speakers’ fees or travel and lodging coverage.
When the data were analyzed by state, California had the highest amount of total payments ($27,769,124), followed by New York and Texas, while Arizona had the highest spending per rheumatologist ($143,559). By region, based on U.S. Census divisions, the highest spending occurred in the Middle Atlantic Division ($46,327,351) and the highest per rheumatologist spending occurred in the East-South Central Division ($49,605).
“These data suggest industry payments in rheumatology have followed two distinct patterns, which have been observed in other medical subspecialties,” specifically, that many small payments are made to a large number of physicians, and large-value payments are made to a small number of physicians, the researchers noted.
The impact of small payments cannot be discounted, they said, “as even small gifts may affect behavior and are associated with prescribing patterns.” The impact of large payments on behavior and practice deserve further investigation, “but it is notable that a recent evaluation of rheumatology clinical practice guidelines identified substantial involvement from rheumatologists who had accepted large values of industry payments,” the researchers added.
Approximately half the total value of payments came from three companies: Bristol-Myers Squibb (20%), Abbvie (17%), and Pfizer (12%). Medications associated with the highest spending included Otezla, Humira, and Xeljanz.
Of note, the data showed that H.P. Acthar gel was among the top 10 agents for total payments, and “over 90% of rheumatologists who frequently prescribe H.P. Acthar gel have also received H.P. Acthar–related payments, raising the possibility that such payments have influenced prescribing behavior,” given the lack of high-quality evidence to support its use and the availability of less expensive alternatives, the researchers said.
The study findings were limited by several factors, including the focus only on general payments to rheumatologists, and the lack of external sources to verify payments, the researchers noted. “Most importantly, this was a descriptive study, and the degree to which payments have influenced physician behavior lies outside the scope of this work. Future studies should investigate the degree to which industry payments have influenced prescribing in the field of rheumatology.”
Focus on collaborations that add value
The study is important because previous data on the magnitude of payments or payment patterns from pharmaceutical companies to practicing rheumatologists were limited, lead author Dr. Putman said in an interview.
“I was most surprised by some of the medications that received high values of payments,” he said. “Many payments were linked to medications that we use commonly and that have high-quality data supporting their use. That was not surprising, and you could imagine dollars spent on [interleukin]-23 or IL-17 inhibitors being used in a way that is valuable to other physicians or to patients with rheumatic diseases. On the other hand, some medications – most notably H.P. Acthar gel – have no high-quality data supporting their use, are used by a very small cadre of physicians, and are extraordinarily expensive. At least in my opinion, there is no world where payments linked to H.P. Acthar gel provide any benefit for physicians or patients.”
Dr. Putman said he expected that the patterns and the increases observed in the study are likely to continue.
“Ultimately, I have a somewhat nuanced view of financial conflicts of interest,” he said. “Collaborations between the pharmaceutical industry and rheumatologists have provided extraordinary value to our field. I think rheumatologists should be much more involved in some areas. At the same time, I think we should be much less involved in marketing drugs that provide little value to patients and great cost to society. H.P. Acthar Gel is the classic example of this, but there are others as well. I think future research should focus on how these payments influence behavior and should seek to identify areas where they result in low-value care.” Going forward, valuable collaborations between rheumatologists and the pharmaceutical industry should be encouraged, but collaborations without value should be discouraged, he said.
Industry payments serve no useful purpose
The findings “highlight the overarching concern regarding the ability of industry payments to adversely affect care quality within the specific context of rheumatology practice,” Aaron P. Mitchell, MD, of Memorial Sloan Kettering Cancer Center, New York, wrote in an accompanying editorial.
Dr. Mitchell emphasized several points, starting with the temporal trend showing an increase in industry payments beyond the rate of inflation that has not been universal across specialties. He also emphasized the “highly skewed distribution of payments,” with a large majority going to a relatively small number of rheumatologists. “This suggests an industry strategy of targeting ‘key opinion leaders,’ or KOLs, with higher payments,” and which was not surprising, as similar patterns have been seen in other specialties. Dr. Mitchell noted that 10 drugs accounted for more than half of the payments, and that “the unifying feature of these drugs is their high cost.”
“The picture of industry strategy that emerges from Putman et al. and other similar reports is that of intense, sustained KOL-focused marketing soon after the release of a new high-margin drug,” he wrote.
Despite the descriptive nature of the study, the findings have clinical implications based on other studies of the consequences of industry payments with respect to care quality, Dr. Mitchell said. “Hypothetically, industry spending to promote drugs to physicians could increase dissemination of new, superior drugs, improving patient outcomes.” However, physicians tend to opt for game-changing drugs without added incentive; “it is the less-innovative drugs that industry has to push harder.”
The practice of industry payments for physicians becomes even more difficult to rationalize given the potential for increased out-of-pocket costs and potentially avoidable toxicities for patients, Dr. Mitchell said. “Moreover, industry payments serve no unmet need; through our professional societies and other nonprofit sources, we physicians are fully capable of staying up-to-date on new treatments without relying on industry meals and sponsored events.”
Disclosure of payments is important
The study is important because it is essential to understand how public disclosure of industry payments influences financial relationship between the biomedical industry and physicians, said Amarnath Annapureddy, MD, a clinical fellow in cardiology at Yale University, New Haven, Conn., who has studied and written about industry payments to physicians.
Dr. Annapureddy said in an interview that he was surprised by how the study findings were opposite to the assumption that public disclosure would dissuade continuation of financial ties between physicians and industry. “This study showed payments increased over time rather than decreasing due to public disclosure.”
However, Dr. Annapureddy said that he was not surprised at how few physicians received the bulk of industry payments. “These physicians are considered to be ‘key opinion leaders’ who could influence practicing patterns of other physicians. These findings are similar to payment patterns for other specialties, including cardiology.
“So far, no study has evaluated factors that drive changes in industry payment patterns,” Dr. Annapureddy said. “I anticipate the patterns noted in this study will continue at least in the short term. If health care systems mandate physicians to disclose potential conflicts of interest to the patients, it may reduce payments.”
However, “unless, there is a major health policy mandate by government, I anticipate public disclosure of payments through the open payments program will not impact industry-physician ties,” he said. “This study has not evaluated impact of payments on prescribing practices. There are overwhelming data from several studies that showed payments influence physicians practicing patterns, whether it is prescribing a medication or implanting a device.” However, as for additional research, Dr. Annapureddy said that it would interesting to see a randomized trial to show whether the way physicians disclose their financial ties with patients would impact their practicing patterns.
The study received no outside funding. Dr. Putman was supported by a Rheumatology Research grant, but he and the other researchers had no financial conflicts to disclose. Dr. Mitchell disclosed a merit award from the nonprofit Conquer Cancer Foundation, for which the Foundation received financial support from Merck. Dr. Annapureddy had no financial conflicts to disclose.
FROM ARTHRITIS & RHEUMATOLOGY
‘Gold cards’ allow Texas docs to skip prior authorizations
The law was passed in June and will take effect in September. It excuses physicians from having to obtain prior authorization if, during the previous 6 months, 90% of their treatments met medical necessity criteria by the health insurer. Through this law, doctors in the state will spend less time getting approvals for treatments for their patients.
Automatic approval of authorizations for treatments – or what the Texas Medical Association (TMA) calls a “gold card” – “allows patients to get the care they need in a more timely fashion,” says Debra Patt, MD, an Austin, Tex.–based oncologist and former chair of the council on legislation for the TMA.
Eighty-seven percent of Texas physicians reported a “drastic increase over the past five years in the burden of prior authorization on their patients and their practices,” per a 2020 survey by the TMA. Nearly half (48%) of Texas physicians have hired staff whose work focuses on processing requests for prior authorization, according to the survey.
Jack Resneck Jr., MD, a San Francisco–based dermatologist and president-elect of the American Medical Association (AMA), said other states have investigated ways to ease the impact of prior authorizations on physicians, but no other state has passed such a law.
Administrative burdens plague physicians around the country. The Medscape Physician Compensation Report 2021 found that physicians spend on average 15.6 hours per week on paperwork and administrative duties.
Better outcomes, less anxiety for patients
Dr. Patt, who testified in support of the law’s passage in the Texas legislature, says automatic approval of authorizations “is better for patients because it reduces their anxiety about whether they’re able to get the treatments they need now, and they will have better outcomes if they’re able to receive more timely care.”
Recently, a chemotherapy treatment Dr. Patt prescribed for one of her patients was not authorized by an insurer. The result is “a lot of anxiety and potentially health problems” for the patient, said Dr. Patt.
She expects that automatic approval for treatments will be based on prescribing patterns during the preceding 6 months. “It means that when I order a test today, the [health insurer] looks back at my record 6 months previously,” she said. Still, Dr. Patt awaits guidance from the Texas Department of Insurance, which regulates health insurers in the state, regarding the law.
Dr. Resneck said the pharmacy counter is where most patients encounter prior authorization delays. “That’s when the pharmacist looks at them and says, ‘Actually, this isn’t covered by your health insurer’s formulary,’ or it isn’t covered fully on their formulary.”
One of Dr. Resneck’s patients had a life-altering case of eczema that lasted many years. Because of the condition, the patient couldn’t work or maintain meaningful bonds with family members. A biologic treatment transformed his patient’s life. The patient was able to return to work and to re-engage with family, said Dr. Resneck. But a year after his patient started the treatment, the health insurer wouldn’t authorize the treatment because the patient wasn’t experiencing the same symptoms.
The patient didn’t have the same symptoms because the biologic treatment worked, said Dr. Resneck.
Kristine Grow, a spokesperson for America’s Health Insurance Plans, a national association for health insurers, said, “The use of prior authorization is relatively small – typically, less than 15% – and can help ensure safer opioid prescribing, help prevent dangerous drug interactions, and help protect patients from unnecessary exposure to potentially harmful radiation for inappropriate diagnostic imaging. Numerous studies show that Americans frequently receive inappropriate care, and 25% of unnecessary treatments are associated with complications or adverse events.”
Medical management tools, such as prior authorization, are an “an important way” to deliver “safe, high-quality care” to patients, she added.
State and federal efforts to curb prior authorization
In addition to efforts to curb prior authorization in other states, the AMA supports the Improving Seniors’ Timely Access to Care Act (HR 3173). The act includes a provision related to “gold-carding,” said Robert Mills, an AMA spokesperson.
The bill establishes requirements and standards for prior authorization processes related to Medicare Advantage (MA) plans. The requirements and standards for MA plans include the following:
- Establishing an electronic prior authorization program that meets specific standards, such as the ability to provide real-time decisions in response to requests for items and services that are routinely approved.
- Publishing on an annual basis specific prior authorization information, including the percentage of requests approved and the average response time.
- Meeting standards set by the Centers for Medicare & Medicaid Services related to the quality and timeliness of prior authorization determinations.
The act was introduced to the U.S. House of Representatives in May, after which it was referred to two committees for consideration.
A version of this article first appeared on Medscape.com.
The law was passed in June and will take effect in September. It excuses physicians from having to obtain prior authorization if, during the previous 6 months, 90% of their treatments met medical necessity criteria by the health insurer. Through this law, doctors in the state will spend less time getting approvals for treatments for their patients.
Automatic approval of authorizations for treatments – or what the Texas Medical Association (TMA) calls a “gold card” – “allows patients to get the care they need in a more timely fashion,” says Debra Patt, MD, an Austin, Tex.–based oncologist and former chair of the council on legislation for the TMA.
Eighty-seven percent of Texas physicians reported a “drastic increase over the past five years in the burden of prior authorization on their patients and their practices,” per a 2020 survey by the TMA. Nearly half (48%) of Texas physicians have hired staff whose work focuses on processing requests for prior authorization, according to the survey.
Jack Resneck Jr., MD, a San Francisco–based dermatologist and president-elect of the American Medical Association (AMA), said other states have investigated ways to ease the impact of prior authorizations on physicians, but no other state has passed such a law.
Administrative burdens plague physicians around the country. The Medscape Physician Compensation Report 2021 found that physicians spend on average 15.6 hours per week on paperwork and administrative duties.
Better outcomes, less anxiety for patients
Dr. Patt, who testified in support of the law’s passage in the Texas legislature, says automatic approval of authorizations “is better for patients because it reduces their anxiety about whether they’re able to get the treatments they need now, and they will have better outcomes if they’re able to receive more timely care.”
Recently, a chemotherapy treatment Dr. Patt prescribed for one of her patients was not authorized by an insurer. The result is “a lot of anxiety and potentially health problems” for the patient, said Dr. Patt.
She expects that automatic approval for treatments will be based on prescribing patterns during the preceding 6 months. “It means that when I order a test today, the [health insurer] looks back at my record 6 months previously,” she said. Still, Dr. Patt awaits guidance from the Texas Department of Insurance, which regulates health insurers in the state, regarding the law.
Dr. Resneck said the pharmacy counter is where most patients encounter prior authorization delays. “That’s when the pharmacist looks at them and says, ‘Actually, this isn’t covered by your health insurer’s formulary,’ or it isn’t covered fully on their formulary.”
One of Dr. Resneck’s patients had a life-altering case of eczema that lasted many years. Because of the condition, the patient couldn’t work or maintain meaningful bonds with family members. A biologic treatment transformed his patient’s life. The patient was able to return to work and to re-engage with family, said Dr. Resneck. But a year after his patient started the treatment, the health insurer wouldn’t authorize the treatment because the patient wasn’t experiencing the same symptoms.
The patient didn’t have the same symptoms because the biologic treatment worked, said Dr. Resneck.
Kristine Grow, a spokesperson for America’s Health Insurance Plans, a national association for health insurers, said, “The use of prior authorization is relatively small – typically, less than 15% – and can help ensure safer opioid prescribing, help prevent dangerous drug interactions, and help protect patients from unnecessary exposure to potentially harmful radiation for inappropriate diagnostic imaging. Numerous studies show that Americans frequently receive inappropriate care, and 25% of unnecessary treatments are associated with complications or adverse events.”
Medical management tools, such as prior authorization, are an “an important way” to deliver “safe, high-quality care” to patients, she added.
State and federal efforts to curb prior authorization
In addition to efforts to curb prior authorization in other states, the AMA supports the Improving Seniors’ Timely Access to Care Act (HR 3173). The act includes a provision related to “gold-carding,” said Robert Mills, an AMA spokesperson.
The bill establishes requirements and standards for prior authorization processes related to Medicare Advantage (MA) plans. The requirements and standards for MA plans include the following:
- Establishing an electronic prior authorization program that meets specific standards, such as the ability to provide real-time decisions in response to requests for items and services that are routinely approved.
- Publishing on an annual basis specific prior authorization information, including the percentage of requests approved and the average response time.
- Meeting standards set by the Centers for Medicare & Medicaid Services related to the quality and timeliness of prior authorization determinations.
The act was introduced to the U.S. House of Representatives in May, after which it was referred to two committees for consideration.
A version of this article first appeared on Medscape.com.
The law was passed in June and will take effect in September. It excuses physicians from having to obtain prior authorization if, during the previous 6 months, 90% of their treatments met medical necessity criteria by the health insurer. Through this law, doctors in the state will spend less time getting approvals for treatments for their patients.
Automatic approval of authorizations for treatments – or what the Texas Medical Association (TMA) calls a “gold card” – “allows patients to get the care they need in a more timely fashion,” says Debra Patt, MD, an Austin, Tex.–based oncologist and former chair of the council on legislation for the TMA.
Eighty-seven percent of Texas physicians reported a “drastic increase over the past five years in the burden of prior authorization on their patients and their practices,” per a 2020 survey by the TMA. Nearly half (48%) of Texas physicians have hired staff whose work focuses on processing requests for prior authorization, according to the survey.
Jack Resneck Jr., MD, a San Francisco–based dermatologist and president-elect of the American Medical Association (AMA), said other states have investigated ways to ease the impact of prior authorizations on physicians, but no other state has passed such a law.
Administrative burdens plague physicians around the country. The Medscape Physician Compensation Report 2021 found that physicians spend on average 15.6 hours per week on paperwork and administrative duties.
Better outcomes, less anxiety for patients
Dr. Patt, who testified in support of the law’s passage in the Texas legislature, says automatic approval of authorizations “is better for patients because it reduces their anxiety about whether they’re able to get the treatments they need now, and they will have better outcomes if they’re able to receive more timely care.”
Recently, a chemotherapy treatment Dr. Patt prescribed for one of her patients was not authorized by an insurer. The result is “a lot of anxiety and potentially health problems” for the patient, said Dr. Patt.
She expects that automatic approval for treatments will be based on prescribing patterns during the preceding 6 months. “It means that when I order a test today, the [health insurer] looks back at my record 6 months previously,” she said. Still, Dr. Patt awaits guidance from the Texas Department of Insurance, which regulates health insurers in the state, regarding the law.
Dr. Resneck said the pharmacy counter is where most patients encounter prior authorization delays. “That’s when the pharmacist looks at them and says, ‘Actually, this isn’t covered by your health insurer’s formulary,’ or it isn’t covered fully on their formulary.”
One of Dr. Resneck’s patients had a life-altering case of eczema that lasted many years. Because of the condition, the patient couldn’t work or maintain meaningful bonds with family members. A biologic treatment transformed his patient’s life. The patient was able to return to work and to re-engage with family, said Dr. Resneck. But a year after his patient started the treatment, the health insurer wouldn’t authorize the treatment because the patient wasn’t experiencing the same symptoms.
The patient didn’t have the same symptoms because the biologic treatment worked, said Dr. Resneck.
Kristine Grow, a spokesperson for America’s Health Insurance Plans, a national association for health insurers, said, “The use of prior authorization is relatively small – typically, less than 15% – and can help ensure safer opioid prescribing, help prevent dangerous drug interactions, and help protect patients from unnecessary exposure to potentially harmful radiation for inappropriate diagnostic imaging. Numerous studies show that Americans frequently receive inappropriate care, and 25% of unnecessary treatments are associated with complications or adverse events.”
Medical management tools, such as prior authorization, are an “an important way” to deliver “safe, high-quality care” to patients, she added.
State and federal efforts to curb prior authorization
In addition to efforts to curb prior authorization in other states, the AMA supports the Improving Seniors’ Timely Access to Care Act (HR 3173). The act includes a provision related to “gold-carding,” said Robert Mills, an AMA spokesperson.
The bill establishes requirements and standards for prior authorization processes related to Medicare Advantage (MA) plans. The requirements and standards for MA plans include the following:
- Establishing an electronic prior authorization program that meets specific standards, such as the ability to provide real-time decisions in response to requests for items and services that are routinely approved.
- Publishing on an annual basis specific prior authorization information, including the percentage of requests approved and the average response time.
- Meeting standards set by the Centers for Medicare & Medicaid Services related to the quality and timeliness of prior authorization determinations.
The act was introduced to the U.S. House of Representatives in May, after which it was referred to two committees for consideration.
A version of this article first appeared on Medscape.com.
Obstetric units place twice as many wrong-patient orders as medical-surgical units
Clinicians in obstetric units place nearly twice as many wrong-patient orders as their medical-surgical counterparts, based on a retrospective look at more than 1.3 million orders.
These findings suggest that obstetric patients are at particular risk for this type of medical error, and that steps are needed to address obstetric clinical culture, work flow, and electronic medical record interfaces, reported lead author Adina R. Kern-Goldberger, MD, of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and colleagues.
The root of the issue may come from the very nature of obstetrics, and the homogeneity of the patient population, they wrote in Obstetrics & Gynecology.
“Obstetrics is a unique clinical environment because all patients are admitted with a common diagnosis – pregnancy – and have much more overlap in demographic characteristics than a typical inpatient unit given that they are all females of reproductive age,” the investigators wrote. “The labor and delivery environment also is distinct in the hospital given its dynamic tempo and unpredictable work flow. There also is the added risk of neonates typically being registered in the hospital record under the mother’s name after birth. This generates abundant opportunity for errors in order placement, both between obstetric patients and between postpartum patients and their newborns.”
To determine the relative magnitude of this risk, Dr. Kern-Goldberger and colleagues analyzed EMRs from 45,436 obstetric patients and 12,915 medical-surgical patients at “a large, urban, integrated health system in New York City,” including 1,329,463 order sessions placed between 2016 and 2018.
The primary outcome was near-miss wrong-patient orders, which were identified by the Wrong-Patient Retract-and-Reorder measure.
“The measure uses an electronic query to detect retract-and-reorder events, defined as one or more orders placed for patient A, canceled by the same clinician within 10 minutes, and reordered by the same clinician for patient B within the next 10 minutes,” the investigators wrote.In obstetric units, 79.5 wrong-patient orders were placed per 100,000 order sessions, which was 98% higher than the rate of 42.3 wrong-patient orders per 100,000 order sessions in medical-surgical units (odds ratio, 1.98; 95% confidence interval, 1.64-2.39), a disparity that was observed across clinician types and times of day.Advanced practice clinicians in obstetrics placed 47.3 wrong-patient orders per 100,000 order sessions, which was significantly lower than that of their colleagues: attending physicians (127.0 per 100,000) and house staff (119.9 per 100,000).
Wrong-patient orders in obstetrics most often involved medication (73.2 per 100,000), particularly nifedipine, antibiotics, tocolytics, and nonoxytocin uterotonics. The “other” category, including but not limited to lab studies and nursing orders, was associated with 51.0 wrong-patient orders per 100,000 order sessions, while errors in diagnostic imaging orders followed distantly behind, at a rate of 5.7 per 1000,000.
“Although the obstetric clinical environment – particularly labor and delivery – is vibrant and frequently chaotic, it is critical to establish a calm, orderly, and safe culture around order entry,” the investigators wrote. “This, combined with efforts to improve house staff work flow and to optimize EMR interfaces, is likely to help mitigate the threat of wrong order errors to patient care and ultimately improve maternal health and safety.”
According to Catherine D. Cansino, MD, associate clinical professor of obstetrics and gynecology at UC Davis (Calif.) Health, the findings highlight the value of medical informatics while revealing a need to improve EMR interfaces.
“Medical informatics is a growing field and expertise among ob.gyns. is very important,” Dr. Cansino said in an interview. “This study by Kern-Goldberger and colleagues highlights the vulnerability of our EMR systems (and our patients, indirectly) when medical informatics systems are not optimized. The investigators present a study that advocates for greater emphasis on optimizing such systems in obstetrics units, especially in the context of high acuity settings such as obstetrics, compared to medical-surgical units. Appropriately, the study highlights the avoided harm when correcting medical errors for obstetric patients since such errors potentially affect both the delivering patient and the newborn.”
The study was funded by AHRQ. One coauthor disclosed funding from the Icahn School of Medicine at Mount Sinai, Georgetown University, the National Institutes of Health – Office of Scientific Review, and the Social Science Research Council. Another reported funding from Roche.
Clinicians in obstetric units place nearly twice as many wrong-patient orders as their medical-surgical counterparts, based on a retrospective look at more than 1.3 million orders.
These findings suggest that obstetric patients are at particular risk for this type of medical error, and that steps are needed to address obstetric clinical culture, work flow, and electronic medical record interfaces, reported lead author Adina R. Kern-Goldberger, MD, of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and colleagues.
The root of the issue may come from the very nature of obstetrics, and the homogeneity of the patient population, they wrote in Obstetrics & Gynecology.
“Obstetrics is a unique clinical environment because all patients are admitted with a common diagnosis – pregnancy – and have much more overlap in demographic characteristics than a typical inpatient unit given that they are all females of reproductive age,” the investigators wrote. “The labor and delivery environment also is distinct in the hospital given its dynamic tempo and unpredictable work flow. There also is the added risk of neonates typically being registered in the hospital record under the mother’s name after birth. This generates abundant opportunity for errors in order placement, both between obstetric patients and between postpartum patients and their newborns.”
To determine the relative magnitude of this risk, Dr. Kern-Goldberger and colleagues analyzed EMRs from 45,436 obstetric patients and 12,915 medical-surgical patients at “a large, urban, integrated health system in New York City,” including 1,329,463 order sessions placed between 2016 and 2018.
The primary outcome was near-miss wrong-patient orders, which were identified by the Wrong-Patient Retract-and-Reorder measure.
“The measure uses an electronic query to detect retract-and-reorder events, defined as one or more orders placed for patient A, canceled by the same clinician within 10 minutes, and reordered by the same clinician for patient B within the next 10 minutes,” the investigators wrote.In obstetric units, 79.5 wrong-patient orders were placed per 100,000 order sessions, which was 98% higher than the rate of 42.3 wrong-patient orders per 100,000 order sessions in medical-surgical units (odds ratio, 1.98; 95% confidence interval, 1.64-2.39), a disparity that was observed across clinician types and times of day.Advanced practice clinicians in obstetrics placed 47.3 wrong-patient orders per 100,000 order sessions, which was significantly lower than that of their colleagues: attending physicians (127.0 per 100,000) and house staff (119.9 per 100,000).
Wrong-patient orders in obstetrics most often involved medication (73.2 per 100,000), particularly nifedipine, antibiotics, tocolytics, and nonoxytocin uterotonics. The “other” category, including but not limited to lab studies and nursing orders, was associated with 51.0 wrong-patient orders per 100,000 order sessions, while errors in diagnostic imaging orders followed distantly behind, at a rate of 5.7 per 1000,000.
“Although the obstetric clinical environment – particularly labor and delivery – is vibrant and frequently chaotic, it is critical to establish a calm, orderly, and safe culture around order entry,” the investigators wrote. “This, combined with efforts to improve house staff work flow and to optimize EMR interfaces, is likely to help mitigate the threat of wrong order errors to patient care and ultimately improve maternal health and safety.”
According to Catherine D. Cansino, MD, associate clinical professor of obstetrics and gynecology at UC Davis (Calif.) Health, the findings highlight the value of medical informatics while revealing a need to improve EMR interfaces.
“Medical informatics is a growing field and expertise among ob.gyns. is very important,” Dr. Cansino said in an interview. “This study by Kern-Goldberger and colleagues highlights the vulnerability of our EMR systems (and our patients, indirectly) when medical informatics systems are not optimized. The investigators present a study that advocates for greater emphasis on optimizing such systems in obstetrics units, especially in the context of high acuity settings such as obstetrics, compared to medical-surgical units. Appropriately, the study highlights the avoided harm when correcting medical errors for obstetric patients since such errors potentially affect both the delivering patient and the newborn.”
The study was funded by AHRQ. One coauthor disclosed funding from the Icahn School of Medicine at Mount Sinai, Georgetown University, the National Institutes of Health – Office of Scientific Review, and the Social Science Research Council. Another reported funding from Roche.
Clinicians in obstetric units place nearly twice as many wrong-patient orders as their medical-surgical counterparts, based on a retrospective look at more than 1.3 million orders.
These findings suggest that obstetric patients are at particular risk for this type of medical error, and that steps are needed to address obstetric clinical culture, work flow, and electronic medical record interfaces, reported lead author Adina R. Kern-Goldberger, MD, of the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, and colleagues.
The root of the issue may come from the very nature of obstetrics, and the homogeneity of the patient population, they wrote in Obstetrics & Gynecology.
“Obstetrics is a unique clinical environment because all patients are admitted with a common diagnosis – pregnancy – and have much more overlap in demographic characteristics than a typical inpatient unit given that they are all females of reproductive age,” the investigators wrote. “The labor and delivery environment also is distinct in the hospital given its dynamic tempo and unpredictable work flow. There also is the added risk of neonates typically being registered in the hospital record under the mother’s name after birth. This generates abundant opportunity for errors in order placement, both between obstetric patients and between postpartum patients and their newborns.”
To determine the relative magnitude of this risk, Dr. Kern-Goldberger and colleagues analyzed EMRs from 45,436 obstetric patients and 12,915 medical-surgical patients at “a large, urban, integrated health system in New York City,” including 1,329,463 order sessions placed between 2016 and 2018.
The primary outcome was near-miss wrong-patient orders, which were identified by the Wrong-Patient Retract-and-Reorder measure.
“The measure uses an electronic query to detect retract-and-reorder events, defined as one or more orders placed for patient A, canceled by the same clinician within 10 minutes, and reordered by the same clinician for patient B within the next 10 minutes,” the investigators wrote.In obstetric units, 79.5 wrong-patient orders were placed per 100,000 order sessions, which was 98% higher than the rate of 42.3 wrong-patient orders per 100,000 order sessions in medical-surgical units (odds ratio, 1.98; 95% confidence interval, 1.64-2.39), a disparity that was observed across clinician types and times of day.Advanced practice clinicians in obstetrics placed 47.3 wrong-patient orders per 100,000 order sessions, which was significantly lower than that of their colleagues: attending physicians (127.0 per 100,000) and house staff (119.9 per 100,000).
Wrong-patient orders in obstetrics most often involved medication (73.2 per 100,000), particularly nifedipine, antibiotics, tocolytics, and nonoxytocin uterotonics. The “other” category, including but not limited to lab studies and nursing orders, was associated with 51.0 wrong-patient orders per 100,000 order sessions, while errors in diagnostic imaging orders followed distantly behind, at a rate of 5.7 per 1000,000.
“Although the obstetric clinical environment – particularly labor and delivery – is vibrant and frequently chaotic, it is critical to establish a calm, orderly, and safe culture around order entry,” the investigators wrote. “This, combined with efforts to improve house staff work flow and to optimize EMR interfaces, is likely to help mitigate the threat of wrong order errors to patient care and ultimately improve maternal health and safety.”
According to Catherine D. Cansino, MD, associate clinical professor of obstetrics and gynecology at UC Davis (Calif.) Health, the findings highlight the value of medical informatics while revealing a need to improve EMR interfaces.
“Medical informatics is a growing field and expertise among ob.gyns. is very important,” Dr. Cansino said in an interview. “This study by Kern-Goldberger and colleagues highlights the vulnerability of our EMR systems (and our patients, indirectly) when medical informatics systems are not optimized. The investigators present a study that advocates for greater emphasis on optimizing such systems in obstetrics units, especially in the context of high acuity settings such as obstetrics, compared to medical-surgical units. Appropriately, the study highlights the avoided harm when correcting medical errors for obstetric patients since such errors potentially affect both the delivering patient and the newborn.”
The study was funded by AHRQ. One coauthor disclosed funding from the Icahn School of Medicine at Mount Sinai, Georgetown University, the National Institutes of Health – Office of Scientific Review, and the Social Science Research Council. Another reported funding from Roche.
FROM OBSTETRICS & GYNECOLOGY
Bullying in academic medicine rife, underreported
Bullying in academic medicine, especially among women, is rife, underreported, and remains largely unaddressed, new research suggests.
Investigators reviewed close to 70 studies, encompassing over 82,000 medical consultants or trainees in academic medical settings, and found that men were identified as the most common perpetrators – close to 70% of respondents – whereas women were the most common victims (56%).
Collectively, respondents in all of the studies identified the most common bullies to be consultants (54%), followed by residents (22%), and nurses (15%).
Disturbingly, less than one-third of victims overall reported that they were bullied, and close to 60% who formally reported the abuse said they did not have a positive outcome.
“We found that bullies are commonly men and senior consultants, while more than half of their victims are women,” senior author Harriette G.C. Van Spall, MD, MPH, associate professor of medicine and director of e-health and virtual care, Division of Cardiology, McMaster University, Hamilton, Ont., said in an interview.
“The greatest barriers to addressing academic bullying are the fear of reprisal, lack of impact of reporting, and non-enforcement of anti-bullying policies,” she added.
The study was published online July 12 in BMJ Open.
Personal experience
“Some behaviors were excruciating to deal with, protesting against them would bring more on, and every day was filled with dread. It took sheer will to show up at work to care for patients, to complete research I was leading, and to have hope, and my academic output, income, and personal well-being dropped during those years,” she added.
Dr. Van Spall thought the subject “merited research because our performance as clinicians, researchers, and educators relies on our work environment.”
To investigate, the researchers reviewed 68 studies (n = 82,349 respondents) conducted between 1999 and 2021 in academic medical settings, in which victims were either consultants or trainees. Many of the studies (31) were conducted in the U.S.
Other countries included the United Kingdom, Canada, Australia, Pakistan, Egypt, Iran, Turkey, New Zealand, Lithuania, Greece, India, Germany, Nigeria, Oman, and Finland.
Studies were required to describe the method and impact of bullying; characteristics of the perpetrators and victims; or interventions that were used to address the bullying.
“Bullying” was defined as “the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviors that include overwork, destabilization, and isolation in order to impede the education or career of the target.”
Systemic sexism
Bullying behaviors, reported in 28 studies (n = 35,779 respondents), were grouped into destabilization, threats to professional status, overwork, and isolation, with overwork found to be the most common form of bullying.
The most common impact of being bullied was psychological distress, reported by 39.1% of respondents in 14 studies, followed by considerations of quitting (35.9%; 7 studies), and worsening of clinical performance (34.6%, 8 studies).
“Among demographic groups, men were identified as the most common perpetrators (67.2% of 4,722 respondents in 5 studies) and women the most common victims (56.2% of 15,246 respondents in 27 studies),” the authors report.
“Academic medicine in many institutions is encumbered by systemic sexism that is evident in processes around remuneration, recognition, opportunities for advancement, and leadership positions,” said Dr. Van Spall.
“There are fewer women at decision-making tables in academic medicine, the climb is uphill at the best of times, and women are likely easier targets for bullies, as their voices are easier to drown out,” she added.
She noted that many men do “exhibit wonderful attributes of professionalism and decency,” but “some in positions of power are given impunity by virtue of other accomplishments.”
Multiple deterrents
Thirty-one studies (n = 15,868) described characteristics of the bullies and showed the most common to be consultants (53.6% [30 studies]), residents (22% [22 studies]), and nurses (14.9% [21 studies]).
Only a minority of victims (28.9% of 9,410 victims [10 studies]) formally reported the bullying. The researchers identified multiple deterrents to reporting.
When a formal complaint was submitted (n = 1,139 respondents), it most frequently had no perceived effect (35.6%); more than one-fifth (21.9%) experienced worsening of the bullying, and only 13.7% reported improvement.
The common institutional facilitators of bullying, described in 25 studies, included lack of enforcement of anti-bullying policies (13 studies), the hierarchical structure of medicine (7 studies), and normalization of bullying (10 studies).
Forty-nine studies looked at strategies to address academic bullying, including anti-bullying policies, mandatory workshops on mistreatment, establishing an anti-bullying oversight committee, and institutional support for victims. However, the studies testing the effectiveness of these interventions “had a high risk of bias.”
Support available
Commenting on the research for this news organization, Roberta Gebhard, DO, past president of the American Medical Women’s Association (AMWA) and a member of the advisory board for Physician Just Equity, called it a “good study, large, international, and well-written.”
Dr. Gebhard, a member of the Governing Council for the American Medical Association Women Physician Section, was not associated with this study but said she is currently researching women who left medical school and residency.
“A common reason for leaving is being bullied. Bullying is often not reported and if reported, often not addressed. Or, if addressed, the person who reports it is often retaliated against, which is a common experience, especially in women.”
She advised female physicians who are bullied to get support from other female physicians – for example, by joining the AMWA, which has an online women’s leadership group.
“Having other women physicians throughout the country you can call for advice and support can be helpful,” said Dr. Gebhard, a family practice physician based in Grand Island, New York.
Dr. Van Spall receives support from the Canadian Institutes of Health Research, the Heart and Stroke Foundation, the Women As One Escalator Award, and McMaster Department of Medicine. The study authors and Dr. Gebhard have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Bullying in academic medicine, especially among women, is rife, underreported, and remains largely unaddressed, new research suggests.
Investigators reviewed close to 70 studies, encompassing over 82,000 medical consultants or trainees in academic medical settings, and found that men were identified as the most common perpetrators – close to 70% of respondents – whereas women were the most common victims (56%).
Collectively, respondents in all of the studies identified the most common bullies to be consultants (54%), followed by residents (22%), and nurses (15%).
Disturbingly, less than one-third of victims overall reported that they were bullied, and close to 60% who formally reported the abuse said they did not have a positive outcome.
“We found that bullies are commonly men and senior consultants, while more than half of their victims are women,” senior author Harriette G.C. Van Spall, MD, MPH, associate professor of medicine and director of e-health and virtual care, Division of Cardiology, McMaster University, Hamilton, Ont., said in an interview.
“The greatest barriers to addressing academic bullying are the fear of reprisal, lack of impact of reporting, and non-enforcement of anti-bullying policies,” she added.
The study was published online July 12 in BMJ Open.
Personal experience
“Some behaviors were excruciating to deal with, protesting against them would bring more on, and every day was filled with dread. It took sheer will to show up at work to care for patients, to complete research I was leading, and to have hope, and my academic output, income, and personal well-being dropped during those years,” she added.
Dr. Van Spall thought the subject “merited research because our performance as clinicians, researchers, and educators relies on our work environment.”
To investigate, the researchers reviewed 68 studies (n = 82,349 respondents) conducted between 1999 and 2021 in academic medical settings, in which victims were either consultants or trainees. Many of the studies (31) were conducted in the U.S.
Other countries included the United Kingdom, Canada, Australia, Pakistan, Egypt, Iran, Turkey, New Zealand, Lithuania, Greece, India, Germany, Nigeria, Oman, and Finland.
Studies were required to describe the method and impact of bullying; characteristics of the perpetrators and victims; or interventions that were used to address the bullying.
“Bullying” was defined as “the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviors that include overwork, destabilization, and isolation in order to impede the education or career of the target.”
Systemic sexism
Bullying behaviors, reported in 28 studies (n = 35,779 respondents), were grouped into destabilization, threats to professional status, overwork, and isolation, with overwork found to be the most common form of bullying.
The most common impact of being bullied was psychological distress, reported by 39.1% of respondents in 14 studies, followed by considerations of quitting (35.9%; 7 studies), and worsening of clinical performance (34.6%, 8 studies).
“Among demographic groups, men were identified as the most common perpetrators (67.2% of 4,722 respondents in 5 studies) and women the most common victims (56.2% of 15,246 respondents in 27 studies),” the authors report.
“Academic medicine in many institutions is encumbered by systemic sexism that is evident in processes around remuneration, recognition, opportunities for advancement, and leadership positions,” said Dr. Van Spall.
“There are fewer women at decision-making tables in academic medicine, the climb is uphill at the best of times, and women are likely easier targets for bullies, as their voices are easier to drown out,” she added.
She noted that many men do “exhibit wonderful attributes of professionalism and decency,” but “some in positions of power are given impunity by virtue of other accomplishments.”
Multiple deterrents
Thirty-one studies (n = 15,868) described characteristics of the bullies and showed the most common to be consultants (53.6% [30 studies]), residents (22% [22 studies]), and nurses (14.9% [21 studies]).
Only a minority of victims (28.9% of 9,410 victims [10 studies]) formally reported the bullying. The researchers identified multiple deterrents to reporting.
When a formal complaint was submitted (n = 1,139 respondents), it most frequently had no perceived effect (35.6%); more than one-fifth (21.9%) experienced worsening of the bullying, and only 13.7% reported improvement.
The common institutional facilitators of bullying, described in 25 studies, included lack of enforcement of anti-bullying policies (13 studies), the hierarchical structure of medicine (7 studies), and normalization of bullying (10 studies).
Forty-nine studies looked at strategies to address academic bullying, including anti-bullying policies, mandatory workshops on mistreatment, establishing an anti-bullying oversight committee, and institutional support for victims. However, the studies testing the effectiveness of these interventions “had a high risk of bias.”
Support available
Commenting on the research for this news organization, Roberta Gebhard, DO, past president of the American Medical Women’s Association (AMWA) and a member of the advisory board for Physician Just Equity, called it a “good study, large, international, and well-written.”
Dr. Gebhard, a member of the Governing Council for the American Medical Association Women Physician Section, was not associated with this study but said she is currently researching women who left medical school and residency.
“A common reason for leaving is being bullied. Bullying is often not reported and if reported, often not addressed. Or, if addressed, the person who reports it is often retaliated against, which is a common experience, especially in women.”
She advised female physicians who are bullied to get support from other female physicians – for example, by joining the AMWA, which has an online women’s leadership group.
“Having other women physicians throughout the country you can call for advice and support can be helpful,” said Dr. Gebhard, a family practice physician based in Grand Island, New York.
Dr. Van Spall receives support from the Canadian Institutes of Health Research, the Heart and Stroke Foundation, the Women As One Escalator Award, and McMaster Department of Medicine. The study authors and Dr. Gebhard have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Bullying in academic medicine, especially among women, is rife, underreported, and remains largely unaddressed, new research suggests.
Investigators reviewed close to 70 studies, encompassing over 82,000 medical consultants or trainees in academic medical settings, and found that men were identified as the most common perpetrators – close to 70% of respondents – whereas women were the most common victims (56%).
Collectively, respondents in all of the studies identified the most common bullies to be consultants (54%), followed by residents (22%), and nurses (15%).
Disturbingly, less than one-third of victims overall reported that they were bullied, and close to 60% who formally reported the abuse said they did not have a positive outcome.
“We found that bullies are commonly men and senior consultants, while more than half of their victims are women,” senior author Harriette G.C. Van Spall, MD, MPH, associate professor of medicine and director of e-health and virtual care, Division of Cardiology, McMaster University, Hamilton, Ont., said in an interview.
“The greatest barriers to addressing academic bullying are the fear of reprisal, lack of impact of reporting, and non-enforcement of anti-bullying policies,” she added.
The study was published online July 12 in BMJ Open.
Personal experience
“Some behaviors were excruciating to deal with, protesting against them would bring more on, and every day was filled with dread. It took sheer will to show up at work to care for patients, to complete research I was leading, and to have hope, and my academic output, income, and personal well-being dropped during those years,” she added.
Dr. Van Spall thought the subject “merited research because our performance as clinicians, researchers, and educators relies on our work environment.”
To investigate, the researchers reviewed 68 studies (n = 82,349 respondents) conducted between 1999 and 2021 in academic medical settings, in which victims were either consultants or trainees. Many of the studies (31) were conducted in the U.S.
Other countries included the United Kingdom, Canada, Australia, Pakistan, Egypt, Iran, Turkey, New Zealand, Lithuania, Greece, India, Germany, Nigeria, Oman, and Finland.
Studies were required to describe the method and impact of bullying; characteristics of the perpetrators and victims; or interventions that were used to address the bullying.
“Bullying” was defined as “the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviors that include overwork, destabilization, and isolation in order to impede the education or career of the target.”
Systemic sexism
Bullying behaviors, reported in 28 studies (n = 35,779 respondents), were grouped into destabilization, threats to professional status, overwork, and isolation, with overwork found to be the most common form of bullying.
The most common impact of being bullied was psychological distress, reported by 39.1% of respondents in 14 studies, followed by considerations of quitting (35.9%; 7 studies), and worsening of clinical performance (34.6%, 8 studies).
“Among demographic groups, men were identified as the most common perpetrators (67.2% of 4,722 respondents in 5 studies) and women the most common victims (56.2% of 15,246 respondents in 27 studies),” the authors report.
“Academic medicine in many institutions is encumbered by systemic sexism that is evident in processes around remuneration, recognition, opportunities for advancement, and leadership positions,” said Dr. Van Spall.
“There are fewer women at decision-making tables in academic medicine, the climb is uphill at the best of times, and women are likely easier targets for bullies, as their voices are easier to drown out,” she added.
She noted that many men do “exhibit wonderful attributes of professionalism and decency,” but “some in positions of power are given impunity by virtue of other accomplishments.”
Multiple deterrents
Thirty-one studies (n = 15,868) described characteristics of the bullies and showed the most common to be consultants (53.6% [30 studies]), residents (22% [22 studies]), and nurses (14.9% [21 studies]).
Only a minority of victims (28.9% of 9,410 victims [10 studies]) formally reported the bullying. The researchers identified multiple deterrents to reporting.
When a formal complaint was submitted (n = 1,139 respondents), it most frequently had no perceived effect (35.6%); more than one-fifth (21.9%) experienced worsening of the bullying, and only 13.7% reported improvement.
The common institutional facilitators of bullying, described in 25 studies, included lack of enforcement of anti-bullying policies (13 studies), the hierarchical structure of medicine (7 studies), and normalization of bullying (10 studies).
Forty-nine studies looked at strategies to address academic bullying, including anti-bullying policies, mandatory workshops on mistreatment, establishing an anti-bullying oversight committee, and institutional support for victims. However, the studies testing the effectiveness of these interventions “had a high risk of bias.”
Support available
Commenting on the research for this news organization, Roberta Gebhard, DO, past president of the American Medical Women’s Association (AMWA) and a member of the advisory board for Physician Just Equity, called it a “good study, large, international, and well-written.”
Dr. Gebhard, a member of the Governing Council for the American Medical Association Women Physician Section, was not associated with this study but said she is currently researching women who left medical school and residency.
“A common reason for leaving is being bullied. Bullying is often not reported and if reported, often not addressed. Or, if addressed, the person who reports it is often retaliated against, which is a common experience, especially in women.”
She advised female physicians who are bullied to get support from other female physicians – for example, by joining the AMWA, which has an online women’s leadership group.
“Having other women physicians throughout the country you can call for advice and support can be helpful,” said Dr. Gebhard, a family practice physician based in Grand Island, New York.
Dr. Van Spall receives support from the Canadian Institutes of Health Research, the Heart and Stroke Foundation, the Women As One Escalator Award, and McMaster Department of Medicine. The study authors and Dr. Gebhard have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Denial or a call to action?
Now that everyone in my family has been vaccinated, we’re starting to do more.
Last week we met my mom and some of her (vaccinated) friends for dinner at a local restaurant. Except for picking up takeout, I hadn’t been to one since early March 2020.
During the usual chatting about jobs, music, my kids, and trips we were thinking about, one of her friends suddenly said: “That’s funny.”
I asked him what was funny, and he said: “My left vision suddenly went dark.”
It only takes a fraction of a second to shift into doctor mode. I asked a few pointed questions and did a quick neuroscan for asymmetries, slurred speech, the things that, after 23 years, have become second nature.
It resolved after about 30 seconds. He clearly didn’t think it was anything to be alarmed about. He’s intelligent and well educated, but not a doctor. I wasn’t going to let it go, and quietly spoke to him a short while later. He may not be my patient, but pushing him in the needed direction is the right thing to do.
I’ve gotten him to the right doctors now, and the ball is rolling, but I keep thinking about it. If I hadn’t been there it’s likely nothing would have been done. In fact, he seemed to think it was more amusing than potentially serious.
Medical blogs and doctors’ lounge stories are full of similar anecdotes, where we wonder why people don’t take such things seriously. We tend to view such people as stupid and/or ignorant.
Yet, this gentleman is neither. I’ve known him since childhood. He’s smart, well educated, and well read. He’s not a medical person, though.
In reality, I don’t think doctors or nurses are any better. I suspect that’s more human nature, which is hard to override regardless of training.
But maybe it’s time to start giving these people, like my family friend, a pass, with the realization that denial and different training are part of being human, and not something to be poked fun at.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Now that everyone in my family has been vaccinated, we’re starting to do more.
Last week we met my mom and some of her (vaccinated) friends for dinner at a local restaurant. Except for picking up takeout, I hadn’t been to one since early March 2020.
During the usual chatting about jobs, music, my kids, and trips we were thinking about, one of her friends suddenly said: “That’s funny.”
I asked him what was funny, and he said: “My left vision suddenly went dark.”
It only takes a fraction of a second to shift into doctor mode. I asked a few pointed questions and did a quick neuroscan for asymmetries, slurred speech, the things that, after 23 years, have become second nature.
It resolved after about 30 seconds. He clearly didn’t think it was anything to be alarmed about. He’s intelligent and well educated, but not a doctor. I wasn’t going to let it go, and quietly spoke to him a short while later. He may not be my patient, but pushing him in the needed direction is the right thing to do.
I’ve gotten him to the right doctors now, and the ball is rolling, but I keep thinking about it. If I hadn’t been there it’s likely nothing would have been done. In fact, he seemed to think it was more amusing than potentially serious.
Medical blogs and doctors’ lounge stories are full of similar anecdotes, where we wonder why people don’t take such things seriously. We tend to view such people as stupid and/or ignorant.
Yet, this gentleman is neither. I’ve known him since childhood. He’s smart, well educated, and well read. He’s not a medical person, though.
In reality, I don’t think doctors or nurses are any better. I suspect that’s more human nature, which is hard to override regardless of training.
But maybe it’s time to start giving these people, like my family friend, a pass, with the realization that denial and different training are part of being human, and not something to be poked fun at.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Now that everyone in my family has been vaccinated, we’re starting to do more.
Last week we met my mom and some of her (vaccinated) friends for dinner at a local restaurant. Except for picking up takeout, I hadn’t been to one since early March 2020.
During the usual chatting about jobs, music, my kids, and trips we were thinking about, one of her friends suddenly said: “That’s funny.”
I asked him what was funny, and he said: “My left vision suddenly went dark.”
It only takes a fraction of a second to shift into doctor mode. I asked a few pointed questions and did a quick neuroscan for asymmetries, slurred speech, the things that, after 23 years, have become second nature.
It resolved after about 30 seconds. He clearly didn’t think it was anything to be alarmed about. He’s intelligent and well educated, but not a doctor. I wasn’t going to let it go, and quietly spoke to him a short while later. He may not be my patient, but pushing him in the needed direction is the right thing to do.
I’ve gotten him to the right doctors now, and the ball is rolling, but I keep thinking about it. If I hadn’t been there it’s likely nothing would have been done. In fact, he seemed to think it was more amusing than potentially serious.
Medical blogs and doctors’ lounge stories are full of similar anecdotes, where we wonder why people don’t take such things seriously. We tend to view such people as stupid and/or ignorant.
Yet, this gentleman is neither. I’ve known him since childhood. He’s smart, well educated, and well read. He’s not a medical person, though.
In reality, I don’t think doctors or nurses are any better. I suspect that’s more human nature, which is hard to override regardless of training.
But maybe it’s time to start giving these people, like my family friend, a pass, with the realization that denial and different training are part of being human, and not something to be poked fun at.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.