We posed this question to the SERMO community recently; the results and discussion shed light on physician sentiment.

Should compassionate use be allowed for unproven drugs or therapies?

• 74%    Yes, but only when the patient has no other options
• 19%    Yes, clinical trials take too long
• 7%      No, it’s unethical to do so

What Doctors Think of Compassionate Use

In the wake of Ebola and the use of experimental treatment options and rushed vaccine trials, many doctors discussed the pros and the cons. A family practitioner wrote, “As with almost everything in medicine, you weigh the risk of the treatment and the disease to the benefit and try to make an intelligent decision. In Ebola, the risk of the disease is astronomical, so even a little benefit or a potential benefit is acceptable. If the benefit is essentially zero, as in many alternative treatments, then even a small risk of treatment outweighs and precludes its ethical use. “

A surgeon countered, “these treatment options are offered at a time when coercion is remarkably easy. “What have you got to lose? Are you going to miss out on a potential cure?” and worse, to families, “Are you gonna let money stand between you and the chance to save your parent/spouse/child?”

“Compassionate use has to be offered in a VERY circumspect fashion, and patient and family must be treated as fairly as possible,” he continued. “And frankly, I’m not sure that playing fair with families, in this situation, is EVER possible.

A second family practitioner talked about private insurance decision-making. “I was frequently presented this question when I was in charge of medical policy for a large insurance company. Cost was not the main consideration; plausibility was. This is, there had to be a good reason to believe the proposal could work.”

Several doctors voiced the need to take profit out of the equation when making these tough decisions. An internist wrote, “compassionate use should be mediated through the 340B drug program to avoid profiteering from a serious illness scenario.”

As a physician, what do you think about compassionate use? Has the recent Ebola crisis and the experimental drugs used on some patients changed your perspective? Have you ever had the opportunity to assist a patient through a compassionate use scenario? We discuss this and a myriad of clinical topics inside SERMO, if you’re an M.D. or D.O., please join us.

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A recent SERMO poll found 92 percent of doctors think the current measles outbreak is directly attributable to parents who do not vaccinate their children.  Further, a physician poll conducted in August 2014 found the majority of doctors think unvaccinated children should not be allowed to attend public schools.

Public health officials agree, last week a California high school barred 66 students from attending school for not having the MMR vaccine when a suspected measles case appeared in the study body.

Measles Infographic

Our infographic shows the importance of a measles vaccine, and its impact on patients.  A recent discussion inside SERMO talked about the problem. One internist wrote, “It is dangerous for every other patient in your practice. An anti-vax kid brought in by a parent for a rash sitting in the waiting room of a busy pediatric practice could spread measles to countless others in a matter of minutes.”

Some doctors believe seeing non-vaccinated patients is an opportunity to educate. An OBGYN wrote, “We have a large community of anti-vaxxers in my state, and it would be difficult to refuse them outright. Instead, I use persuasion to try to educate them and make my advocacy position very clear. I have had some limited success with this tactic.”

The American Academy of Pediatrics has urged doctors to respect each patient’s preferences but continue to educate about vaccinations unless there is a heightened medical issue for getting a vaccine.

What do you think about vaccinations and the current measles outbreak?  Should unvaccinated children be banned from public schools?  Should doctors urge patients to get vaccinated and turn away those who refuse?  If you’re an M.D. or D.O. you can join the conversation right now inside SERMO.

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Telemedicine has been around, well, since the telephone. But the definition of telemedicine is broadening to include any electronic interaction between patient and doctor. For the first time, doctors in 22 states receive compensation for telemedicine consults. We asked doctors what they thought of the changes.

Overall, 71 percent of doctors say they would participate in telemedicine with their patients if they received compensation. Only 29 percent said they wouldn’t use phone, email, or video means of communication.

Doctors Support Telemedicine

While the majority of doctors support telemedicine, all of them had caveats for proper use. One family practitioner listed where it is most helpful:

• For remote patients to improve care and save the patient time and money
• To help send patients to the proper medical facility such as urgent care centers over emergency departments
• To help abate the physician shortage by quickly and efficiently using doctor’s time
• Doctors are typically paid $30 for a 10-minute consult

We even heard from physicians who are currently working through telemedicine. One geriatric physician, who works part-time via an online telemedicine network, wrote, “Patients can show rash, throat or any other snaps of their ailment. We can write prescriptions except narcotics and psychiatric meds. My network has over 65,000 US doctors now.”

Physicians Against Telemedicine

Many doctors voiced concerns about missed diagnoses, further straining doctor/patient relationships and the increased likelihood of lawsuits.

A nephrologist stated, ”Have good tele-malpractice insurance, the state medical boards love to sue for tele-prescriptions that are devoid of face-to-face evaluations.”

“The greatest foe is not necessarily telemedicine, but its attendant laws (or lack thereof),” wrote a psychiatrist. “The legal system moves glacially compared with technology, for many years to come, a jury will not be kind to the physician who makes a mistake over Facetime.”

Patients Demand Telemedicine

Many doctors cited rural patients and patients with chronic but manageable disease as perfect candidates for telemedicine. A neurologist noted that population changes could spark increased requests. “As the elderly patients who aren’t tech savvy age out of the system, and younger patients are used to communicating with each other in these ways replace them, they are going to demand telemedicine,” he wrote.

Is it Really a Big Deal?

Many doctors wrote that telemedicine has been happening for years with few problems. A cash-only doctor wrote, “Physicians have been doing telemedicine for years- all those phone triages are telemedicine. It’s all about knowing when it’s appropriate and when a patient needs to be seen.”

While most doctors support telemedicine, do you? As a physician, have you tried it or are you waiting for reimbursements to begin in your state? Would you even have a nurse practitioner or physicians’ assistant handle telemedicine on your behalf? There is an active discussion on SERMO, if you’re an M.D. or D.O. please join us.

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Eighty-eight percent of physicians in the US think obesity should not be declared a disability after a Dutch court ruled for a plaintiff seeking damages, claiming his weight was a disability. The ruling is binding for the European Union and could mean big changes for companies accommodating employees with work-related weight issues.

The Denmark court rules in favor of a childcare worker who fired for being unable to perform his job due to his weight. According to the BBC, the court said, “if obesity could hinder ‘full and effective participation’ then it could be considered a disability.”

To further clarify, “obesity in itself was not a disability – but if a person had a long-term impairment because of their obesity, they would be protected by disability legislation.”

The Danish court appealed to the European Court of Justice (ECJ) for clarification, and the ECJ returned the opinion on obesity and disability. ECJ rulings are binding for all EU member nations.

Do US courts have an opinion?

In a handful of cases, some local courts have found for the plaintiff on the grounds obesity is a disability as defined by the Americans with Disability Act (ADA). In 2008, new guidelines for the ADA widened the definition of disability. In one 2011 case, the judge found obesity was a disability for a fired 527-pounds woman who worked for a non-profit. To date, none of the cases have reached a statewide or national level that would affect US companies in the way the EU ruling has.

What doctors think about obesity as a disability

As our poll numbers indicate, doctors strongly disagree with obesity being the sole reason to obtain disability status. “There are legitimate medical illnesses that cause obesity, and these should be respected as such. However, the vast majority of obese individuals do not have medical illnesses and are not entitled to disability,” said Dr. Andrew Wilner, neurologist and SERMO member.

Another SERMO member, Dr. Linda Girgis, a family practitioner wrote, “The key to solving this problem is prevention, not enablement. Governments should invest in curbing the epidemic and preventing obesity.”

As a physician, what do you think of obesity as a disability? Have you seen a patient who faced discrimination due to their weight? Do you think obesity guidelines should be set by Body Mass Index (BMI)?

We will be discussing this further inside the SERMO community, come join us.

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An astonishing 71 percent of physicians say they were verbally and/or physically assaulted by a patient at some point in their careers according to a recent SERMOpoll.  If anything, violence against doctors seems to be increasing.

According to the Bureau of Labor Statistics, health care workers are assaulted at a rate of 146 per 10,000 workers in a given year. This compares to a national average of only seven assaults per 10,000 workers.

While 71 percent of physicians overall reported assault, the numbers vary greatly by specialty:

• Emergency Medicine: 93%
• Psychiatry: 90%
• Family Practice: 78%
• Internal Medicine: 71%
• Pediatrics: 64%

Here is the full breakdown of the poll for all physicians: Have you ever been assaulted?

• 44%    Yes, verbally
• 29%    Never
• 22%    Both
•   5%    Yes, physically

As seen from the breakdown above, one of the toughest specialties to work in is Emergency Medicine. In a study of 96 hospitals, 34 percent reported a rise in patient and family violence in the ER, while 29 percent reported an uptick in patient and family violence against other staff.

Charges Often Not Filed

A physician posted on SERMO about a violent incident he was involved with in a lockdown psychiatric ward with a patient with a “shiv.” He attempted to press charges against the patient but neither the facility nor the local police supported the decision.

Another psychiatrist wrote, “In the best of places, the docs rally together and push the DA to press charges even if the hospital doesn’t want to consider it. I have several times done an immediate MSE/competency exam on a patient that assaulted a colleague with the explicit goal of determining if we should press charges.”

Decreasing Assaults

Should doctors have training to protect themselves from possible assault? An article in LaborNotes, an online site for nurses, suggested four steps to improve safety.

1. Improve hospital reporting of assaults
2. Improve training for violence prevention
3. Boost security personnel and other security measures in hospital settings
4. Regulation to hold hospitals accountable for violent behavior by patients

How this Impacts Healthcare

The last thing anyone wants, is health care workers who are afraid to go to work. The impact in workdays lost, on the job stress, and practicing “defensive medicine” are taking a toll on the medical system.

As a physician how do you handle assault from patients? Have you found an effective way to diffuse situations before they get out of hand? Have you ever had difficulty working with police when a patient attacks you or staff? We will discuss this in detail inside SERMO. Please join us.

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Medicine and technology will continue to integrate creating the biggest trends in medicine in 2015 according to a poll of physicians from SERMO.  The top three trends to look for are:

• Remote patient monitoring through wearable apps
• Telemedicine expanding with compensation to physicians
• More genetic discoveries to improve patient diagnoses and care

Remote patient monitoring via Apps

Cardiologists are familiar with the strap on heart rate monitors that then must be sent to a lab for analysis.  What if you could skip that step and monitor a patient in real-time, at the click of a button?  From a contact lens that monitors a diabetic’s insulin levels, to a smart phone app that detects behavioral changes when the flu is coming on, there are many areas of research with promising early results.  In the video below, Dr. Sandy Pentland from MIT’s Media Lab talks about how veterans with mental health issues can be tracked when medications are adjusted to see if they are working.

Caveat:  Physicians need solid research proving the devices and apps are as effective as current monitoring systems or improve on diagnostic tools already in place.  Without those standards in place, they will be at a greater risk for malpractice suits.

Telemedicine expands

Instead of coming in regularly to check on insulin levels, what if a diabetic could handle it all remotely with a quick phone or video call with their doctor?  Or what if a specialist hundreds of miles away could review records electronically and offer a consult without putting the patient through unnecessary stress or travel?

Telemedicine has been around for decades but with a boost from technology it’s got new legs.  Physicians can easily share patient files with anyone, anywhere.  While some patients absolutely need to see a doctor in an exam room, there are many instances where a video call can be just as effective.  This has particular value with monitoring patients with long-term, but manageable disease and in rural parts of the country where access to specialists may be limited.

Caveat:  Currently most private insurers and government reimbursement programs do not cover telemedicine.  Many physicians who consult electronically can not get reimbursed for their time.  We need to look at laws and guidelines that will open up this treatment option.

Genetic discoveries continue

2014 saw several genetic discoveries, perhaps one of the most important being a genome sequence for under $1,000 when just a few short years ago it cost tens of thousands of dollars.  Acting in the opposite direction, the FDA’s squelching of genetic information to laypeople via companies like 23 and Me dampens database growth and big data research, while perhaps protecting potential patients from false or missed diagnoses.

The video below from genetic researcher John Quackenbush, Ph.D., professor at Dana-Farber Cancer Institute and Harvard School of Publish Health discusses the intersection between genomics and how physicians can use it with their patients.

Caveat:  We’re still in the early days of genomics research, physicians need to watch the research closely for where it can best help their specialties and their patients, particularly with rare disease diagnosis.

Complete Poll Results

We asked our physicians to predict the Top Three Trends in Medicine for 2015 (choose three).  We’ve already discussed the top three vote getters.  Below are the full results:

• 42% patient monitoring using wearable apps
• 41% telemedicine taking a foothold and becoming compensated
• 39% more genetic discoveries
• 36% an Ebola vaccine
• 29% new diabetes medications coming to market
• 28% interoperable EHR systems
• 20% breakthroughs in cancer treatment
• 16% a migration to DPC models of payment
• 13% improvement in the efficacy of the influenza vaccine

As a physician, what trends do you think will uptick in 2015?  From the list above what do you consider the Top 3?  If you’re an MD or DO please join us inside the Sermo physician community for further discussion of the latest research and medical techniques.

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A recent SERMO poll asked our doctors if they considered themselves workaholics.  While 54 percent answered yes, a strong majority, 46 percent, said they happily were not.

As one physician put it, “I believe I am a workaholic due to circumstances and would be happy not to be one … much of it stems from a reality of expenses and uncertainty of our future, with a desire to save for an early exit.”

Definition of a workaholic

Many physicians noted the difference between working hard and being a workaholic.  Per Wikipedia, a workaholic is addicted to work.  The term implies the person enjoys their work, but they feel a compulsion to do it above other activities and social relationships.

Many doctors noted workaholic tendencies form during med school and residency.  A medical school program is long hours of memorization.  Internship and residency are now capped at 80-hour work weeks, far above the average American work week of  47 hours.  One surgeon wrote, “The workaholic component I suffer from comes from good old-fashioned abusive general surgery training.  Rule 1 – trust no one.  Rule 2 – if you want something done correctly, do it yourself.”

But many can just turn it off as they head out for the day.  An osteopath wrote, “I’ve never been a workaholic.  Always give it my all while at work, but never felt the need to be at work when I had no need to be.  Some people thrive on work, the more the better.  I like my time off.”

Physician Burnout

Physician burnout is quite real, doctors often talk about the factors that contribute to burnout.  From a bigger perspective, US doctors don’t make as much as their counterparts around the globe when you factor in time off and hours worked per week.

As a physician do you consider yourself a workaholic?  What do you do to beat stress on the job?  We frequently talk about this topic inside the Sermo community, if you’re an MD or DO please join us.

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click to enlarge

Being a doctor isn’t what it used to be; crazy busy schedules, wrangling with computerized records, trying to remember what your children look like after another long week.

We asked our physicians what is the hardest problem they face in their practice.  While no one is surprised about Work/Life balance being number one at 52 percent, the fact that 21 percent of physicians name EHRs as their biggest work headache is telling.

EHR challenges led to a new niche in medicine.  A medical scribe is a person with knowledge of medical terminology who follows a physician throughout their day and enters EHR information for them.  Medical scribes are a small but growing part of medicine.

Another new challenge facing physicians is the increased demands of MOCs (maintenance of certifications).  Doctors now need continuing education credits more frequently and often the MOCs are tied to their ability to work in their specialty.  If MOCs aren’t kept up-to-date physicians can lose hospital privileges or worse.

Work Life Balance for Doctors

We asked doctors earlier this year about physician burnout and what contributed to it.  The top answers included:

• Lack of control
• Dysfunctional workplace
• Extremes in work (boredom/chaos)

As a physician what is the hardest thing for you about your practice?  What would you change?  Do you agree with the poll or do you think there’s something important missing?

If you’re an M.D. or D.O. you can join our free, physician-exclusive community.  Come on in and contribute to cases, vote on polls like this one and more.

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credit: Shutterstock

As Melissa Rivers prepares a lawsuit for damages against the clinic that performed her mother’s fatal surgery, a new report released yesterday details what went wrong with her procedure.

A 22-page report issued yesterday said the clinic where Joan Rivers received care made “major mistakes.” Violations include:

• failure to recognize deteriorating vital signs
• improper regulation of the dosage of Propofol
• failure to obtain consent for each procedure
• not cared for by authorized physicians
• and perhaps most telling, a staff member taking a picture while sedated

The report clearly indicates that, at least for Ms. Rivers, she received celebrity treatment that might have cost her life. We asked our physicians about celebrity treatment, and they had a lot to say about it.

Do Celebrities Deserve Different Treatment?

Some physicians found deferential treatment to be against the idea of being a doctor. The goal is to give everyone the best medicine, period.   One anesthesiologist wrote, “I told the CEO of a Fortune 500 company that he’ll get my best effort, just like the homeless guy I took care of right before him.”

An oncologist echoed that sentiment strongly, “When VIPs in need of care enter my realm, I bend over backward not to cut corners. It is a superstition of mine based on a Palmer Slogan, “only the very rich can afford poor healthcare.” Every patient deserves the best efforts I can give them, and there is ALWAYS a cost to cutting corners for anyone.”

Some doctors acknowledged there are reasons to treat celebrities differently, but it’s more about the mechanics of practice management than patient treatment options. An Emergency Medicine doctor wrote, “We get a fair amount of celebrities where I work, some VERY famous. The majority get a room quickly and seen within minutes of arrival. It’s a perk of celebrity, but it also keeps the ER functional. The treatment is the same. I do have to say the vast majority of them have been very decent, patient, and cooperative.”

Some specialties lend themselves to a higher level of celebrity patients. One in particular is Otolaryngology: a doctor wrote, “It really isn’t as cut and dried as ‘treat every patient the same,’ because not every patient has the same needs. Would I treat my next-door neighbor’s voice problems the same as the Bono’s if he was in town for a concert and needed to perform tonight? I don’t think anyone would.”

VIP Syndrome

One cardiologist described what sometimes happens when doctors treat celebrities. “There is a name for this, the VIP syndrome. It is often doing either slightly more or slightly less often at the request of the famous. Alternatively, the physician tries to do more to make sure the procedure will be successful. Unfortunately, things tend to go wrong in these circumstances the most.”

Having famous parents can have an impact on your care as well, one pediatrician wrote, “I covered a practice with lots of household names. The parents brought their kids in and were perfectly normal. The only issue was they were constantly refusing immunizations. They were nice about it, however. It was time consuming to talk about why these immunizations are recommended, the risks of the diseases, etc. They also needed to sign a form they had refused immunizations.”

An otarologist summed up the pitfalls of celebrity and medicine. “By human nature, doctors are just as awe-struck by celebrities as anyone else. Many times celebrities are treated as royalty, and there are many celebrities that expect it—-and demand it. The problem when too many rules are bent to please the celebrity can be fatal. We don’t tell them how to perform and do their business—therefore the celebrity should not command what we do—-especially if you bend rules or push the envelope.”

What do you think about celebrity status and medical treatment? Are there times when treating celebrities differently makes sense such as a singer with a throat problem or a busy urban Emergency Room suddenly dealing with a celebrity? What controls should be in place to protect the famous? If you’re an M.D. or D.O. you can see the full conversation inside Sermo.

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A recent Sermo Physician Poll supports medical personnel receiving flu vaccines to protect both employees and patients.

The question asked, “Do you support mandatory flu shots for medical personnel?” The results:

• 70%  Yes
• 30%  No

Why Flu Shots Matter

One endocrinologist who worked in a hospital commented, “The interest is not in minimizing sick days but in protecting immunocompromised or frail patients who come for care. All hospitalized patients are also offered immunization though I would assume there are no negative consequences to refusal.”

As we reported earlier, some facilities, like Johns Hopkins, require the flu shot or terminate the employee.  Another doctor noted a more novel approach for compliance.  “The flu vaccine is mandatory for all employees. If anyone refuses, they would need to wear a face mask at work for the entire flu season. Not surprisingly, we have 100% compliance.”

Population Compliance

The CDC tracks the numbers annually of the general population receiving the flu vaccine.  Last flu season was a five-year high for compliance rate.  Across the U.S., 58.9 percent of children and 42.2 percent of adults received vaccinations.  The CDC added:

Based on a study of the 2012–13 flu season, flu vaccination … prevented an estimated 6.6 million illnesses, 3.2 million medically attended illnesses, and 79,260 hospitalizations.

Compliance did vary greatly by state.  South Dakota had the highest compliance rate of 57.4 percent and Nevada had the lowest at 36.4 percent.

Some theorize the increase in vaccination could be due to the anti-vaccination movement which supports other immune-boosting strategies such as eating well and avoiding sick people.  Sermo columnist Linda Girgis, MD, family practitioner recently debunked many of the myths common in the “anti-vaxx” movement.”

A Warning for This Year’s Flu Season

Early indicators suggest the predominant strains for the 2014 – 2015 flu season will be influenza A (H3N2) and influenza B.  However, Ascel Bio Vice President and Infectious Disease Forecaster, James Wilson, M.D. said there is an issue with the nasal spray vaccine (“FluMist”) this season, it might not be as effective against H1N1 (swine flu) as in prior years:

“As forecasted, we are seeing an H3N2-dominant type A season, so concerns about whether the vaccine will protect against H1N1 infection is not looking relevant at this moment in the season.  We will of course continue to monitor the season in the coming months to see how much H1N1 activity there ultimately is.”

As a physician do you prefer using a shot or the nasal spray for your patients?

Physicians Strongly Support Childhood Vaccinations

Doctors know the threat of low vaccination rates.  We have seen diseases cropping back up that had been under control such as whooping cough in California and measles in the New York area.  Another vaccination poll, conducted in August, showed 79 percent of physicians think unvaccinated children should not be allowed to attend school.

As a physician, do you get an annual flu shot?  Do you think medical personnel should be required to vaccinate or risk losing their jobs?  Do you think wearing a mask is enough encouragement for medical personnel to receive a shot?  We will be discussing this more inside Sermo, if you’re an M.D. or D.O. please join us.

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