Ann M. Hoppel

Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.

Q: With which of the following statements do you agree?

a) I’m safe, because I’ve never intentionally committed fraud.

b) Mistakes made by the billing department are their problem, not mine.

c) A fraud investigation is only costly if you’re found guilty.

If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.

YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.

How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.

While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.

“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”

Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”

But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”

Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”

Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.

HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.

“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.

Q: With which of the following statements do you agree?

a) I’m safe, because I’ve never intentionally committed fraud.

b) Mistakes made by the billing department are their problem, not mine.

c) A fraud investigation is only costly if you’re found guilty.

If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.

YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.

How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.

While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.

“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”

Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”

But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”

Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”

Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.

HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.

“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.

Q: With which of the following statements do you agree?

a) I’m safe, because I’ve never intentionally committed fraud.

b) Mistakes made by the billing department are their problem, not mine.

c) A fraud investigation is only costly if you’re found guilty.

If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.

YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.

How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.

While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.

“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”

Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”

But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”

Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”

Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.

HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.

“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:

“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”

Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.

The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.

NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.

That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.

“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”

Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”

The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.

Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.

“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”

“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”

The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”

Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.

For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”

In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”

THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.

“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”

Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.

“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”

PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”

Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.

“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”

The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?

“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”

How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)

TRULY SPECIALIZED

KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.

Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”

The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.

“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”

Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”

Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.

“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”

Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.

Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.

“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”

Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.

“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”

All of this is daunting—but there will come a time when it is no longer optional.

PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).

Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).

Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”

To be blunt: People have filed lawsuits for less.

Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.

“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”

Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”

The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.

“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”

And you’d better do it before Baker joins the geriatric set!

Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:

“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”

Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.

The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.

NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.

That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.

“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”

Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”

The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.

Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.

“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”

“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”

The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”

Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.

For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”

In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”

THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.

“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”

Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.

“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”

PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”

Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.

“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”

The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?

“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”

How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)

TRULY SPECIALIZED

KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.

Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”

The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.

“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”

Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”

Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.

“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”

Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.

Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.

“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”

Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.

“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”

All of this is daunting—but there will come a time when it is no longer optional.

PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).

Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).

Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”

To be blunt: People have filed lawsuits for less.

Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.

“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”

Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”

The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.

“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”

And you’d better do it before Baker joins the geriatric set!

Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:

“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”

Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.

The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.

NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.

That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.

“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”

Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”

The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.

Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.

“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”

“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”

The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”

Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.

For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”

In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”

THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.

“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”

Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.

“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”

PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”

Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.

“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”

The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?

“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”

How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)

TRULY SPECIALIZED

KNOWLEDGE
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.

Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”

The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.

“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”

Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”

Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.

“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”

Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.

Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.

“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”

Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.

“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”

All of this is daunting—but there will come a time when it is no longer optional.

PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).

Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).

Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”

To be blunt: People have filed lawsuits for less.

Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.

“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”

Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”

The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.

“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”

And you’d better do it before Baker joins the geriatric set!

Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).

More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.

While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.

“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”

WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.

But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.

How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.

“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”

Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.

“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”

By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.

“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”

Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.

“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”

BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.

Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.

But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)

“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”

Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”

The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”

In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.

“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”

Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.

“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”

Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).

More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.

While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.

“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”

WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.

But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.

How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.

“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”

Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.

“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”

By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.

“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”

Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.

“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”

BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.

Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.

But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)

“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”

Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”

The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”

In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.

“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”

Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.

“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”

Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).

More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.

While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.

“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”

WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.

But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.

How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.

“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”

Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.

“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”

By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.

“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”

Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.

“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”

BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.

Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.

But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)

“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”

Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”

The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”

In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.

“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”

Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.

“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.” 

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

Providing patients and families with reliable information is helpful, Barry says. If they need or want to review the material and have a discussion at home, they are welcome to come back with questions. “That’s the key: In a busy day it’s sometimes hard to do, but it’s important to spend the time to counsel patients and parents about vaccines,” Barry says, “so they know that you’re really giving all the time and attention they need.”

Given the publicity that ACIP’s recommendation has already received, there will undoubtedly be more discussions about HPV vaccine between clinicians and adolescent patients (and their parents). Clinicians need to be prepared to answer questions about why boys can benefit from a vaccine that protects against a virus that causes, most notably, cervical cancer.

“They may say, ‘Well, my son doesn’t have a cervix,’” Barry says, “so there might need to be additional discussions just to clarify the exact reasons for giving the vaccine to males.”

Whether the concern is cervical cancer, anal cancer, cancers of the head and neck, or any of the other variations caused by HPV, the bottom line for clinicians is that the HPV vaccine is a powerful tool at their disposal that can help to prevent serious illness.

“You get a shot and you can potentially prevent your child from getting cancer,” Barry says. “That’s the main point I try to make. I just look at it as caring for the children.”

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.” 

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

Providing patients and families with reliable information is helpful, Barry says. If they need or want to review the material and have a discussion at home, they are welcome to come back with questions. “That’s the key: In a busy day it’s sometimes hard to do, but it’s important to spend the time to counsel patients and parents about vaccines,” Barry says, “so they know that you’re really giving all the time and attention they need.”

Given the publicity that ACIP’s recommendation has already received, there will undoubtedly be more discussions about HPV vaccine between clinicians and adolescent patients (and their parents). Clinicians need to be prepared to answer questions about why boys can benefit from a vaccine that protects against a virus that causes, most notably, cervical cancer.

“They may say, ‘Well, my son doesn’t have a cervix,’” Barry says, “so there might need to be additional discussions just to clarify the exact reasons for giving the vaccine to males.”

Whether the concern is cervical cancer, anal cancer, cancers of the head and neck, or any of the other variations caused by HPV, the bottom line for clinicians is that the HPV vaccine is a powerful tool at their disposal that can help to prevent serious illness.

“You get a shot and you can potentially prevent your child from getting cancer,” Barry says. “That’s the main point I try to make. I just look at it as caring for the children.”

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine to protect against human papillomavirus (HPV). This recommendation must be reviewed by the CDC before being finalized but is a more firm declaration than previously.

Following FDA approval of the quadrivalent HPV vaccine for use in boys and young men (in October 2009), there was a “permissive recommendation” that young males could receive the vaccine, but it was not part of the ACIP schedule. Routine vaccination of girls ages 11 and 12 has been recommended since June 2006.

There has already been speculation as to whether uptake rates in males will be better than those in females. “I actually think recommending the vaccine for both males and females will make it a little more accepted among females,” says Chris Barry, PA-C, MMSc, a past president of the Society for PAs in Pediatrics and current AAPA Medical Liaison to the American Academy of Pediatrics, “because it will be recommended for all children. Perhaps parents will take that as an additional point to immunize their children.”

ACIP’S RATIONALE
About 20 million Americans are currently infected with HPV, which has been associated with cancers of the cervix, vulva, vagina, penis, and anus, as well as of the head and neck. Each year in the US, about 18,000 women and 7,000 men are affected by HPV-associated cancers; cervical cancer is the most common in women and cancers of the head and neck in men.

“The HPV vaccine is a strong weapon in cancer prevention,” Dr. Anne Schuchat, the Director of CDC’s National Center for Immunization and Respiratory Diseases, said in a telebriefing about the recommendation. “The quadrivalent HPV vaccine prevents the types of HPV that cause cervical cancer in women, as well as anal cancer and genital warts in both women and men.”

In fact, the quadrivalent vaccine includes the HPV types that cause 80% of anal cancers. Since rates of anal cancer and cancers of the head and neck have increased in the past few decades, the committee deemed this an important consideration in their decision.

The committee also reviewed the trend in HPV vaccine use among girls, which Schuchat deemed “disappointing.” In addition to providing direct benefit to boys by preventing future cases of genital warts or anal cancer, the committee believes there is also the potential that vaccinating boys will reduce male-to-female transmission of HPV.

“All of the studies really point to the fact that to achieve the best prevention, vaccinating males as well as females is the way to go,” says Barry, who attended the ACIP meeting at which the recommendation and the rationale to support it were discussed. “A lot of times, HPV infection does not cause any symptoms, so through sexual contact males and females may be exchanging this virus that can later on potentially cause different forms of cancer.” 

ANSWERING QUESTIONS
Acceptance of HPV vaccine for girls has been something of a “tough sell,” in part because some parents seem to have taken the vaccine to be a moral indictment of their children. Some, of course, just question any and every vaccine that is offered. Clinicians may find themselves facing new and additional queries when the recommendation for boys becomes official.

“There is a lot of misinformation out there,” Barry says, “so I think it’s important that we counter that with good information.”

In the telebriefing, Schuchat acknowledged “confusion” about when children should be vaccinated against HPV; immune response and prevention are the key elements of that decision. Studies have indicated that younger girls achieve a better immune response.

“A lot of parents question the giving of HPV vaccine to a girl who is 11 or 12 and not currently sexually active,” Barry points out. “There are also parents who believe that by giving the vaccine we’re condoning sexuality at an early age. That is certainly not the point of giving it so early. It’s important to give the vaccine well prior to onset of any type of sexual contact.”

Making sure parents understand these distinctions is an essential part of the discussion. In the years since the HPV vaccine was recommended for girls, Barry and his colleagues have encountered patients and parents with a variety of responses to the offer of vaccination. Some are prepared and readily say yes; others are adamant in their refusal. But many fall in the middle—they have heard about the vaccine, but they want more information.

“I try to think of the vaccine discussion as a dialogue,” Barry says. “If parents have questions, I don’t try to rush or pressure them into getting it.”

Providing patients and families with reliable information is helpful, Barry says. If they need or want to review the material and have a discussion at home, they are welcome to come back with questions. “That’s the key: In a busy day it’s sometimes hard to do, but it’s important to spend the time to counsel patients and parents about vaccines,” Barry says, “so they know that you’re really giving all the time and attention they need.”

Given the publicity that ACIP’s recommendation has already received, there will undoubtedly be more discussions about HPV vaccine between clinicians and adolescent patients (and their parents). Clinicians need to be prepared to answer questions about why boys can benefit from a vaccine that protects against a virus that causes, most notably, cervical cancer.

“They may say, ‘Well, my son doesn’t have a cervix,’” Barry says, “so there might need to be additional discussions just to clarify the exact reasons for giving the vaccine to males.”

Whether the concern is cervical cancer, anal cancer, cancers of the head and neck, or any of the other variations caused by HPV, the bottom line for clinicians is that the HPV vaccine is a powerful tool at their disposal that can help to prevent serious illness.

“You get a shot and you can potentially prevent your child from getting cancer,” Barry says. “That’s the main point I try to make. I just look at it as caring for the children.”

When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”

While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.

“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”

READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.

“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”

The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.

Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.

“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”

The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”

Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.

“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.

“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”

SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.

“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”

Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.

Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.

At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.

“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.

While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”

To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”

Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.

THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?

“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”

“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”

“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”

For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”

Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.

Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”

On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”

There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)

“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”

Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.

“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”

“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”

When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”

While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.

“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”

READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.

“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”

The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.

Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.

“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”

The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”

Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.

“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.

“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”

SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.

“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”

Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.

Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.

At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.

“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.

While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”

To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”

Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.

THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?

“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”

“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”

“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”

For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”

Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.

Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”

On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”

There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)

“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”

Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.

“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”

“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”

When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”

While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.

“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”

READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.

“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”

The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.

Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.

“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”

The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”

Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.

“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.

“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”

SAFETY FIRST
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.

“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”

Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.

Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.

At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.

“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.

While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”

To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”

Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.

THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?

“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”

“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”

“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”

For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”

Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.

Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”

On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”

There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)

“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”

Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.

“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”

“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”

This year, New York became the second state to enact a law requiring health care providers to provide information on end-of-life options to terminally ill patients. California was the first; the Right to Know End-of-Life Options Act has been in effect there since January 1, 2009. New York’s Palliative Care Information Act took effect on February 9, 2011.

What do these laws mean, to whom do they apply—and in a larger context, is it possible to legislate one of the most difficult and intimate conversations a health care provider can have with a patient?

It’s the Law, But What Does That Mean?
First, the facts about these laws:

California’s Right to Know End-of-Life Options Act states that “when a health care provider … makes a diagnosis that a patient has a terminal illness, the health care provider shall, upon the patient’s request, provide the patient with comprehensive information and counseling regarding legal end-of-life options … and provide for the referral or transfer of a patient ... if the patient’s health care provider does not wish to comply with the patient’s request for information on end-of-life options.”

The law defines a “health care provider” as an attending physician or surgeon. However, it is further stipulated that the phrase “also means a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols.”

New York’s Palliative Care Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including … prognosis, risk and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management.”

The state Department of Health further clarifies that physicians and NPs are subject to the requirements of the law. PAs and other health care professionals may also, consistent with their scope of practice, provide information about these services but are not required to do so.

It is unclear how much of a difference these laws will make. In California, there has not been a noticeable flurry of concern or activity in response to the law; some clinicians haven’t even registered its existence on their radar. In a state facing an ongoing and major fiscal crisis, enforcing this type of law probably is not going to be a top priority.

New York’s law was passed despite protests from the medical society, which felt that parties that would be directly impacted by the law were not sufficiently consulted on its import and implementation. In May, two physicians from Maimonides Medical Center in Brooklyn wrote in the New England Journal of Medicine that “Physicians and health care organizations are struggling to understand what the law requires.”

Whether such laws are enforceable or effective in and of themselves, they do serve another purpose. They remind us of a largely unmet need in patient care: the need for an open and honest discussion about the end of life.

Shattering Hospice Myths
Medicine is about healing. Some­one becomes sick, and the clinician strives to make him or her well again. But there are devastating diseases about which we don’t know everything, and for many of them, a full-blown cure is not yet available. Even where life can be prolonged, death is never completely vanquished. Everyone knows that, but it is not easy to accept.

“Because most people die in old age, these issues get a lot of attention in the geriatric medicine arena—but this is across the life­span,” says Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey. “Many people spend a lot of money in their last months of life because we are a very interventionist medical society. And we still believe that we can cure and save everybody.”

“It’s true that we can always do something more,” says Karen Ayers, ACNP, who works with Hospice of Humboldt in California. “But is it futile? Is it going to work? Or is it just going to flog somebody? That’s really the question.”

Americans have already proven that they are not ready for a discussion of the financial aspects of treatment for terminal illnesses and other chronic, life-shortening conditions. (Recall the “death panels” propaganda?) But the larger issue is how individual patients would prefer to die, if “in my sleep, at a very old age” is not possible.

Some are inclined to fight until the last moment; if two rounds of chemo didn’t do the job, well, let’s try a third. Others would prefer to be as comfortable as possible for the remaining days/weeks/months of their lives. Most do not want to spend the end of their lives hooked up to machines in a hospital.

The question is whether patients know that they have choices and really understand what the options are. There are often misperceptions that when a clinician brings up end-of-life care, it is because he or she has “given up on” the patient.

“People think when you talk about end-of-life care that means ‘We’re going to give you morphine until you go into oblivion, and then you die,’” says Debbie Miller-Saultz, DNP, FNP-BC, of the Department of Pain Medicine and Palliative Care at Beth-Israel Medical Center in New York City. “And people think the morphine is causing someone to die faster. But all of those myths are really quelled when you talk to people who have palliative care, because they are offered services in a way that is timely and that provides much more support. People aren’t distressed or living in pain.”

 By way of evidence, Miller-Saultz cites a study published last August in the New England Journal of Medicine (2010;363:733-742). Researchers at Massachusetts General Hospital randomized patients with metastatic non–small cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone.

Patients who received early palliative care showed significant improvements in quality of life and mood, compared to their counterparts. Furthermore, while fewer patients in the palliative care group underwent aggressive end-of-life care (eg, chemotherapy within 14 days of death), median survival was higher for them than for patients in the oncologic care–only group (11.6 months vs 8.9 months).

Temel and colleagues said their results “offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.”

A Tough Talk to Have
Despite such positive findings, hospice remains an underutilized resource; the average length of stay is less than two weeks. “The reality is, the hospice literature shows that people get into hospice too late,” says Segal-Gidan.

In New York State, the average length of stay in hospice is 11 days. “People have end-of-life issues and disease longer than 11 days,” says Miller-Saultz. “So that’s a big part of the problem.”

Clearly, this is part of the impetus for legislative efforts such as those in California and New York. The implication of these laws is that, left to their own devices, clinicians are not providing terminally ill patients with essential information about the services available to them. Physicians in particular have often been criticized by advocates of palliative care and hospice for pushing aggressive treatments and dismissing the other options as “not real medicine.”

Nurses’ training may make them more receptive to alternatives. “We’re not schooled to ‘cure,’ that everything you do is driven to cure,” Miller-Saultz says. “You palliate. You do pain and symptom management. To me, it’s really no different from what we do anyway.”

That may change as medical schools try to incorporate more on end-of-life care into their curricula. But knowing you need to have these conversations—and in some cases being mandated to have them—does not make the discussion any easier.

Ayers considers herself fortunate to live and work in a relatively isolated area of California, centered around Eureka. The medical/nursing professionals are used to working together and do a lot of community outreach. When the local St. Joseph’s Hospital surveyed patients and providers, for example, they discovered that patients felt they weren’t getting information about the end of their lives, and clinicians said the hospital was not the right setting to deliver that information.

“It was just too late, it was too chaotic, and the patients were too upset,” Ayers explains. “It wasn’t the right time to be having that conversation.”

From this finding came the Physician Communication Initiative (it was named before the NPs got involved). The group held a series of dinners at a physician’s house “to talk about these issues, what is tough about it, how do you do it, how do you work it into the conversation,” Ayers says, “and how can we do it better.”

The Only Certainty Is …
While not everyone lives in that kind of community, Ayers suggests clinicians in other areas reach out to local medical and nursing groups, hospice services, or other community groups that may have an interest in educating people about what palliative care and end-of-life services are available locally. Major organizations also have resources on their Web sites that may help clinicians prepare for conversations with patients (see box).

A lot depends on context. Segal-Gidan works with patients who have Alzheimer’s disease, dementia, or other neurologic problems. “I’m able to bring up end-of-life care in the context of, say, ‘You’ve had a stroke, and you’re more likely to have another one. We hope not, but if so, let’s talk about what you would want to happen,’” she says. “When people are elderly and they have multiple chronic illnesses or a degenerative disease, people realize they’re coming to the end of their life. And in some ways, these discussions are more likely to happen.”

Timing is another question. The New York law, for example, requires that information on palliative and end-of-life options be provided to patients whose life expectancy does not exceed six months. Can that really be predicted with any certainty?

“We can identify the person with Alzheimer’s disease or multiple sclerosis or cancer,” Segal-Gidan says, “but we can’t identify very well when they’re six months before death. And then it may be too late.” This is another likely reason why so many people spend so little time in hospice programs before they die.

It may make sense to encourage patients to consider the choices they would make sooner rather than later. But even if a plan of care has been established or an advanced directive has been completed, nothing is set in stone. People can change their minds; death is an emotional issue and even those who are capable of frank discussion in the abstract may feel differently when it becomes reality.

In their editorial, the doctors from Maimonides Medical Center described an elderly patient with gastrointestinal and lung cancer for whom a satisfactory care plan had been developed—or so they thought. When the patient’s condition started to decline, his daughter found that she no longer agreed with the plan.

“She had previously accepted the fact of her father’s impending death as a theoretical matter,” the doctors wrote, “but when she came face to face with the troubling reality of his deteriorating condition, her thoughts and feelings had changed.”

How patients will respond to treatment, how long they will survive, and how they will choose to end their lives—there is so much uncertainty. Yet who might have pressing need for these services typically is not part of it. As Segal-Gidan said, it is possible to identify patients with terminal illnesses or degenerative conditions (although the diagnosis sometimes comes much too late in the process). But what of the 32- or 45-year-old who survives a car accident but has a traumatic brain injury and can no longer problem-solve, process, or plan? Who will make the decisions for that person? Did he or she ever discuss with a spouse or parent what he or she would want?

“It’s when death occurs at younger ages, more suddenly or unexpectedly, or even after the course of an illness, that I think it doesn’t really get a lot of attention,” Segal-Gidan says. “The grief gets a lot of attention, but all of the things around it—preparing for it, acknowledging it as a possibility—aren’t talked about.”

It isn’t possible to predict death and it certainly isn’t possible to avoid it forever. If there is one thing that frustrates humans, it is that we do not have all the answers.

This year, New York became the second state to enact a law requiring health care providers to provide information on end-of-life options to terminally ill patients. California was the first; the Right to Know End-of-Life Options Act has been in effect there since January 1, 2009. New York’s Palliative Care Information Act took effect on February 9, 2011.

What do these laws mean, to whom do they apply—and in a larger context, is it possible to legislate one of the most difficult and intimate conversations a health care provider can have with a patient?

It’s the Law, But What Does That Mean?
First, the facts about these laws:

California’s Right to Know End-of-Life Options Act states that “when a health care provider … makes a diagnosis that a patient has a terminal illness, the health care provider shall, upon the patient’s request, provide the patient with comprehensive information and counseling regarding legal end-of-life options … and provide for the referral or transfer of a patient ... if the patient’s health care provider does not wish to comply with the patient’s request for information on end-of-life options.”

The law defines a “health care provider” as an attending physician or surgeon. However, it is further stipulated that the phrase “also means a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols.”

New York’s Palliative Care Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including … prognosis, risk and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management.”

The state Department of Health further clarifies that physicians and NPs are subject to the requirements of the law. PAs and other health care professionals may also, consistent with their scope of practice, provide information about these services but are not required to do so.

It is unclear how much of a difference these laws will make. In California, there has not been a noticeable flurry of concern or activity in response to the law; some clinicians haven’t even registered its existence on their radar. In a state facing an ongoing and major fiscal crisis, enforcing this type of law probably is not going to be a top priority.

New York’s law was passed despite protests from the medical society, which felt that parties that would be directly impacted by the law were not sufficiently consulted on its import and implementation. In May, two physicians from Maimonides Medical Center in Brooklyn wrote in the New England Journal of Medicine that “Physicians and health care organizations are struggling to understand what the law requires.”

Whether such laws are enforceable or effective in and of themselves, they do serve another purpose. They remind us of a largely unmet need in patient care: the need for an open and honest discussion about the end of life.

Shattering Hospice Myths
Medicine is about healing. Some­one becomes sick, and the clinician strives to make him or her well again. But there are devastating diseases about which we don’t know everything, and for many of them, a full-blown cure is not yet available. Even where life can be prolonged, death is never completely vanquished. Everyone knows that, but it is not easy to accept.

“Because most people die in old age, these issues get a lot of attention in the geriatric medicine arena—but this is across the life­span,” says Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey. “Many people spend a lot of money in their last months of life because we are a very interventionist medical society. And we still believe that we can cure and save everybody.”

“It’s true that we can always do something more,” says Karen Ayers, ACNP, who works with Hospice of Humboldt in California. “But is it futile? Is it going to work? Or is it just going to flog somebody? That’s really the question.”

Americans have already proven that they are not ready for a discussion of the financial aspects of treatment for terminal illnesses and other chronic, life-shortening conditions. (Recall the “death panels” propaganda?) But the larger issue is how individual patients would prefer to die, if “in my sleep, at a very old age” is not possible.

Some are inclined to fight until the last moment; if two rounds of chemo didn’t do the job, well, let’s try a third. Others would prefer to be as comfortable as possible for the remaining days/weeks/months of their lives. Most do not want to spend the end of their lives hooked up to machines in a hospital.

The question is whether patients know that they have choices and really understand what the options are. There are often misperceptions that when a clinician brings up end-of-life care, it is because he or she has “given up on” the patient.

“People think when you talk about end-of-life care that means ‘We’re going to give you morphine until you go into oblivion, and then you die,’” says Debbie Miller-Saultz, DNP, FNP-BC, of the Department of Pain Medicine and Palliative Care at Beth-Israel Medical Center in New York City. “And people think the morphine is causing someone to die faster. But all of those myths are really quelled when you talk to people who have palliative care, because they are offered services in a way that is timely and that provides much more support. People aren’t distressed or living in pain.”

 By way of evidence, Miller-Saultz cites a study published last August in the New England Journal of Medicine (2010;363:733-742). Researchers at Massachusetts General Hospital randomized patients with metastatic non–small cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone.

Patients who received early palliative care showed significant improvements in quality of life and mood, compared to their counterparts. Furthermore, while fewer patients in the palliative care group underwent aggressive end-of-life care (eg, chemotherapy within 14 days of death), median survival was higher for them than for patients in the oncologic care–only group (11.6 months vs 8.9 months).

Temel and colleagues said their results “offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.”

A Tough Talk to Have
Despite such positive findings, hospice remains an underutilized resource; the average length of stay is less than two weeks. “The reality is, the hospice literature shows that people get into hospice too late,” says Segal-Gidan.

In New York State, the average length of stay in hospice is 11 days. “People have end-of-life issues and disease longer than 11 days,” says Miller-Saultz. “So that’s a big part of the problem.”

Clearly, this is part of the impetus for legislative efforts such as those in California and New York. The implication of these laws is that, left to their own devices, clinicians are not providing terminally ill patients with essential information about the services available to them. Physicians in particular have often been criticized by advocates of palliative care and hospice for pushing aggressive treatments and dismissing the other options as “not real medicine.”

Nurses’ training may make them more receptive to alternatives. “We’re not schooled to ‘cure,’ that everything you do is driven to cure,” Miller-Saultz says. “You palliate. You do pain and symptom management. To me, it’s really no different from what we do anyway.”

That may change as medical schools try to incorporate more on end-of-life care into their curricula. But knowing you need to have these conversations—and in some cases being mandated to have them—does not make the discussion any easier.

Ayers considers herself fortunate to live and work in a relatively isolated area of California, centered around Eureka. The medical/nursing professionals are used to working together and do a lot of community outreach. When the local St. Joseph’s Hospital surveyed patients and providers, for example, they discovered that patients felt they weren’t getting information about the end of their lives, and clinicians said the hospital was not the right setting to deliver that information.

“It was just too late, it was too chaotic, and the patients were too upset,” Ayers explains. “It wasn’t the right time to be having that conversation.”

From this finding came the Physician Communication Initiative (it was named before the NPs got involved). The group held a series of dinners at a physician’s house “to talk about these issues, what is tough about it, how do you do it, how do you work it into the conversation,” Ayers says, “and how can we do it better.”

The Only Certainty Is …
While not everyone lives in that kind of community, Ayers suggests clinicians in other areas reach out to local medical and nursing groups, hospice services, or other community groups that may have an interest in educating people about what palliative care and end-of-life services are available locally. Major organizations also have resources on their Web sites that may help clinicians prepare for conversations with patients (see box).

A lot depends on context. Segal-Gidan works with patients who have Alzheimer’s disease, dementia, or other neurologic problems. “I’m able to bring up end-of-life care in the context of, say, ‘You’ve had a stroke, and you’re more likely to have another one. We hope not, but if so, let’s talk about what you would want to happen,’” she says. “When people are elderly and they have multiple chronic illnesses or a degenerative disease, people realize they’re coming to the end of their life. And in some ways, these discussions are more likely to happen.”

Timing is another question. The New York law, for example, requires that information on palliative and end-of-life options be provided to patients whose life expectancy does not exceed six months. Can that really be predicted with any certainty?

“We can identify the person with Alzheimer’s disease or multiple sclerosis or cancer,” Segal-Gidan says, “but we can’t identify very well when they’re six months before death. And then it may be too late.” This is another likely reason why so many people spend so little time in hospice programs before they die.

It may make sense to encourage patients to consider the choices they would make sooner rather than later. But even if a plan of care has been established or an advanced directive has been completed, nothing is set in stone. People can change their minds; death is an emotional issue and even those who are capable of frank discussion in the abstract may feel differently when it becomes reality.

In their editorial, the doctors from Maimonides Medical Center described an elderly patient with gastrointestinal and lung cancer for whom a satisfactory care plan had been developed—or so they thought. When the patient’s condition started to decline, his daughter found that she no longer agreed with the plan.

“She had previously accepted the fact of her father’s impending death as a theoretical matter,” the doctors wrote, “but when she came face to face with the troubling reality of his deteriorating condition, her thoughts and feelings had changed.”

How patients will respond to treatment, how long they will survive, and how they will choose to end their lives—there is so much uncertainty. Yet who might have pressing need for these services typically is not part of it. As Segal-Gidan said, it is possible to identify patients with terminal illnesses or degenerative conditions (although the diagnosis sometimes comes much too late in the process). But what of the 32- or 45-year-old who survives a car accident but has a traumatic brain injury and can no longer problem-solve, process, or plan? Who will make the decisions for that person? Did he or she ever discuss with a spouse or parent what he or she would want?

“It’s when death occurs at younger ages, more suddenly or unexpectedly, or even after the course of an illness, that I think it doesn’t really get a lot of attention,” Segal-Gidan says. “The grief gets a lot of attention, but all of the things around it—preparing for it, acknowledging it as a possibility—aren’t talked about.”

It isn’t possible to predict death and it certainly isn’t possible to avoid it forever. If there is one thing that frustrates humans, it is that we do not have all the answers.

This year, New York became the second state to enact a law requiring health care providers to provide information on end-of-life options to terminally ill patients. California was the first; the Right to Know End-of-Life Options Act has been in effect there since January 1, 2009. New York’s Palliative Care Information Act took effect on February 9, 2011.

What do these laws mean, to whom do they apply—and in a larger context, is it possible to legislate one of the most difficult and intimate conversations a health care provider can have with a patient?

It’s the Law, But What Does That Mean?
First, the facts about these laws:

California’s Right to Know End-of-Life Options Act states that “when a health care provider … makes a diagnosis that a patient has a terminal illness, the health care provider shall, upon the patient’s request, provide the patient with comprehensive information and counseling regarding legal end-of-life options … and provide for the referral or transfer of a patient ... if the patient’s health care provider does not wish to comply with the patient’s request for information on end-of-life options.”

The law defines a “health care provider” as an attending physician or surgeon. However, it is further stipulated that the phrase “also means a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols.”

New York’s Palliative Care Information Act states that “If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including … prognosis, risk and benefits of the various options; and the patient’s legal rights to comprehensive pain and symptom management.”

The state Department of Health further clarifies that physicians and NPs are subject to the requirements of the law. PAs and other health care professionals may also, consistent with their scope of practice, provide information about these services but are not required to do so.

It is unclear how much of a difference these laws will make. In California, there has not been a noticeable flurry of concern or activity in response to the law; some clinicians haven’t even registered its existence on their radar. In a state facing an ongoing and major fiscal crisis, enforcing this type of law probably is not going to be a top priority.

New York’s law was passed despite protests from the medical society, which felt that parties that would be directly impacted by the law were not sufficiently consulted on its import and implementation. In May, two physicians from Maimonides Medical Center in Brooklyn wrote in the New England Journal of Medicine that “Physicians and health care organizations are struggling to understand what the law requires.”

Whether such laws are enforceable or effective in and of themselves, they do serve another purpose. They remind us of a largely unmet need in patient care: the need for an open and honest discussion about the end of life.

Shattering Hospice Myths
Medicine is about healing. Some­one becomes sick, and the clinician strives to make him or her well again. But there are devastating diseases about which we don’t know everything, and for many of them, a full-blown cure is not yet available. Even where life can be prolonged, death is never completely vanquished. Everyone knows that, but it is not easy to accept.

“Because most people die in old age, these issues get a lot of attention in the geriatric medicine arena—but this is across the life­span,” says Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey. “Many people spend a lot of money in their last months of life because we are a very interventionist medical society. And we still believe that we can cure and save everybody.”

“It’s true that we can always do something more,” says Karen Ayers, ACNP, who works with Hospice of Humboldt in California. “But is it futile? Is it going to work? Or is it just going to flog somebody? That’s really the question.”

Americans have already proven that they are not ready for a discussion of the financial aspects of treatment for terminal illnesses and other chronic, life-shortening conditions. (Recall the “death panels” propaganda?) But the larger issue is how individual patients would prefer to die, if “in my sleep, at a very old age” is not possible.

Some are inclined to fight until the last moment; if two rounds of chemo didn’t do the job, well, let’s try a third. Others would prefer to be as comfortable as possible for the remaining days/weeks/months of their lives. Most do not want to spend the end of their lives hooked up to machines in a hospital.

The question is whether patients know that they have choices and really understand what the options are. There are often misperceptions that when a clinician brings up end-of-life care, it is because he or she has “given up on” the patient.

“People think when you talk about end-of-life care that means ‘We’re going to give you morphine until you go into oblivion, and then you die,’” says Debbie Miller-Saultz, DNP, FNP-BC, of the Department of Pain Medicine and Palliative Care at Beth-Israel Medical Center in New York City. “And people think the morphine is causing someone to die faster. But all of those myths are really quelled when you talk to people who have palliative care, because they are offered services in a way that is timely and that provides much more support. People aren’t distressed or living in pain.”

 By way of evidence, Miller-Saultz cites a study published last August in the New England Journal of Medicine (2010;363:733-742). Researchers at Massachusetts General Hospital randomized patients with metastatic non–small cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone.

Patients who received early palliative care showed significant improvements in quality of life and mood, compared to their counterparts. Furthermore, while fewer patients in the palliative care group underwent aggressive end-of-life care (eg, chemotherapy within 14 days of death), median survival was higher for them than for patients in the oncologic care–only group (11.6 months vs 8.9 months).

Temel and colleagues said their results “offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.”

A Tough Talk to Have
Despite such positive findings, hospice remains an underutilized resource; the average length of stay is less than two weeks. “The reality is, the hospice literature shows that people get into hospice too late,” says Segal-Gidan.

In New York State, the average length of stay in hospice is 11 days. “People have end-of-life issues and disease longer than 11 days,” says Miller-Saultz. “So that’s a big part of the problem.”

Clearly, this is part of the impetus for legislative efforts such as those in California and New York. The implication of these laws is that, left to their own devices, clinicians are not providing terminally ill patients with essential information about the services available to them. Physicians in particular have often been criticized by advocates of palliative care and hospice for pushing aggressive treatments and dismissing the other options as “not real medicine.”

Nurses’ training may make them more receptive to alternatives. “We’re not schooled to ‘cure,’ that everything you do is driven to cure,” Miller-Saultz says. “You palliate. You do pain and symptom management. To me, it’s really no different from what we do anyway.”

That may change as medical schools try to incorporate more on end-of-life care into their curricula. But knowing you need to have these conversations—and in some cases being mandated to have them—does not make the discussion any easier.

Ayers considers herself fortunate to live and work in a relatively isolated area of California, centered around Eureka. The medical/nursing professionals are used to working together and do a lot of community outreach. When the local St. Joseph’s Hospital surveyed patients and providers, for example, they discovered that patients felt they weren’t getting information about the end of their lives, and clinicians said the hospital was not the right setting to deliver that information.

“It was just too late, it was too chaotic, and the patients were too upset,” Ayers explains. “It wasn’t the right time to be having that conversation.”

From this finding came the Physician Communication Initiative (it was named before the NPs got involved). The group held a series of dinners at a physician’s house “to talk about these issues, what is tough about it, how do you do it, how do you work it into the conversation,” Ayers says, “and how can we do it better.”

The Only Certainty Is …
While not everyone lives in that kind of community, Ayers suggests clinicians in other areas reach out to local medical and nursing groups, hospice services, or other community groups that may have an interest in educating people about what palliative care and end-of-life services are available locally. Major organizations also have resources on their Web sites that may help clinicians prepare for conversations with patients (see box).

A lot depends on context. Segal-Gidan works with patients who have Alzheimer’s disease, dementia, or other neurologic problems. “I’m able to bring up end-of-life care in the context of, say, ‘You’ve had a stroke, and you’re more likely to have another one. We hope not, but if so, let’s talk about what you would want to happen,’” she says. “When people are elderly and they have multiple chronic illnesses or a degenerative disease, people realize they’re coming to the end of their life. And in some ways, these discussions are more likely to happen.”

Timing is another question. The New York law, for example, requires that information on palliative and end-of-life options be provided to patients whose life expectancy does not exceed six months. Can that really be predicted with any certainty?

“We can identify the person with Alzheimer’s disease or multiple sclerosis or cancer,” Segal-Gidan says, “but we can’t identify very well when they’re six months before death. And then it may be too late.” This is another likely reason why so many people spend so little time in hospice programs before they die.

It may make sense to encourage patients to consider the choices they would make sooner rather than later. But even if a plan of care has been established or an advanced directive has been completed, nothing is set in stone. People can change their minds; death is an emotional issue and even those who are capable of frank discussion in the abstract may feel differently when it becomes reality.

In their editorial, the doctors from Maimonides Medical Center described an elderly patient with gastrointestinal and lung cancer for whom a satisfactory care plan had been developed—or so they thought. When the patient’s condition started to decline, his daughter found that she no longer agreed with the plan.

“She had previously accepted the fact of her father’s impending death as a theoretical matter,” the doctors wrote, “but when she came face to face with the troubling reality of his deteriorating condition, her thoughts and feelings had changed.”

How patients will respond to treatment, how long they will survive, and how they will choose to end their lives—there is so much uncertainty. Yet who might have pressing need for these services typically is not part of it. As Segal-Gidan said, it is possible to identify patients with terminal illnesses or degenerative conditions (although the diagnosis sometimes comes much too late in the process). But what of the 32- or 45-year-old who survives a car accident but has a traumatic brain injury and can no longer problem-solve, process, or plan? Who will make the decisions for that person? Did he or she ever discuss with a spouse or parent what he or she would want?

“It’s when death occurs at younger ages, more suddenly or unexpectedly, or even after the course of an illness, that I think it doesn’t really get a lot of attention,” Segal-Gidan says. “The grief gets a lot of attention, but all of the things around it—preparing for it, acknowledging it as a possibility—aren’t talked about.”

It isn’t possible to predict death and it certainly isn’t possible to avoid it forever. If there is one thing that frustrates humans, it is that we do not have all the answers.

This summer, primary care NPs and PAs, who increasingly face the challenging clinical conundrum of metabolic and endocrine diseases, have a unique opportunity to enhance their knowledge—and therefore their patient care—in these areas. The first Metabolic and Endocrine Disease Summit (MEDS) will be held from July 28 to 30 at the Walt Disney World Swan and Dolphin in Orlando.

Sponsored by Clinician Reviews and the Primary Care Metabolic Group, MEDS is designed to provide “practical, case-based advice on how to really manage patients with diabetes” and other endocrinopathies, says Chris Sadler, MA, PA-C, CDE, Co-Chair of MEDS and President-Elect of the American Society of Endocrine PAs (ASEPA). “Attendees are not just going to get the typical statistics.”

MEDS is unique in that it was designed with primary care providers in mind. Other endocrinology-themed meetings may focus more on updating specialists about what is happening within the field.

“Those meetings don’t teach how to tackle the primary care presentation of an endocrine or metabolic disease—how to work it up and have a good thought process on how to manage it, whether the case needs to be referred out or can be handled in the primary care setting,” says Scott Urquhart, PA-C, DFAAPA, Chair of MEDS and Immediate Past President of ASEPA. “With the shortage of endocrinologists, we need to educate our primary care providers on how to manage these diseases, because we can’t do it all.”

DIABETES IN DEPTH, AND MORE
During the 2.5-day program, NPs and PAs can earn up to 18.5 hours of CE/CME credit while attending lectures on a variety of topics. As Christine Kessler, MN, CNS, ANP, BC-ADM, Co-Chair of MEDS, says, “What isn’t covered? There will be everything from the ‘big ones’—diabetes, thyroid disorders, obesity, and osteoporosis—all the way down to hypogonadism.”

“On Day 1 and on Day 3, which is a half-day, we want to focus on areas that may not get enough attention and that may need clarification on how to handle them,” Urquhart says, “because a lot of these conditions can be worked up in primary care offices.”

These areas include hypothyroidism, hyperthyroidism, hypercalcemia, adrenal dysfunctions, dyslipidemia, polycystic ovary syndrome, obesity, and vitamin D deficiency.

“A lot of primary care clinicians have expressed—at least in the past—a lack of comfort with managing some of these diagnoses,” Sadler says. “Considering how much disease we’re seeing in these areas, [this meeting] will really enhance their clinical practice and their ability to diagnose and treat these illnesses in an appropriate way.”

Day 2 of the meeting is what Urquhart calls “Diabetes Day” and will focus on this most common disorder “so people aren’t being pulled on track and off track again.” Both type 1 and type 2 diabetes will be covered, with lectures aimed at helping clinicians navigate the therapeutic agents used to treat type 2 diabetes (there are almost a dozen classes), become more comfortable with insulin, and understand the appropriate use of finger-stick versus continuous glucose monitoring.

Diabetes is a complex topic, in part because patients with type 2 diabetes are an extremely heterogeneous population. The “one size fits all” approach of most guidelines may not adequately address the needs of an individual patient, as Sadler explains:

“You have patients at one end of the spectrum who are extremely insulin-resistant and you have other patients at the other end who are extremely insulin-deficient—and you have everyone in between. That’s what is so complex—understanding the nuances of someone’s diabetes, in terms of what is the appropriate work-up to differentiate one patient from another and why you would use different agents in one patient versus another.”

It is the hope of the MEDS chairs that attendees will leave the meeting with “current and relevant information that they can use right away in practice,” Kessler says.

ALL TOGETHER NOW
In addition to the in-depth coverage of a wide variety of metabolic and endocrine disorders, another key component of MEDS is the interaction. The faculty is comprised of NPs and PAs who are experts in the field. While they may conduct clinical research or present at meetings, they are not researchers or lecturers by trade but rather clinicians who are in the field, seeing patients. This means they can provide “clinical pearls that you’ll never learn from a book; they come from dealing with these disorders day in and day out,” as Kessler says. And the faculty members do want attendees to ask questions; part of each session will be devoted to Q&A (not that queries must be limited to the classroom).

“It will be like having an endocrine consultant right there for you,” Kessler says. “So it’s not just didactic, with somebody speaking. Clinicians can approach us with certain of their own challenging cases, and then we can help them with that.”

“The faculty will be there the whole time,” Sadler adds, “so people will be around to converse with at breaks or in between sessions. I think there will be a lot more interaction with faculty than you typically get at conferences.”

In fact, Sadler hopes one of the things NPs and PAs will take from MEDS is a network of colleagues they can contact for “further dialogue” later. And those colleagues will be representatives of both professions, since MEDS brings PAs and NPs together to address common educational needs.

“There are physician meetings, PA meetings, and NP meetings, but in the office setting, we work together,” Urquhart says. “There are some differences in training and philosophy, but put in the same clinical setting, we are expected to have the same outcomes. Quality of care won’t be compromised based on the fact that you’re a PA, an NP, or an MD, as long as you have been trained and the practice you’re working with fully understands your competencies and skill set.”

Skill sets can be enhanced through educational initiatives such as MEDS, and if attendees leave the meeting with “confidence, and maybe even a bit of a passion for endocrinology,” as Kessler hopes, the end result will improve more than just their own professional lives.

“This meeting brings providers together and focuses on our common interest,” Sadler says, “which is taking care of patients.”

Information about MEDS, including registration, can be found ­online at www.MEDSummit.qhc.com.               

This summer, primary care NPs and PAs, who increasingly face the challenging clinical conundrum of metabolic and endocrine diseases, have a unique opportunity to enhance their knowledge—and therefore their patient care—in these areas. The first Metabolic and Endocrine Disease Summit (MEDS) will be held from July 28 to 30 at the Walt Disney World Swan and Dolphin in Orlando.

Sponsored by Clinician Reviews and the Primary Care Metabolic Group, MEDS is designed to provide “practical, case-based advice on how to really manage patients with diabetes” and other endocrinopathies, says Chris Sadler, MA, PA-C, CDE, Co-Chair of MEDS and President-Elect of the American Society of Endocrine PAs (ASEPA). “Attendees are not just going to get the typical statistics.”

MEDS is unique in that it was designed with primary care providers in mind. Other endocrinology-themed meetings may focus more on updating specialists about what is happening within the field.

“Those meetings don’t teach how to tackle the primary care presentation of an endocrine or metabolic disease—how to work it up and have a good thought process on how to manage it, whether the case needs to be referred out or can be handled in the primary care setting,” says Scott Urquhart, PA-C, DFAAPA, Chair of MEDS and Immediate Past President of ASEPA. “With the shortage of endocrinologists, we need to educate our primary care providers on how to manage these diseases, because we can’t do it all.”

DIABETES IN DEPTH, AND MORE
During the 2.5-day program, NPs and PAs can earn up to 18.5 hours of CE/CME credit while attending lectures on a variety of topics. As Christine Kessler, MN, CNS, ANP, BC-ADM, Co-Chair of MEDS, says, “What isn’t covered? There will be everything from the ‘big ones’—diabetes, thyroid disorders, obesity, and osteoporosis—all the way down to hypogonadism.”

“On Day 1 and on Day 3, which is a half-day, we want to focus on areas that may not get enough attention and that may need clarification on how to handle them,” Urquhart says, “because a lot of these conditions can be worked up in primary care offices.”

These areas include hypothyroidism, hyperthyroidism, hypercalcemia, adrenal dysfunctions, dyslipidemia, polycystic ovary syndrome, obesity, and vitamin D deficiency.

“A lot of primary care clinicians have expressed—at least in the past—a lack of comfort with managing some of these diagnoses,” Sadler says. “Considering how much disease we’re seeing in these areas, [this meeting] will really enhance their clinical practice and their ability to diagnose and treat these illnesses in an appropriate way.”

Day 2 of the meeting is what Urquhart calls “Diabetes Day” and will focus on this most common disorder “so people aren’t being pulled on track and off track again.” Both type 1 and type 2 diabetes will be covered, with lectures aimed at helping clinicians navigate the therapeutic agents used to treat type 2 diabetes (there are almost a dozen classes), become more comfortable with insulin, and understand the appropriate use of finger-stick versus continuous glucose monitoring.

Diabetes is a complex topic, in part because patients with type 2 diabetes are an extremely heterogeneous population. The “one size fits all” approach of most guidelines may not adequately address the needs of an individual patient, as Sadler explains:

“You have patients at one end of the spectrum who are extremely insulin-resistant and you have other patients at the other end who are extremely insulin-deficient—and you have everyone in between. That’s what is so complex—understanding the nuances of someone’s diabetes, in terms of what is the appropriate work-up to differentiate one patient from another and why you would use different agents in one patient versus another.”

It is the hope of the MEDS chairs that attendees will leave the meeting with “current and relevant information that they can use right away in practice,” Kessler says.

ALL TOGETHER NOW
In addition to the in-depth coverage of a wide variety of metabolic and endocrine disorders, another key component of MEDS is the interaction. The faculty is comprised of NPs and PAs who are experts in the field. While they may conduct clinical research or present at meetings, they are not researchers or lecturers by trade but rather clinicians who are in the field, seeing patients. This means they can provide “clinical pearls that you’ll never learn from a book; they come from dealing with these disorders day in and day out,” as Kessler says. And the faculty members do want attendees to ask questions; part of each session will be devoted to Q&A (not that queries must be limited to the classroom).

“It will be like having an endocrine consultant right there for you,” Kessler says. “So it’s not just didactic, with somebody speaking. Clinicians can approach us with certain of their own challenging cases, and then we can help them with that.”

“The faculty will be there the whole time,” Sadler adds, “so people will be around to converse with at breaks or in between sessions. I think there will be a lot more interaction with faculty than you typically get at conferences.”

In fact, Sadler hopes one of the things NPs and PAs will take from MEDS is a network of colleagues they can contact for “further dialogue” later. And those colleagues will be representatives of both professions, since MEDS brings PAs and NPs together to address common educational needs.

“There are physician meetings, PA meetings, and NP meetings, but in the office setting, we work together,” Urquhart says. “There are some differences in training and philosophy, but put in the same clinical setting, we are expected to have the same outcomes. Quality of care won’t be compromised based on the fact that you’re a PA, an NP, or an MD, as long as you have been trained and the practice you’re working with fully understands your competencies and skill set.”

Skill sets can be enhanced through educational initiatives such as MEDS, and if attendees leave the meeting with “confidence, and maybe even a bit of a passion for endocrinology,” as Kessler hopes, the end result will improve more than just their own professional lives.

“This meeting brings providers together and focuses on our common interest,” Sadler says, “which is taking care of patients.”

Information about MEDS, including registration, can be found ­online at www.MEDSummit.qhc.com.               

This summer, primary care NPs and PAs, who increasingly face the challenging clinical conundrum of metabolic and endocrine diseases, have a unique opportunity to enhance their knowledge—and therefore their patient care—in these areas. The first Metabolic and Endocrine Disease Summit (MEDS) will be held from July 28 to 30 at the Walt Disney World Swan and Dolphin in Orlando.

Sponsored by Clinician Reviews and the Primary Care Metabolic Group, MEDS is designed to provide “practical, case-based advice on how to really manage patients with diabetes” and other endocrinopathies, says Chris Sadler, MA, PA-C, CDE, Co-Chair of MEDS and President-Elect of the American Society of Endocrine PAs (ASEPA). “Attendees are not just going to get the typical statistics.”

MEDS is unique in that it was designed with primary care providers in mind. Other endocrinology-themed meetings may focus more on updating specialists about what is happening within the field.

“Those meetings don’t teach how to tackle the primary care presentation of an endocrine or metabolic disease—how to work it up and have a good thought process on how to manage it, whether the case needs to be referred out or can be handled in the primary care setting,” says Scott Urquhart, PA-C, DFAAPA, Chair of MEDS and Immediate Past President of ASEPA. “With the shortage of endocrinologists, we need to educate our primary care providers on how to manage these diseases, because we can’t do it all.”

DIABETES IN DEPTH, AND MORE
During the 2.5-day program, NPs and PAs can earn up to 18.5 hours of CE/CME credit while attending lectures on a variety of topics. As Christine Kessler, MN, CNS, ANP, BC-ADM, Co-Chair of MEDS, says, “What isn’t covered? There will be everything from the ‘big ones’—diabetes, thyroid disorders, obesity, and osteoporosis—all the way down to hypogonadism.”

“On Day 1 and on Day 3, which is a half-day, we want to focus on areas that may not get enough attention and that may need clarification on how to handle them,” Urquhart says, “because a lot of these conditions can be worked up in primary care offices.”

These areas include hypothyroidism, hyperthyroidism, hypercalcemia, adrenal dysfunctions, dyslipidemia, polycystic ovary syndrome, obesity, and vitamin D deficiency.

“A lot of primary care clinicians have expressed—at least in the past—a lack of comfort with managing some of these diagnoses,” Sadler says. “Considering how much disease we’re seeing in these areas, [this meeting] will really enhance their clinical practice and their ability to diagnose and treat these illnesses in an appropriate way.”

Day 2 of the meeting is what Urquhart calls “Diabetes Day” and will focus on this most common disorder “so people aren’t being pulled on track and off track again.” Both type 1 and type 2 diabetes will be covered, with lectures aimed at helping clinicians navigate the therapeutic agents used to treat type 2 diabetes (there are almost a dozen classes), become more comfortable with insulin, and understand the appropriate use of finger-stick versus continuous glucose monitoring.

Diabetes is a complex topic, in part because patients with type 2 diabetes are an extremely heterogeneous population. The “one size fits all” approach of most guidelines may not adequately address the needs of an individual patient, as Sadler explains:

“You have patients at one end of the spectrum who are extremely insulin-resistant and you have other patients at the other end who are extremely insulin-deficient—and you have everyone in between. That’s what is so complex—understanding the nuances of someone’s diabetes, in terms of what is the appropriate work-up to differentiate one patient from another and why you would use different agents in one patient versus another.”

It is the hope of the MEDS chairs that attendees will leave the meeting with “current and relevant information that they can use right away in practice,” Kessler says.

ALL TOGETHER NOW
In addition to the in-depth coverage of a wide variety of metabolic and endocrine disorders, another key component of MEDS is the interaction. The faculty is comprised of NPs and PAs who are experts in the field. While they may conduct clinical research or present at meetings, they are not researchers or lecturers by trade but rather clinicians who are in the field, seeing patients. This means they can provide “clinical pearls that you’ll never learn from a book; they come from dealing with these disorders day in and day out,” as Kessler says. And the faculty members do want attendees to ask questions; part of each session will be devoted to Q&A (not that queries must be limited to the classroom).

“It will be like having an endocrine consultant right there for you,” Kessler says. “So it’s not just didactic, with somebody speaking. Clinicians can approach us with certain of their own challenging cases, and then we can help them with that.”

“The faculty will be there the whole time,” Sadler adds, “so people will be around to converse with at breaks or in between sessions. I think there will be a lot more interaction with faculty than you typically get at conferences.”

In fact, Sadler hopes one of the things NPs and PAs will take from MEDS is a network of colleagues they can contact for “further dialogue” later. And those colleagues will be representatives of both professions, since MEDS brings PAs and NPs together to address common educational needs.

“There are physician meetings, PA meetings, and NP meetings, but in the office setting, we work together,” Urquhart says. “There are some differences in training and philosophy, but put in the same clinical setting, we are expected to have the same outcomes. Quality of care won’t be compromised based on the fact that you’re a PA, an NP, or an MD, as long as you have been trained and the practice you’re working with fully understands your competencies and skill set.”

Skill sets can be enhanced through educational initiatives such as MEDS, and if attendees leave the meeting with “confidence, and maybe even a bit of a passion for endocrinology,” as Kessler hopes, the end result will improve more than just their own professional lives.

“This meeting brings providers together and focuses on our common interest,” Sadler says, “which is taking care of patients.”

Information about MEDS, including registration, can be found ­online at www.MEDSummit.qhc.com.               

This year’s Oscar-winning film The King’s Speech delivered the important message that each of us has a voice and deserves to be heard. Thanks to two passionate, driven clinicians, satellite radio—specifically, ReachMD (XM160)—is providing another venue for NPs and PAs to reach new audiences and expand their message, not only to their colleagues but also to physicians and the general public.

Lisa Dandrea Lenell, MPAS, PA-C, and Mimi Secor, MS, MEd, APRN, BC, FNP, FAANP, are the co-hosts of Partners in Practice. They are also Clinician Reviews Editorial Board members, so we decided to turn the tables and put them in the interview chair.

CR: How and when did you get involved with ReachMD?

LENELL: Dr. David Preskill, who started ReachMD, is in our practice’s referral chain. He was advised that if he wanted to expand the listening audience, he needed to get an NP or a PA on board. So, one day he called and asked me if I wanted to get involved. At first, I wasn’t interested, because I had a lot on my plate and I wasn’t really experienced in radio. But he said, “Well, just try.” So I contacted Ed Lopez, PA-C, for my guest, and we put together a demo, and they said, “OK, we’ll   get back to you.” And a month later, I was in my car listening to ReachMD, and my show came on! That was October 2007.

I did the show myself—we just called it “The PA Show” then—until Mimi came on board. There had always been talk about expanding the show and bringing out the roles that different people play in health care. Having an NP was always on the agenda.

SECOR: When I got involved was just about a year ago, and how was with the help of a PA [Clinician Reviews Publisher Gary Falcetano, PA-C] who gave my name as a possible host when he heard that ReachMD might be considering adding an NP host. So I actually have a PA to thank for that!

Lisa was so gracious and helpful in assisting me to “get up to speed” as a national radio host. She was supportive, offered constructive suggestions, and wasn’t intimidated when I was added to what had, to that point, been “her” show.

CR: What is your approach to the show, in terms of choosing topics or guests?

SECOR: I have two reasons for doing the show: One is to enhance the visibility of NPs in a positive way, to show how smart they are, how expert they are, what a difference they make in health care, really showcasing the profession in a positive light to the world. And the second is to get good content out there. So the good content is actually used to illustrate how great NPs are.

As far as topics, number one, I have to have my finger on the pulse of what’s going on in my profession. So I’m constantly scanning the literature and keeping an eye on the national monthly occurrences so I can try to coordinate some of the programs we do with, say, Breast Cancer Awareness Month or whatever is going on in the world. Often when I’m interacting with my colleagues at conferences, I’m looking for “the expert.”

LENELL: My goal is to provide a forum where people can get simple answers to simple questions that they might want to ask but for whatever reason won’t ask or don’t know who to ask or how to find out. The goal from the beginning has always been to educate the public, medical professionals, and anyone we can about what a PA is and what we can do, to move the myths and misconceptions out of the way and do a professional, responsible job.

If I hear someone say something about PAs, and I didn’t know that bit of information, I’ll start researching it for a show. I’ve done several on coding and reimbursement for PAs, because I think it’s super important and I get those questions all the time. It’s confusing, and there’s no really great source for PAs. So I’ve had great people on the show to help us walk through that. I’ve done malpractice shows several times, because that’s another one that is really confusing for PAs. So I ask the questions that people want to ask but don’t know how.

I’ve seen a progression from the early shows. Some of the original topics, I knew only what I needed to know. But as I started peeling the onion of the PA profession, something new would come out that interested me, and we’d go after that for a show. It became almost like detective work to get interesting stories that were different.

CR: What are some of the memorable moments from Partners in Practice?

LENELL: My favorite shows, always, are the personal interest stories. My favorite was Vic Germino, one of the original four PAs from Duke. He is such a humble, amazing man, and he came on and told his story in a beautiful, personal way. I had goosebumps when it was over.

Another favorite is Russ Dorr, the medical writer for Stephen King. He’s a PA who still works full-time in pediatrics and he’s “Russ Dorr, the man behind the gore.” I got so many comments after that show, because who knew that the guy who writes all the medical info for Stephen King is a PA?

The only time we did a “breaking news” show was in Haiti. There were many, many PAs there, and of course no one talked about them. So I really wanted to get a PA who was in Haiti on the air. Eric Holden was in Haiti, and he managed to get a phone—we waited for him at the studio for a couple hours, in the hope that he could reach us. Anyway, Eric got a phone from a military operation that was assisting his group of responders. And you could hear in the background, while he was talking to us, everything that was going on. I was really grateful for him to come on.

My favorite topics in the past two years have been the global developments of the PA profession; I’ve become a little bit of an addict. I decided I was going to interview someone from every single country where there was a PA program. [These segments covered programs in Ghana, Canada, Australia, Scotland, England, Puerto Rico, and the Netherlands; Lenell has also interviewed PAs who did humanitarian work in Sudan and coordinated an exchange program with Thailand.]

SECOR: I think the most touching interview I have done was with Maryana McGlasson, who had just come back from working with Doctors Without Borders on the Nigerian cholera epidemic. That interview is just wrenching—how she found herself in the midst of hundreds of people suffering from cholera and she was basically put in charge, she had nothing to work with, and people were dying around her.

She also discussed how she had changed her life—she sold her house and moved back with her parents so that she could have the flexibility to, with two days’ notice, be dispatched wherever she’s needed in the world, to work for Doctors Without Borders. She described feeling like this was the reason she went into health care and became an NP, to make that kind of difference. It’s a poignant interview about how much of an impact we can have.

The most surprising guest was probably CAPT Linnea Axman, one of the top-ranked NPs in the Navy. I expected her to be a little more formal, but actually, she was so humanistic and so real in how she described her commitment to her service in the military, that it was just beautiful. She was so articulate and so personally motivated. She described her family history of multiple family members being in the military. I just didn’t expect to be moved that much.

CR: Who is on your wish list of future guests?

SECOR: My wish list includes the incredibly overachieving fellows in the American Academy of Nurse Practitioners. I would like to do a radio show with every single one of them. I consider them the top-ranked NPs in the country. And I would need to do a live radio show every day to get through; there are several hundred now!

LENELL: One is Richard (Dick) Smith, who many consider one of, if not the, founders of the PA profession. He agreed to come on the show a while back, but then he had to cancel due to illness. So I still think it would be the capstone of my radio career to have Dick Smith on.

I would love to have President Obama on, but that’s probably not going to work out. We’ve reached out to Michelle Obama a few times for her diabetes work, so we’re hopeful that might work out at some point.

CR: What do you find most rewarding about your work on Partners in Practice?

LENELL: For me, it has always been about the opportunity to meet so many people. Along the way, I have learned more from the show than I’ve learned in any school or practice in life. I do my own writing—so does Mimi—and for a while I produced the show myself, so to do a good show, you have to know your topic. It forced me to learn about everyone and everything I was going to talk about.

SECOR: When I talk to groups, I always say, “You all have a story, and I can help you be successful in the media.” I am dedicated to media success for NPs, and my show is a way of coaching my peers to prepare for media opportunities that might not be so supportive. My job is to be a coach, and unlike Howard Stern, I’m not going to try to trip people up; I’m going to try to make them successful.

CR: All segments of Partners in Practice are archived on the ReachMD Web site (www.reachmd.com). Tune in next time to see what Lisa and Mimi have in store!

This year’s Oscar-winning film The King’s Speech delivered the important message that each of us has a voice and deserves to be heard. Thanks to two passionate, driven clinicians, satellite radio—specifically, ReachMD (XM160)—is providing another venue for NPs and PAs to reach new audiences and expand their message, not only to their colleagues but also to physicians and the general public.

Lisa Dandrea Lenell, MPAS, PA-C, and Mimi Secor, MS, MEd, APRN, BC, FNP, FAANP, are the co-hosts of Partners in Practice. They are also Clinician Reviews Editorial Board members, so we decided to turn the tables and put them in the interview chair.

CR: How and when did you get involved with ReachMD?

LENELL: Dr. David Preskill, who started ReachMD, is in our practice’s referral chain. He was advised that if he wanted to expand the listening audience, he needed to get an NP or a PA on board. So, one day he called and asked me if I wanted to get involved. At first, I wasn’t interested, because I had a lot on my plate and I wasn’t really experienced in radio. But he said, “Well, just try.” So I contacted Ed Lopez, PA-C, for my guest, and we put together a demo, and they said, “OK, we’ll   get back to you.” And a month later, I was in my car listening to ReachMD, and my show came on! That was October 2007.

I did the show myself—we just called it “The PA Show” then—until Mimi came on board. There had always been talk about expanding the show and bringing out the roles that different people play in health care. Having an NP was always on the agenda.

SECOR: When I got involved was just about a year ago, and how was with the help of a PA [Clinician Reviews Publisher Gary Falcetano, PA-C] who gave my name as a possible host when he heard that ReachMD might be considering adding an NP host. So I actually have a PA to thank for that!

Lisa was so gracious and helpful in assisting me to “get up to speed” as a national radio host. She was supportive, offered constructive suggestions, and wasn’t intimidated when I was added to what had, to that point, been “her” show.

CR: What is your approach to the show, in terms of choosing topics or guests?

SECOR: I have two reasons for doing the show: One is to enhance the visibility of NPs in a positive way, to show how smart they are, how expert they are, what a difference they make in health care, really showcasing the profession in a positive light to the world. And the second is to get good content out there. So the good content is actually used to illustrate how great NPs are.

As far as topics, number one, I have to have my finger on the pulse of what’s going on in my profession. So I’m constantly scanning the literature and keeping an eye on the national monthly occurrences so I can try to coordinate some of the programs we do with, say, Breast Cancer Awareness Month or whatever is going on in the world. Often when I’m interacting with my colleagues at conferences, I’m looking for “the expert.”

LENELL: My goal is to provide a forum where people can get simple answers to simple questions that they might want to ask but for whatever reason won’t ask or don’t know who to ask or how to find out. The goal from the beginning has always been to educate the public, medical professionals, and anyone we can about what a PA is and what we can do, to move the myths and misconceptions out of the way and do a professional, responsible job.

If I hear someone say something about PAs, and I didn’t know that bit of information, I’ll start researching it for a show. I’ve done several on coding and reimbursement for PAs, because I think it’s super important and I get those questions all the time. It’s confusing, and there’s no really great source for PAs. So I’ve had great people on the show to help us walk through that. I’ve done malpractice shows several times, because that’s another one that is really confusing for PAs. So I ask the questions that people want to ask but don’t know how.

I’ve seen a progression from the early shows. Some of the original topics, I knew only what I needed to know. But as I started peeling the onion of the PA profession, something new would come out that interested me, and we’d go after that for a show. It became almost like detective work to get interesting stories that were different.

CR: What are some of the memorable moments from Partners in Practice?

LENELL: My favorite shows, always, are the personal interest stories. My favorite was Vic Germino, one of the original four PAs from Duke. He is such a humble, amazing man, and he came on and told his story in a beautiful, personal way. I had goosebumps when it was over.

Another favorite is Russ Dorr, the medical writer for Stephen King. He’s a PA who still works full-time in pediatrics and he’s “Russ Dorr, the man behind the gore.” I got so many comments after that show, because who knew that the guy who writes all the medical info for Stephen King is a PA?

The only time we did a “breaking news” show was in Haiti. There were many, many PAs there, and of course no one talked about them. So I really wanted to get a PA who was in Haiti on the air. Eric Holden was in Haiti, and he managed to get a phone—we waited for him at the studio for a couple hours, in the hope that he could reach us. Anyway, Eric got a phone from a military operation that was assisting his group of responders. And you could hear in the background, while he was talking to us, everything that was going on. I was really grateful for him to come on.

My favorite topics in the past two years have been the global developments of the PA profession; I’ve become a little bit of an addict. I decided I was going to interview someone from every single country where there was a PA program. [These segments covered programs in Ghana, Canada, Australia, Scotland, England, Puerto Rico, and the Netherlands; Lenell has also interviewed PAs who did humanitarian work in Sudan and coordinated an exchange program with Thailand.]

SECOR: I think the most touching interview I have done was with Maryana McGlasson, who had just come back from working with Doctors Without Borders on the Nigerian cholera epidemic. That interview is just wrenching—how she found herself in the midst of hundreds of people suffering from cholera and she was basically put in charge, she had nothing to work with, and people were dying around her.

She also discussed how she had changed her life—she sold her house and moved back with her parents so that she could have the flexibility to, with two days’ notice, be dispatched wherever she’s needed in the world, to work for Doctors Without Borders. She described feeling like this was the reason she went into health care and became an NP, to make that kind of difference. It’s a poignant interview about how much of an impact we can have.

The most surprising guest was probably CAPT Linnea Axman, one of the top-ranked NPs in the Navy. I expected her to be a little more formal, but actually, she was so humanistic and so real in how she described her commitment to her service in the military, that it was just beautiful. She was so articulate and so personally motivated. She described her family history of multiple family members being in the military. I just didn’t expect to be moved that much.

CR: Who is on your wish list of future guests?

SECOR: My wish list includes the incredibly overachieving fellows in the American Academy of Nurse Practitioners. I would like to do a radio show with every single one of them. I consider them the top-ranked NPs in the country. And I would need to do a live radio show every day to get through; there are several hundred now!

LENELL: One is Richard (Dick) Smith, who many consider one of, if not the, founders of the PA profession. He agreed to come on the show a while back, but then he had to cancel due to illness. So I still think it would be the capstone of my radio career to have Dick Smith on.

I would love to have President Obama on, but that’s probably not going to work out. We’ve reached out to Michelle Obama a few times for her diabetes work, so we’re hopeful that might work out at some point.

CR: What do you find most rewarding about your work on Partners in Practice?

LENELL: For me, it has always been about the opportunity to meet so many people. Along the way, I have learned more from the show than I’ve learned in any school or practice in life. I do my own writing—so does Mimi—and for a while I produced the show myself, so to do a good show, you have to know your topic. It forced me to learn about everyone and everything I was going to talk about.

SECOR: When I talk to groups, I always say, “You all have a story, and I can help you be successful in the media.” I am dedicated to media success for NPs, and my show is a way of coaching my peers to prepare for media opportunities that might not be so supportive. My job is to be a coach, and unlike Howard Stern, I’m not going to try to trip people up; I’m going to try to make them successful.

CR: All segments of Partners in Practice are archived on the ReachMD Web site (www.reachmd.com). Tune in next time to see what Lisa and Mimi have in store!

This year’s Oscar-winning film The King’s Speech delivered the important message that each of us has a voice and deserves to be heard. Thanks to two passionate, driven clinicians, satellite radio—specifically, ReachMD (XM160)—is providing another venue for NPs and PAs to reach new audiences and expand their message, not only to their colleagues but also to physicians and the general public.

Lisa Dandrea Lenell, MPAS, PA-C, and Mimi Secor, MS, MEd, APRN, BC, FNP, FAANP, are the co-hosts of Partners in Practice. They are also Clinician Reviews Editorial Board members, so we decided to turn the tables and put them in the interview chair.

CR: How and when did you get involved with ReachMD?

LENELL: Dr. David Preskill, who started ReachMD, is in our practice’s referral chain. He was advised that if he wanted to expand the listening audience, he needed to get an NP or a PA on board. So, one day he called and asked me if I wanted to get involved. At first, I wasn’t interested, because I had a lot on my plate and I wasn’t really experienced in radio. But he said, “Well, just try.” So I contacted Ed Lopez, PA-C, for my guest, and we put together a demo, and they said, “OK, we’ll   get back to you.” And a month later, I was in my car listening to ReachMD, and my show came on! That was October 2007.

I did the show myself—we just called it “The PA Show” then—until Mimi came on board. There had always been talk about expanding the show and bringing out the roles that different people play in health care. Having an NP was always on the agenda.

SECOR: When I got involved was just about a year ago, and how was with the help of a PA [Clinician Reviews Publisher Gary Falcetano, PA-C] who gave my name as a possible host when he heard that ReachMD might be considering adding an NP host. So I actually have a PA to thank for that!

Lisa was so gracious and helpful in assisting me to “get up to speed” as a national radio host. She was supportive, offered constructive suggestions, and wasn’t intimidated when I was added to what had, to that point, been “her” show.

CR: What is your approach to the show, in terms of choosing topics or guests?

SECOR: I have two reasons for doing the show: One is to enhance the visibility of NPs in a positive way, to show how smart they are, how expert they are, what a difference they make in health care, really showcasing the profession in a positive light to the world. And the second is to get good content out there. So the good content is actually used to illustrate how great NPs are.

As far as topics, number one, I have to have my finger on the pulse of what’s going on in my profession. So I’m constantly scanning the literature and keeping an eye on the national monthly occurrences so I can try to coordinate some of the programs we do with, say, Breast Cancer Awareness Month or whatever is going on in the world. Often when I’m interacting with my colleagues at conferences, I’m looking for “the expert.”

LENELL: My goal is to provide a forum where people can get simple answers to simple questions that they might want to ask but for whatever reason won’t ask or don’t know who to ask or how to find out. The goal from the beginning has always been to educate the public, medical professionals, and anyone we can about what a PA is and what we can do, to move the myths and misconceptions out of the way and do a professional, responsible job.

If I hear someone say something about PAs, and I didn’t know that bit of information, I’ll start researching it for a show. I’ve done several on coding and reimbursement for PAs, because I think it’s super important and I get those questions all the time. It’s confusing, and there’s no really great source for PAs. So I’ve had great people on the show to help us walk through that. I’ve done malpractice shows several times, because that’s another one that is really confusing for PAs. So I ask the questions that people want to ask but don’t know how.

I’ve seen a progression from the early shows. Some of the original topics, I knew only what I needed to know. But as I started peeling the onion of the PA profession, something new would come out that interested me, and we’d go after that for a show. It became almost like detective work to get interesting stories that were different.

CR: What are some of the memorable moments from Partners in Practice?

LENELL: My favorite shows, always, are the personal interest stories. My favorite was Vic Germino, one of the original four PAs from Duke. He is such a humble, amazing man, and he came on and told his story in a beautiful, personal way. I had goosebumps when it was over.

Another favorite is Russ Dorr, the medical writer for Stephen King. He’s a PA who still works full-time in pediatrics and he’s “Russ Dorr, the man behind the gore.” I got so many comments after that show, because who knew that the guy who writes all the medical info for Stephen King is a PA?

The only time we did a “breaking news” show was in Haiti. There were many, many PAs there, and of course no one talked about them. So I really wanted to get a PA who was in Haiti on the air. Eric Holden was in Haiti, and he managed to get a phone—we waited for him at the studio for a couple hours, in the hope that he could reach us. Anyway, Eric got a phone from a military operation that was assisting his group of responders. And you could hear in the background, while he was talking to us, everything that was going on. I was really grateful for him to come on.

My favorite topics in the past two years have been the global developments of the PA profession; I’ve become a little bit of an addict. I decided I was going to interview someone from every single country where there was a PA program. [These segments covered programs in Ghana, Canada, Australia, Scotland, England, Puerto Rico, and the Netherlands; Lenell has also interviewed PAs who did humanitarian work in Sudan and coordinated an exchange program with Thailand.]

SECOR: I think the most touching interview I have done was with Maryana McGlasson, who had just come back from working with Doctors Without Borders on the Nigerian cholera epidemic. That interview is just wrenching—how she found herself in the midst of hundreds of people suffering from cholera and she was basically put in charge, she had nothing to work with, and people were dying around her.

She also discussed how she had changed her life—she sold her house and moved back with her parents so that she could have the flexibility to, with two days’ notice, be dispatched wherever she’s needed in the world, to work for Doctors Without Borders. She described feeling like this was the reason she went into health care and became an NP, to make that kind of difference. It’s a poignant interview about how much of an impact we can have.

The most surprising guest was probably CAPT Linnea Axman, one of the top-ranked NPs in the Navy. I expected her to be a little more formal, but actually, she was so humanistic and so real in how she described her commitment to her service in the military, that it was just beautiful. She was so articulate and so personally motivated. She described her family history of multiple family members being in the military. I just didn’t expect to be moved that much.

CR: Who is on your wish list of future guests?

SECOR: My wish list includes the incredibly overachieving fellows in the American Academy of Nurse Practitioners. I would like to do a radio show with every single one of them. I consider them the top-ranked NPs in the country. And I would need to do a live radio show every day to get through; there are several hundred now!

LENELL: One is Richard (Dick) Smith, who many consider one of, if not the, founders of the PA profession. He agreed to come on the show a while back, but then he had to cancel due to illness. So I still think it would be the capstone of my radio career to have Dick Smith on.

I would love to have President Obama on, but that’s probably not going to work out. We’ve reached out to Michelle Obama a few times for her diabetes work, so we’re hopeful that might work out at some point.

CR: What do you find most rewarding about your work on Partners in Practice?

LENELL: For me, it has always been about the opportunity to meet so many people. Along the way, I have learned more from the show than I’ve learned in any school or practice in life. I do my own writing—so does Mimi—and for a while I produced the show myself, so to do a good show, you have to know your topic. It forced me to learn about everyone and everything I was going to talk about.

SECOR: When I talk to groups, I always say, “You all have a story, and I can help you be successful in the media.” I am dedicated to media success for NPs, and my show is a way of coaching my peers to prepare for media opportunities that might not be so supportive. My job is to be a coach, and unlike Howard Stern, I’m not going to try to trip people up; I’m going to try to make them successful.

CR: All segments of Partners in Practice are archived on the ReachMD Web site (www.reachmd.com). Tune in next time to see what Lisa and Mimi have in store!

Between 1995 and 2008, the number of pediatric visits to an emergency department (ED) that included computed tomography (CT) increased fivefold, according to study results published online ahead of print by the journal Radiology. The researchers, led by David B. Larson, MD, MBA, Director of Quality Improvement in the Department of Radiology at Cincinnati Children's Hospital Medical Center in Ohio, say the substantial growth in CT use "is explained by increasing frequency of use, not by an increase in the number of pediatric visits to the ED."

Larson and colleagues also reported that about 90% of the visits associated with CT in children were made to nonpediatric-focused EDs (ie, those in which the average patient was older than 10). Given what is understood about the increased risks of radiation exposure in children, this finding raises additional questions and concerns about whether children received a radiation dose that was scaled to their body size or an adult dose. (The study was not designed to assess that.)

Whether to order CT in a child may be a daunting proposition for a clinician, particularly if he or she does not have subspecialty training in pediatrics. Ordering an unnecessary test may needlessly expose the patient to radiation, but missing a diagnosis that results in a negative outcome is also fraught with peril.

"This is the fine line that we walk in this conversation: On the one hand, CT uses radiation, so we should use it cautiously," Larson says. "On the other hand, the risk is very low, and we don't want to scare people out of getting CT."

Boom Years for CT Use
The National Cancer Institute reports that four to seven million CT exams are performed in children annually in the US, and that the use of CT (in both adults and children) has increased significantly since 1980, growing at an estimated rate of 10% per year. Larson attributes much of the increase observed in his study—an annual growth rate of about 13%—to the fact that the technology "improved significantly" during the time period examined.

"This is a time when the technology moved from basically axial scanning to helical scanning, and also from single detector to multichannel detectors," he says. "So, that translates into a much faster scan and a much higher-resolution scan. This is especially important in children, because it means less sedation, and in the ED, it means you can come to a decision very quickly."

Another factor driving the increased use of CT has been the ready availability of the equipment. A decade ago, major hospitals might have had a scanner, but it was not necessarily located adjacent to, let alone within, the ED. Smaller facilities may not have had a scanner, period.

"The availability of CT has increased exponentially over the past 10 years, and it has been a very reliable diagnostic tool," says John J. Graykoski, MPAS, PA-C, President of the Society of Emergency Medicine PAs and ER PA Supervisor at Luther Midelfort Mayo Health System in Colfax, Wisconsin. "It has tremendously enhanced our ability to identify problems much earlier and with much greater accuracy than our old plain films could do."

Speed and accuracy are particularly valuable in the emergency department, where, in the words of Michael P. Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School, and Fellowship Director, Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, "you have one chance to get it right."

That time pressure to make an accurate diagnosis, coupled with the ever-present fear of litigation if the wrong decision is made or a negative outcome occurs despite the clinician's best efforts, may lead to the ordering of a CT scan that is not truly necessary. The prevailing wisdom might be "It's better to rule out the worst-case scenario and have that reassurance than to take the chance of missing something."

The drawback to that philosophy is that CT uses radiation—more of it than the average x-ray. The effective dose of radiation in the average CT scan of the head is equivalent to approximately 100 x-rays and in the average abdominal CT scan, 400 x-rays. Granted, these doses are from scans that are unadjusted for body weight, and in theory children should be undergoing CT with reduced radiation exposure parameters. Whether they actually are, particularly at nonpediatric facilities, is unknown.

"We hope that at all facilities, whether they are pediatric-focused or not, the dose is being tailored to the patient's size," Larson says, "but we don't know. We know that it has [improved] at children's hospitals; that study just hasn't been done at non-children's hospitals. I think the concern is that right now, it's actually rather difficult to monitor that."

At Graykoski's facility, which is not pediatric-focused, the staff is "acutely aware of this issue." Consultations with the radiologist prior to the ordering of scans are common, protocols are in place to limit the amount of radiation exposure in CT scans, and the newest-generation equipment, which has built-in capabilities to limit exposure, is available. "We're trying to do everything we can to make sure that the risks associated with imaging are offset by the benefits to be realized from it," Graykoski says.

The National Cancer Institute stresses that "the individual cancer risks associated with CT scans are small," with lifetime risks estimated at less than 1 in 1,000. However, as the data indicate, children are increasingly being exposed to those risks, and they may be particularly vulnerable. "From age 0 to 14 especially, the DNA is rapidly replicating, and that's when it is most vulnerable to insult from radiation," Graykoski explains.

Furthermore, "the risk of radiation is a cumulative lifetime risk. It's not the case that you just take a picture and in 24 hours, the side effects are gone," he adds. Young children have the rest of their lives to accumulate radiation exposure from additional imaging tests and from natural circumstances. (The average effective dose of natural background radiation is 3 mSv per year in the United States.)

"It's not that we have the crisis right now—this is a problem that will be growing into the future," Graykoski says, especially if the boom in the use of this imaging modality does not abate. "And of course, our concern is for safety—we don't want to be responsible for causing harm to any patient, especially a youngster."

First, Do No Harm
Any clinician who is considering ordering CT for a pediatric patient may want to paraphrase a classic World War II adage. Instead of asking, "Is this trip really necessary?" the question should be, "Is this test really necessary?"

As with any type of test, the decision to order CT should be made after careful consideration of the risks and benefits, as well as how the specific test will change the clinical management of the patient. Will the child be able to go home? Will he/she require an operation? Will the child need to be admitted?

Health care providers "need to be absolutely sure that the results of that test are actually going to help them make a decision or a diagnosis," Poirier says. "And if time will help you make a diagnosis and does not put the patient at risk, then sometimes you don't do the test. You talk to the family, and maybe you admit the patient or maybe you have them follow up the next day."

A classic example is a child who has experienced head trauma; perhaps he or she was stunned at the time of the event or had an episode or two of vomiting. "It used to be pretty routine that all of those kids would get CT evaluations," Poirier says. "The recent studies have shown that those CT scans don't change the management of those patients. It's just unnecessary radiation."

Instead, it may be more appropriate to watch the patient in the ED until it is clear his/her condition is not going to deteriorate, ensure the family has adequate follow-up, or even keep the child in the ED or admit him/her for overnight observation. Of course, there are geographic factors to consider as well.

"A lot has to do with the comfort level of the parents—are they comfortable waiting and watching? Is it convenient?" says Graykoski, whose facility is in west-central Wisconsin. "We have patients who are two hours away from the hospital, so it's not the easiest thing to say, 'Well, go home; if it gets worse, bring him back.' A couple of hours can certainly be very serious."

Communication is key so that parents have a full understanding of why an imaging study may or may not be in their child's best interest. Despite reports in the mainstream media about the radiation risk of CT, none of the clinicians interviewed has yet encountered parents who refused CT because of that risk. Graykoski says he is usually the one to broach the subject with parents.

"Most parents, I think, want to hear that discussion," he says, "but I would say the majority want the reassurance of having some of these tests done and frequently will err on the side of getting that information and ruling something out, as opposed to thinking about the future effect of radiation accumulation."

In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."

How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.

"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."

Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."

As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."

Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."

Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.

"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."

Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."

Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."

"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."

Between 1995 and 2008, the number of pediatric visits to an emergency department (ED) that included computed tomography (CT) increased fivefold, according to study results published online ahead of print by the journal Radiology. The researchers, led by David B. Larson, MD, MBA, Director of Quality Improvement in the Department of Radiology at Cincinnati Children's Hospital Medical Center in Ohio, say the substantial growth in CT use "is explained by increasing frequency of use, not by an increase in the number of pediatric visits to the ED."

Larson and colleagues also reported that about 90% of the visits associated with CT in children were made to nonpediatric-focused EDs (ie, those in which the average patient was older than 10). Given what is understood about the increased risks of radiation exposure in children, this finding raises additional questions and concerns about whether children received a radiation dose that was scaled to their body size or an adult dose. (The study was not designed to assess that.)

Whether to order CT in a child may be a daunting proposition for a clinician, particularly if he or she does not have subspecialty training in pediatrics. Ordering an unnecessary test may needlessly expose the patient to radiation, but missing a diagnosis that results in a negative outcome is also fraught with peril.

"This is the fine line that we walk in this conversation: On the one hand, CT uses radiation, so we should use it cautiously," Larson says. "On the other hand, the risk is very low, and we don't want to scare people out of getting CT."

Boom Years for CT Use
The National Cancer Institute reports that four to seven million CT exams are performed in children annually in the US, and that the use of CT (in both adults and children) has increased significantly since 1980, growing at an estimated rate of 10% per year. Larson attributes much of the increase observed in his study—an annual growth rate of about 13%—to the fact that the technology "improved significantly" during the time period examined.

"This is a time when the technology moved from basically axial scanning to helical scanning, and also from single detector to multichannel detectors," he says. "So, that translates into a much faster scan and a much higher-resolution scan. This is especially important in children, because it means less sedation, and in the ED, it means you can come to a decision very quickly."

Another factor driving the increased use of CT has been the ready availability of the equipment. A decade ago, major hospitals might have had a scanner, but it was not necessarily located adjacent to, let alone within, the ED. Smaller facilities may not have had a scanner, period.

"The availability of CT has increased exponentially over the past 10 years, and it has been a very reliable diagnostic tool," says John J. Graykoski, MPAS, PA-C, President of the Society of Emergency Medicine PAs and ER PA Supervisor at Luther Midelfort Mayo Health System in Colfax, Wisconsin. "It has tremendously enhanced our ability to identify problems much earlier and with much greater accuracy than our old plain films could do."

Speed and accuracy are particularly valuable in the emergency department, where, in the words of Michael P. Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School, and Fellowship Director, Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, "you have one chance to get it right."

That time pressure to make an accurate diagnosis, coupled with the ever-present fear of litigation if the wrong decision is made or a negative outcome occurs despite the clinician's best efforts, may lead to the ordering of a CT scan that is not truly necessary. The prevailing wisdom might be "It's better to rule out the worst-case scenario and have that reassurance than to take the chance of missing something."

The drawback to that philosophy is that CT uses radiation—more of it than the average x-ray. The effective dose of radiation in the average CT scan of the head is equivalent to approximately 100 x-rays and in the average abdominal CT scan, 400 x-rays. Granted, these doses are from scans that are unadjusted for body weight, and in theory children should be undergoing CT with reduced radiation exposure parameters. Whether they actually are, particularly at nonpediatric facilities, is unknown.

"We hope that at all facilities, whether they are pediatric-focused or not, the dose is being tailored to the patient's size," Larson says, "but we don't know. We know that it has [improved] at children's hospitals; that study just hasn't been done at non-children's hospitals. I think the concern is that right now, it's actually rather difficult to monitor that."

At Graykoski's facility, which is not pediatric-focused, the staff is "acutely aware of this issue." Consultations with the radiologist prior to the ordering of scans are common, protocols are in place to limit the amount of radiation exposure in CT scans, and the newest-generation equipment, which has built-in capabilities to limit exposure, is available. "We're trying to do everything we can to make sure that the risks associated with imaging are offset by the benefits to be realized from it," Graykoski says.

The National Cancer Institute stresses that "the individual cancer risks associated with CT scans are small," with lifetime risks estimated at less than 1 in 1,000. However, as the data indicate, children are increasingly being exposed to those risks, and they may be particularly vulnerable. "From age 0 to 14 especially, the DNA is rapidly replicating, and that's when it is most vulnerable to insult from radiation," Graykoski explains.

Furthermore, "the risk of radiation is a cumulative lifetime risk. It's not the case that you just take a picture and in 24 hours, the side effects are gone," he adds. Young children have the rest of their lives to accumulate radiation exposure from additional imaging tests and from natural circumstances. (The average effective dose of natural background radiation is 3 mSv per year in the United States.)

"It's not that we have the crisis right now—this is a problem that will be growing into the future," Graykoski says, especially if the boom in the use of this imaging modality does not abate. "And of course, our concern is for safety—we don't want to be responsible for causing harm to any patient, especially a youngster."

First, Do No Harm
Any clinician who is considering ordering CT for a pediatric patient may want to paraphrase a classic World War II adage. Instead of asking, "Is this trip really necessary?" the question should be, "Is this test really necessary?"

As with any type of test, the decision to order CT should be made after careful consideration of the risks and benefits, as well as how the specific test will change the clinical management of the patient. Will the child be able to go home? Will he/she require an operation? Will the child need to be admitted?

Health care providers "need to be absolutely sure that the results of that test are actually going to help them make a decision or a diagnosis," Poirier says. "And if time will help you make a diagnosis and does not put the patient at risk, then sometimes you don't do the test. You talk to the family, and maybe you admit the patient or maybe you have them follow up the next day."

A classic example is a child who has experienced head trauma; perhaps he or she was stunned at the time of the event or had an episode or two of vomiting. "It used to be pretty routine that all of those kids would get CT evaluations," Poirier says. "The recent studies have shown that those CT scans don't change the management of those patients. It's just unnecessary radiation."

Instead, it may be more appropriate to watch the patient in the ED until it is clear his/her condition is not going to deteriorate, ensure the family has adequate follow-up, or even keep the child in the ED or admit him/her for overnight observation. Of course, there are geographic factors to consider as well.

"A lot has to do with the comfort level of the parents—are they comfortable waiting and watching? Is it convenient?" says Graykoski, whose facility is in west-central Wisconsin. "We have patients who are two hours away from the hospital, so it's not the easiest thing to say, 'Well, go home; if it gets worse, bring him back.' A couple of hours can certainly be very serious."

Communication is key so that parents have a full understanding of why an imaging study may or may not be in their child's best interest. Despite reports in the mainstream media about the radiation risk of CT, none of the clinicians interviewed has yet encountered parents who refused CT because of that risk. Graykoski says he is usually the one to broach the subject with parents.

"Most parents, I think, want to hear that discussion," he says, "but I would say the majority want the reassurance of having some of these tests done and frequently will err on the side of getting that information and ruling something out, as opposed to thinking about the future effect of radiation accumulation."

In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."

How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.

"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."

Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."

As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."

Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."

Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.

"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."

Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."

Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."

"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."

Between 1995 and 2008, the number of pediatric visits to an emergency department (ED) that included computed tomography (CT) increased fivefold, according to study results published online ahead of print by the journal Radiology. The researchers, led by David B. Larson, MD, MBA, Director of Quality Improvement in the Department of Radiology at Cincinnati Children's Hospital Medical Center in Ohio, say the substantial growth in CT use "is explained by increasing frequency of use, not by an increase in the number of pediatric visits to the ED."

Larson and colleagues also reported that about 90% of the visits associated with CT in children were made to nonpediatric-focused EDs (ie, those in which the average patient was older than 10). Given what is understood about the increased risks of radiation exposure in children, this finding raises additional questions and concerns about whether children received a radiation dose that was scaled to their body size or an adult dose. (The study was not designed to assess that.)

Whether to order CT in a child may be a daunting proposition for a clinician, particularly if he or she does not have subspecialty training in pediatrics. Ordering an unnecessary test may needlessly expose the patient to radiation, but missing a diagnosis that results in a negative outcome is also fraught with peril.

"This is the fine line that we walk in this conversation: On the one hand, CT uses radiation, so we should use it cautiously," Larson says. "On the other hand, the risk is very low, and we don't want to scare people out of getting CT."

Boom Years for CT Use
The National Cancer Institute reports that four to seven million CT exams are performed in children annually in the US, and that the use of CT (in both adults and children) has increased significantly since 1980, growing at an estimated rate of 10% per year. Larson attributes much of the increase observed in his study—an annual growth rate of about 13%—to the fact that the technology "improved significantly" during the time period examined.

"This is a time when the technology moved from basically axial scanning to helical scanning, and also from single detector to multichannel detectors," he says. "So, that translates into a much faster scan and a much higher-resolution scan. This is especially important in children, because it means less sedation, and in the ED, it means you can come to a decision very quickly."

Another factor driving the increased use of CT has been the ready availability of the equipment. A decade ago, major hospitals might have had a scanner, but it was not necessarily located adjacent to, let alone within, the ED. Smaller facilities may not have had a scanner, period.

"The availability of CT has increased exponentially over the past 10 years, and it has been a very reliable diagnostic tool," says John J. Graykoski, MPAS, PA-C, President of the Society of Emergency Medicine PAs and ER PA Supervisor at Luther Midelfort Mayo Health System in Colfax, Wisconsin. "It has tremendously enhanced our ability to identify problems much earlier and with much greater accuracy than our old plain films could do."

Speed and accuracy are particularly valuable in the emergency department, where, in the words of Michael P. Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School, and Fellowship Director, Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, "you have one chance to get it right."

That time pressure to make an accurate diagnosis, coupled with the ever-present fear of litigation if the wrong decision is made or a negative outcome occurs despite the clinician's best efforts, may lead to the ordering of a CT scan that is not truly necessary. The prevailing wisdom might be "It's better to rule out the worst-case scenario and have that reassurance than to take the chance of missing something."

The drawback to that philosophy is that CT uses radiation—more of it than the average x-ray. The effective dose of radiation in the average CT scan of the head is equivalent to approximately 100 x-rays and in the average abdominal CT scan, 400 x-rays. Granted, these doses are from scans that are unadjusted for body weight, and in theory children should be undergoing CT with reduced radiation exposure parameters. Whether they actually are, particularly at nonpediatric facilities, is unknown.

"We hope that at all facilities, whether they are pediatric-focused or not, the dose is being tailored to the patient's size," Larson says, "but we don't know. We know that it has [improved] at children's hospitals; that study just hasn't been done at non-children's hospitals. I think the concern is that right now, it's actually rather difficult to monitor that."

At Graykoski's facility, which is not pediatric-focused, the staff is "acutely aware of this issue." Consultations with the radiologist prior to the ordering of scans are common, protocols are in place to limit the amount of radiation exposure in CT scans, and the newest-generation equipment, which has built-in capabilities to limit exposure, is available. "We're trying to do everything we can to make sure that the risks associated with imaging are offset by the benefits to be realized from it," Graykoski says.

The National Cancer Institute stresses that "the individual cancer risks associated with CT scans are small," with lifetime risks estimated at less than 1 in 1,000. However, as the data indicate, children are increasingly being exposed to those risks, and they may be particularly vulnerable. "From age 0 to 14 especially, the DNA is rapidly replicating, and that's when it is most vulnerable to insult from radiation," Graykoski explains.

Furthermore, "the risk of radiation is a cumulative lifetime risk. It's not the case that you just take a picture and in 24 hours, the side effects are gone," he adds. Young children have the rest of their lives to accumulate radiation exposure from additional imaging tests and from natural circumstances. (The average effective dose of natural background radiation is 3 mSv per year in the United States.)

"It's not that we have the crisis right now—this is a problem that will be growing into the future," Graykoski says, especially if the boom in the use of this imaging modality does not abate. "And of course, our concern is for safety—we don't want to be responsible for causing harm to any patient, especially a youngster."

First, Do No Harm
Any clinician who is considering ordering CT for a pediatric patient may want to paraphrase a classic World War II adage. Instead of asking, "Is this trip really necessary?" the question should be, "Is this test really necessary?"

As with any type of test, the decision to order CT should be made after careful consideration of the risks and benefits, as well as how the specific test will change the clinical management of the patient. Will the child be able to go home? Will he/she require an operation? Will the child need to be admitted?

Health care providers "need to be absolutely sure that the results of that test are actually going to help them make a decision or a diagnosis," Poirier says. "And if time will help you make a diagnosis and does not put the patient at risk, then sometimes you don't do the test. You talk to the family, and maybe you admit the patient or maybe you have them follow up the next day."

A classic example is a child who has experienced head trauma; perhaps he or she was stunned at the time of the event or had an episode or two of vomiting. "It used to be pretty routine that all of those kids would get CT evaluations," Poirier says. "The recent studies have shown that those CT scans don't change the management of those patients. It's just unnecessary radiation."

Instead, it may be more appropriate to watch the patient in the ED until it is clear his/her condition is not going to deteriorate, ensure the family has adequate follow-up, or even keep the child in the ED or admit him/her for overnight observation. Of course, there are geographic factors to consider as well.

"A lot has to do with the comfort level of the parents—are they comfortable waiting and watching? Is it convenient?" says Graykoski, whose facility is in west-central Wisconsin. "We have patients who are two hours away from the hospital, so it's not the easiest thing to say, 'Well, go home; if it gets worse, bring him back.' A couple of hours can certainly be very serious."

Communication is key so that parents have a full understanding of why an imaging study may or may not be in their child's best interest. Despite reports in the mainstream media about the radiation risk of CT, none of the clinicians interviewed has yet encountered parents who refused CT because of that risk. Graykoski says he is usually the one to broach the subject with parents.

"Most parents, I think, want to hear that discussion," he says, "but I would say the majority want the reassurance of having some of these tests done and frequently will err on the side of getting that information and ruling something out, as opposed to thinking about the future effect of radiation accumulation."

In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."

How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.

"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."

Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."

As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."

Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."

Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.

"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."

Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."

Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."

"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."

By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).

The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.

“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”

Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?

For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.

“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”

At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?

“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”

Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)

For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.

“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”

In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”

And for those who insist that “first come, first served” is fair, Friedewald has a different opinion, calling it “a complete fallacy. The first come aren’t the first served. Some people won’t live long enough to wait for a kidney, if the line is too long. Everyone believes that a line is ‘first come, first served,’ because we’re used to delis and things like that, where you actually get served. But a lot of people aren’t getting served.”

That may never change, but the concepts outlined in the UNOS document aim to achieve an additional 15,223 life-years lived with a transplanted kidney for every year’s worth of deceased-donor transplants. How? Let’s explore.

How the System Would Change
Early on, Concepts for Kidney Allocation (available at optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.pdf) outlines the flaws of the current system: “[I]t does not strive to minimize death on the waiting list nor maximize survival following transplant. It does not recognize that all candidates do not have the same ability to survive the wait. It does not attempt to match the characteristics of a donor’s kidney to the candidate’s characteristics to promote a long and healthy survival post-transplant. The system can be better, and it can be designed to achieve more in the way of health and longevity than it currently does.”

Aware of the problems, and with input from hundreds of individuals—including transplant professionals, recipients, and candidates, as well as donor families, living donors, and the general public—UNOS’s Kidney Transplantation Committee has spent six years (so far) developing goals for a new allocation system. The concept document delineates three key factors in achieving those goals:

• Utilizing a kidney donor profile index (KDPI), a continuous measure used to estimate the potential function of a donated kidney if it were transplanted into the average recipient, to better characterize donor kidneys.

• Allocating some kidneys (20%) by a combination of the KDPI and a candidate’s estimated post-transplant survival (EPTS).

• Allocating the majority of organs (80%) by age-matching so that candidates within 15 years older or younger than the donor are prioritized.

The KDPI is based on the characteristics of the donor, including age, race/ethnicity, height, and weight, and whether he/she had any of the following factors: hypertension, diabetes, hepatitis C, elevated creatinine level, a cerebrovascular cause of death, or cardiac death. It is important to remember that a score below 20% indicates a kidney with the predicted longest function; it’s like being in the top 20% of your graduating class.

A candidate’s EPTS is based on age, length of time on dialysis, diabetes status, and history of prior organ transplant. “While no calculation will be able to predict life expectancy with 100% certainty, these four factors provide a reasonable estimate for identifying those candidates who have the longest possible EPTS,” the committee writes.

Once a KDPI has been established, there are two scenarios for how a candidate might be selected. Kidneys with a KDPI of 20% or lower are allocated based on EPTS. Those with a KDPI of more than 20% are allocated based on age-matching within 15 years (older or younger) of the recipient’s age.

To use the examples given in the report: Let’s say there are three candidates for a kidney. Mary is 30, Sophia is 21, and David is 60. Along comes a kidney with a KDPI of 10%. Since Mary and Sophia have better estimated survival than David (EPTS, 19%, 12%, and 75% respectively; again, it’s the percentile, so lower is better), they would have priority for that kidney.

However, if the available kidney has a KDPI of, say, 40%, age becomes a bigger factor. If the donor is 34, Mary and Sophia continue to have priority over David, since recipients ages 19 to 49 would be considered first. If the donor is 55, however, David would have precedence over Mary and Sophia, since the age range for that kidney recipient would be 40 to 70.

All of this can be confusing, and it leads one to suspect that some of the news entities who misspoke either did not understand what they were reading or perhaps did not even finish reading the report. But these components do not even tell the entire story; they are exactly that, components. The final proposal, which will be written only when all the feedback from a public comment period has been compiled and analyzed, “will include all the details of who gets the kidney,” as Friedewald says.

What is important to know now is that “waiting time will continue to be a major part of who gets a kidney” if the revised allocation concepts become policy, Friedewald emphasizes. “What this document says is that we’re generally going to group people based on the quality of the donor kidney. But once we do that—let’s say it’s a top 20% kidney—well, then the top 20% of candidates who are expected to live the longest will be up for that kidney. But that may be 10,000 people. Which of the 10,000 people gets the kidney? The person who waits the longest.”

Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.

“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”

Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”

Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”

Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.

In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?

For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”

For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”

And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”

By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).

The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.

“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”

Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?

For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.

“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”

At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?

“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”

Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)

For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.

“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”

In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”

And for those who insist that “first come, first served” is fair, Friedewald has a different opinion, calling it “a complete fallacy. The first come aren’t the first served. Some people won’t live long enough to wait for a kidney, if the line is too long. Everyone believes that a line is ‘first come, first served,’ because we’re used to delis and things like that, where you actually get served. But a lot of people aren’t getting served.”

That may never change, but the concepts outlined in the UNOS document aim to achieve an additional 15,223 life-years lived with a transplanted kidney for every year’s worth of deceased-donor transplants. How? Let’s explore.

How the System Would Change
Early on, Concepts for Kidney Allocation (available at optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.pdf) outlines the flaws of the current system: “[I]t does not strive to minimize death on the waiting list nor maximize survival following transplant. It does not recognize that all candidates do not have the same ability to survive the wait. It does not attempt to match the characteristics of a donor’s kidney to the candidate’s characteristics to promote a long and healthy survival post-transplant. The system can be better, and it can be designed to achieve more in the way of health and longevity than it currently does.”

Aware of the problems, and with input from hundreds of individuals—including transplant professionals, recipients, and candidates, as well as donor families, living donors, and the general public—UNOS’s Kidney Transplantation Committee has spent six years (so far) developing goals for a new allocation system. The concept document delineates three key factors in achieving those goals:

• Utilizing a kidney donor profile index (KDPI), a continuous measure used to estimate the potential function of a donated kidney if it were transplanted into the average recipient, to better characterize donor kidneys.

• Allocating some kidneys (20%) by a combination of the KDPI and a candidate’s estimated post-transplant survival (EPTS).

• Allocating the majority of organs (80%) by age-matching so that candidates within 15 years older or younger than the donor are prioritized.

The KDPI is based on the characteristics of the donor, including age, race/ethnicity, height, and weight, and whether he/she had any of the following factors: hypertension, diabetes, hepatitis C, elevated creatinine level, a cerebrovascular cause of death, or cardiac death. It is important to remember that a score below 20% indicates a kidney with the predicted longest function; it’s like being in the top 20% of your graduating class.

A candidate’s EPTS is based on age, length of time on dialysis, diabetes status, and history of prior organ transplant. “While no calculation will be able to predict life expectancy with 100% certainty, these four factors provide a reasonable estimate for identifying those candidates who have the longest possible EPTS,” the committee writes.

Once a KDPI has been established, there are two scenarios for how a candidate might be selected. Kidneys with a KDPI of 20% or lower are allocated based on EPTS. Those with a KDPI of more than 20% are allocated based on age-matching within 15 years (older or younger) of the recipient’s age.

To use the examples given in the report: Let’s say there are three candidates for a kidney. Mary is 30, Sophia is 21, and David is 60. Along comes a kidney with a KDPI of 10%. Since Mary and Sophia have better estimated survival than David (EPTS, 19%, 12%, and 75% respectively; again, it’s the percentile, so lower is better), they would have priority for that kidney.

However, if the available kidney has a KDPI of, say, 40%, age becomes a bigger factor. If the donor is 34, Mary and Sophia continue to have priority over David, since recipients ages 19 to 49 would be considered first. If the donor is 55, however, David would have precedence over Mary and Sophia, since the age range for that kidney recipient would be 40 to 70.

All of this can be confusing, and it leads one to suspect that some of the news entities who misspoke either did not understand what they were reading or perhaps did not even finish reading the report. But these components do not even tell the entire story; they are exactly that, components. The final proposal, which will be written only when all the feedback from a public comment period has been compiled and analyzed, “will include all the details of who gets the kidney,” as Friedewald says.

What is important to know now is that “waiting time will continue to be a major part of who gets a kidney” if the revised allocation concepts become policy, Friedewald emphasizes. “What this document says is that we’re generally going to group people based on the quality of the donor kidney. But once we do that—let’s say it’s a top 20% kidney—well, then the top 20% of candidates who are expected to live the longest will be up for that kidney. But that may be 10,000 people. Which of the 10,000 people gets the kidney? The person who waits the longest.”

Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.

“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”

Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”

Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”

Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.

In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?

For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”

For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”

And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”

By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).

The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.

“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”

Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?

For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.

“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”

At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?

“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”

Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)

For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.

“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”

In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”

And for those who insist that “first come, first served” is fair, Friedewald has a different opinion, calling it “a complete fallacy. The first come aren’t the first served. Some people won’t live long enough to wait for a kidney, if the line is too long. Everyone believes that a line is ‘first come, first served,’ because we’re used to delis and things like that, where you actually get served. But a lot of people aren’t getting served.”

That may never change, but the concepts outlined in the UNOS document aim to achieve an additional 15,223 life-years lived with a transplanted kidney for every year’s worth of deceased-donor transplants. How? Let’s explore.

How the System Would Change
Early on, Concepts for Kidney Allocation (available at optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.pdf) outlines the flaws of the current system: “[I]t does not strive to minimize death on the waiting list nor maximize survival following transplant. It does not recognize that all candidates do not have the same ability to survive the wait. It does not attempt to match the characteristics of a donor’s kidney to the candidate’s characteristics to promote a long and healthy survival post-transplant. The system can be better, and it can be designed to achieve more in the way of health and longevity than it currently does.”

Aware of the problems, and with input from hundreds of individuals—including transplant professionals, recipients, and candidates, as well as donor families, living donors, and the general public—UNOS’s Kidney Transplantation Committee has spent six years (so far) developing goals for a new allocation system. The concept document delineates three key factors in achieving those goals:

• Utilizing a kidney donor profile index (KDPI), a continuous measure used to estimate the potential function of a donated kidney if it were transplanted into the average recipient, to better characterize donor kidneys.

• Allocating some kidneys (20%) by a combination of the KDPI and a candidate’s estimated post-transplant survival (EPTS).

• Allocating the majority of organs (80%) by age-matching so that candidates within 15 years older or younger than the donor are prioritized.

The KDPI is based on the characteristics of the donor, including age, race/ethnicity, height, and weight, and whether he/she had any of the following factors: hypertension, diabetes, hepatitis C, elevated creatinine level, a cerebrovascular cause of death, or cardiac death. It is important to remember that a score below 20% indicates a kidney with the predicted longest function; it’s like being in the top 20% of your graduating class.

A candidate’s EPTS is based on age, length of time on dialysis, diabetes status, and history of prior organ transplant. “While no calculation will be able to predict life expectancy with 100% certainty, these four factors provide a reasonable estimate for identifying those candidates who have the longest possible EPTS,” the committee writes.

Once a KDPI has been established, there are two scenarios for how a candidate might be selected. Kidneys with a KDPI of 20% or lower are allocated based on EPTS. Those with a KDPI of more than 20% are allocated based on age-matching within 15 years (older or younger) of the recipient’s age.

To use the examples given in the report: Let’s say there are three candidates for a kidney. Mary is 30, Sophia is 21, and David is 60. Along comes a kidney with a KDPI of 10%. Since Mary and Sophia have better estimated survival than David (EPTS, 19%, 12%, and 75% respectively; again, it’s the percentile, so lower is better), they would have priority for that kidney.

However, if the available kidney has a KDPI of, say, 40%, age becomes a bigger factor. If the donor is 34, Mary and Sophia continue to have priority over David, since recipients ages 19 to 49 would be considered first. If the donor is 55, however, David would have precedence over Mary and Sophia, since the age range for that kidney recipient would be 40 to 70.

All of this can be confusing, and it leads one to suspect that some of the news entities who misspoke either did not understand what they were reading or perhaps did not even finish reading the report. But these components do not even tell the entire story; they are exactly that, components. The final proposal, which will be written only when all the feedback from a public comment period has been compiled and analyzed, “will include all the details of who gets the kidney,” as Friedewald says.

What is important to know now is that “waiting time will continue to be a major part of who gets a kidney” if the revised allocation concepts become policy, Friedewald emphasizes. “What this document says is that we’re generally going to group people based on the quality of the donor kidney. But once we do that—let’s say it’s a top 20% kidney—well, then the top 20% of candidates who are expected to live the longest will be up for that kidney. But that may be 10,000 people. Which of the 10,000 people gets the kidney? The person who waits the longest.”

Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.

“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”

Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”

Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”

Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.

In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?

For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”

For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”

And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”