During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

Physician registrants can get a big boost in collecting required Continuing Medical Education (CME) and Maintenance of Certification (MOC) self-assessment credits at the Vascular Annual Meeting.

The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. SVS has designated the 2019 Vascular Annual Meeting for a maximum of 30 AMA PRA Category 1 Credits™.

Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Full credit is not available for attendance at two sessions occurring simultaneously.

A number of sessions also permit earning of MOC credits.

Participants may claim credits beginning Wednesday, June 12. Credits must be claimed by Dec. 31, 2019. 

Physician registrants can get a big boost in collecting required Continuing Medical Education (CME) and Maintenance of Certification (MOC) self-assessment credits at the Vascular Annual Meeting.

The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. SVS has designated the 2019 Vascular Annual Meeting for a maximum of 30 AMA PRA Category 1 Credits™.

Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Full credit is not available for attendance at two sessions occurring simultaneously.

A number of sessions also permit earning of MOC credits.

Participants may claim credits beginning Wednesday, June 12. Credits must be claimed by Dec. 31, 2019. 

Physician registrants can get a big boost in collecting required Continuing Medical Education (CME) and Maintenance of Certification (MOC) self-assessment credits at the Vascular Annual Meeting.

The Society for Vascular Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. SVS has designated the 2019 Vascular Annual Meeting for a maximum of 30 AMA PRA Category 1 Credits™.

Physicians should claim only the credits commensurate with the extent of their participation in the activity.

Full credit is not available for attendance at two sessions occurring simultaneously.

A number of sessions also permit earning of MOC credits.

Participants may claim credits beginning Wednesday, June 12. Credits must be claimed by Dec. 31, 2019. 

A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

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Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

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As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

Nationwide Photographers

Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

Nationwide Photographers

As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

A tradition at the Vascular Annual Meeting, the E. Stanley Crawford Critical Issues Forum is organized by the incoming SVS President and devotes itself to assessing and discussing particular challenges currently facing the society. This year’s Forum focused on how vascular surgeons could use evidence-based medicine to develop tools to improve outcomes, reduce costs, and ensure appropriate utilization of resources.

Nationwide Photographers

Session moderator and organizer Kim J. Hodgson, MD, SVS president-elect and chair of the division of vascular surgery at Southern Illinois University School of Medicine, outlined the problem in his introductory presentation “Why Good Outcomes Are No Longer Good Enough.”

He pointed out how there are several driving forces influencing the inappropriate use of medical procedures, resulting in diminished quality of outcomes and increased costs of health care: These comprise incorrect evaluation, incorrect treatment and planning, and improper motivation. The first two factors can be improved through education and development and promulgation of evidence-based medical practices, but the last is correctable only through enforced regulation and peer-review. This has become increasingly more difficult as procedures move from the hospital to outpatient centers, where the profit motive for performing inappropriate procedures, and the means to satisfy it, are increasingly more tempting.

He emphasized how SVS has tools such as the Vascular Quality Initiative and its registries to provide evidence-based input on the appropriateness of procedures and whether an institution is matching up to its peers in providing appropriate patient care. The importance of the VQI was also stressed by the majority of the Crawford Forum speakers.

“Unfortunately, like it or not, the reality is that some degree of regulation is inevitable, and if we don’t step up and regulate ourselves, there are plenty of other people willing to do it for us. I would say that we let the bureaucrats develop our EHRs, and you know how that worked out. So, I think it is incumbent upon us to be able to regulate ourselves.”

Dr. Hodgson turned over the discussion to Arlene Seid, MD, MPH, medical director of the quality assurance office within the Pennsylvania Department of Health. Her presentation, “The Government’s Perspective on When & Where Endovascular Interventions Should Be Performed,” detailed how her department recently became concerned about an increase in the volume of endovascular procedures, and complications thereof, mainly in outpatient settings. The department also raised questions about the procedures and discussed whether reimbursement via programs such as Medicaid should be ceased.

She pointed out how federal regulations from the Centers for Medicare & Medicaid Services (CMS) only regulate through payments and their choice of procedures to be reimbursed, the vast majority of other regulations are established at the state level and vary widely from state to state. And at the state level, such as hers, there was great difficulty finding trustworthy expert opinion, and she added how organizations like the SVS could be of tremendous use in providing guidance in developing regulations.

Nationwide Photographers

As an example she used Ambulatory Surgical Centers, which are defined differently from state to state and vary widely in their requirements for licensing. The state’s job is made much simpler, and more effective, when expert organizations like the SVS can provide certification programs as a firm foundation for basing such licensing efforts.

She also suggested that if individuals have problems with or disagree with state regulations, they must become knowledgeable as to what level of state organization is involved, and ideally enlist the help of groups such as SVS to provide the expert justification for change.

MADRID – The musculoskeletal complications of checkpoint inhibitors therapy are sometimes described as RA like, but a detailed analysis of a consecutive series of patients presented at the European Congress of Rheumatology produced the conclusion that the phenotypic expression is unique.

“These manifestations do not necessarily include synovial involvement, so their description as a rheumatoid arthritis–like presentation is not accurate. Rather, our findings suggest the pathology is something completely different and completely new,” said Alexandra Filippopoulou, MD, a rheumatology resident at the University of Patras (Greece).

This comment was based on a prospective study evaluating musculoskeletal complications in patients treated with checkpoint inhibitors over a recent 2-year period. Of the 130 consecutive patients who received a checkpoint inhibitor in the study period, 10 (7.7%) complained of joint pain and were determined to have an inflammatory complication.

The median time to development of musculoskeletal symptoms in this mostly male patient series was 2.5 months. The site of cancer was lung in four, bladder in three, kidney in two, and skin in one. Nivolumab (Opdivo) was the most common checkpoint inhibitor used, but others were represented.

MRI studies were conducted in 8 of the 10 patients. Overall, the MRI studies showed more myofascial than synovial involvement, but Dr. Filippopoulou described three distinct patterns.

In four patients, there was prominent periarticular involvement marked by diffuse swelling in the hands, feet, knees, or a combination of these joints. Synovitis, when observed, was mild, but myositis and fasciitis were common in adjacent tissues.

In three patients with a chief complaint of knee pain, myofasciitis was prominent in the surrounding muscles. Again, synovitis, when observed, was mild. It was unclear whether a partial tear of the quadriceps tendon observed in one patient was checkpoint inhibitor related.

In a third pattern, shared by three other patients, synovitis was prominent, but so was myositis in adjacent muscles. In two of these patients, the inflammatory activity was confined to the hands; in the third, both the knees and the ankle were also involved.


Regardless of these patterns of inflammation, “almost all of these patients continued to show good range of motion, which is not something that is commonly seen in patients with rheumatoid arthritis,” Dr. Filippopoulou observed.

Overall, the joint pain tended to be mild to moderate. They all responded well to low-dose glucocorticoids or analgesics without need to discontinue the anticancer therapy, Dr. Filippopoulou reported.

Not least interesting of the findings, 50% of the patients with musculoskeletal adverse events had a favorable response to the checkpoint inhibitor therapy, compared with just 12.5% of patients without these complaints, a difference that reached statistical significance (P = .0016), according to Dr. Filippopoulou. This observation is consistent with a study published last year that also associated immune-related adverse events with a greater likelihood of an anticancer response (Ann Rheumatic Dis. 2018;77:393-8).

“This is an interesting finding, but the theory that musculoskeletal adverse events predict a better response to checkpoint inhibitor therapy needs to be proven,” she said.

A larger case series is needed to better characterize joint inflammation associated with checkpoint inhibitors, but Dr. Filippopoulou concluded from her series that these adverse events are not accurately described as RA like. Rather, the phenotypic expression appears to be unique, not fully resembling any other joint pathology.

Dr. Filippopoulou reported no potential conflicts of interest.

SOURCE: Filippopoulou A et al. Ann Rheum Dis. Jun 2019;78 (Suppl 2):251. Abstract OP0335. doi: 10.1136/annrheumdis-2019-eular.5029.

MADRID – The musculoskeletal complications of checkpoint inhibitors therapy are sometimes described as RA like, but a detailed analysis of a consecutive series of patients presented at the European Congress of Rheumatology produced the conclusion that the phenotypic expression is unique.

“These manifestations do not necessarily include synovial involvement, so their description as a rheumatoid arthritis–like presentation is not accurate. Rather, our findings suggest the pathology is something completely different and completely new,” said Alexandra Filippopoulou, MD, a rheumatology resident at the University of Patras (Greece).

This comment was based on a prospective study evaluating musculoskeletal complications in patients treated with checkpoint inhibitors over a recent 2-year period. Of the 130 consecutive patients who received a checkpoint inhibitor in the study period, 10 (7.7%) complained of joint pain and were determined to have an inflammatory complication.

The median time to development of musculoskeletal symptoms in this mostly male patient series was 2.5 months. The site of cancer was lung in four, bladder in three, kidney in two, and skin in one. Nivolumab (Opdivo) was the most common checkpoint inhibitor used, but others were represented.

MRI studies were conducted in 8 of the 10 patients. Overall, the MRI studies showed more myofascial than synovial involvement, but Dr. Filippopoulou described three distinct patterns.

In four patients, there was prominent periarticular involvement marked by diffuse swelling in the hands, feet, knees, or a combination of these joints. Synovitis, when observed, was mild, but myositis and fasciitis were common in adjacent tissues.

In three patients with a chief complaint of knee pain, myofasciitis was prominent in the surrounding muscles. Again, synovitis, when observed, was mild. It was unclear whether a partial tear of the quadriceps tendon observed in one patient was checkpoint inhibitor related.

In a third pattern, shared by three other patients, synovitis was prominent, but so was myositis in adjacent muscles. In two of these patients, the inflammatory activity was confined to the hands; in the third, both the knees and the ankle were also involved.


Regardless of these patterns of inflammation, “almost all of these patients continued to show good range of motion, which is not something that is commonly seen in patients with rheumatoid arthritis,” Dr. Filippopoulou observed.

Overall, the joint pain tended to be mild to moderate. They all responded well to low-dose glucocorticoids or analgesics without need to discontinue the anticancer therapy, Dr. Filippopoulou reported.

Not least interesting of the findings, 50% of the patients with musculoskeletal adverse events had a favorable response to the checkpoint inhibitor therapy, compared with just 12.5% of patients without these complaints, a difference that reached statistical significance (P = .0016), according to Dr. Filippopoulou. This observation is consistent with a study published last year that also associated immune-related adverse events with a greater likelihood of an anticancer response (Ann Rheumatic Dis. 2018;77:393-8).

“This is an interesting finding, but the theory that musculoskeletal adverse events predict a better response to checkpoint inhibitor therapy needs to be proven,” she said.

A larger case series is needed to better characterize joint inflammation associated with checkpoint inhibitors, but Dr. Filippopoulou concluded from her series that these adverse events are not accurately described as RA like. Rather, the phenotypic expression appears to be unique, not fully resembling any other joint pathology.

Dr. Filippopoulou reported no potential conflicts of interest.

SOURCE: Filippopoulou A et al. Ann Rheum Dis. Jun 2019;78 (Suppl 2):251. Abstract OP0335. doi: 10.1136/annrheumdis-2019-eular.5029.

MADRID – The musculoskeletal complications of checkpoint inhibitors therapy are sometimes described as RA like, but a detailed analysis of a consecutive series of patients presented at the European Congress of Rheumatology produced the conclusion that the phenotypic expression is unique.

“These manifestations do not necessarily include synovial involvement, so their description as a rheumatoid arthritis–like presentation is not accurate. Rather, our findings suggest the pathology is something completely different and completely new,” said Alexandra Filippopoulou, MD, a rheumatology resident at the University of Patras (Greece).

This comment was based on a prospective study evaluating musculoskeletal complications in patients treated with checkpoint inhibitors over a recent 2-year period. Of the 130 consecutive patients who received a checkpoint inhibitor in the study period, 10 (7.7%) complained of joint pain and were determined to have an inflammatory complication.

The median time to development of musculoskeletal symptoms in this mostly male patient series was 2.5 months. The site of cancer was lung in four, bladder in three, kidney in two, and skin in one. Nivolumab (Opdivo) was the most common checkpoint inhibitor used, but others were represented.

MRI studies were conducted in 8 of the 10 patients. Overall, the MRI studies showed more myofascial than synovial involvement, but Dr. Filippopoulou described three distinct patterns.

In four patients, there was prominent periarticular involvement marked by diffuse swelling in the hands, feet, knees, or a combination of these joints. Synovitis, when observed, was mild, but myositis and fasciitis were common in adjacent tissues.

In three patients with a chief complaint of knee pain, myofasciitis was prominent in the surrounding muscles. Again, synovitis, when observed, was mild. It was unclear whether a partial tear of the quadriceps tendon observed in one patient was checkpoint inhibitor related.

In a third pattern, shared by three other patients, synovitis was prominent, but so was myositis in adjacent muscles. In two of these patients, the inflammatory activity was confined to the hands; in the third, both the knees and the ankle were also involved.


Regardless of these patterns of inflammation, “almost all of these patients continued to show good range of motion, which is not something that is commonly seen in patients with rheumatoid arthritis,” Dr. Filippopoulou observed.

Overall, the joint pain tended to be mild to moderate. They all responded well to low-dose glucocorticoids or analgesics without need to discontinue the anticancer therapy, Dr. Filippopoulou reported.

Not least interesting of the findings, 50% of the patients with musculoskeletal adverse events had a favorable response to the checkpoint inhibitor therapy, compared with just 12.5% of patients without these complaints, a difference that reached statistical significance (P = .0016), according to Dr. Filippopoulou. This observation is consistent with a study published last year that also associated immune-related adverse events with a greater likelihood of an anticancer response (Ann Rheumatic Dis. 2018;77:393-8).

“This is an interesting finding, but the theory that musculoskeletal adverse events predict a better response to checkpoint inhibitor therapy needs to be proven,” she said.

A larger case series is needed to better characterize joint inflammation associated with checkpoint inhibitors, but Dr. Filippopoulou concluded from her series that these adverse events are not accurately described as RA like. Rather, the phenotypic expression appears to be unique, not fully resembling any other joint pathology.

Dr. Filippopoulou reported no potential conflicts of interest.

SOURCE: Filippopoulou A et al. Ann Rheum Dis. Jun 2019;78 (Suppl 2):251. Abstract OP0335. doi: 10.1136/annrheumdis-2019-eular.5029.

After 30 years in a traditional family medicine practice, Jesse Hsieh, MD, was ready for a change.

Alicia Gallegos/MDedge News

Data entry and insurance paperwork had drastically reduced his time with patients, and practicing medicine was no longer enjoyable or meaningful, said Dr. Hsieh of Granger, Ind.

“I felt very strongly that we were not delivering the kind of care that could be the best for the patient,” he said. “I explored other ways I could continue to practice the way I wanted; spend time with patients, teach them about things, and not spend so much time with regulatory paperwork and insurance.”

The answer for Dr. Hsieh was direct primary care (DPC), a model that cuts out insurance and centers on unlimited physician access for a flat, membership fee. For $2,500 a year, Dr. Hsieh’s patients can schedule visits as often as they like and communicate with him as the need arises by phone, text, or email.

For Dr. Hsieh, the model allows for a more manageable panel size, ample time to spend with patients, and the ability to make a greater impact on their health.

“I’m practicing the way I did 30 years ago,” Dr. Hsieh said. “I’m spending more time with people, I can call the patient myself about their labs and results and take their questions. I spend a lot more time educating the patient.”

Dr. Hsieh is one of a growing number of physicians moving to direct primary care. In 2009, about 100 practices were providing direct primary care, according to Jay Keese, executive director for the Direct Primary Care Coalition. Today, about 1,000 practices in 48 states provide direct primary care to more than 300,000 patients.

A direct primary care practice can be designed in different ways, but most opt out of insurance and offer a flat fee to patients for all primary care provided, said James A. Ellzy, MD, a family physician in Washington who serves on the American Academy of Family Physicians (AAFP) board of directors. A smaller number of practices operate a hybrid structure that includes both direct patients and fee-for-service patients.

About 3% of AAFP members are currently practicing direct primary care, and another 1% are currently converting, according to the AAFP 2018 Practice Profile Survey.

Nationally, about a third of survey respondents said they were learning about or considering a conversion to direct primary care, while another third said they were unfamiliar with the concept. The AAFP is working to educate physicians about the model, including holding an annual DPC summit.

But the move to direct primary care isn’t a sure bet. Success requires significant preparation, marketing, and structuring, experts say.

“There [can be] challenges in building a practice from scratch after you’ve had a fee-for-service practice,” Mr. Keese said. “If you’ve had a panel size of 2,500 or 3,000, and you’re looking at filling in 600 to 800 patients, it can take some time, which can cause some economic stress. But I think most people who go into direct primary care are excited and never look back.


 

Preparing for transition

When Rob Lamberts, MD, left his traditional practice in 2012, there were few leaders in direct primary care and not many resources available.

“I ended up just kind of figuring it out myself,” said Dr. Lamberts, an internist based in Augusta, Ga. “Over the past 6 1/2 years, I’ve built the practice to about 800 patients.”

Today, Dr. Lamberts is highly satisfied with his work and is helping local colleagues set up similar practices. He charges patients between $35 and $70 a month, depending on age, and offers a family fee between $150 and $175 for up to five members. Services include: extended physician access, office visits, discounted in-house labs, and discounted medications dispensed from his office.

“The amount of paperwork I have to do is substantially less,” Dr. Lamberts said. “My income is at least the same, if not a little more. My quality of life is tons better, and the quality of care is so much better.

Before making the jump to direct primary care, do your research and talk to other doctors about their experiences, Dr. Lamberts advised.

One important consideration is what type of direct primary care design to choose – the direct-to-consumer route or the direct-to-employer road. The first model targets patients as members, while the latter contracts with employers to provide services to their employees.

“There has been a surge in amount of interest in direct primary care to employers,” said Michael Tetreault, editor in chief for the DPC Journal, a news source that conducts data analytics on concierge medicine and DPC practices.

Reader surveys conducted by the DPC Journal found that a growing number of DPC physicians are looking to partner with local employers. Of 141 DPC physicians in 2019, 52% expressed an interest in employer partnerships, up from 35% in 2015, according to data provided by Mr. Tetreault.

One example of such growth is Nextera Healthcare, a network that started out with a handful of physicians about 10 years ago and now has more than 50, according to CEO and founder Clint Flanagan, MD.

The network contracts with employers across Colorado and eight other states to provide direct primary care services to their employees. Once affiliated, Nextera operates the marketing, sales, accounting, legal, and development side of the business. Most Nextera physicians have an average of 15 years practice experience, Dr. Flanagan said. Physicians receive most of the monthly revenue generated by their patients; Nextera retains a portion. Dr. Flanagan declined to specify the exact percentage retained.
 

Attracting patients, starting strong

For Dr. Hsieh, being well known in his community and having built a reputation as a family physician contributed to his success in direct primary care. In addition to taking on leadership roles in the health care community over the years, Dr. Hsieh regularly offers perspective for local media regarding medical topics, plays in a popular band at charity events, and teaches courses at two major universities in the area.

“When starting out in this practice, you really have to have built a reputation in town,” said Dr. Hsieh. “In this city, we’ve already had people try direct primary care who have failed because they came out of residency or people didn’t know who they were. You really have to have had a reputation of quality and service and patients should know about you.”

In many cases, physicians can bring their patients with them into direct primary care practice; however, some may not be able to based on their prior employment contract. Dr. Hsieh, for example, could not speak about his new practice or market the business until the day after he left his former practice, he said.

Dr. Lamberts said about 200 of his former patients initially followed him to direct primary care and another 100 have joined since. Before departing his former office, he gave a presentation to his patients about the direct primary care model and what the structure entailed.

Making patients aware of direct primary care and how it works is a top challenge to the model, Dr. Ellzy of the AAFP said. Some patients incorrectly believe that DPC covers all health services including hospitalizations and surgeries. Many DPC patients still carry insurance for hospitalizations as well as specialist visits.

“Part of it is understanding what direct primary care is and isn’t as you move from an insurance basis,” Dr. Ellzy said. “A lot of it is patient education, That’s one of the biggest issues.”
 

Strong team, alternate mindset

Putting in place an efficient, dedicated staff is also key to establishing a fruitful DPC practice, Dr. Hsieh noted. He credits his practice director, Jami Feitz, with keeping things running smoothly through patient education and advocacy. Ms. Feitz aids patients in navigating specialist visits, medication access issues, and payment.

“You can have the best business plan, you can have the best economics, you can even have the best reputation in town, but if you don’t have someone to run the logistics of your practice, you’re sunk,” Dr. Hsieh said. “As soon as you walk out of the exam room, that patient is going into that fragmented, complicated health care system. They need someone experienced with the special skills to help them through that process”

Dr. Lamberts adds that of all the shifts necessary for a prosperous direct primary care practice, a different mindset is among the most important for physicians.

“It’s a big change in philosophy,” he said. “You suddenly are focused on keeping patients away from the office rather than having a full office. You’re focused on keeping people well, rather than benefiting from people getting sick. That’s a challenge to lose the mindset and to suddenly celebrate if you have a day that’s not very busy or your office is empty. That’s a good thing.”
 

Direct primary care by the numbers

A 2018 survey by AAFP of 148 direct primary care physicians reveals how doctors are structuring their practices.

• 80% charge a fee to patients and do not bill any third-party payer.
• 14% engage with one or more third-party payers.
• 54% are male.
• 56% are greater than 15 years post residency.
• 20% are less than 7 years post residency.
• 72% of practices have been in operation less than 3 years.
• 11% of practices have been in operation less than 1 year.
• 54% of practices started from scratch.
• 34% of practices were converted from an existing practice.
• 57% of practices have employer-based contracts.
• 29% of practices are interested in employer-based contracts.
• 58% of practices supplement their income through other practice opportunities.
• 345 patients is the average panel size.
• 596 is the average target panel size.
• 91% of physicians would promote the model to others.

SOURCE: The American Academy of Family Physicians

agallegos@mdedge.com

After 30 years in a traditional family medicine practice, Jesse Hsieh, MD, was ready for a change.

Alicia Gallegos/MDedge News

Data entry and insurance paperwork had drastically reduced his time with patients, and practicing medicine was no longer enjoyable or meaningful, said Dr. Hsieh of Granger, Ind.

“I felt very strongly that we were not delivering the kind of care that could be the best for the patient,” he said. “I explored other ways I could continue to practice the way I wanted; spend time with patients, teach them about things, and not spend so much time with regulatory paperwork and insurance.”

The answer for Dr. Hsieh was direct primary care (DPC), a model that cuts out insurance and centers on unlimited physician access for a flat, membership fee. For $2,500 a year, Dr. Hsieh’s patients can schedule visits as often as they like and communicate with him as the need arises by phone, text, or email.

For Dr. Hsieh, the model allows for a more manageable panel size, ample time to spend with patients, and the ability to make a greater impact on their health.

“I’m practicing the way I did 30 years ago,” Dr. Hsieh said. “I’m spending more time with people, I can call the patient myself about their labs and results and take their questions. I spend a lot more time educating the patient.”

Dr. Hsieh is one of a growing number of physicians moving to direct primary care. In 2009, about 100 practices were providing direct primary care, according to Jay Keese, executive director for the Direct Primary Care Coalition. Today, about 1,000 practices in 48 states provide direct primary care to more than 300,000 patients.

A direct primary care practice can be designed in different ways, but most opt out of insurance and offer a flat fee to patients for all primary care provided, said James A. Ellzy, MD, a family physician in Washington who serves on the American Academy of Family Physicians (AAFP) board of directors. A smaller number of practices operate a hybrid structure that includes both direct patients and fee-for-service patients.

About 3% of AAFP members are currently practicing direct primary care, and another 1% are currently converting, according to the AAFP 2018 Practice Profile Survey.

Nationally, about a third of survey respondents said they were learning about or considering a conversion to direct primary care, while another third said they were unfamiliar with the concept. The AAFP is working to educate physicians about the model, including holding an annual DPC summit.

But the move to direct primary care isn’t a sure bet. Success requires significant preparation, marketing, and structuring, experts say.

“There [can be] challenges in building a practice from scratch after you’ve had a fee-for-service practice,” Mr. Keese said. “If you’ve had a panel size of 2,500 or 3,000, and you’re looking at filling in 600 to 800 patients, it can take some time, which can cause some economic stress. But I think most people who go into direct primary care are excited and never look back.


 

Preparing for transition

When Rob Lamberts, MD, left his traditional practice in 2012, there were few leaders in direct primary care and not many resources available.

“I ended up just kind of figuring it out myself,” said Dr. Lamberts, an internist based in Augusta, Ga. “Over the past 6 1/2 years, I’ve built the practice to about 800 patients.”

Today, Dr. Lamberts is highly satisfied with his work and is helping local colleagues set up similar practices. He charges patients between $35 and $70 a month, depending on age, and offers a family fee between $150 and $175 for up to five members. Services include: extended physician access, office visits, discounted in-house labs, and discounted medications dispensed from his office.

“The amount of paperwork I have to do is substantially less,” Dr. Lamberts said. “My income is at least the same, if not a little more. My quality of life is tons better, and the quality of care is so much better.

Before making the jump to direct primary care, do your research and talk to other doctors about their experiences, Dr. Lamberts advised.

One important consideration is what type of direct primary care design to choose – the direct-to-consumer route or the direct-to-employer road. The first model targets patients as members, while the latter contracts with employers to provide services to their employees.

“There has been a surge in amount of interest in direct primary care to employers,” said Michael Tetreault, editor in chief for the DPC Journal, a news source that conducts data analytics on concierge medicine and DPC practices.

Reader surveys conducted by the DPC Journal found that a growing number of DPC physicians are looking to partner with local employers. Of 141 DPC physicians in 2019, 52% expressed an interest in employer partnerships, up from 35% in 2015, according to data provided by Mr. Tetreault.

One example of such growth is Nextera Healthcare, a network that started out with a handful of physicians about 10 years ago and now has more than 50, according to CEO and founder Clint Flanagan, MD.

The network contracts with employers across Colorado and eight other states to provide direct primary care services to their employees. Once affiliated, Nextera operates the marketing, sales, accounting, legal, and development side of the business. Most Nextera physicians have an average of 15 years practice experience, Dr. Flanagan said. Physicians receive most of the monthly revenue generated by their patients; Nextera retains a portion. Dr. Flanagan declined to specify the exact percentage retained.
 

Attracting patients, starting strong

For Dr. Hsieh, being well known in his community and having built a reputation as a family physician contributed to his success in direct primary care. In addition to taking on leadership roles in the health care community over the years, Dr. Hsieh regularly offers perspective for local media regarding medical topics, plays in a popular band at charity events, and teaches courses at two major universities in the area.

“When starting out in this practice, you really have to have built a reputation in town,” said Dr. Hsieh. “In this city, we’ve already had people try direct primary care who have failed because they came out of residency or people didn’t know who they were. You really have to have had a reputation of quality and service and patients should know about you.”

In many cases, physicians can bring their patients with them into direct primary care practice; however, some may not be able to based on their prior employment contract. Dr. Hsieh, for example, could not speak about his new practice or market the business until the day after he left his former practice, he said.

Dr. Lamberts said about 200 of his former patients initially followed him to direct primary care and another 100 have joined since. Before departing his former office, he gave a presentation to his patients about the direct primary care model and what the structure entailed.

Making patients aware of direct primary care and how it works is a top challenge to the model, Dr. Ellzy of the AAFP said. Some patients incorrectly believe that DPC covers all health services including hospitalizations and surgeries. Many DPC patients still carry insurance for hospitalizations as well as specialist visits.

“Part of it is understanding what direct primary care is and isn’t as you move from an insurance basis,” Dr. Ellzy said. “A lot of it is patient education, That’s one of the biggest issues.”
 

Strong team, alternate mindset

Putting in place an efficient, dedicated staff is also key to establishing a fruitful DPC practice, Dr. Hsieh noted. He credits his practice director, Jami Feitz, with keeping things running smoothly through patient education and advocacy. Ms. Feitz aids patients in navigating specialist visits, medication access issues, and payment.

“You can have the best business plan, you can have the best economics, you can even have the best reputation in town, but if you don’t have someone to run the logistics of your practice, you’re sunk,” Dr. Hsieh said. “As soon as you walk out of the exam room, that patient is going into that fragmented, complicated health care system. They need someone experienced with the special skills to help them through that process”

Dr. Lamberts adds that of all the shifts necessary for a prosperous direct primary care practice, a different mindset is among the most important for physicians.

“It’s a big change in philosophy,” he said. “You suddenly are focused on keeping patients away from the office rather than having a full office. You’re focused on keeping people well, rather than benefiting from people getting sick. That’s a challenge to lose the mindset and to suddenly celebrate if you have a day that’s not very busy or your office is empty. That’s a good thing.”
 

Direct primary care by the numbers

A 2018 survey by AAFP of 148 direct primary care physicians reveals how doctors are structuring their practices.

• 80% charge a fee to patients and do not bill any third-party payer.
• 14% engage with one or more third-party payers.
• 54% are male.
• 56% are greater than 15 years post residency.
• 20% are less than 7 years post residency.
• 72% of practices have been in operation less than 3 years.
• 11% of practices have been in operation less than 1 year.
• 54% of practices started from scratch.
• 34% of practices were converted from an existing practice.
• 57% of practices have employer-based contracts.
• 29% of practices are interested in employer-based contracts.
• 58% of practices supplement their income through other practice opportunities.
• 345 patients is the average panel size.
• 596 is the average target panel size.
• 91% of physicians would promote the model to others.

SOURCE: The American Academy of Family Physicians

agallegos@mdedge.com

After 30 years in a traditional family medicine practice, Jesse Hsieh, MD, was ready for a change.

Alicia Gallegos/MDedge News

Data entry and insurance paperwork had drastically reduced his time with patients, and practicing medicine was no longer enjoyable or meaningful, said Dr. Hsieh of Granger, Ind.

“I felt very strongly that we were not delivering the kind of care that could be the best for the patient,” he said. “I explored other ways I could continue to practice the way I wanted; spend time with patients, teach them about things, and not spend so much time with regulatory paperwork and insurance.”

The answer for Dr. Hsieh was direct primary care (DPC), a model that cuts out insurance and centers on unlimited physician access for a flat, membership fee. For $2,500 a year, Dr. Hsieh’s patients can schedule visits as often as they like and communicate with him as the need arises by phone, text, or email.

For Dr. Hsieh, the model allows for a more manageable panel size, ample time to spend with patients, and the ability to make a greater impact on their health.

“I’m practicing the way I did 30 years ago,” Dr. Hsieh said. “I’m spending more time with people, I can call the patient myself about their labs and results and take their questions. I spend a lot more time educating the patient.”

Dr. Hsieh is one of a growing number of physicians moving to direct primary care. In 2009, about 100 practices were providing direct primary care, according to Jay Keese, executive director for the Direct Primary Care Coalition. Today, about 1,000 practices in 48 states provide direct primary care to more than 300,000 patients.

A direct primary care practice can be designed in different ways, but most opt out of insurance and offer a flat fee to patients for all primary care provided, said James A. Ellzy, MD, a family physician in Washington who serves on the American Academy of Family Physicians (AAFP) board of directors. A smaller number of practices operate a hybrid structure that includes both direct patients and fee-for-service patients.

About 3% of AAFP members are currently practicing direct primary care, and another 1% are currently converting, according to the AAFP 2018 Practice Profile Survey.

Nationally, about a third of survey respondents said they were learning about or considering a conversion to direct primary care, while another third said they were unfamiliar with the concept. The AAFP is working to educate physicians about the model, including holding an annual DPC summit.

But the move to direct primary care isn’t a sure bet. Success requires significant preparation, marketing, and structuring, experts say.

“There [can be] challenges in building a practice from scratch after you’ve had a fee-for-service practice,” Mr. Keese said. “If you’ve had a panel size of 2,500 or 3,000, and you’re looking at filling in 600 to 800 patients, it can take some time, which can cause some economic stress. But I think most people who go into direct primary care are excited and never look back.


 

Preparing for transition

When Rob Lamberts, MD, left his traditional practice in 2012, there were few leaders in direct primary care and not many resources available.

“I ended up just kind of figuring it out myself,” said Dr. Lamberts, an internist based in Augusta, Ga. “Over the past 6 1/2 years, I’ve built the practice to about 800 patients.”

Today, Dr. Lamberts is highly satisfied with his work and is helping local colleagues set up similar practices. He charges patients between $35 and $70 a month, depending on age, and offers a family fee between $150 and $175 for up to five members. Services include: extended physician access, office visits, discounted in-house labs, and discounted medications dispensed from his office.

“The amount of paperwork I have to do is substantially less,” Dr. Lamberts said. “My income is at least the same, if not a little more. My quality of life is tons better, and the quality of care is so much better.

Before making the jump to direct primary care, do your research and talk to other doctors about their experiences, Dr. Lamberts advised.

One important consideration is what type of direct primary care design to choose – the direct-to-consumer route or the direct-to-employer road. The first model targets patients as members, while the latter contracts with employers to provide services to their employees.

“There has been a surge in amount of interest in direct primary care to employers,” said Michael Tetreault, editor in chief for the DPC Journal, a news source that conducts data analytics on concierge medicine and DPC practices.

Reader surveys conducted by the DPC Journal found that a growing number of DPC physicians are looking to partner with local employers. Of 141 DPC physicians in 2019, 52% expressed an interest in employer partnerships, up from 35% in 2015, according to data provided by Mr. Tetreault.

One example of such growth is Nextera Healthcare, a network that started out with a handful of physicians about 10 years ago and now has more than 50, according to CEO and founder Clint Flanagan, MD.

The network contracts with employers across Colorado and eight other states to provide direct primary care services to their employees. Once affiliated, Nextera operates the marketing, sales, accounting, legal, and development side of the business. Most Nextera physicians have an average of 15 years practice experience, Dr. Flanagan said. Physicians receive most of the monthly revenue generated by their patients; Nextera retains a portion. Dr. Flanagan declined to specify the exact percentage retained.
 

Attracting patients, starting strong

For Dr. Hsieh, being well known in his community and having built a reputation as a family physician contributed to his success in direct primary care. In addition to taking on leadership roles in the health care community over the years, Dr. Hsieh regularly offers perspective for local media regarding medical topics, plays in a popular band at charity events, and teaches courses at two major universities in the area.

“When starting out in this practice, you really have to have built a reputation in town,” said Dr. Hsieh. “In this city, we’ve already had people try direct primary care who have failed because they came out of residency or people didn’t know who they were. You really have to have had a reputation of quality and service and patients should know about you.”

In many cases, physicians can bring their patients with them into direct primary care practice; however, some may not be able to based on their prior employment contract. Dr. Hsieh, for example, could not speak about his new practice or market the business until the day after he left his former practice, he said.

Dr. Lamberts said about 200 of his former patients initially followed him to direct primary care and another 100 have joined since. Before departing his former office, he gave a presentation to his patients about the direct primary care model and what the structure entailed.

Making patients aware of direct primary care and how it works is a top challenge to the model, Dr. Ellzy of the AAFP said. Some patients incorrectly believe that DPC covers all health services including hospitalizations and surgeries. Many DPC patients still carry insurance for hospitalizations as well as specialist visits.

“Part of it is understanding what direct primary care is and isn’t as you move from an insurance basis,” Dr. Ellzy said. “A lot of it is patient education, That’s one of the biggest issues.”
 

Strong team, alternate mindset

Putting in place an efficient, dedicated staff is also key to establishing a fruitful DPC practice, Dr. Hsieh noted. He credits his practice director, Jami Feitz, with keeping things running smoothly through patient education and advocacy. Ms. Feitz aids patients in navigating specialist visits, medication access issues, and payment.

“You can have the best business plan, you can have the best economics, you can even have the best reputation in town, but if you don’t have someone to run the logistics of your practice, you’re sunk,” Dr. Hsieh said. “As soon as you walk out of the exam room, that patient is going into that fragmented, complicated health care system. They need someone experienced with the special skills to help them through that process”

Dr. Lamberts adds that of all the shifts necessary for a prosperous direct primary care practice, a different mindset is among the most important for physicians.

“It’s a big change in philosophy,” he said. “You suddenly are focused on keeping patients away from the office rather than having a full office. You’re focused on keeping people well, rather than benefiting from people getting sick. That’s a challenge to lose the mindset and to suddenly celebrate if you have a day that’s not very busy or your office is empty. That’s a good thing.”
 

Direct primary care by the numbers

A 2018 survey by AAFP of 148 direct primary care physicians reveals how doctors are structuring their practices.

• 80% charge a fee to patients and do not bill any third-party payer.
• 14% engage with one or more third-party payers.
• 54% are male.
• 56% are greater than 15 years post residency.
• 20% are less than 7 years post residency.
• 72% of practices have been in operation less than 3 years.
• 11% of practices have been in operation less than 1 year.
• 54% of practices started from scratch.
• 34% of practices were converted from an existing practice.
• 57% of practices have employer-based contracts.
• 29% of practices are interested in employer-based contracts.
• 58% of practices supplement their income through other practice opportunities.
• 345 patients is the average panel size.
• 596 is the average target panel size.
• 91% of physicians would promote the model to others.

SOURCE: The American Academy of Family Physicians

agallegos@mdedge.com

TORONTO – Foot osteoarthritis has been a relatively neglected topic by researchers – but that’s finally changing, Michelle Marshall, PhD, observed at the OARSI 2019 World Congress.

Bruce Jancin/MDedge News

She was a coinvestigator in the groundbreaking Clinical Assessment of the Foot (CASF), a large prospective study that has brought new insights into the prevalence of foot osteoarthritis (OA), its risk factors, the sizable disease burden, and foot OA’s diverse phenotypes. She shared study highlights at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Elsewhere at OARSI 2019, Lucy S. Gates, PhD, presented the eagerly awaited results of the Chingford 1000 Women Study of the progression pattern of symptomatic radiographic OA of the first metatarsophalangeal joint (MTPJ). With 19 years of follow-up, Chingford is far and away the largest and longest longitudinal study of first MTP joint OA.

The prospective, population-based, observational cohort CASF study was carried out by Dr. Marshall and her coinvestigators at Keele University in Staffordshire, England. They surveyed Staffordshire residents aged 50 and older regarding whether they had experienced foot pain within the last 12 months. Those who answered affirmatively were invited to come in for a more detailed assessment and get weight-bearing x-rays of both feet. Among the 557 symptomatic participants with foot x-rays, the prevalence of radiographic OA of the foot was 16.7%, or roughly one in six – underscoring that it’s a common condition. The first MTP joint was the most commonly affected site, with a prevalence of 7.8%, followed by the second cuneometatarsal joint (CMJ) at 6.8%, the talonavicular joint (TNJ) at 5.2%, the navicular first cuneiform joint (NCJ) at 5.2%, and the first CMJ at 3.9%. Three-quarters of those who had symptomatic radiographic foot OA reported disabling symptoms, an established risk factor for falls (Ann Rheum Dis. 2015 Jan;74[1]:156-63).

With an eye toward identification of potential distinct phenotypes of foot OA, the CASF investigators conducted a separate analysis of those study participants with symptomatic radiographic midfoot OA – that is, OA of the TNJ, NCJ, and/or first or second CMJs, but not the first MTP joint. The prevalence in the Staffordshire population over age 50 with a history of foot pain was 12%. Independent risk factors for midfoot OA included obesity, with an adjusted odds ratio of 2.0; pain in other weight-bearing lower limb joints, with an adjusted odds ratio of 8.5; diabetes, odds ratio of 1.9; and previous foot injury, with an associated 1.6-fold increased risk. Midfoot OA was most prevalent in women older than 75 years; however, contrary to the conventional wisdom, a history of frequently wearing high-heeled shoes posed no increased risk.


The burden associated with midfoot OA was reflected in affected individuals’ frequent use of health care resources: During the past year, 46% of them had consulted their primary care physicians about their foot pain, 48% had been to a podiatrist, and 19% had seen a physical therapist (Arthritis Res Ther. 2015 Jul 13;17:178. doi: 10.1186/s13075-015-0693-3).

In a separate analysis, the investigators compiled additional evidence from CASF pointing to the existence of two phenotypes of foot OA: isolated first MTP OA and polyarticular foot OA, with distinct risk factors and symptom profiles (Arthritis Care Res [Hoboken]. 2016 Feb;68[2]:217-27).

“We found that OA affected both feet significantly more than was expected by chance, and we identified strong symmetrical patterns. This mirrors findings in hand OA and implies involvement of systemic components within a foot,” Dr. Marshall said.

The course of foot OA

During 18 months of prospective follow-up in CASF, subjects with isolated first MTP joint or polyarticular foot OA showed no clinically meaningful change in symptoms (Arthritis Care Res [Hoboken]. 2018 Jul;70[7]:1107-12).

But that finding may have been a function of the relatively brief follow-up, as the Chingford 1000 Women Study, with its 19 years of prospective follow-up, told a different story. Dr. Gates, of the University of Southampton (England), reported that among the 193 patients with foot x-rays at both baseline and follow-up, by which point they averaged nearly 76 years in age, 33.2% had OA of the first MTP joint of either foot at baseline as defined by at least a grade 2 score on the LaTrobe foot atlas, and 13% had prevalent involvement of both feet. During 19 years of follow-up of the women from Chingford, an area in northeast London, the incidence of new-onset radiographic first MTP joint OA was 7% in the left foot and 17% in the right. Meanwhile, progression to grade 3 radiographic OA occurred in the left foot of 28% of those with grade 2 disease at baseline and in 35% of those with baseline first MTP joint OA of the right foot. Twenty-eight percent of patients with unilateral first MTP joint OA at baseline progressed to bilateral involvement within 19 years.

Dr. Gates reported having no financial conflicts regarding the Chingford study, funded primarily by Arthritis Research UK, which merged with Arthritis Care in 2018 to form Versus Arthritis.

Similarly, Dr. Marshall reported no financial conflicts regarding CASF, also funded by Arthritis Research UK.

bjancin@mdedge.com

SOURCES: Marshall M. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S16, Abstract I-8 and Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S260-S261, Abstract 367.

TORONTO – Foot osteoarthritis has been a relatively neglected topic by researchers – but that’s finally changing, Michelle Marshall, PhD, observed at the OARSI 2019 World Congress.

Bruce Jancin/MDedge News

She was a coinvestigator in the groundbreaking Clinical Assessment of the Foot (CASF), a large prospective study that has brought new insights into the prevalence of foot osteoarthritis (OA), its risk factors, the sizable disease burden, and foot OA’s diverse phenotypes. She shared study highlights at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Elsewhere at OARSI 2019, Lucy S. Gates, PhD, presented the eagerly awaited results of the Chingford 1000 Women Study of the progression pattern of symptomatic radiographic OA of the first metatarsophalangeal joint (MTPJ). With 19 years of follow-up, Chingford is far and away the largest and longest longitudinal study of first MTP joint OA.

The prospective, population-based, observational cohort CASF study was carried out by Dr. Marshall and her coinvestigators at Keele University in Staffordshire, England. They surveyed Staffordshire residents aged 50 and older regarding whether they had experienced foot pain within the last 12 months. Those who answered affirmatively were invited to come in for a more detailed assessment and get weight-bearing x-rays of both feet. Among the 557 symptomatic participants with foot x-rays, the prevalence of radiographic OA of the foot was 16.7%, or roughly one in six – underscoring that it’s a common condition. The first MTP joint was the most commonly affected site, with a prevalence of 7.8%, followed by the second cuneometatarsal joint (CMJ) at 6.8%, the talonavicular joint (TNJ) at 5.2%, the navicular first cuneiform joint (NCJ) at 5.2%, and the first CMJ at 3.9%. Three-quarters of those who had symptomatic radiographic foot OA reported disabling symptoms, an established risk factor for falls (Ann Rheum Dis. 2015 Jan;74[1]:156-63).

With an eye toward identification of potential distinct phenotypes of foot OA, the CASF investigators conducted a separate analysis of those study participants with symptomatic radiographic midfoot OA – that is, OA of the TNJ, NCJ, and/or first or second CMJs, but not the first MTP joint. The prevalence in the Staffordshire population over age 50 with a history of foot pain was 12%. Independent risk factors for midfoot OA included obesity, with an adjusted odds ratio of 2.0; pain in other weight-bearing lower limb joints, with an adjusted odds ratio of 8.5; diabetes, odds ratio of 1.9; and previous foot injury, with an associated 1.6-fold increased risk. Midfoot OA was most prevalent in women older than 75 years; however, contrary to the conventional wisdom, a history of frequently wearing high-heeled shoes posed no increased risk.


The burden associated with midfoot OA was reflected in affected individuals’ frequent use of health care resources: During the past year, 46% of them had consulted their primary care physicians about their foot pain, 48% had been to a podiatrist, and 19% had seen a physical therapist (Arthritis Res Ther. 2015 Jul 13;17:178. doi: 10.1186/s13075-015-0693-3).

In a separate analysis, the investigators compiled additional evidence from CASF pointing to the existence of two phenotypes of foot OA: isolated first MTP OA and polyarticular foot OA, with distinct risk factors and symptom profiles (Arthritis Care Res [Hoboken]. 2016 Feb;68[2]:217-27).

“We found that OA affected both feet significantly more than was expected by chance, and we identified strong symmetrical patterns. This mirrors findings in hand OA and implies involvement of systemic components within a foot,” Dr. Marshall said.

The course of foot OA

During 18 months of prospective follow-up in CASF, subjects with isolated first MTP joint or polyarticular foot OA showed no clinically meaningful change in symptoms (Arthritis Care Res [Hoboken]. 2018 Jul;70[7]:1107-12).

But that finding may have been a function of the relatively brief follow-up, as the Chingford 1000 Women Study, with its 19 years of prospective follow-up, told a different story. Dr. Gates, of the University of Southampton (England), reported that among the 193 patients with foot x-rays at both baseline and follow-up, by which point they averaged nearly 76 years in age, 33.2% had OA of the first MTP joint of either foot at baseline as defined by at least a grade 2 score on the LaTrobe foot atlas, and 13% had prevalent involvement of both feet. During 19 years of follow-up of the women from Chingford, an area in northeast London, the incidence of new-onset radiographic first MTP joint OA was 7% in the left foot and 17% in the right. Meanwhile, progression to grade 3 radiographic OA occurred in the left foot of 28% of those with grade 2 disease at baseline and in 35% of those with baseline first MTP joint OA of the right foot. Twenty-eight percent of patients with unilateral first MTP joint OA at baseline progressed to bilateral involvement within 19 years.

Dr. Gates reported having no financial conflicts regarding the Chingford study, funded primarily by Arthritis Research UK, which merged with Arthritis Care in 2018 to form Versus Arthritis.

Similarly, Dr. Marshall reported no financial conflicts regarding CASF, also funded by Arthritis Research UK.

bjancin@mdedge.com

SOURCES: Marshall M. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S16, Abstract I-8 and Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S260-S261, Abstract 367.

TORONTO – Foot osteoarthritis has been a relatively neglected topic by researchers – but that’s finally changing, Michelle Marshall, PhD, observed at the OARSI 2019 World Congress.

Bruce Jancin/MDedge News

She was a coinvestigator in the groundbreaking Clinical Assessment of the Foot (CASF), a large prospective study that has brought new insights into the prevalence of foot osteoarthritis (OA), its risk factors, the sizable disease burden, and foot OA’s diverse phenotypes. She shared study highlights at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Elsewhere at OARSI 2019, Lucy S. Gates, PhD, presented the eagerly awaited results of the Chingford 1000 Women Study of the progression pattern of symptomatic radiographic OA of the first metatarsophalangeal joint (MTPJ). With 19 years of follow-up, Chingford is far and away the largest and longest longitudinal study of first MTP joint OA.

The prospective, population-based, observational cohort CASF study was carried out by Dr. Marshall and her coinvestigators at Keele University in Staffordshire, England. They surveyed Staffordshire residents aged 50 and older regarding whether they had experienced foot pain within the last 12 months. Those who answered affirmatively were invited to come in for a more detailed assessment and get weight-bearing x-rays of both feet. Among the 557 symptomatic participants with foot x-rays, the prevalence of radiographic OA of the foot was 16.7%, or roughly one in six – underscoring that it’s a common condition. The first MTP joint was the most commonly affected site, with a prevalence of 7.8%, followed by the second cuneometatarsal joint (CMJ) at 6.8%, the talonavicular joint (TNJ) at 5.2%, the navicular first cuneiform joint (NCJ) at 5.2%, and the first CMJ at 3.9%. Three-quarters of those who had symptomatic radiographic foot OA reported disabling symptoms, an established risk factor for falls (Ann Rheum Dis. 2015 Jan;74[1]:156-63).

With an eye toward identification of potential distinct phenotypes of foot OA, the CASF investigators conducted a separate analysis of those study participants with symptomatic radiographic midfoot OA – that is, OA of the TNJ, NCJ, and/or first or second CMJs, but not the first MTP joint. The prevalence in the Staffordshire population over age 50 with a history of foot pain was 12%. Independent risk factors for midfoot OA included obesity, with an adjusted odds ratio of 2.0; pain in other weight-bearing lower limb joints, with an adjusted odds ratio of 8.5; diabetes, odds ratio of 1.9; and previous foot injury, with an associated 1.6-fold increased risk. Midfoot OA was most prevalent in women older than 75 years; however, contrary to the conventional wisdom, a history of frequently wearing high-heeled shoes posed no increased risk.


The burden associated with midfoot OA was reflected in affected individuals’ frequent use of health care resources: During the past year, 46% of them had consulted their primary care physicians about their foot pain, 48% had been to a podiatrist, and 19% had seen a physical therapist (Arthritis Res Ther. 2015 Jul 13;17:178. doi: 10.1186/s13075-015-0693-3).

In a separate analysis, the investigators compiled additional evidence from CASF pointing to the existence of two phenotypes of foot OA: isolated first MTP OA and polyarticular foot OA, with distinct risk factors and symptom profiles (Arthritis Care Res [Hoboken]. 2016 Feb;68[2]:217-27).

“We found that OA affected both feet significantly more than was expected by chance, and we identified strong symmetrical patterns. This mirrors findings in hand OA and implies involvement of systemic components within a foot,” Dr. Marshall said.

The course of foot OA

During 18 months of prospective follow-up in CASF, subjects with isolated first MTP joint or polyarticular foot OA showed no clinically meaningful change in symptoms (Arthritis Care Res [Hoboken]. 2018 Jul;70[7]:1107-12).

But that finding may have been a function of the relatively brief follow-up, as the Chingford 1000 Women Study, with its 19 years of prospective follow-up, told a different story. Dr. Gates, of the University of Southampton (England), reported that among the 193 patients with foot x-rays at both baseline and follow-up, by which point they averaged nearly 76 years in age, 33.2% had OA of the first MTP joint of either foot at baseline as defined by at least a grade 2 score on the LaTrobe foot atlas, and 13% had prevalent involvement of both feet. During 19 years of follow-up of the women from Chingford, an area in northeast London, the incidence of new-onset radiographic first MTP joint OA was 7% in the left foot and 17% in the right. Meanwhile, progression to grade 3 radiographic OA occurred in the left foot of 28% of those with grade 2 disease at baseline and in 35% of those with baseline first MTP joint OA of the right foot. Twenty-eight percent of patients with unilateral first MTP joint OA at baseline progressed to bilateral involvement within 19 years.

Dr. Gates reported having no financial conflicts regarding the Chingford study, funded primarily by Arthritis Research UK, which merged with Arthritis Care in 2018 to form Versus Arthritis.

Similarly, Dr. Marshall reported no financial conflicts regarding CASF, also funded by Arthritis Research UK.

bjancin@mdedge.com

SOURCES: Marshall M. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S16, Abstract I-8 and Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S260-S261, Abstract 367.

In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.

Nationwide Photographers

In introducing the subject, he quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.

“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution and a demographic cliff of our membership,” Dr. Makaroun said.

The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida and California are well below average,” he said.

Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.

The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”

“Change does not come easy!” Dr. Makaroun warned.

“We cannot ignore in the discussion of workforce issues, the major shifts, change and uncertainty we are experiencing in health care delivery, education and the generational change of our newest members,” he said.

More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities.

Despite this movement, nearly two-thirds of SVS members are currently employed by hospital systems that are getting larger and larger, making it essential to navigate an ever more complex decision-making process in employment, compensation and spectrum of activities. Practice environments are becoming more corporate and bureaucratic.

Dr. Makaroun pointed out that the current landscape of our manpower has a clear two tiers divided by hospital size and location. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.

“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem.

The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.

Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.

The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.

The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing and understanding the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” according to Dr. Makaroun.

The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.

In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.

Nationwide Photographers

In introducing the subject, he quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.

“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution and a demographic cliff of our membership,” Dr. Makaroun said.

The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida and California are well below average,” he said.

Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.

The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”

“Change does not come easy!” Dr. Makaroun warned.

“We cannot ignore in the discussion of workforce issues, the major shifts, change and uncertainty we are experiencing in health care delivery, education and the generational change of our newest members,” he said.

More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities.

Despite this movement, nearly two-thirds of SVS members are currently employed by hospital systems that are getting larger and larger, making it essential to navigate an ever more complex decision-making process in employment, compensation and spectrum of activities. Practice environments are becoming more corporate and bureaucratic.

Dr. Makaroun pointed out that the current landscape of our manpower has a clear two tiers divided by hospital size and location. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.

“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem.

The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.

Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.

The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.

The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing and understanding the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” according to Dr. Makaroun.

The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.

In selecting the subject of his presidential address, SVS President Michel Makaroun, MD, decided to focus on the inadequacy of vascular manpower to meet the demands and needs of the public.

Nationwide Photographers

In introducing the subject, he quoted a favorite saying from Mark Twain that gave him the topic of his address, “I am in favor of progress; it’s change I don’t like.” He then proceeded to outline why changes are necessary and what the Society for Vascular Surgery is doing to help implement them.

“You are all familiar with the highlights of the problem: It is in our numbers! A problem with multiple facets, including unfilled jobs, increasing demand, maldistribution and a demographic cliff of our membership,” Dr. Makaroun said.

The manifestations of this shortage are multiple. The number of advertised jobs far exceeds the number of graduates. There is also a significant maldistribution of the workforce. “We are concentrated in the northeast, and many populous states including Texas, Florida and California are well below average,” he said.

Additionally, many community hospitals, in both suburban areas or small towns completely lack any access to vascular surgical care, even in states with seemingly adequate numbers.

The shortage problem in vascular surgery will get worse before it gets better, he added, saying “Our pipeline is simply not large enough to overcome an older retiring generation of vascular surgeons, with nearly half retiring before 65.”

“Change does not come easy!” Dr. Makaroun warned.

“We cannot ignore in the discussion of workforce issues, the major shifts, change and uncertainty we are experiencing in health care delivery, education and the generational change of our newest members,” he said.

More than 10% of vascular surgeons now practice primarily if not exclusively in ambulatory facilities. This direction is gathering steam and reduces the pool of vascular surgeons available to accept hospital practices and cover emergencies, particularly in underserved communities.

Despite this movement, nearly two-thirds of SVS members are currently employed by hospital systems that are getting larger and larger, making it essential to navigate an ever more complex decision-making process in employment, compensation and spectrum of activities. Practice environments are becoming more corporate and bureaucratic.

Dr. Makaroun pointed out that the current landscape of our manpower has a clear two tiers divided by hospital size and location. “The most pressing concern is the inability of our specialty to provide vascular surgery services to the multitude of hospitals located in smaller communities.

“The SVS established a task force to study our manpower issues last fall. The taskforce was divided into three workgroups to focus on different areas of the problem.

The first workgroup, under the leadership of Malachi Sheehan III, MD, and Jeffrey Jim, MD, focused on the obvious solution: a campaign to increase training programs and available positions. Unfortunately, this is only aspirational, since reality fails the SVS in this effort. The pool of general surgery graduates is finite, with competition from several specialties that are more analogous to modern general surgery than vascular surgery.

Increasing the number of integrated programs is less efficient because of a 5- to 6-year lag between initiation of a new program and graduation, but it can tap into an almost unlimited pool of applicants from medical school, and more recently some very qualified international medical graduates. This makes it potentially a far more effective solution for the long term, Dr. Makaroun said.

The workgroup attempted to contact all hospitals with a general surgery program and no associated vascular fellowship. Help in navigating the process of securing financing and applying for a new program was offered. A session was conducted at VAM for interested potential sites to start discussing the process, and representatives from 27 hospitals were there expressing interest.

The second workgroup, under the leadership of Rick Powell, MD, and Andy Schanzer, MD, was tasked with analyzing and understanding the entire spectrum of surgeons’ clinical activities and producing a valuation study that illustrates the economic and vital impact of vascular surgery for hospitals and patients. “The work of this group is essential to promote a healthier relationship between our specialty and our institutions, making vascular surgery more attractive for future recruits,” according to Dr. Makaroun.

The third workgroup under the leadership of Will Jordan, MD, and Tim Sarac, MD, had the toughest job, said Dr. Makaroun. It was tasked with thinking outside the box and suggesting methods to address the most glaring need: the community hospitals, where most of the advertised jobs are, jobs that are being shunned by graduates of current training programs.

Chemotherapy plus radiation therapy (chemoradiotherapy) was not associated with improved relapse-free survival versus chemotherapy alone in patients with stage III or IVA endometrial cancer, according to results from a phase 3 trial.

“This combined approach has been studied, but its efficacy relative to that of chemotherapy alone is not known,” wrote Daniela Matei, MD, of Northwestern University, Chicago, and colleagues. The results were published in the New England Journal of Medicine.

The Gynecologic Oncology Group (GOG) 258 study included 736 patients with stage III or IVA endometrial carcinoma who were randomized in a 1:1 fashion to receive platinum­-based chemotherapy plus volume–directed external-beam radiation ther­apy every 21 days for a total of four cycles or chemotherapy alone every 21 days for a total of six cycles.

The primary endpoint measured was relapse-­free survival; secondary endpoints included safety, overall survival (OS), and quality of life.

At 60 months, the proportion of patients alive and relapse ­free was 59% (95% confidence interval, 53-65) and 58% (95% CI, 53-64) in the chemoradiotherapy and chemotherapy­ alone arms, respectively (hazard ratio, 0.90; 90% CI, 0.74-1.10).

“The data on over­all survival are not sufficiently mature to allow comparison between the groups,” the researchers wrote.

With respect to safety, grade 3, 4, or 5 toxicities were reported in 58% and 63% of patients in the chemoradiotherapy and chemotherapy alone arms, respectively.

“Although acute toxic effects were more common in the chemoradiotherapy group than in the chemotherapy-­only group in our trial, most were low-­grade and reversible on treatment discontinuation,” Dr. Matei and colleagues explained.

A major strength of the study was the broad inclusion criteria, which included patients with nonperitoneal, lymph-­node, pelvic, and adnexal metastasis, the researchers noted.

“Our data are compatible with the hypoth­esis from previous studies that completion of chemotherapy is important for the prevention of distant relapse,” they concluded.

The National Cancer Institute supported the study. The authors reported financial affiliations with AstraZeneca, Clovis, Genentech, the GOG Foundation, Tesaro, and several others.

SOURCE: Matei D et al. N Engl J Med. 2019 Jun 13. doi: 10.1056/NEJMoa1813181.

Chemotherapy plus radiation therapy (chemoradiotherapy) was not associated with improved relapse-free survival versus chemotherapy alone in patients with stage III or IVA endometrial cancer, according to results from a phase 3 trial.

“This combined approach has been studied, but its efficacy relative to that of chemotherapy alone is not known,” wrote Daniela Matei, MD, of Northwestern University, Chicago, and colleagues. The results were published in the New England Journal of Medicine.

The Gynecologic Oncology Group (GOG) 258 study included 736 patients with stage III or IVA endometrial carcinoma who were randomized in a 1:1 fashion to receive platinum­-based chemotherapy plus volume–directed external-beam radiation ther­apy every 21 days for a total of four cycles or chemotherapy alone every 21 days for a total of six cycles.

The primary endpoint measured was relapse-­free survival; secondary endpoints included safety, overall survival (OS), and quality of life.

At 60 months, the proportion of patients alive and relapse ­free was 59% (95% confidence interval, 53-65) and 58% (95% CI, 53-64) in the chemoradiotherapy and chemotherapy­ alone arms, respectively (hazard ratio, 0.90; 90% CI, 0.74-1.10).

“The data on over­all survival are not sufficiently mature to allow comparison between the groups,” the researchers wrote.

With respect to safety, grade 3, 4, or 5 toxicities were reported in 58% and 63% of patients in the chemoradiotherapy and chemotherapy alone arms, respectively.

“Although acute toxic effects were more common in the chemoradiotherapy group than in the chemotherapy-­only group in our trial, most were low-­grade and reversible on treatment discontinuation,” Dr. Matei and colleagues explained.

A major strength of the study was the broad inclusion criteria, which included patients with nonperitoneal, lymph-­node, pelvic, and adnexal metastasis, the researchers noted.

“Our data are compatible with the hypoth­esis from previous studies that completion of chemotherapy is important for the prevention of distant relapse,” they concluded.

The National Cancer Institute supported the study. The authors reported financial affiliations with AstraZeneca, Clovis, Genentech, the GOG Foundation, Tesaro, and several others.

SOURCE: Matei D et al. N Engl J Med. 2019 Jun 13. doi: 10.1056/NEJMoa1813181.

Chemotherapy plus radiation therapy (chemoradiotherapy) was not associated with improved relapse-free survival versus chemotherapy alone in patients with stage III or IVA endometrial cancer, according to results from a phase 3 trial.

“This combined approach has been studied, but its efficacy relative to that of chemotherapy alone is not known,” wrote Daniela Matei, MD, of Northwestern University, Chicago, and colleagues. The results were published in the New England Journal of Medicine.

The Gynecologic Oncology Group (GOG) 258 study included 736 patients with stage III or IVA endometrial carcinoma who were randomized in a 1:1 fashion to receive platinum­-based chemotherapy plus volume–directed external-beam radiation ther­apy every 21 days for a total of four cycles or chemotherapy alone every 21 days for a total of six cycles.

The primary endpoint measured was relapse-­free survival; secondary endpoints included safety, overall survival (OS), and quality of life.

At 60 months, the proportion of patients alive and relapse ­free was 59% (95% confidence interval, 53-65) and 58% (95% CI, 53-64) in the chemoradiotherapy and chemotherapy­ alone arms, respectively (hazard ratio, 0.90; 90% CI, 0.74-1.10).

“The data on over­all survival are not sufficiently mature to allow comparison between the groups,” the researchers wrote.

With respect to safety, grade 3, 4, or 5 toxicities were reported in 58% and 63% of patients in the chemoradiotherapy and chemotherapy alone arms, respectively.

“Although acute toxic effects were more common in the chemoradiotherapy group than in the chemotherapy-­only group in our trial, most were low-­grade and reversible on treatment discontinuation,” Dr. Matei and colleagues explained.

A major strength of the study was the broad inclusion criteria, which included patients with nonperitoneal, lymph-­node, pelvic, and adnexal metastasis, the researchers noted.

“Our data are compatible with the hypoth­esis from previous studies that completion of chemotherapy is important for the prevention of distant relapse,” they concluded.

The National Cancer Institute supported the study. The authors reported financial affiliations with AstraZeneca, Clovis, Genentech, the GOG Foundation, Tesaro, and several others.

SOURCE: Matei D et al. N Engl J Med. 2019 Jun 13. doi: 10.1056/NEJMoa1813181.

CRYSTAL CITY, VA. – Be aware of the potential iatrogenic properties of medications prescribed when patients present with new psychiatric symptoms, Henry A. Nasrallah, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Drugs that can cause iatrogenic psychiatric symptoms include stimulants, anabolic steroids, ACE inhibitors, anticholinergics, tricyclic antidepressants, antiepileptics, benzodiazepines, beta-adrenergic blockers, dopamine receptor agonists, among many others. A diverse class of medications can cause depression, anxiety, mania, and psychotic symptoms, and some medications cause multiple iatrogenic effects.

“Iatrogenic psychopathology can occur with a wide array of medications that are used in general medical practice,” said Dr. Nasrallah, editor in chief of Current Psychiatry and professor and chairman of the department of neurology and psychiatry at Saint Louis University. For example, the drug reserpine can cause depression in about 10% of cases, and corticosteroids can cause mood disorders such as depression or mania in about 6% of cases.

In other situations, use of alcohol, cannabis, hallucinogens, opioids, and other recreational drugs can cause psychiatric symptoms, and withdrawal from alcohol and sedatives can induce psychosis.

The DSM-5 defines a psychiatric disorder as a disorder that is not caused by a general medical condition and is not attributable to recreational or prescription drugs. However, a direct causal connection is sometimes difficult to establish, said Dr. Nasrallah, because psychiatric symptoms that manifest during treatment with prescription medications also could be tied to an underlying medical illness, psychosocial factors, withdrawal from a different prescription medication, or an unrecognized psychopathology. To confirm the drug is causing the disorder, clinicians should also rechallenge the patient.

“We have to maintain an index of suspicion whenever we have a potential prescription drug,” he said at the meeting presented by Global Academy for Medical Education. “First-episode psychiatric disorder is always suspect. Iatrogenesis can occur for the first time in a patient who never had that symptom before, so you suspect it might be iatrogenic.”

Some drugs might induce psychiatric symptoms at higher but not lower doses, he added.

Other risk factors for iatrogenesis include simultaneous use of prescription medications, administration method, narrow therapeutic index, and rapid titration. Patients with slow metabolisms or hepatic insufficiency are at risk for iatrogenesis, as are those who are very young or very old, in stressful settings, or in a postpartum period.

Evaluate when psychiatric symptoms occurred, whether symptoms worsened and when, the dates of medication use, rechallenge and dechallenge dates, and any previous history of psychiatric disorders, said Dr. Nasrallah, who holds the Sydney W. Souers Endowed Chair at the university. If a patient is using more than one medication at a time, record the dates of each drug and their discontinuations.

Determine when the iatrogenesis occurred with psychiatric drugs, Dr. Nasrallah noted. “Iatrogenesis can complicate the course and outcome of the main medical or psychiatric illness being treated. Sometimes psychiatric medication can cause iatrogenic medical conditions; it’s not just a one-way street.”

Dr. Nasrallah reported receiving research grants from Forest, Forum, and Otsuka. In addition, he is a consultant for Acadia, Alkermes, Boehringer Ingelheim, Forum, Janssen, Merck, Novartis, Otsuka, Sunovion, and Teva, and he serves on the speaker’s bureau for Acadia, Alkermes, Janssen, Otsuka, and Sunovion.

Global Academy and this news organization are owned by the same parent company.

CRYSTAL CITY, VA. – Be aware of the potential iatrogenic properties of medications prescribed when patients present with new psychiatric symptoms, Henry A. Nasrallah, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Drugs that can cause iatrogenic psychiatric symptoms include stimulants, anabolic steroids, ACE inhibitors, anticholinergics, tricyclic antidepressants, antiepileptics, benzodiazepines, beta-adrenergic blockers, dopamine receptor agonists, among many others. A diverse class of medications can cause depression, anxiety, mania, and psychotic symptoms, and some medications cause multiple iatrogenic effects.

“Iatrogenic psychopathology can occur with a wide array of medications that are used in general medical practice,” said Dr. Nasrallah, editor in chief of Current Psychiatry and professor and chairman of the department of neurology and psychiatry at Saint Louis University. For example, the drug reserpine can cause depression in about 10% of cases, and corticosteroids can cause mood disorders such as depression or mania in about 6% of cases.

In other situations, use of alcohol, cannabis, hallucinogens, opioids, and other recreational drugs can cause psychiatric symptoms, and withdrawal from alcohol and sedatives can induce psychosis.

The DSM-5 defines a psychiatric disorder as a disorder that is not caused by a general medical condition and is not attributable to recreational or prescription drugs. However, a direct causal connection is sometimes difficult to establish, said Dr. Nasrallah, because psychiatric symptoms that manifest during treatment with prescription medications also could be tied to an underlying medical illness, psychosocial factors, withdrawal from a different prescription medication, or an unrecognized psychopathology. To confirm the drug is causing the disorder, clinicians should also rechallenge the patient.

“We have to maintain an index of suspicion whenever we have a potential prescription drug,” he said at the meeting presented by Global Academy for Medical Education. “First-episode psychiatric disorder is always suspect. Iatrogenesis can occur for the first time in a patient who never had that symptom before, so you suspect it might be iatrogenic.”

Some drugs might induce psychiatric symptoms at higher but not lower doses, he added.

Other risk factors for iatrogenesis include simultaneous use of prescription medications, administration method, narrow therapeutic index, and rapid titration. Patients with slow metabolisms or hepatic insufficiency are at risk for iatrogenesis, as are those who are very young or very old, in stressful settings, or in a postpartum period.

Evaluate when psychiatric symptoms occurred, whether symptoms worsened and when, the dates of medication use, rechallenge and dechallenge dates, and any previous history of psychiatric disorders, said Dr. Nasrallah, who holds the Sydney W. Souers Endowed Chair at the university. If a patient is using more than one medication at a time, record the dates of each drug and their discontinuations.

Determine when the iatrogenesis occurred with psychiatric drugs, Dr. Nasrallah noted. “Iatrogenesis can complicate the course and outcome of the main medical or psychiatric illness being treated. Sometimes psychiatric medication can cause iatrogenic medical conditions; it’s not just a one-way street.”

Dr. Nasrallah reported receiving research grants from Forest, Forum, and Otsuka. In addition, he is a consultant for Acadia, Alkermes, Boehringer Ingelheim, Forum, Janssen, Merck, Novartis, Otsuka, Sunovion, and Teva, and he serves on the speaker’s bureau for Acadia, Alkermes, Janssen, Otsuka, and Sunovion.

Global Academy and this news organization are owned by the same parent company.

CRYSTAL CITY, VA. – Be aware of the potential iatrogenic properties of medications prescribed when patients present with new psychiatric symptoms, Henry A. Nasrallah, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

Drugs that can cause iatrogenic psychiatric symptoms include stimulants, anabolic steroids, ACE inhibitors, anticholinergics, tricyclic antidepressants, antiepileptics, benzodiazepines, beta-adrenergic blockers, dopamine receptor agonists, among many others. A diverse class of medications can cause depression, anxiety, mania, and psychotic symptoms, and some medications cause multiple iatrogenic effects.

“Iatrogenic psychopathology can occur with a wide array of medications that are used in general medical practice,” said Dr. Nasrallah, editor in chief of Current Psychiatry and professor and chairman of the department of neurology and psychiatry at Saint Louis University. For example, the drug reserpine can cause depression in about 10% of cases, and corticosteroids can cause mood disorders such as depression or mania in about 6% of cases.

In other situations, use of alcohol, cannabis, hallucinogens, opioids, and other recreational drugs can cause psychiatric symptoms, and withdrawal from alcohol and sedatives can induce psychosis.

The DSM-5 defines a psychiatric disorder as a disorder that is not caused by a general medical condition and is not attributable to recreational or prescription drugs. However, a direct causal connection is sometimes difficult to establish, said Dr. Nasrallah, because psychiatric symptoms that manifest during treatment with prescription medications also could be tied to an underlying medical illness, psychosocial factors, withdrawal from a different prescription medication, or an unrecognized psychopathology. To confirm the drug is causing the disorder, clinicians should also rechallenge the patient.

“We have to maintain an index of suspicion whenever we have a potential prescription drug,” he said at the meeting presented by Global Academy for Medical Education. “First-episode psychiatric disorder is always suspect. Iatrogenesis can occur for the first time in a patient who never had that symptom before, so you suspect it might be iatrogenic.”

Some drugs might induce psychiatric symptoms at higher but not lower doses, he added.

Other risk factors for iatrogenesis include simultaneous use of prescription medications, administration method, narrow therapeutic index, and rapid titration. Patients with slow metabolisms or hepatic insufficiency are at risk for iatrogenesis, as are those who are very young or very old, in stressful settings, or in a postpartum period.

Evaluate when psychiatric symptoms occurred, whether symptoms worsened and when, the dates of medication use, rechallenge and dechallenge dates, and any previous history of psychiatric disorders, said Dr. Nasrallah, who holds the Sydney W. Souers Endowed Chair at the university. If a patient is using more than one medication at a time, record the dates of each drug and their discontinuations.

Determine when the iatrogenesis occurred with psychiatric drugs, Dr. Nasrallah noted. “Iatrogenesis can complicate the course and outcome of the main medical or psychiatric illness being treated. Sometimes psychiatric medication can cause iatrogenic medical conditions; it’s not just a one-way street.”

Dr. Nasrallah reported receiving research grants from Forest, Forum, and Otsuka. In addition, he is a consultant for Acadia, Alkermes, Boehringer Ingelheim, Forum, Janssen, Merck, Novartis, Otsuka, Sunovion, and Teva, and he serves on the speaker’s bureau for Acadia, Alkermes, Janssen, Otsuka, and Sunovion.

Global Academy and this news organization are owned by the same parent company.