Hospitalists and other health care workers will be introduced to the concept of using point-of-care ultrasound to guide bedside diagnostics and clinical decision making at a Sunday pre-course titled “Point-of-Care Ultrasound for the Hospitalist.”

HM19 marks the 10th anniversary of this particular pre-course offering. “It is the SHM annual meeting’s longest-standing pre-course, and it has sold out every year since its inception. Learners always rate it highly,” said course director Nilam J. Soni, MD, MS, associate professor in the department of medicine at the University of Texas, San Antonio. “Faculty members are very experienced and passionate about teaching this innovative technology.”

Dr. Soni said that using portable ultrasound takes clinicians back to the bedside, which is a rarity with new technologies. “It allows clinicians to spend more time with patients, which is fulfilling for the patient and clinician,” he said. “Based on what we’ve seen over the past decade, it can improve hospitalists’ job satisfaction and enjoyment of their clinical work.”

While most medical schools are now introducing point-of-care ultrasound to their medical students, many currently practicing physicians haven’t been trained in using this new technology. This pre-course can help fill that gap.

Although ultrasound technology has existed since the 1940s, large bulky machines weren’t practical for bedside use. Now, ultrasound machines are so small that they can be carried in a coat pocket. “Small machines can be as powerful as some of the larger ones and cost only a few thousand dollars due to increasing market competition,” said Dr. Soni, whose course codirector is Ricardo Franco-Sadud, MD, a hospitalist at Naples (Fla.) Community Hospital. “The availability and portability is driving the uptake of ultrasound.”

In addition to being used at the bedside, ultrasound has other advantages, such as being noninvasive and not emitting radiation like CT scans do.

“It’s time for physicians to have another bedside tool in their black bag,” said Dr. Soni, who notes that the stethoscope is more than 200 years old and human hands and eyes have limitations.

This session will appeal to a mix of attendees. Administrators will gain a better understanding of the multitude of applications of point-of-care ultrasound and how ultrasound can be integrated into their practice. Clinicians will get hands-on experience by practicing a multitude of applications during scanning sessions with live models. Medical educators will glean insight on how to develop training programs and curricula.

“Our goal is to familiarize attendees with using ultrasound for different applications to evaluate common conditions, such as heart failure, pleural effusions, pneumonia, and lower-extremity swelling,” Dr. Soni said.

The pre-course will feature practical and focused lectures combined with hands-on practice sessions. “We’ll start with the basics on how to use ultrasound, then we’ll practicing acquiring images on live models and reviewing normal and abnormal images. We’ll conclude with real patient cases.” Learners will rotate in small groups to different tables where they will practice different skills on varying body parts.

Dr. Soni reports grants from the Department of Veterans Affairs Quality Enhancement Research Initiative Partnered Evaluation Initiative Grant (HX002263-01A1) outside of the submitted work.
 

Point-of-Care Ultrasound for the Hospitalist
Sunday, 7:30 a.m. – 12:30 p.m. and 1:00 – 6:00 p.m.
Potomac C/1-3

Hospitalists and other health care workers will be introduced to the concept of using point-of-care ultrasound to guide bedside diagnostics and clinical decision making at a Sunday pre-course titled “Point-of-Care Ultrasound for the Hospitalist.”

HM19 marks the 10th anniversary of this particular pre-course offering. “It is the SHM annual meeting’s longest-standing pre-course, and it has sold out every year since its inception. Learners always rate it highly,” said course director Nilam J. Soni, MD, MS, associate professor in the department of medicine at the University of Texas, San Antonio. “Faculty members are very experienced and passionate about teaching this innovative technology.”

Dr. Soni said that using portable ultrasound takes clinicians back to the bedside, which is a rarity with new technologies. “It allows clinicians to spend more time with patients, which is fulfilling for the patient and clinician,” he said. “Based on what we’ve seen over the past decade, it can improve hospitalists’ job satisfaction and enjoyment of their clinical work.”

While most medical schools are now introducing point-of-care ultrasound to their medical students, many currently practicing physicians haven’t been trained in using this new technology. This pre-course can help fill that gap.

Although ultrasound technology has existed since the 1940s, large bulky machines weren’t practical for bedside use. Now, ultrasound machines are so small that they can be carried in a coat pocket. “Small machines can be as powerful as some of the larger ones and cost only a few thousand dollars due to increasing market competition,” said Dr. Soni, whose course codirector is Ricardo Franco-Sadud, MD, a hospitalist at Naples (Fla.) Community Hospital. “The availability and portability is driving the uptake of ultrasound.”

In addition to being used at the bedside, ultrasound has other advantages, such as being noninvasive and not emitting radiation like CT scans do.

“It’s time for physicians to have another bedside tool in their black bag,” said Dr. Soni, who notes that the stethoscope is more than 200 years old and human hands and eyes have limitations.

This session will appeal to a mix of attendees. Administrators will gain a better understanding of the multitude of applications of point-of-care ultrasound and how ultrasound can be integrated into their practice. Clinicians will get hands-on experience by practicing a multitude of applications during scanning sessions with live models. Medical educators will glean insight on how to develop training programs and curricula.

“Our goal is to familiarize attendees with using ultrasound for different applications to evaluate common conditions, such as heart failure, pleural effusions, pneumonia, and lower-extremity swelling,” Dr. Soni said.

The pre-course will feature practical and focused lectures combined with hands-on practice sessions. “We’ll start with the basics on how to use ultrasound, then we’ll practicing acquiring images on live models and reviewing normal and abnormal images. We’ll conclude with real patient cases.” Learners will rotate in small groups to different tables where they will practice different skills on varying body parts.

Dr. Soni reports grants from the Department of Veterans Affairs Quality Enhancement Research Initiative Partnered Evaluation Initiative Grant (HX002263-01A1) outside of the submitted work.
 

Point-of-Care Ultrasound for the Hospitalist
Sunday, 7:30 a.m. – 12:30 p.m. and 1:00 – 6:00 p.m.
Potomac C/1-3

Hospitalists and other health care workers will be introduced to the concept of using point-of-care ultrasound to guide bedside diagnostics and clinical decision making at a Sunday pre-course titled “Point-of-Care Ultrasound for the Hospitalist.”

HM19 marks the 10th anniversary of this particular pre-course offering. “It is the SHM annual meeting’s longest-standing pre-course, and it has sold out every year since its inception. Learners always rate it highly,” said course director Nilam J. Soni, MD, MS, associate professor in the department of medicine at the University of Texas, San Antonio. “Faculty members are very experienced and passionate about teaching this innovative technology.”

Dr. Soni said that using portable ultrasound takes clinicians back to the bedside, which is a rarity with new technologies. “It allows clinicians to spend more time with patients, which is fulfilling for the patient and clinician,” he said. “Based on what we’ve seen over the past decade, it can improve hospitalists’ job satisfaction and enjoyment of their clinical work.”

While most medical schools are now introducing point-of-care ultrasound to their medical students, many currently practicing physicians haven’t been trained in using this new technology. This pre-course can help fill that gap.

Although ultrasound technology has existed since the 1940s, large bulky machines weren’t practical for bedside use. Now, ultrasound machines are so small that they can be carried in a coat pocket. “Small machines can be as powerful as some of the larger ones and cost only a few thousand dollars due to increasing market competition,” said Dr. Soni, whose course codirector is Ricardo Franco-Sadud, MD, a hospitalist at Naples (Fla.) Community Hospital. “The availability and portability is driving the uptake of ultrasound.”

In addition to being used at the bedside, ultrasound has other advantages, such as being noninvasive and not emitting radiation like CT scans do.

“It’s time for physicians to have another bedside tool in their black bag,” said Dr. Soni, who notes that the stethoscope is more than 200 years old and human hands and eyes have limitations.

This session will appeal to a mix of attendees. Administrators will gain a better understanding of the multitude of applications of point-of-care ultrasound and how ultrasound can be integrated into their practice. Clinicians will get hands-on experience by practicing a multitude of applications during scanning sessions with live models. Medical educators will glean insight on how to develop training programs and curricula.

“Our goal is to familiarize attendees with using ultrasound for different applications to evaluate common conditions, such as heart failure, pleural effusions, pneumonia, and lower-extremity swelling,” Dr. Soni said.

The pre-course will feature practical and focused lectures combined with hands-on practice sessions. “We’ll start with the basics on how to use ultrasound, then we’ll practicing acquiring images on live models and reviewing normal and abnormal images. We’ll conclude with real patient cases.” Learners will rotate in small groups to different tables where they will practice different skills on varying body parts.

Dr. Soni reports grants from the Department of Veterans Affairs Quality Enhancement Research Initiative Partnered Evaluation Initiative Grant (HX002263-01A1) outside of the submitted work.
 

Point-of-Care Ultrasound for the Hospitalist
Sunday, 7:30 a.m. – 12:30 p.m. and 1:00 – 6:00 p.m.
Potomac C/1-3

This year, the Society of Hospital Medicine will induct two new Masters in Hospital Medicine (MHM), the society’s highest professional honor. After the new honorees receive their designations, there will be only 30 MHMs society-wide, out of a universe of more than 60,000 hospitalists.

“The MHMs are truly the ‘hall of fame’ for hospital medicine and our society,” said Larry Wellikson, MD, MHM, the CEO of SHM.

SHM first introduced the MHM designation in 2010. The honor is reserved for hospitalists who have uniquely distinguished themselves in the specialty through the excellence and significance of their contributions to hospital medicine specifically and health care as a whole. SHM members are nominated for MHM consideration, and the SHM Board of Directors rigorously reviews qualifications and selects each year’s MHM class.

The two hospitalists receiving the MHM designation at HM19 are Brian Harte, MD, MHM, and Samir Shah, MD, MHM.
 

Brian Harte, MD, MHM

“Dr. Harte was selected as an MHM in honor of his unwavering dedication to hospital medicine and the Society as a stellar clinician and inspiring leader,” Dr. Wellikson said.

Dr. Harte is president of Cleveland Clinic Akron General and the Southern Region and is an associate professor of medicine at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He formerly served as president of Cleveland Clinic Hillcrest Hospital and Cleveland Clinic South Pointe Hospital.

Dr. Harte’s contributions to hospital medicine have been numerous, both as an educator and a clinician. “Because of his prowess for improving hospital operations while continuing to uphold the highest standards of clinical care, Dr. Harte advanced quickly, developing and growing the presence of hospital medicine throughout the Cleveland Clinic network,” Dr. Wellikson said.

Regarding the award, Dr. Harte said, “I’m honored to receive this recognition and would like to thank my colleagues at SHM. I will continue to work to advocate for patient care and to challenge physicians to lead improvements in quality and safety.”

Dr. Harte served on the SHM Board of Directors for 6 years, including serving as treasurer and president. He served on a number of committees, including the Annual Conference and Public Policy committees. He has presented at multiple SHM Annual Conferences on leadership, quality and patient safety, and hospital operations.

“SHM is progressive in its thinking,” Dr. Harte said. “The Society’s focus on staying ahead of changes in health care and advocating for patients makes it an organization that will shape health care in the years to come.”

Dr. Harte was also a deputy editor for the Journal of Hospital Medicine – SHM’s flagship, peer-reviewed publication for hospital medicine research – for 9 years, and was instrumental in developing its “Clinical Care Conundrums” series.

Samir S. Shah, MD, MSCE, MHM

Dr. Samir S. Shah was selected as an MHM in honor of his leadership in hospital medicine as a stellar researcher, devoted mentor, and key contributor to the Society.

He is a professor of pediatrics at the University of Cincinnati College of Medicine, as well as director of the division of hospital medicine and chief metrics officer at Cincinnati Children’s Hospital Medical Center, where he holds the James M. Ewell Endowed Chair.

“Dr. Shah is a leading figure in the founding and growing of pediatric hospital medicine, ensuring that research is a central focus of this specialty,” Dr. Wellikson said.

“Much of what I’ve done is foundational – developing leaders and creating networks of mentoring relationships and a culture of sponsorship to help others succeed so that we can advance the field and patient care faster and further together,” Dr. Shah said, commenting on his MHM recognition. “I am honored and humbled. I’m proud to have contributed to the academic development of the field through research, mentorship, and sponsorship. My team and my colleagues have helped me to become a better leader. I view this award as a recognition of their efforts to help me advance pediatric hospital medicine as an academic discipline.”

In January 2019, Dr. Shah assumed the role of Journal of Hospital Medicine editor in chief. He has held other leadership positions with the journal, including associate, deputy, and senior deputy editor, since 2009. He has authored more than 300 peer-reviewed publications and more than 150 book chapters. He is also editor or coeditor of 12 books.

Dr. Shah has also served as the primary research mentor to more than 85 medical students, residents, fellows, junior faculty, and postdoctoral students, and as a career and professional development mentor to countless others. He is the primary research mentor for five current National Institutes of Health or Agency for Healthcare Research and Quality K-series career development award recipients.

Dr. Shah has helped to develop and better leverage data infrastructure to help scale research and link variation in clinical practice to outcomes nationally to determine best clinical practice. For example, he partnered with the Children’s Hospital Association, where he chairs the Pediatric Health Information Research Groups.

“While his individual research accomplishments are exceptional, his more lasting impacts in pediatric hospital medicine are in creating and growing research networks and advancing academic growth of the field,” Dr. Wellikson said.

Dr. Shah received the 2009 Award of Excellence for Research from SHM and has served on both the Awards and Research committees.

This year, the Society of Hospital Medicine will induct two new Masters in Hospital Medicine (MHM), the society’s highest professional honor. After the new honorees receive their designations, there will be only 30 MHMs society-wide, out of a universe of more than 60,000 hospitalists.

“The MHMs are truly the ‘hall of fame’ for hospital medicine and our society,” said Larry Wellikson, MD, MHM, the CEO of SHM.

SHM first introduced the MHM designation in 2010. The honor is reserved for hospitalists who have uniquely distinguished themselves in the specialty through the excellence and significance of their contributions to hospital medicine specifically and health care as a whole. SHM members are nominated for MHM consideration, and the SHM Board of Directors rigorously reviews qualifications and selects each year’s MHM class.

The two hospitalists receiving the MHM designation at HM19 are Brian Harte, MD, MHM, and Samir Shah, MD, MHM.
 

Brian Harte, MD, MHM

“Dr. Harte was selected as an MHM in honor of his unwavering dedication to hospital medicine and the Society as a stellar clinician and inspiring leader,” Dr. Wellikson said.

Dr. Harte is president of Cleveland Clinic Akron General and the Southern Region and is an associate professor of medicine at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He formerly served as president of Cleveland Clinic Hillcrest Hospital and Cleveland Clinic South Pointe Hospital.

Dr. Harte’s contributions to hospital medicine have been numerous, both as an educator and a clinician. “Because of his prowess for improving hospital operations while continuing to uphold the highest standards of clinical care, Dr. Harte advanced quickly, developing and growing the presence of hospital medicine throughout the Cleveland Clinic network,” Dr. Wellikson said.

Regarding the award, Dr. Harte said, “I’m honored to receive this recognition and would like to thank my colleagues at SHM. I will continue to work to advocate for patient care and to challenge physicians to lead improvements in quality and safety.”

Dr. Harte served on the SHM Board of Directors for 6 years, including serving as treasurer and president. He served on a number of committees, including the Annual Conference and Public Policy committees. He has presented at multiple SHM Annual Conferences on leadership, quality and patient safety, and hospital operations.

“SHM is progressive in its thinking,” Dr. Harte said. “The Society’s focus on staying ahead of changes in health care and advocating for patients makes it an organization that will shape health care in the years to come.”

Dr. Harte was also a deputy editor for the Journal of Hospital Medicine – SHM’s flagship, peer-reviewed publication for hospital medicine research – for 9 years, and was instrumental in developing its “Clinical Care Conundrums” series.

Samir S. Shah, MD, MSCE, MHM

Dr. Samir S. Shah was selected as an MHM in honor of his leadership in hospital medicine as a stellar researcher, devoted mentor, and key contributor to the Society.

He is a professor of pediatrics at the University of Cincinnati College of Medicine, as well as director of the division of hospital medicine and chief metrics officer at Cincinnati Children’s Hospital Medical Center, where he holds the James M. Ewell Endowed Chair.

“Dr. Shah is a leading figure in the founding and growing of pediatric hospital medicine, ensuring that research is a central focus of this specialty,” Dr. Wellikson said.

“Much of what I’ve done is foundational – developing leaders and creating networks of mentoring relationships and a culture of sponsorship to help others succeed so that we can advance the field and patient care faster and further together,” Dr. Shah said, commenting on his MHM recognition. “I am honored and humbled. I’m proud to have contributed to the academic development of the field through research, mentorship, and sponsorship. My team and my colleagues have helped me to become a better leader. I view this award as a recognition of their efforts to help me advance pediatric hospital medicine as an academic discipline.”

In January 2019, Dr. Shah assumed the role of Journal of Hospital Medicine editor in chief. He has held other leadership positions with the journal, including associate, deputy, and senior deputy editor, since 2009. He has authored more than 300 peer-reviewed publications and more than 150 book chapters. He is also editor or coeditor of 12 books.

Dr. Shah has also served as the primary research mentor to more than 85 medical students, residents, fellows, junior faculty, and postdoctoral students, and as a career and professional development mentor to countless others. He is the primary research mentor for five current National Institutes of Health or Agency for Healthcare Research and Quality K-series career development award recipients.

Dr. Shah has helped to develop and better leverage data infrastructure to help scale research and link variation in clinical practice to outcomes nationally to determine best clinical practice. For example, he partnered with the Children’s Hospital Association, where he chairs the Pediatric Health Information Research Groups.

“While his individual research accomplishments are exceptional, his more lasting impacts in pediatric hospital medicine are in creating and growing research networks and advancing academic growth of the field,” Dr. Wellikson said.

Dr. Shah received the 2009 Award of Excellence for Research from SHM and has served on both the Awards and Research committees.

This year, the Society of Hospital Medicine will induct two new Masters in Hospital Medicine (MHM), the society’s highest professional honor. After the new honorees receive their designations, there will be only 30 MHMs society-wide, out of a universe of more than 60,000 hospitalists.

“The MHMs are truly the ‘hall of fame’ for hospital medicine and our society,” said Larry Wellikson, MD, MHM, the CEO of SHM.

SHM first introduced the MHM designation in 2010. The honor is reserved for hospitalists who have uniquely distinguished themselves in the specialty through the excellence and significance of their contributions to hospital medicine specifically and health care as a whole. SHM members are nominated for MHM consideration, and the SHM Board of Directors rigorously reviews qualifications and selects each year’s MHM class.

The two hospitalists receiving the MHM designation at HM19 are Brian Harte, MD, MHM, and Samir Shah, MD, MHM.
 

Brian Harte, MD, MHM

“Dr. Harte was selected as an MHM in honor of his unwavering dedication to hospital medicine and the Society as a stellar clinician and inspiring leader,” Dr. Wellikson said.

Dr. Harte is president of Cleveland Clinic Akron General and the Southern Region and is an associate professor of medicine at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He formerly served as president of Cleveland Clinic Hillcrest Hospital and Cleveland Clinic South Pointe Hospital.

Dr. Harte’s contributions to hospital medicine have been numerous, both as an educator and a clinician. “Because of his prowess for improving hospital operations while continuing to uphold the highest standards of clinical care, Dr. Harte advanced quickly, developing and growing the presence of hospital medicine throughout the Cleveland Clinic network,” Dr. Wellikson said.

Regarding the award, Dr. Harte said, “I’m honored to receive this recognition and would like to thank my colleagues at SHM. I will continue to work to advocate for patient care and to challenge physicians to lead improvements in quality and safety.”

Dr. Harte served on the SHM Board of Directors for 6 years, including serving as treasurer and president. He served on a number of committees, including the Annual Conference and Public Policy committees. He has presented at multiple SHM Annual Conferences on leadership, quality and patient safety, and hospital operations.

“SHM is progressive in its thinking,” Dr. Harte said. “The Society’s focus on staying ahead of changes in health care and advocating for patients makes it an organization that will shape health care in the years to come.”

Dr. Harte was also a deputy editor for the Journal of Hospital Medicine – SHM’s flagship, peer-reviewed publication for hospital medicine research – for 9 years, and was instrumental in developing its “Clinical Care Conundrums” series.

Samir S. Shah, MD, MSCE, MHM

Dr. Samir S. Shah was selected as an MHM in honor of his leadership in hospital medicine as a stellar researcher, devoted mentor, and key contributor to the Society.

He is a professor of pediatrics at the University of Cincinnati College of Medicine, as well as director of the division of hospital medicine and chief metrics officer at Cincinnati Children’s Hospital Medical Center, where he holds the James M. Ewell Endowed Chair.

“Dr. Shah is a leading figure in the founding and growing of pediatric hospital medicine, ensuring that research is a central focus of this specialty,” Dr. Wellikson said.

“Much of what I’ve done is foundational – developing leaders and creating networks of mentoring relationships and a culture of sponsorship to help others succeed so that we can advance the field and patient care faster and further together,” Dr. Shah said, commenting on his MHM recognition. “I am honored and humbled. I’m proud to have contributed to the academic development of the field through research, mentorship, and sponsorship. My team and my colleagues have helped me to become a better leader. I view this award as a recognition of their efforts to help me advance pediatric hospital medicine as an academic discipline.”

In January 2019, Dr. Shah assumed the role of Journal of Hospital Medicine editor in chief. He has held other leadership positions with the journal, including associate, deputy, and senior deputy editor, since 2009. He has authored more than 300 peer-reviewed publications and more than 150 book chapters. He is also editor or coeditor of 12 books.

Dr. Shah has also served as the primary research mentor to more than 85 medical students, residents, fellows, junior faculty, and postdoctoral students, and as a career and professional development mentor to countless others. He is the primary research mentor for five current National Institutes of Health or Agency for Healthcare Research and Quality K-series career development award recipients.

Dr. Shah has helped to develop and better leverage data infrastructure to help scale research and link variation in clinical practice to outcomes nationally to determine best clinical practice. For example, he partnered with the Children’s Hospital Association, where he chairs the Pediatric Health Information Research Groups.

“While his individual research accomplishments are exceptional, his more lasting impacts in pediatric hospital medicine are in creating and growing research networks and advancing academic growth of the field,” Dr. Wellikson said.

Dr. Shah received the 2009 Award of Excellence for Research from SHM and has served on both the Awards and Research committees.

Welcome to HM19 in National Harbor, Maryland! This marks the fourth time the SHM’s annual conference has been held in National Harbor, beginning with Hospital Medicine 2013. With close proximity to the nation’s capital and a number of national museums, memorials, and other historic sites, National Harbor has much to offer in addition to the jam-packed education conference schedule we have planned for you. There is also a nearby Ferris wheel dubbed the “Capital Wheel” for thrill seekers.

Thanks to the many responses you provided to SHM’s newly opened call for conference content suggestions for HM19, we are proud to present you with a conference genuinely created “by hospitalists, for hospitalists.” We encourage you to take full advantage of the wide array of learning opportunities the Annual Conference Committee curated from your input for HM19. We encourage you to explore new ideas, attend sessions that catch your eye, and dive head first into interactive workshops at HM19.

The Annual Conference Committee members will be wearing large buttons to identify themselves, and we welcome any questions and feedback about the meeting. The committee members worked hard to create a pre-course day and main meeting with something for everyone, knowing there is great diversity under the hospitalist tent. In addition to cultivating relevant and timely sessions sourced from your input, the committee’s guiding lens for HM19 content has always been “what do practicing hospitalists need to know now.”

Dr. Smith is an associate professor of medicine at Emory University School of Medicine, Atlanta, and course director of HM19.

Welcome to HM19 in National Harbor, Maryland! This marks the fourth time the SHM’s annual conference has been held in National Harbor, beginning with Hospital Medicine 2013. With close proximity to the nation’s capital and a number of national museums, memorials, and other historic sites, National Harbor has much to offer in addition to the jam-packed education conference schedule we have planned for you. There is also a nearby Ferris wheel dubbed the “Capital Wheel” for thrill seekers.

Thanks to the many responses you provided to SHM’s newly opened call for conference content suggestions for HM19, we are proud to present you with a conference genuinely created “by hospitalists, for hospitalists.” We encourage you to take full advantage of the wide array of learning opportunities the Annual Conference Committee curated from your input for HM19. We encourage you to explore new ideas, attend sessions that catch your eye, and dive head first into interactive workshops at HM19.

The Annual Conference Committee members will be wearing large buttons to identify themselves, and we welcome any questions and feedback about the meeting. The committee members worked hard to create a pre-course day and main meeting with something for everyone, knowing there is great diversity under the hospitalist tent. In addition to cultivating relevant and timely sessions sourced from your input, the committee’s guiding lens for HM19 content has always been “what do practicing hospitalists need to know now.”

Dr. Smith is an associate professor of medicine at Emory University School of Medicine, Atlanta, and course director of HM19.

Welcome to HM19 in National Harbor, Maryland! This marks the fourth time the SHM’s annual conference has been held in National Harbor, beginning with Hospital Medicine 2013. With close proximity to the nation’s capital and a number of national museums, memorials, and other historic sites, National Harbor has much to offer in addition to the jam-packed education conference schedule we have planned for you. There is also a nearby Ferris wheel dubbed the “Capital Wheel” for thrill seekers.

Thanks to the many responses you provided to SHM’s newly opened call for conference content suggestions for HM19, we are proud to present you with a conference genuinely created “by hospitalists, for hospitalists.” We encourage you to take full advantage of the wide array of learning opportunities the Annual Conference Committee curated from your input for HM19. We encourage you to explore new ideas, attend sessions that catch your eye, and dive head first into interactive workshops at HM19.

The Annual Conference Committee members will be wearing large buttons to identify themselves, and we welcome any questions and feedback about the meeting. The committee members worked hard to create a pre-course day and main meeting with something for everyone, knowing there is great diversity under the hospitalist tent. In addition to cultivating relevant and timely sessions sourced from your input, the committee’s guiding lens for HM19 content has always been “what do practicing hospitalists need to know now.”

Dr. Smith is an associate professor of medicine at Emory University School of Medicine, Atlanta, and course director of HM19.

Welcome to Hospital Medicine 2019 (HM19), the largest conference of the year specifically focused on hospital medicine. The Society of Hospital Medicine is proud that HM19 brings together a broad range of stakeholders in hospital medicine, including physicians of many specialties, advanced practice providers, administrators, pharmacists, C-suite executives, recruiters, and educators. Your decision to join your colleagues at HM19 demonstrates your commitment not only to the specialty of hospital medicine but also to the patients you serve.

This year’s renowned speakers will present important sessions addressing the rapidly evolving health care landscape. To open the main meeting on March 25, Marc Harrison, MD, president and CEO of Intermountain Healthcare, will present his featured address on the future of health care. You will also hear from the president of SHM, Nasim Afsar, MD, MBA, SFHM, about the state of hospital medicine.

On March 26, we are proud to welcome Tait Shanafelt, MD, from Stanford, who will talk about strategies to prevent burnout and create resilient hospitalists.

On March 25 and 26, be sure to attend one of SHM’s Special Interest Forums, where you can choose to network and connect with other hospitalists interested in the same areas you are. There are more than 30 forums from which to choose. On March 26, SHM will open the International Hospital Medicine Lounge. We hope to welcome more than 100 hospitalists from around the world to HM19.

Please make sure to download the HM19 At Hand meeting app, a wonderful resource for every HM19 attendee that puts the conference at your fingertips. Create an individualized conference experience from your smartphone, tablet, or laptop.

Don’t miss the opportunity to meet one-on-one with members of SHM’s Board of Directors, who will be available in the SHM Pavilion during scheduled visit times. Please consult the Meet the Board schedule in the HM19 At Hand app for further information.

On behalf of the SHM Board of Directors and staff, welcome to HM19 and to the Gaylord at National Harbor. Through this meeting’s rich selection of educational opportunities, research offerings, and networking events, SHM continues to further its mission to promote excellence in the practice of hospital medicine. SHM remains at the forefront of health care today, empowering hospitalists and transforming patient care.

Dr. Wellikson is CEO of SHM.

Welcome to Hospital Medicine 2019 (HM19), the largest conference of the year specifically focused on hospital medicine. The Society of Hospital Medicine is proud that HM19 brings together a broad range of stakeholders in hospital medicine, including physicians of many specialties, advanced practice providers, administrators, pharmacists, C-suite executives, recruiters, and educators. Your decision to join your colleagues at HM19 demonstrates your commitment not only to the specialty of hospital medicine but also to the patients you serve.

This year’s renowned speakers will present important sessions addressing the rapidly evolving health care landscape. To open the main meeting on March 25, Marc Harrison, MD, president and CEO of Intermountain Healthcare, will present his featured address on the future of health care. You will also hear from the president of SHM, Nasim Afsar, MD, MBA, SFHM, about the state of hospital medicine.

On March 26, we are proud to welcome Tait Shanafelt, MD, from Stanford, who will talk about strategies to prevent burnout and create resilient hospitalists.

On March 25 and 26, be sure to attend one of SHM’s Special Interest Forums, where you can choose to network and connect with other hospitalists interested in the same areas you are. There are more than 30 forums from which to choose. On March 26, SHM will open the International Hospital Medicine Lounge. We hope to welcome more than 100 hospitalists from around the world to HM19.

Please make sure to download the HM19 At Hand meeting app, a wonderful resource for every HM19 attendee that puts the conference at your fingertips. Create an individualized conference experience from your smartphone, tablet, or laptop.

Don’t miss the opportunity to meet one-on-one with members of SHM’s Board of Directors, who will be available in the SHM Pavilion during scheduled visit times. Please consult the Meet the Board schedule in the HM19 At Hand app for further information.

On behalf of the SHM Board of Directors and staff, welcome to HM19 and to the Gaylord at National Harbor. Through this meeting’s rich selection of educational opportunities, research offerings, and networking events, SHM continues to further its mission to promote excellence in the practice of hospital medicine. SHM remains at the forefront of health care today, empowering hospitalists and transforming patient care.

Dr. Wellikson is CEO of SHM.

Welcome to Hospital Medicine 2019 (HM19), the largest conference of the year specifically focused on hospital medicine. The Society of Hospital Medicine is proud that HM19 brings together a broad range of stakeholders in hospital medicine, including physicians of many specialties, advanced practice providers, administrators, pharmacists, C-suite executives, recruiters, and educators. Your decision to join your colleagues at HM19 demonstrates your commitment not only to the specialty of hospital medicine but also to the patients you serve.

This year’s renowned speakers will present important sessions addressing the rapidly evolving health care landscape. To open the main meeting on March 25, Marc Harrison, MD, president and CEO of Intermountain Healthcare, will present his featured address on the future of health care. You will also hear from the president of SHM, Nasim Afsar, MD, MBA, SFHM, about the state of hospital medicine.

On March 26, we are proud to welcome Tait Shanafelt, MD, from Stanford, who will talk about strategies to prevent burnout and create resilient hospitalists.

On March 25 and 26, be sure to attend one of SHM’s Special Interest Forums, where you can choose to network and connect with other hospitalists interested in the same areas you are. There are more than 30 forums from which to choose. On March 26, SHM will open the International Hospital Medicine Lounge. We hope to welcome more than 100 hospitalists from around the world to HM19.

Please make sure to download the HM19 At Hand meeting app, a wonderful resource for every HM19 attendee that puts the conference at your fingertips. Create an individualized conference experience from your smartphone, tablet, or laptop.

Don’t miss the opportunity to meet one-on-one with members of SHM’s Board of Directors, who will be available in the SHM Pavilion during scheduled visit times. Please consult the Meet the Board schedule in the HM19 At Hand app for further information.

On behalf of the SHM Board of Directors and staff, welcome to HM19 and to the Gaylord at National Harbor. Through this meeting’s rich selection of educational opportunities, research offerings, and networking events, SHM continues to further its mission to promote excellence in the practice of hospital medicine. SHM remains at the forefront of health care today, empowering hospitalists and transforming patient care.

Dr. Wellikson is CEO of SHM.

The opening keynote at HM19 features one of the more prominent physician executives in the United States, speaking about a subject of great interest to hospitalists – how to increase the quality and value of care.

Dr. Marc Harrison is president and CEO of Intermountain Healthcare, based in Salt Lake City, the largest health care provider in the Intermountain West. Trained as a pediatric critical care physician, Dr. Harrison ranked second on the 2018 Modern Healthcare list of “Most Influential Physician Executives and Leaders.” His previous experience has included service as CEO of Cleveland Clinic Abu Dhabi, chief of international business development at Cleveland Clinic, and chief medical operations officer at Cleveland Clinic.

As the HM19 keynote speaker, Dr. Harrison said he will speak about how to move U.S. health care toward a model that adds more value for people, in the form of not only better quality and more accessible and affordable health care but overall healthier people, as well.

“I will talk about some of the market forces that are affecting health care and why we’re in the health care environment we’re in today,” Dr. Harrison said. “The cost of health care is unsustainable and unaffordable for people, and I want to talk about how Intermountain Healthcare is moving to a population-health and value-based model.”

Influencing Lives Earlier, More Effectively and More Affordably
Marc Harrison, MD
Monday, 8:40 a.m. – 9:30 a.m.
Potomac ABCD

The opening keynote at HM19 features one of the more prominent physician executives in the United States, speaking about a subject of great interest to hospitalists – how to increase the quality and value of care.

Dr. Marc Harrison is president and CEO of Intermountain Healthcare, based in Salt Lake City, the largest health care provider in the Intermountain West. Trained as a pediatric critical care physician, Dr. Harrison ranked second on the 2018 Modern Healthcare list of “Most Influential Physician Executives and Leaders.” His previous experience has included service as CEO of Cleveland Clinic Abu Dhabi, chief of international business development at Cleveland Clinic, and chief medical operations officer at Cleveland Clinic.

As the HM19 keynote speaker, Dr. Harrison said he will speak about how to move U.S. health care toward a model that adds more value for people, in the form of not only better quality and more accessible and affordable health care but overall healthier people, as well.

“I will talk about some of the market forces that are affecting health care and why we’re in the health care environment we’re in today,” Dr. Harrison said. “The cost of health care is unsustainable and unaffordable for people, and I want to talk about how Intermountain Healthcare is moving to a population-health and value-based model.”

Influencing Lives Earlier, More Effectively and More Affordably
Marc Harrison, MD
Monday, 8:40 a.m. – 9:30 a.m.
Potomac ABCD

The opening keynote at HM19 features one of the more prominent physician executives in the United States, speaking about a subject of great interest to hospitalists – how to increase the quality and value of care.

Dr. Marc Harrison is president and CEO of Intermountain Healthcare, based in Salt Lake City, the largest health care provider in the Intermountain West. Trained as a pediatric critical care physician, Dr. Harrison ranked second on the 2018 Modern Healthcare list of “Most Influential Physician Executives and Leaders.” His previous experience has included service as CEO of Cleveland Clinic Abu Dhabi, chief of international business development at Cleveland Clinic, and chief medical operations officer at Cleveland Clinic.

As the HM19 keynote speaker, Dr. Harrison said he will speak about how to move U.S. health care toward a model that adds more value for people, in the form of not only better quality and more accessible and affordable health care but overall healthier people, as well.

“I will talk about some of the market forces that are affecting health care and why we’re in the health care environment we’re in today,” Dr. Harrison said. “The cost of health care is unsustainable and unaffordable for people, and I want to talk about how Intermountain Healthcare is moving to a population-health and value-based model.”

Influencing Lives Earlier, More Effectively and More Affordably
Marc Harrison, MD
Monday, 8:40 a.m. – 9:30 a.m.
Potomac ABCD

The Food and Drug Administration has approved Trazimera (trastuzumab-qyyp), a biosimilar of Herceptin (trastuzumab), for the treatment of HER2-positive breast cancer and HER2-positive metastatic gastric or gastroesophageal junction adenocarcinoma.

FDA approval was based on a review of a comprehensive data package, which included results from the REFLECTIONS B327-02 trial. In this trial, Trazimera was found to have clinical equivalence with trastuzumab in the first-line treatment setting in patients with HER2-positive metastatic breast cancer.

The most common adverse events associated with Trazimera in patients with breast cancer include fever, nausea, vomiting, infusion reactions, diarrhea, infections, increased cough, headache, fatigue, shortness of breath, rash, low white and red blood cell counts, and muscle pain. For patients with metastatic adenocarcinoma, the most common adverse events include low white and red blood cell counts; diarrhea; fatigue; swelling of the mouth lining, mucous membranes, nose, or throat; weight loss; upper respiratory tract infections; fever; low platelet counts; and change in taste.

“Approximately 15-30% of breast cancers and 10-30% of gastric cancers are HER2-positive, which is associated with aggressive disease and poor prognoses for patients. With the availability of biosimilars like Trazimera in the U.S., oncologists will have additional treatment options to choose from, which may help provide patients with greater access to the medicines they need,” Mark Pegram, MD, director of the breast oncology program at the Stanford Women’s Cancer Center at Stanford (Calif.) University, said in the press release.

Find the full press release on the Pfizer website.

lfranki@mdedge.com

The Food and Drug Administration has approved Trazimera (trastuzumab-qyyp), a biosimilar of Herceptin (trastuzumab), for the treatment of HER2-positive breast cancer and HER2-positive metastatic gastric or gastroesophageal junction adenocarcinoma.

FDA approval was based on a review of a comprehensive data package, which included results from the REFLECTIONS B327-02 trial. In this trial, Trazimera was found to have clinical equivalence with trastuzumab in the first-line treatment setting in patients with HER2-positive metastatic breast cancer.

The most common adverse events associated with Trazimera in patients with breast cancer include fever, nausea, vomiting, infusion reactions, diarrhea, infections, increased cough, headache, fatigue, shortness of breath, rash, low white and red blood cell counts, and muscle pain. For patients with metastatic adenocarcinoma, the most common adverse events include low white and red blood cell counts; diarrhea; fatigue; swelling of the mouth lining, mucous membranes, nose, or throat; weight loss; upper respiratory tract infections; fever; low platelet counts; and change in taste.

“Approximately 15-30% of breast cancers and 10-30% of gastric cancers are HER2-positive, which is associated with aggressive disease and poor prognoses for patients. With the availability of biosimilars like Trazimera in the U.S., oncologists will have additional treatment options to choose from, which may help provide patients with greater access to the medicines they need,” Mark Pegram, MD, director of the breast oncology program at the Stanford Women’s Cancer Center at Stanford (Calif.) University, said in the press release.

Find the full press release on the Pfizer website.

lfranki@mdedge.com

The Food and Drug Administration has approved Trazimera (trastuzumab-qyyp), a biosimilar of Herceptin (trastuzumab), for the treatment of HER2-positive breast cancer and HER2-positive metastatic gastric or gastroesophageal junction adenocarcinoma.

FDA approval was based on a review of a comprehensive data package, which included results from the REFLECTIONS B327-02 trial. In this trial, Trazimera was found to have clinical equivalence with trastuzumab in the first-line treatment setting in patients with HER2-positive metastatic breast cancer.

The most common adverse events associated with Trazimera in patients with breast cancer include fever, nausea, vomiting, infusion reactions, diarrhea, infections, increased cough, headache, fatigue, shortness of breath, rash, low white and red blood cell counts, and muscle pain. For patients with metastatic adenocarcinoma, the most common adverse events include low white and red blood cell counts; diarrhea; fatigue; swelling of the mouth lining, mucous membranes, nose, or throat; weight loss; upper respiratory tract infections; fever; low platelet counts; and change in taste.

“Approximately 15-30% of breast cancers and 10-30% of gastric cancers are HER2-positive, which is associated with aggressive disease and poor prognoses for patients. With the availability of biosimilars like Trazimera in the U.S., oncologists will have additional treatment options to choose from, which may help provide patients with greater access to the medicines they need,” Mark Pegram, MD, director of the breast oncology program at the Stanford Women’s Cancer Center at Stanford (Calif.) University, said in the press release.

Find the full press release on the Pfizer website.

lfranki@mdedge.com

DALLAS – Systemic lupus erythematosus, depression, hyperthyroidism, and anxiety are among the comorbidities that most affect health-related quality of life in patients with multiple sclerosis (MS), according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. In addition, comorbidities account for about 18% of the variance in health-related quality of life, and a higher number of comorbidities correlates with lower health-related quality of life in a “clear dose–response” manner, the researchers said.

The “magnitude of effect emphasizes the need for recognition and appropriate management of comorbidities,” said presenting author Lara Marie Pangan Lo, a researcher at Menzies Institute for Medical Research at the University of Tasmania, Australia, and her research colleagues. “The individual effect sizes may assist with the prioritizing of comorbidities that require more or less aggressive treatment in order to minimize” their impact.

Prior studies have found that patients with MS have lower health-related quality of life, compared with the general population, and that comorbidities affect patients’ quality of life, but few studies have looked at the effects of individual comorbidities on quality of life, Ms. Lo and her colleagues said. To examine the total impact and relative importance of comorbidities on psychosocial, physical, and overall health-related quality of life in people with MS, the investigators analyzed survey data from 902 participants in the survey-based Australian MS Longitudinal Study. They used linear regression and dominance analysis to assess relationships between comorbidities and participants’ Assessment of Quality of Life-8 Dimensions scores, which can range from 0 (death) to 1 (perfect health).

The predicted health-related quality of life for patients without comorbidities was 0.74. After the researchers adjusted for age, sex, and education, they found that systemic lupus erythematosus (reported by 1.56% of patients), depression (41.25%), hyperthyroidism (3.01%), and anxiety (38.35%) were associated with the greatest estimated decreases in health-related quality of life (–0.16, –0.15, –0.12, and –0.11, respectively). Depression and anxiety had the largest effect on psychosocial health–related quality of life, whereas systemic lupus erythematosus, rheumatoid arthritis, and hyperthyroidism had the largest impact on physical health–related quality of life. Other comorbidities that significantly correlated with quality of life included osteoporosis, type 2 diabetes, migraine, and inflammatory bowel disease.

The study was supported by Multiple Sclerosis Research Australia. The authors had no relevant disclosures.

jremaly@mdedge.com

SOURCE: Lo LMP et al. ACTRIMS Forum 2019, Abstract 80.

DALLAS – Systemic lupus erythematosus, depression, hyperthyroidism, and anxiety are among the comorbidities that most affect health-related quality of life in patients with multiple sclerosis (MS), according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. In addition, comorbidities account for about 18% of the variance in health-related quality of life, and a higher number of comorbidities correlates with lower health-related quality of life in a “clear dose–response” manner, the researchers said.

The “magnitude of effect emphasizes the need for recognition and appropriate management of comorbidities,” said presenting author Lara Marie Pangan Lo, a researcher at Menzies Institute for Medical Research at the University of Tasmania, Australia, and her research colleagues. “The individual effect sizes may assist with the prioritizing of comorbidities that require more or less aggressive treatment in order to minimize” their impact.

Prior studies have found that patients with MS have lower health-related quality of life, compared with the general population, and that comorbidities affect patients’ quality of life, but few studies have looked at the effects of individual comorbidities on quality of life, Ms. Lo and her colleagues said. To examine the total impact and relative importance of comorbidities on psychosocial, physical, and overall health-related quality of life in people with MS, the investigators analyzed survey data from 902 participants in the survey-based Australian MS Longitudinal Study. They used linear regression and dominance analysis to assess relationships between comorbidities and participants’ Assessment of Quality of Life-8 Dimensions scores, which can range from 0 (death) to 1 (perfect health).

The predicted health-related quality of life for patients without comorbidities was 0.74. After the researchers adjusted for age, sex, and education, they found that systemic lupus erythematosus (reported by 1.56% of patients), depression (41.25%), hyperthyroidism (3.01%), and anxiety (38.35%) were associated with the greatest estimated decreases in health-related quality of life (–0.16, –0.15, –0.12, and –0.11, respectively). Depression and anxiety had the largest effect on psychosocial health–related quality of life, whereas systemic lupus erythematosus, rheumatoid arthritis, and hyperthyroidism had the largest impact on physical health–related quality of life. Other comorbidities that significantly correlated with quality of life included osteoporosis, type 2 diabetes, migraine, and inflammatory bowel disease.

The study was supported by Multiple Sclerosis Research Australia. The authors had no relevant disclosures.

jremaly@mdedge.com

SOURCE: Lo LMP et al. ACTRIMS Forum 2019, Abstract 80.

DALLAS – Systemic lupus erythematosus, depression, hyperthyroidism, and anxiety are among the comorbidities that most affect health-related quality of life in patients with multiple sclerosis (MS), according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. In addition, comorbidities account for about 18% of the variance in health-related quality of life, and a higher number of comorbidities correlates with lower health-related quality of life in a “clear dose–response” manner, the researchers said.

The “magnitude of effect emphasizes the need for recognition and appropriate management of comorbidities,” said presenting author Lara Marie Pangan Lo, a researcher at Menzies Institute for Medical Research at the University of Tasmania, Australia, and her research colleagues. “The individual effect sizes may assist with the prioritizing of comorbidities that require more or less aggressive treatment in order to minimize” their impact.

Prior studies have found that patients with MS have lower health-related quality of life, compared with the general population, and that comorbidities affect patients’ quality of life, but few studies have looked at the effects of individual comorbidities on quality of life, Ms. Lo and her colleagues said. To examine the total impact and relative importance of comorbidities on psychosocial, physical, and overall health-related quality of life in people with MS, the investigators analyzed survey data from 902 participants in the survey-based Australian MS Longitudinal Study. They used linear regression and dominance analysis to assess relationships between comorbidities and participants’ Assessment of Quality of Life-8 Dimensions scores, which can range from 0 (death) to 1 (perfect health).

The predicted health-related quality of life for patients without comorbidities was 0.74. After the researchers adjusted for age, sex, and education, they found that systemic lupus erythematosus (reported by 1.56% of patients), depression (41.25%), hyperthyroidism (3.01%), and anxiety (38.35%) were associated with the greatest estimated decreases in health-related quality of life (–0.16, –0.15, –0.12, and –0.11, respectively). Depression and anxiety had the largest effect on psychosocial health–related quality of life, whereas systemic lupus erythematosus, rheumatoid arthritis, and hyperthyroidism had the largest impact on physical health–related quality of life. Other comorbidities that significantly correlated with quality of life included osteoporosis, type 2 diabetes, migraine, and inflammatory bowel disease.

The study was supported by Multiple Sclerosis Research Australia. The authors had no relevant disclosures.

jremaly@mdedge.com

SOURCE: Lo LMP et al. ACTRIMS Forum 2019, Abstract 80.

Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.

Discussion

Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.

Both medications and specific types of psychotherapy are effective for treating depression in adolescents.

Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.¹ A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.

John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.² This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.

A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.

The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.³ Of course, it remains important to discuss this issue with families.

Flamingo_Photography/Getty Images

Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.⁴ Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.

CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.

Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.

Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. JAMA. 2007 Apr 18;297(15):1683-96.

2. Am J Psychiatry. 2017 May 1;174(5):430-7.

3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.

4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.

Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.

Discussion

Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.

Both medications and specific types of psychotherapy are effective for treating depression in adolescents.

Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.¹ A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.

John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.² This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.

A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.

The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.³ Of course, it remains important to discuss this issue with families.

Flamingo_Photography/Getty Images

Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.⁴ Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.

CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.

Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.

Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. JAMA. 2007 Apr 18;297(15):1683-96.

2. Am J Psychiatry. 2017 May 1;174(5):430-7.

3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.

4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.

Paul is 13-year-old male in seventh grade with a history of inattentive ADHD and a positive family history of depression and anxiety in his mother. He always has had a few friends, but recently they have not wanted to hang out with him; he feels like people are ignoring him. For the past 2 months, Paul’s mood has gotten very low. He feels sad and also bored because he is not enjoying anything anymore. He feels as though he is “a loser,” and as though nothing will ever get better. His grades have dropped. He has thoughts of wishing he were dead, although he has no specific plan and says he wouldn’t do it because he doesn’t want to hurt his parents. He is looking at his phone at night and gets to bed late, then doesn’t want to get up in the morning. He sleeps until noon on weekends. Appetite is increased. He doesn’t have energy to do things on the weekends.

Discussion

Paul clearly meets diagnostic criteria for depression. He feels sad and has lost pleasure in activities he used to enjoy. He has negative, hopeless thoughts, and vague thoughts of death although no specific plans. He has vegetative signs of depression with increased appetite and sleep; he likely has worse concentration than usual, given that his grades have dropped. Energy is low.

Both medications and specific types of psychotherapy are effective for treating depression in adolescents.

Meta-analyses have demonstrated the efficacy of SSRIs (fluoxetine, sertraline, citalopram, escitalopram) as well as venlafaxine, mirtazapine, and nefazodone with small to very small effect sizes.¹ A large placebo effect is seen in many of these studies, correlating with the number of study sites – a feature of many industry-sponsored studies.

John Walkup, MD, a leading researcher on both medication and psychotherapeutic interventions in children’s mood disorders, has pointed out that the quality of industry-sponsored studies (vs. National Institute of Mental Health–sponsored studies) is likely lower, with more pressure to get in large numbers of patients in a short period of time, less trained investigators leading to less clear-cut diagnoses, and other sources of bias.² This raises the question of whether we should weight NIMH-sponsored studies more heavily in meta-analyses.

A second factor to consider is the risk of harm, and a significant issue here is the question of whether suicidal ideation is increased among those patients taking SSRIs. Meta-analyses from the late 2000s, which balanced the number needed to treat vs. the number needed to harm, judged that for children under age 13 years, fluoxetine was the only antidepressant that was worth the cost-benefit ratio. However, in the past several years there has been a major improvement in the assessment of suicidal ideation in the form of the Columbia Suicide Severity Rating Scale, a standardized method of assessing the presence and significance of suicidal thoughts and behaviors. Studies that have used this assessment have found no significant increase in suicidal ideation with SSRIs vs. placebo.

The takeaway here is that the SSRIs can work, with fluoxetine, sertraline, and escitalopram leading the evidence, and that with refinements of the assessment they do not appear to increase the risk of suicidal ideation.³ Of course, it remains important to discuss this issue with families.

Flamingo_Photography/Getty Images

Psychotherapy is the other major treatment for depression. Cognitive behavioral therapy (CBT) and Interpersonal therapy (IPT) for adolescents show effectiveness in teens.⁴ Recent meta-analyses have gotten stronger through the use of stringent quality criteria and the inclusion of negative studies; these therapies continue to be considered well established. It is worthwhile to talk to therapists in your community to understand what type of treatment they offer. If you are hiring therapists to be embedded in your practice, look for people who have been trained in CBT or IPT. It is particularly helpful to know whether therapists have seen patients using CBT or IPT while getting supervision in these modalities.

CBT and IPT are different. CBT puts an emphasis on the thought-feeling-behavior triangle while IPT focuses more on relationships. Someone who has tried one and has not benefited nevertheless may benefit from the other.

Working with your patients to choose what type of psychotherapy modality for depression they would like is particularly effective.

Finally, be aware of how the environment may be affecting your patient. School issues related to peers, learning style or disabilities, and organization have a major effect on teens. In this case, Paul is looking at his phone nightly, which may be affecting both his sleep and self-esteem. Family issues continue to play a key role.

Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. JAMA. 2007 Apr 18;297(15):1683-96.

2. Am J Psychiatry. 2017 May 1;174(5):430-7.

3. J Child Adolesc Psychopharmacol. 2018. doi: 10.1089/cap.2017.0174.

4. J Clin Child Adolesc Psychol. 2017 Jan-Feb;46(1):11-43.

SAN FRANCISCO – A combination of two novel immune-stimulating agents has shown early evidence of efficacy against malignant melanoma, leiomyosarcoma, and triple-negative breast cancer in a phase 1b, dose-escalating study.

Neil Osterweil/MDedge News

Among 11 evaluable patients enrolled in a trial of NKTR-262, a small molecule agonist of toll-like receptors (TLR) 7/8, and bempegaldesleukin, an interleukin-2 pathway agonist, 2 had a partial response and 3 had stable disease, reported Adi Diab, MD, from the University of Texas MD Anderson Cancer Center, Houston, and his colleagues.

Patients tolerated the combination well, and there have been no serious adverse events or dose-limiting toxicities.

“Pharmacodynamic data demonstrate both activation of the systemic adaptive and the local innate immune system, and we have seen early evidence of clinical activity in patients who are refractory to checkpoint inhibitors with immunotherapy regimens,” Dr. Diab said at the American Society of Clinical Oncology (ASCO) – Society for Immunotherapy of Cancer (SITC): Clinical Immuno-Oncology Symposium.

NKTR-262 is injected into tumors and is designed to be retained in the tumor microenvironment where it helps to activate antigen-presenting cells, such as dendritic cells, and primes development of new, antigen-specific cytotoxic T cells. Bempegaldesleukin is a cytokine that works within the IL-2 pathway to increase CD8-positive T cells and natural killer (NK) cells in the tumor microenvironment.

The rationale for the combination is that NKTR-262 can activate innate immunity in cells surrounding the tumor microenvironment and activate the machinery of antigen-presenting cells, and bempegaldesleukin can prime and boost a systemic tumor immune response that can ultimately mediate antitumor activity in distant lesions, Dr. Adib said.

In preclinical models, the combination of these agents led to a robust antitumor effect that also involved distant lesions through mediation of the abscopal effect, in which treatment of a tumor activates an immune response against distant tumor cells as well, Dr. Diab said.

The REVEAL study is an ongoing, phase 1b/2 trial looking at the combination in melanoma, Merkel cell carcinoma, triple-negative breast cancer (TNBC), ovarian cancer, renal cell carcinoma, colorectal cancer, urothelial carcinoma, and sarcoma.

The primary goal of the study is to evaluate safety and determine the optimal phase 2 dose of the combination, evaluate biomarkers of response, and assess antitumor activity. As of Jan. 23, 2019, 13 patients were enrolled and evaluable for safety, and 11 were evaluable for the preliminary efficacy analysis.

The most common treatment-related adverse events (TRAEs) with the combination were transient grade 1 or 2 flu-like symptoms, rash, fatigue, pruritus, and nausea. One patients developed grade 3 maculopapular rash and leukocytosis.

Most of the TRAEs are attributable to bempegaldesleukin. There were no immune-mediated AEs and no TRAEs resulted in study discontinuation.

Tumor biopsies obtained 24 hours after injection of NKTR-262 confirmed the activation of TLR 7/8 and robust induction of type 1 interferon, interferon-alpha, and interferon-beta gene-related signatures necessary for optimal antigen presentation.

Dr. Diab noted that in a different trial of bempegaldesleukin monotherapy there was no significant increase in the type 1 interferon gene signature, but the agent did promote activation of the adaptive immune system.

The complementary nature of the two novel agents could also be demonstrated in evaluation of peripheral blood samples, which showed that, although there was no proliferation of T or NK cells following NKTR-262 injection, the addition of bempegaldesleukin resulted in the proliferation of both effector T cells and NK cells to enhance the systemic immune response.

The preliminary efficacy analysis showed that two of five patients with stage IV melanoma who experienced disease progression on prior immune checkpoint inhibitors had partial responses, including one who had a 100% reduction in target lesions and the other with a 50% reduction. In addition, two patients with heavily pretreated leiomyosarcoma had stable disease as the best response, as did the single patient with TNBC.

The maximum tolerated dose of the combination has not been identified, and the investigators are continuing to enroll patients.

The REVEAL study is supported by Nektar Therapeutics. Dr. Diab reported institutional research funding, consulting fees, and advisory board participation from Nektar, Bristol-Myers Squib, Idera Pharmaceuticals, Jounce Therapeutics, and Array BioPharma.

SOURCE: Diab A et al. ASCO-SITC, Abstract 26.

SAN FRANCISCO – A combination of two novel immune-stimulating agents has shown early evidence of efficacy against malignant melanoma, leiomyosarcoma, and triple-negative breast cancer in a phase 1b, dose-escalating study.

Neil Osterweil/MDedge News

Among 11 evaluable patients enrolled in a trial of NKTR-262, a small molecule agonist of toll-like receptors (TLR) 7/8, and bempegaldesleukin, an interleukin-2 pathway agonist, 2 had a partial response and 3 had stable disease, reported Adi Diab, MD, from the University of Texas MD Anderson Cancer Center, Houston, and his colleagues.

Patients tolerated the combination well, and there have been no serious adverse events or dose-limiting toxicities.

“Pharmacodynamic data demonstrate both activation of the systemic adaptive and the local innate immune system, and we have seen early evidence of clinical activity in patients who are refractory to checkpoint inhibitors with immunotherapy regimens,” Dr. Diab said at the American Society of Clinical Oncology (ASCO) – Society for Immunotherapy of Cancer (SITC): Clinical Immuno-Oncology Symposium.

NKTR-262 is injected into tumors and is designed to be retained in the tumor microenvironment where it helps to activate antigen-presenting cells, such as dendritic cells, and primes development of new, antigen-specific cytotoxic T cells. Bempegaldesleukin is a cytokine that works within the IL-2 pathway to increase CD8-positive T cells and natural killer (NK) cells in the tumor microenvironment.

The rationale for the combination is that NKTR-262 can activate innate immunity in cells surrounding the tumor microenvironment and activate the machinery of antigen-presenting cells, and bempegaldesleukin can prime and boost a systemic tumor immune response that can ultimately mediate antitumor activity in distant lesions, Dr. Adib said.

In preclinical models, the combination of these agents led to a robust antitumor effect that also involved distant lesions through mediation of the abscopal effect, in which treatment of a tumor activates an immune response against distant tumor cells as well, Dr. Diab said.

The REVEAL study is an ongoing, phase 1b/2 trial looking at the combination in melanoma, Merkel cell carcinoma, triple-negative breast cancer (TNBC), ovarian cancer, renal cell carcinoma, colorectal cancer, urothelial carcinoma, and sarcoma.

The primary goal of the study is to evaluate safety and determine the optimal phase 2 dose of the combination, evaluate biomarkers of response, and assess antitumor activity. As of Jan. 23, 2019, 13 patients were enrolled and evaluable for safety, and 11 were evaluable for the preliminary efficacy analysis.

The most common treatment-related adverse events (TRAEs) with the combination were transient grade 1 or 2 flu-like symptoms, rash, fatigue, pruritus, and nausea. One patients developed grade 3 maculopapular rash and leukocytosis.

Most of the TRAEs are attributable to bempegaldesleukin. There were no immune-mediated AEs and no TRAEs resulted in study discontinuation.

Tumor biopsies obtained 24 hours after injection of NKTR-262 confirmed the activation of TLR 7/8 and robust induction of type 1 interferon, interferon-alpha, and interferon-beta gene-related signatures necessary for optimal antigen presentation.

Dr. Diab noted that in a different trial of bempegaldesleukin monotherapy there was no significant increase in the type 1 interferon gene signature, but the agent did promote activation of the adaptive immune system.

The complementary nature of the two novel agents could also be demonstrated in evaluation of peripheral blood samples, which showed that, although there was no proliferation of T or NK cells following NKTR-262 injection, the addition of bempegaldesleukin resulted in the proliferation of both effector T cells and NK cells to enhance the systemic immune response.

The preliminary efficacy analysis showed that two of five patients with stage IV melanoma who experienced disease progression on prior immune checkpoint inhibitors had partial responses, including one who had a 100% reduction in target lesions and the other with a 50% reduction. In addition, two patients with heavily pretreated leiomyosarcoma had stable disease as the best response, as did the single patient with TNBC.

The maximum tolerated dose of the combination has not been identified, and the investigators are continuing to enroll patients.

The REVEAL study is supported by Nektar Therapeutics. Dr. Diab reported institutional research funding, consulting fees, and advisory board participation from Nektar, Bristol-Myers Squib, Idera Pharmaceuticals, Jounce Therapeutics, and Array BioPharma.

SOURCE: Diab A et al. ASCO-SITC, Abstract 26.

SAN FRANCISCO – A combination of two novel immune-stimulating agents has shown early evidence of efficacy against malignant melanoma, leiomyosarcoma, and triple-negative breast cancer in a phase 1b, dose-escalating study.

Neil Osterweil/MDedge News

Among 11 evaluable patients enrolled in a trial of NKTR-262, a small molecule agonist of toll-like receptors (TLR) 7/8, and bempegaldesleukin, an interleukin-2 pathway agonist, 2 had a partial response and 3 had stable disease, reported Adi Diab, MD, from the University of Texas MD Anderson Cancer Center, Houston, and his colleagues.

Patients tolerated the combination well, and there have been no serious adverse events or dose-limiting toxicities.

“Pharmacodynamic data demonstrate both activation of the systemic adaptive and the local innate immune system, and we have seen early evidence of clinical activity in patients who are refractory to checkpoint inhibitors with immunotherapy regimens,” Dr. Diab said at the American Society of Clinical Oncology (ASCO) – Society for Immunotherapy of Cancer (SITC): Clinical Immuno-Oncology Symposium.

NKTR-262 is injected into tumors and is designed to be retained in the tumor microenvironment where it helps to activate antigen-presenting cells, such as dendritic cells, and primes development of new, antigen-specific cytotoxic T cells. Bempegaldesleukin is a cytokine that works within the IL-2 pathway to increase CD8-positive T cells and natural killer (NK) cells in the tumor microenvironment.

The rationale for the combination is that NKTR-262 can activate innate immunity in cells surrounding the tumor microenvironment and activate the machinery of antigen-presenting cells, and bempegaldesleukin can prime and boost a systemic tumor immune response that can ultimately mediate antitumor activity in distant lesions, Dr. Adib said.

In preclinical models, the combination of these agents led to a robust antitumor effect that also involved distant lesions through mediation of the abscopal effect, in which treatment of a tumor activates an immune response against distant tumor cells as well, Dr. Diab said.

The REVEAL study is an ongoing, phase 1b/2 trial looking at the combination in melanoma, Merkel cell carcinoma, triple-negative breast cancer (TNBC), ovarian cancer, renal cell carcinoma, colorectal cancer, urothelial carcinoma, and sarcoma.

The primary goal of the study is to evaluate safety and determine the optimal phase 2 dose of the combination, evaluate biomarkers of response, and assess antitumor activity. As of Jan. 23, 2019, 13 patients were enrolled and evaluable for safety, and 11 were evaluable for the preliminary efficacy analysis.

The most common treatment-related adverse events (TRAEs) with the combination were transient grade 1 or 2 flu-like symptoms, rash, fatigue, pruritus, and nausea. One patients developed grade 3 maculopapular rash and leukocytosis.

Most of the TRAEs are attributable to bempegaldesleukin. There were no immune-mediated AEs and no TRAEs resulted in study discontinuation.

Tumor biopsies obtained 24 hours after injection of NKTR-262 confirmed the activation of TLR 7/8 and robust induction of type 1 interferon, interferon-alpha, and interferon-beta gene-related signatures necessary for optimal antigen presentation.

Dr. Diab noted that in a different trial of bempegaldesleukin monotherapy there was no significant increase in the type 1 interferon gene signature, but the agent did promote activation of the adaptive immune system.

The complementary nature of the two novel agents could also be demonstrated in evaluation of peripheral blood samples, which showed that, although there was no proliferation of T or NK cells following NKTR-262 injection, the addition of bempegaldesleukin resulted in the proliferation of both effector T cells and NK cells to enhance the systemic immune response.

The preliminary efficacy analysis showed that two of five patients with stage IV melanoma who experienced disease progression on prior immune checkpoint inhibitors had partial responses, including one who had a 100% reduction in target lesions and the other with a 50% reduction. In addition, two patients with heavily pretreated leiomyosarcoma had stable disease as the best response, as did the single patient with TNBC.

The maximum tolerated dose of the combination has not been identified, and the investigators are continuing to enroll patients.

The REVEAL study is supported by Nektar Therapeutics. Dr. Diab reported institutional research funding, consulting fees, and advisory board participation from Nektar, Bristol-Myers Squib, Idera Pharmaceuticals, Jounce Therapeutics, and Array BioPharma.

SOURCE: Diab A et al. ASCO-SITC, Abstract 26.

Even the best physicians make mistakes.

Each of us can recall a patient for whom our initial diagnosis was incorrect, or conversely, where we uncovered the correct diagnosis. My memorable mistake was missing an obvious case of hypothyroidism, and my happier encounter was correcting an incorrect diagnosis of asthma when the patient actually had primary pulmonary fibrosis. These patients came to mind as I read this month’s cover story, “COPD and asthma: Diagnostic accuracy requires spirometry.”

In a previous editorial, “When our biases derail the diagnosis,”¹ I discussed types of cognitive bias that can lead us to the wrong conclusion. Today, I want to address diagnostic errors in medicine as a patient safety issue.

Listening closely to the patient's and family's concerns can lead in a direction other than my initial impression.

The patient safety movement gained traction in 1999 with the publication of the Institute of Medicine (IOM, now National Academy of Medicine) report, To Err is Human: Building a Safer Health System. That report focused on health care system issues and had little to offer regarding improving diagnoses. It was not until 2015, with the publication of the IOM report Improving Diagnosis in Health Care, that serious national attention was directed to accurate diagnosis. It is worth reading the summary of this report, which includes 8 goals and is available at nas.edu/improvingdiagnosis.

The recommendations most pertinent to family physicians are to: 1) facilitate more effective teamwork among health care professionals, patients, and families, 2) teach health care professionals about the diagnostic process, 3) ensure that technology supports proper diagnosis, 4) establish a work culture that supports diagnostic processes, and 5) identify diagnostic errors and learn from them.

Teamwork. The first recommendation is intriguing because the focus on teamwork includes patients and their families. I have found that listening closely to the patient’s and family’s concerns can lead me in a direction other than my initial impression—especially when they are insistent about a particular diagnosis.

Technology. Despite all of their “warts,” electronic health records are gradually incorporating clinical decision support tools that really do help steer us in the right direction. I have found that electronic point-of-care references can be very helpful in establishing an accurate diagnosis in the exam room—and can help convince patients that my diagnosis is correct when they read it for themselves!

Continue to: Finally, discussing our mistakes...

Finally, discussing our mistakes openly with our colleagues helps us—and them—to avoid that mistake in the future. Let’s be sure to keep that dialogue open. And let’s continue to refine our diagnostic skills so that we can continue to keep our patients safe.

Even the best physicians make mistakes.

Each of us can recall a patient for whom our initial diagnosis was incorrect, or conversely, where we uncovered the correct diagnosis. My memorable mistake was missing an obvious case of hypothyroidism, and my happier encounter was correcting an incorrect diagnosis of asthma when the patient actually had primary pulmonary fibrosis. These patients came to mind as I read this month’s cover story, “COPD and asthma: Diagnostic accuracy requires spirometry.”

In a previous editorial, “When our biases derail the diagnosis,”¹ I discussed types of cognitive bias that can lead us to the wrong conclusion. Today, I want to address diagnostic errors in medicine as a patient safety issue.

Listening closely to the patient's and family's concerns can lead in a direction other than my initial impression.

The patient safety movement gained traction in 1999 with the publication of the Institute of Medicine (IOM, now National Academy of Medicine) report, To Err is Human: Building a Safer Health System. That report focused on health care system issues and had little to offer regarding improving diagnoses. It was not until 2015, with the publication of the IOM report Improving Diagnosis in Health Care, that serious national attention was directed to accurate diagnosis. It is worth reading the summary of this report, which includes 8 goals and is available at nas.edu/improvingdiagnosis.

The recommendations most pertinent to family physicians are to: 1) facilitate more effective teamwork among health care professionals, patients, and families, 2) teach health care professionals about the diagnostic process, 3) ensure that technology supports proper diagnosis, 4) establish a work culture that supports diagnostic processes, and 5) identify diagnostic errors and learn from them.

Teamwork. The first recommendation is intriguing because the focus on teamwork includes patients and their families. I have found that listening closely to the patient’s and family’s concerns can lead me in a direction other than my initial impression—especially when they are insistent about a particular diagnosis.

Technology. Despite all of their “warts,” electronic health records are gradually incorporating clinical decision support tools that really do help steer us in the right direction. I have found that electronic point-of-care references can be very helpful in establishing an accurate diagnosis in the exam room—and can help convince patients that my diagnosis is correct when they read it for themselves!

Continue to: Finally, discussing our mistakes...

Finally, discussing our mistakes openly with our colleagues helps us—and them—to avoid that mistake in the future. Let’s be sure to keep that dialogue open. And let’s continue to refine our diagnostic skills so that we can continue to keep our patients safe.

Even the best physicians make mistakes.

Each of us can recall a patient for whom our initial diagnosis was incorrect, or conversely, where we uncovered the correct diagnosis. My memorable mistake was missing an obvious case of hypothyroidism, and my happier encounter was correcting an incorrect diagnosis of asthma when the patient actually had primary pulmonary fibrosis. These patients came to mind as I read this month’s cover story, “COPD and asthma: Diagnostic accuracy requires spirometry.”

In a previous editorial, “When our biases derail the diagnosis,”¹ I discussed types of cognitive bias that can lead us to the wrong conclusion. Today, I want to address diagnostic errors in medicine as a patient safety issue.

Listening closely to the patient's and family's concerns can lead in a direction other than my initial impression.

The patient safety movement gained traction in 1999 with the publication of the Institute of Medicine (IOM, now National Academy of Medicine) report, To Err is Human: Building a Safer Health System. That report focused on health care system issues and had little to offer regarding improving diagnoses. It was not until 2015, with the publication of the IOM report Improving Diagnosis in Health Care, that serious national attention was directed to accurate diagnosis. It is worth reading the summary of this report, which includes 8 goals and is available at nas.edu/improvingdiagnosis.

The recommendations most pertinent to family physicians are to: 1) facilitate more effective teamwork among health care professionals, patients, and families, 2) teach health care professionals about the diagnostic process, 3) ensure that technology supports proper diagnosis, 4) establish a work culture that supports diagnostic processes, and 5) identify diagnostic errors and learn from them.

Teamwork. The first recommendation is intriguing because the focus on teamwork includes patients and their families. I have found that listening closely to the patient’s and family’s concerns can lead me in a direction other than my initial impression—especially when they are insistent about a particular diagnosis.

Technology. Despite all of their “warts,” electronic health records are gradually incorporating clinical decision support tools that really do help steer us in the right direction. I have found that electronic point-of-care references can be very helpful in establishing an accurate diagnosis in the exam room—and can help convince patients that my diagnosis is correct when they read it for themselves!

Continue to: Finally, discussing our mistakes...

Finally, discussing our mistakes openly with our colleagues helps us—and them—to avoid that mistake in the future. Let’s be sure to keep that dialogue open. And let’s continue to refine our diagnostic skills so that we can continue to keep our patients safe.