Opinion Viewpoint
plans are adopting formulary exclusions as an approach to reducing costs; because of the chance that critical therapies may be excluded, this is a trend that requires close oversight.6 Changes to health care payment require oversight as well. If payments are bundled or capitated solely by chronic disease (eg, diabetes mellitus) and treatment (eg, hip replacement), then the benefit for diagnostic accuracy in health care will be minimal. By contrast, if payments are bundled by symptoms or presenting problems, then incentives will encourage accurate, efficient diagnosis.7 For example, a bundled rate for the management of stroke would leave untouched current incentives for the excessive use ARTICLE INFORMATION
REFERENCES
Published Online: April 20, 2015. doi:10.1001/jamaneurol.2015.0083.
1. Collins SR, Rasmussen PW, Doty MM, Beutel S. The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. http://www.commonwealthfund.org /~/media/files/publications/issue-brief/2015/jan /1800_collins_biennial_survey_brief.pdf?la=en. Commonwealth Fund issue brief. Published January 2015. Accessed January 15, 2015.
Conflict of Interest Disclosures: Dr Sharfstein served as secretary of the Maryland Department of Health and Mental Hygiene and as chair of the board of the Maryland Health Benefit Exchange from 2011 to 2014. Dr Newman-Toker is a board member of the Society to Improve Diagnosis in Medicine, with interests in misdiagnoses; has received support from the National Institutes of Health (grant U01 DC013778-01A1) and has a grant pending as principal investigator that is related to work regarding neurologic diagnoses; and had received honoraria from Janssen and SunPharma, as well as multiple academic institutions in the United States and abroad. No other disclosures are reported.
VIEWPOINT
Joseph R. Berger, MD Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Corresponding Author: Joseph R. Berger, MD, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3 W Gates, Philadelphia, PA 19104 (joseph.berger @uphs.upenn.edu). 624
of imaging for patients with possible stroke symptoms. However, a bundled rate for a patient with a chief symptom of dizziness or vertigo would incentivize making the correct inner ear diagnoses without brain imaging. This would likely drive the use of proven clinical decision rules and enhance the value of bedside neurological diagnosis. As the nation’s health care system evolves, there should be greater demand for the full range of clinical services and expertise of neurologists. The Affordable Care Act offers neurologists unique opportunities to improve care delivery, clinical quality, and health outcomes.
2. Jones SM, Amtmann D. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol. 2014;59(3):354-359. 3. Wilper A, Woolhandler S, Himmelstein D, Nardin R. Impact of insurance status on migraine care in the United States: a population-based study. Neurology. 2010;74(15):1178-1183.
4. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011. 5. Burke JF, Skolarus LE, Callaghan BC, Kerber KA. Choosing Wisely: highest-cost tests in outpatient neurology. Ann Neurol. 2013;73(5):679-683. 6. Smolinski I. Specialty formulary exclusions gaining traction. Morning Consult website. http://morningconsult.com/2015/01/specialty -formulary-exclusions-gaining-traction/. Published January 6, 2015. Accessed January 18, 2015. 7. Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? a health economics perspective. BMJ Qual Saf. 2013;22(suppl 2):ii11-ii20.
Political Correctness of Medical Documentation Having relocated to a new academic institution, I was certain that I would have to learn some new things but revising how I wrote the history and physical examinations of my patients was hardly anticipated. The template I used was largely unchanged in more than 4 decades and it had served me well. While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated. The history and physical examination started with the following description: “This 36-year-old, righthanded, African American man presents to office…” Commencing the report with this descriptive detail provides a mental image of the patient to the reader. The argument my colleague proffered was that race, ethnicity, and country of origin are essentially of no value. Any person could have any illness. He made note of a fact that
I had appreciated in the short time that I have been at the new institution, namely, that few physicians or trainees included such elements in their histories. My immediate thought was that he was right. That evening, I recited verbatim the opening lines of the history to my wife who has a keen ear for anything that smacks of political incorrectness, whether it was regarding race, country of origin, sexual orientation, or other. Curiously, she appeared tone deaf to the issue of race, rather she corrected the grammar (she is an English-as-a-secondlanguage teacher). Her inability to consider the opening phrase, which includes a description of race, inappropriate was heartening. The more I reflected on the issue the more I considered these descriptions not only appropriate but, at times, critically important. There are 3 reasons to consider this to be the case: (1) certain illnesses are far more common in some races, ethnicities, or regions of the world; (2) depending on their genetics, some people may respond to medications differently; and (3) rich descriptions of the patient incorporating elements that may not be essential for diagnosis or management help the physician to recall the patient. With respect to the association of race/ethnicity and country of origin with illness, I will provide some ex-
JAMA Neurology June 2015 Volume 72, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a Florida International University Medical Library User on 06/16/2015
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Opinion
amples. In my multiple sclerosis clinic, neurosarcoidosis is high on the list of differential diagnoses in the African American patient presenting with suspected multiple sclerosis. Similarly, human T-cell lymphotropic virus type 1 myelopathy is a significant concern in certain populations from the Caribbean and southern United States1,2 who present with a progressive, otherwise unexplained, spinal cord disorder. Likewise, sickle cell anemia must be considered in the African American child with stroke or transient ischemic attack, and one might consider intracranial, rather than extracranial, vascular disease a more likely cause of cerebrovascular disease in this adult population.3 Progressive weakness in a child of Japanese ancestry might suggest Fukuyama muscular dystrophy, a condition seen virtually exclusively in Japanese individuals and that is among the most common causes of childhood muscular dystrophy in that population.4 There have been books5,6 devoted to the laundry list of genetic disorders affecting the Ashkenazic Jewish community, many of which, if not most, predominantly affect the nervous system. It is not that other persons are immune to these disorders, it is simply a matter of disease frequencies and how best to rank order our differential diagnostic list. The management of disease may also be tempered by race and ethnicity. There are recognized therapeutic implications for genetiARTICLE INFORMATION Published Online: April 13, 2015. doi:10.1001/jamaneurol.2014.4535. Conflict of Interest Disclosures: Dr Berger has received grants from PML Consortium and Biogen Idec and personal fees from Millenium Pharmaceuticals, Genentech, Amgen, Genzyme, Eisai, and Novartis outside of this work. REFERENCES 1. Khabbaz RF, Onorato IM, Cannon RO, et al. Seroprevalence of HTLV-1 and HTLV-2 among intravenous drug users and persons in clinics for sexually transmitted diseases. N Engl J Med. 1992; 326(6):375-380.
cally determined variability in acetylation and oxidation7 and other mechanisms of drug metabolism. Examples include the poorer response to angiotensin-converting enzyme inhibitors in African American individuals with hypertension8 or to propranolol in Jamaicans with hypertension.9 Another example is drug-resistant epilepsy that has been described in Han Chinese individuals due to an overexpression of efflux drug transporters.10 Lastly, the richness of the description of the patient humanizes the patient and, by association, improves the physician’s ability to recall other details of the patient’s medical history and examination. I have also described elements of the history that do not necessarily help in diagnosing or treating the patient but assist in the social context. For instance, a retired teacher from Florida with sciatica informed me that she would not be returning home anytime soon because she was in Philadelphia to care for a dying son. I made note of that fact. It helps me understand how to approach the patient. Alternatively, I may comment on a tasteful or unusual tattoo or piercing, the quality of dentition, and the nature of how a patient dresses, among other characteristics. I see nothing wrong in these descriptive elements of the history and physical examination; however, I am open to suggestion and would like to hear how others perceive this issue.
type I and adult T-cell leukemia/lymphoma outside Japan and the Caribbean Basin. Yale J Biol Med. 1988;61(3):215-222.
7. Clark DW. Genetically determined variability in acetylation and oxidation: therapeutic implications. Drugs. 1985;29(4):342-375.
3. Lynch GF, Gorelick PB. Stroke in African Americans. Neurol Clin. 2000;18(2):273-290.
8. Duru K, Farrow S, Wang JM, Lockette W, Kurtz T. Frequency of a deletion polymorphism in the gene for angiotensin converting enzyme is increased in African-Americans with hypertension. Am J Hypertens. 1994;7(8):759-762.
4. Fukuyama Y, Osawa M, Suzuki H. Congenital progressive muscular dystrophy of the Fukuyama type: clinical, genetic and pathological considerations. Brain Dev. 1981;3(1):1-29. 5. Abel EL. Jewish Genetic Disorders: A Layman's Guide. Jefferson, North Carolina: McFarland and Co; 2001. 6. Goodman RM. Genetic Disorders Among the Jewish People. Baltimore, Maryland: Johns Hopkins University Press; 1979.
9. Humphreys GS, Delvin DG. Ineffectiveness of propranolol in hypertensive Jamaicans. Br Med J. 1968;2(5605):601-603. 10. Kwan P, Baum L, Wong V, et al. Association between ABCB1 C3435T polymorphism and drug-resistant epilepsy in Han Chinese. Epilepsy Behav. 2007;11(1):112-117.
2. Levine PH, Jaffe ES, Manns A, Murphy EL, Clark J, Blattner WA. Human T-cell lymphotropic virus
jamaneurology.com
(Reprinted) JAMA Neurology June 2015 Volume 72, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a Florida International University Medical Library User on 06/16/2015
625
plans are adopting formulary exclusions as an approach to reducing costs; because of the chance that critical therapies may be excluded, this is a trend that requires close oversight.6 Changes to health care payment require oversight as well. If payments are bundled or capitated solely by chronic disease (eg, diabetes mellitus) and treatment (eg, hip replacement), then the benefit for diagnostic accuracy in health care will be minimal. By contrast, if payments are bundled by symptoms or presenting problems, then incentives will encourage accurate, efficient diagnosis.7 For example, a bundled rate for the management of stroke would leave untouched current incentives for the excessive use ARTICLE INFORMATION
REFERENCES
Published Online: April 20, 2015. doi:10.1001/jamaneurol.2015.0083.
1. Collins SR, Rasmussen PW, Doty MM, Beutel S. The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. http://www.commonwealthfund.org /~/media/files/publications/issue-brief/2015/jan /1800_collins_biennial_survey_brief.pdf?la=en. Commonwealth Fund issue brief. Published January 2015. Accessed January 15, 2015.
Conflict of Interest Disclosures: Dr Sharfstein served as secretary of the Maryland Department of Health and Mental Hygiene and as chair of the board of the Maryland Health Benefit Exchange from 2011 to 2014. Dr Newman-Toker is a board member of the Society to Improve Diagnosis in Medicine, with interests in misdiagnoses; has received support from the National Institutes of Health (grant U01 DC013778-01A1) and has a grant pending as principal investigator that is related to work regarding neurologic diagnoses; and had received honoraria from Janssen and SunPharma, as well as multiple academic institutions in the United States and abroad. No other disclosures are reported.
VIEWPOINT
Joseph R. Berger, MD Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Corresponding Author: Joseph R. Berger, MD, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3 W Gates, Philadelphia, PA 19104 (joseph.berger @uphs.upenn.edu). 624
of imaging for patients with possible stroke symptoms. However, a bundled rate for a patient with a chief symptom of dizziness or vertigo would incentivize making the correct inner ear diagnoses without brain imaging. This would likely drive the use of proven clinical decision rules and enhance the value of bedside neurological diagnosis. As the nation’s health care system evolves, there should be greater demand for the full range of clinical services and expertise of neurologists. The Affordable Care Act offers neurologists unique opportunities to improve care delivery, clinical quality, and health outcomes.
2. Jones SM, Amtmann D. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol. 2014;59(3):354-359. 3. Wilper A, Woolhandler S, Himmelstein D, Nardin R. Impact of insurance status on migraine care in the United States: a population-based study. Neurology. 2010;74(15):1178-1183.
4. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011. 5. Burke JF, Skolarus LE, Callaghan BC, Kerber KA. Choosing Wisely: highest-cost tests in outpatient neurology. Ann Neurol. 2013;73(5):679-683. 6. Smolinski I. Specialty formulary exclusions gaining traction. Morning Consult website. http://morningconsult.com/2015/01/specialty -formulary-exclusions-gaining-traction/. Published January 6, 2015. Accessed January 18, 2015. 7. Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? a health economics perspective. BMJ Qual Saf. 2013;22(suppl 2):ii11-ii20.
Political Correctness of Medical Documentation Having relocated to a new academic institution, I was certain that I would have to learn some new things but revising how I wrote the history and physical examinations of my patients was hardly anticipated. The template I used was largely unchanged in more than 4 decades and it had served me well. While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated. The history and physical examination started with the following description: “This 36-year-old, righthanded, African American man presents to office…” Commencing the report with this descriptive detail provides a mental image of the patient to the reader. The argument my colleague proffered was that race, ethnicity, and country of origin are essentially of no value. Any person could have any illness. He made note of a fact that
I had appreciated in the short time that I have been at the new institution, namely, that few physicians or trainees included such elements in their histories. My immediate thought was that he was right. That evening, I recited verbatim the opening lines of the history to my wife who has a keen ear for anything that smacks of political incorrectness, whether it was regarding race, country of origin, sexual orientation, or other. Curiously, she appeared tone deaf to the issue of race, rather she corrected the grammar (she is an English-as-a-secondlanguage teacher). Her inability to consider the opening phrase, which includes a description of race, inappropriate was heartening. The more I reflected on the issue the more I considered these descriptions not only appropriate but, at times, critically important. There are 3 reasons to consider this to be the case: (1) certain illnesses are far more common in some races, ethnicities, or regions of the world; (2) depending on their genetics, some people may respond to medications differently; and (3) rich descriptions of the patient incorporating elements that may not be essential for diagnosis or management help the physician to recall the patient. With respect to the association of race/ethnicity and country of origin with illness, I will provide some ex-
JAMA Neurology June 2015 Volume 72, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a Florida International University Medical Library User on 06/16/2015
jamaneurology.com
Opinion
amples. In my multiple sclerosis clinic, neurosarcoidosis is high on the list of differential diagnoses in the African American patient presenting with suspected multiple sclerosis. Similarly, human T-cell lymphotropic virus type 1 myelopathy is a significant concern in certain populations from the Caribbean and southern United States1,2 who present with a progressive, otherwise unexplained, spinal cord disorder. Likewise, sickle cell anemia must be considered in the African American child with stroke or transient ischemic attack, and one might consider intracranial, rather than extracranial, vascular disease a more likely cause of cerebrovascular disease in this adult population.3 Progressive weakness in a child of Japanese ancestry might suggest Fukuyama muscular dystrophy, a condition seen virtually exclusively in Japanese individuals and that is among the most common causes of childhood muscular dystrophy in that population.4 There have been books5,6 devoted to the laundry list of genetic disorders affecting the Ashkenazic Jewish community, many of which, if not most, predominantly affect the nervous system. It is not that other persons are immune to these disorders, it is simply a matter of disease frequencies and how best to rank order our differential diagnostic list. The management of disease may also be tempered by race and ethnicity. There are recognized therapeutic implications for genetiARTICLE INFORMATION Published Online: April 13, 2015. doi:10.1001/jamaneurol.2014.4535. Conflict of Interest Disclosures: Dr Berger has received grants from PML Consortium and Biogen Idec and personal fees from Millenium Pharmaceuticals, Genentech, Amgen, Genzyme, Eisai, and Novartis outside of this work. REFERENCES 1. Khabbaz RF, Onorato IM, Cannon RO, et al. Seroprevalence of HTLV-1 and HTLV-2 among intravenous drug users and persons in clinics for sexually transmitted diseases. N Engl J Med. 1992; 326(6):375-380.
cally determined variability in acetylation and oxidation7 and other mechanisms of drug metabolism. Examples include the poorer response to angiotensin-converting enzyme inhibitors in African American individuals with hypertension8 or to propranolol in Jamaicans with hypertension.9 Another example is drug-resistant epilepsy that has been described in Han Chinese individuals due to an overexpression of efflux drug transporters.10 Lastly, the richness of the description of the patient humanizes the patient and, by association, improves the physician’s ability to recall other details of the patient’s medical history and examination. I have also described elements of the history that do not necessarily help in diagnosing or treating the patient but assist in the social context. For instance, a retired teacher from Florida with sciatica informed me that she would not be returning home anytime soon because she was in Philadelphia to care for a dying son. I made note of that fact. It helps me understand how to approach the patient. Alternatively, I may comment on a tasteful or unusual tattoo or piercing, the quality of dentition, and the nature of how a patient dresses, among other characteristics. I see nothing wrong in these descriptive elements of the history and physical examination; however, I am open to suggestion and would like to hear how others perceive this issue.
type I and adult T-cell leukemia/lymphoma outside Japan and the Caribbean Basin. Yale J Biol Med. 1988;61(3):215-222.
7. Clark DW. Genetically determined variability in acetylation and oxidation: therapeutic implications. Drugs. 1985;29(4):342-375.
3. Lynch GF, Gorelick PB. Stroke in African Americans. Neurol Clin. 2000;18(2):273-290.
8. Duru K, Farrow S, Wang JM, Lockette W, Kurtz T. Frequency of a deletion polymorphism in the gene for angiotensin converting enzyme is increased in African-Americans with hypertension. Am J Hypertens. 1994;7(8):759-762.
4. Fukuyama Y, Osawa M, Suzuki H. Congenital progressive muscular dystrophy of the Fukuyama type: clinical, genetic and pathological considerations. Brain Dev. 1981;3(1):1-29. 5. Abel EL. Jewish Genetic Disorders: A Layman's Guide. Jefferson, North Carolina: McFarland and Co; 2001. 6. Goodman RM. Genetic Disorders Among the Jewish People. Baltimore, Maryland: Johns Hopkins University Press; 1979.
9. Humphreys GS, Delvin DG. Ineffectiveness of propranolol in hypertensive Jamaicans. Br Med J. 1968;2(5605):601-603. 10. Kwan P, Baum L, Wong V, et al. Association between ABCB1 C3435T polymorphism and drug-resistant epilepsy in Han Chinese. Epilepsy Behav. 2007;11(1):112-117.
2. Levine PH, Jaffe ES, Manns A, Murphy EL, Clark J, Blattner WA. Human T-cell lymphotropic virus
jamaneurology.com
(Reprinted) JAMA Neurology June 2015 Volume 72, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a Florida International University Medical Library User on 06/16/2015
625
