Letters
ries; everyday interactions with chairs produce 95 times more hospital visits; and injuries from unintentional bites and stings are over 380 times more prevalent in emergency departments than tanning bed mishaps.4 These comparisons to traumas caused by physical objects are relevant because many of the reported tanning bed injuries were not related to UV light but to physical equipment. It is disappointing that the CDC will not release its data when all appearances suggest that the research may not have been accurately portrayed. Gregory Kohs, MA Author Affiliation: MyWikiBiz, West Chester, Pennsylvania. Corresponding Author: Gregory Kohs, MA, Founder, MyWikiBiz, 489 Lake George Circle, West Chester, PA 19382 ([email protected]). Conflict of Interest Disclosures: Mr Kohs was a paid consultant in 2007-2008 for research studies related to consumer attitudes about indoor tanning. No other conflicts are reported. 1. Guy GP Jr, Watson M, Haileyesus T, Annest JL. Indoor tanning-related injuries treated in a national sample of US hospital emergency departments. JAMA Intern Med. 2015;175(2):309-311. 2. National Electronic Injury Surveillance System (NEISS). NEISS Estimates Query Builder CPSC Case #70452756, recorded April 27, 2007. http://www.cpsc .gov/cgibin/NEISSQuery/home.aspx. Accessed July 15, 2015. 3. Lawrence BA, Spicer RS, Miller TR. A fresh look at the costs of non-fatal consumer product injuries. Inj Prev. 2015;21(1):23-29. 4. Centers for Disease Control and Prevention. National Estimates of the 10 Leading Causes of Nonfatal Injuries Treated In Hospital Emergency Departments, United States. 2011. http://www.cdc.gov/injury/wisqars/pdf/10lci _nonfatal_injurytreated_in_hospital-emergency_dept_2011-a.pdf. Accessed April 30, 2015.
In Reply In our study in the February issue of JAMA Internal Medicine,1 we found that an average of 3234 indoor tanning– related injuries were treated annually in hospital emergency departments in the United States from 2003-2012. The majority of injuries were directly related to ultraviolet radiation (UV) from indoor tanning devices: skin burns comprised 79.5% of injuries; and injuries to the eye, primarily burns, 5.8%. Additional injuries (eg, lacerations and broken bones) often related to fainting during or directly following indoor tanning, or being hit by a device’s lid or door, were reported. In his letter, Mr Kohs mentions a narrative from the Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) data set. This is not the data set that we used. Instead, we used the NEISS-All Injury Program (NEISS-AIP). The data set that Mr Kohs mentions, the NEISS, only retains records for consumer products. Since indoor tanning devices are classified as medical devices, not consumer products, indoor tanning device injuries are not included in the NEISS data. The CPSC removes the tanning bed product code from cases with more than 1 product code and removes the case completely if the tanning bed product code was the only code used. The data set we used, the NEISS-AIP, collects information on all injuries rather than just consumer product–related injuries.2 Mr Kohs mentions concerns related to public access to the data included in our analysis. The NEISS-AIP public use data 1584
set, and related documentation, is available to the general public.3 The patient case narratives we used are not available on the public use data set because of preexisting rules of nondisclosure and confidentiality provisions agreed upon by all federal participants funding the NEISS-AIP. As noted in our article, we used a text mining process on the patient case narratives with explicit and objective inclusion and exclusion criteria to ensure that included cases represented injuries attributable to indoor tanning. Cases were initially selected using a keyword search. Each case narrative was reviewed and classified by 3 study researchers to confirm that the injuries were attributable to indoor tanning, with classification differences resolved by consensus. Cases not involving the use of an indoor tanning device were excluded, such as injuries resulting from sun exposure, moving or cleaning an indoor tanning device, and working at a tanning salon. Thus, the narrative provided by Mr Kohs would have been initially selected based on the keyword search but excluded upon case narrative review since the injury was not directly related to the use of an indoor tanning device. Our study provides national estimates of indoor tanning– related injuries treated in emergency departments in the United States. Although indoor tanning–related injuries might account for a small portion of the total injuries treated in US hospital departments, it is clear that these are avoidable injuries that result in harm to the injured person and cost to treat the injuries. In addition to causing acute injuries, indoor tanning, a known carcinogen, increases the risk of skin cancer.4 Gery P. Guy Jr, PhD, MPH Meg Watson, MPH Tadesse Haileyesus, MS Author Affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia. Corresponding Author: Gery P. Guy Jr, PhD, MPH, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mail Stop K-76, Atlanta, GA 30341 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Guy GP Jr, Watson M, Haileyesus T, Annest JL. Indoor tanning-related injuries treated in a national sample of US hospital emergency departments. JAMA Intern Med. 2015;175(2):309-311. 2. NEISS. The National Electronic Injury Surveillance System: A Tool for Researchers. http://www.cpsc.gov/PageFiles/106626/2000d015.pdf. Accessed May 14, 2015. 3. National Electronic Injury Surveillance System All Injury Program, 2011 (ICPSR 35233). Inter-university Consortium for Political and Social Research [distributor]; Ann Arbor, MI. 2014. http://www.icpsr.umich.edu/icpsrweb/NACJD /studies/35233/version/1. Accessed July 10, 2015. 4. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2014.
In Defense of Documentary Cameras To The Editor Neal Baer and I have sparred before on the issue of documentary cameras being allowed into emergent settings.1,2 Alas, I find this latest jeremiad3 shows him to be just as willfully subjective about which facts he includes this time as last. As a viewer, Dr Baer is entitled to his opinion. How-
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Copyright 2015 American Medical Association. All rights reserved.
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ever, let us be clear about his agenda and the lack of context for his assertions. Dr Baer devalues the legal and ethical assessments made by our nation’s leading academic medical centers (eg, Johns Hopkins, New York-Presbyterian, Brigham and Women’s, Massachusetts General, and Boston Medical Center) when they decided to let our camera into emergent care areas. He assumes they cast ethics, legality, and patient interests aside. One might ask why Dr Baer thinks he is better positioned to be a patient advocate than the clinical departments we work with in the actual hospitals where we film. He patronizes patients, assuming they can't understand the implications of consenting to be on television when they agree to have their care portrayed. In our experience, many patients are avid consumers of media, have seen our program, and are worldly about our mission. For someone who touts his experience in network television, Dr Baer is strangely ignorant of the work that must go on behind the scenes to make our program. He ignores what must obviously be diligent consent protocol, careful vetting of footage by risk management, and countless preparatory meetings with medical staff, not to mention specialized training of our own staff to allow them to be in this environment. He casually mislabels our program a “reality show” rather than a documentary, even though we have been making this show since 2000, when Hopkins 24/7 first aired. Nowhere does Dr Baer mention the many positive aspects of this kind of programming. In fairness, how could he know of the hundreds of individuals who have written and approached us over the years, telling us the program inspired them to train as paramedics, go to medical school, or specialize in emergency medicine? I can point to numerous cases where an exchange with doctors has been instructive to the patient and the audience. For instance, they have learned when to call an ambulance or what behaviors are risky. People suffering from anaphylaxis learn to carry epinephrine autoinjectors, women learn the sometimes confusing symptoms of a heart attack, and the audience learns generally what expertise and tools are available at a Level 1 Trauma Center as opposed to a community hospital emergency room. For better or worse, television is the broadest medium available for educating the public. What should be obvious to Dr Baer is that programs contain a great deal of valuable medical information that the public can use. Terence Wrong Author Affiliation: ABC News, Documentary, New York, New York. Corresponding Author: Terence Wrong, ABC News, Documentary, 125 W End Ave, New York, NY 10023 ([email protected]). Conflict of Interest Disclosures: None reported. Additional Information: Terence Wrong was the producer of Hopkins 24/7, a 6-part documentary series that aired in 2000 on ABC. He also was the executive producer of Hopkins, a 7-part documentary series that aired in 2008; Boston Med, an 8-part documentary series that aired in 2010; NY MED: Season 1, an 8-part documentary series that aired in 2012; and NY MED: Season 2, an 8-part documentary series that aired in 2014.
3. Baer N. The circus comes to the emergency department. JAMA Intern Med. 2015;175(6):883-884.
In Reply I certainly have struck a nerve with Terence Wrong in my opinion piece.1 Unfortunately, his defensiveness seems to have blinded him to the critical issues I raise, and he utterly fails to address them. First, and foremost, as difficult as it may be for many of us to accept, the leadership in modern hospitals is not always committed to what is best for patients when marketing goals are at stake, no matter how prestigious the institution. The chance to have one’s hospital featured on network television is enticing, particularly today when there is intense competition for patients. But is it in the best interests of patients to have their most personal and private moments splashed on the screen? Yes, patients on the shows are supposed to give their consent to be filmed. They must in order to protect the television company from legal action. (Note, however, that the widow of Mark Chanko sued ABC after her husband appeared on NY Med—dying before her eyes in the emergency room—without his consent, his face blurred but obviously identifiable to her and her family).2 Contrary to Mr Wrong’s contention, it is not patronizing to ask if patients truly understand the implications of having their medical care team perform under the scrutiny of a camera. Can Mr Wrong guarantee that a camera in the room will not deleteriously affect patient care? Certainly not. For that reason alone cameras should not be allowed in the emergency department. The last thing physicians need to worry about when they are resuscitating a patient is how they will appear to a television audience. And what can patients possibly gain from their illnesses and distress being broadcast to millions of viewers? What is the benefit to that patient or family or to those watching? Mr Wrong fails to answer that except, amusingly, to say that people learn “when to call an ambulance or what behaviors are risky” (he presents no data on what behaviors are learned). If this vague possibility is the best he can offer, he needs to rethink his insistence on the educational value of his shows, which he touts as one of the most important reasons for a hospital to sign on. Finally, Mr Wrong does not address the fundamental question I raise about the conflicting goals of television documentarians and physicians. Filmmakers seek to portray high drama—the “good-bye moments” as Mr Wrong pointedly calls them.3 The focus on grabbing and holding a television audience’s attention has nothing whatsoever to do with the physician’s job of providing the best care possible to the patient and can easily conflict with it. Anything that can interfere with the focus on what’s best for the patient at each moment, including cameras and film crews in the patient’s room or trauma bay, should never be permitted. Mr Wrong’s assertion that the show educates the public cannot disguise itself as justification for making entertainment. There is no sound justification for intruding this way into what are often the most personal and private moments in people’s lives.
1. Wrong T, Baumgart E. Not a “reality” show. J Clin Ethics. 2013;24(1):58-63. 2. Baer N. First, do no harm. J Clin Ethics. 2013;24(1):64-66.
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Neal Baer, EdM, AM, MD (Reprinted) JAMA Internal Medicine September 2015 Volume 175, Number 9
Copyright 2015 American Medical Association. All rights reserved.
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Author Affiliation: Global Media Center for Social Impact, Fielding School of Public Health, University of California-Los Angeles, Los Angeles. Corresponding Author: Neal Baer, EdM, AM, MD, Global Media Center for Social Impact, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, CA 90095 ([email protected]). Conflict of Interest Disclosures: None reported.
Corresponding Author: Ralph J. Turner, MD, Department of Surgery, University of Texas Health Northeast, 11937 US Hwy 271, Tyler, TX 75708 (RJTURNERTX @aol.com).
1. Baer N. The circus comes to the emergency department. JAMA Intern Med. 2015;175(6):883-884.
Conflict of Interest Disclosures: Dr Turner is on the Speakers Bureau for Pfizer and for Merck (Schering-Plough). No other conflicts are reported.
2. Ornstein C. Dying in the E.R., and on TV. The New York Times. January 4, 2015:MB1.
Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors.
3. The 60-Second interview: Terence Wrong, executive producer of “NY Med” on ABC. Capital New York. June 26, 2014. http://www.capitalnewyork.com /article/media/2014/06/8548028/60-second-interview-terence-wrongexecutive-producer-ny-med-abc. Accessed July 13, 2015.
1. Avis NE, Crawford SL, Greendale G, et al; Study of Women’s Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539.
Eu-estrogenemia, KNDy Neurons, and Vasomotor Symptoms To the Editor The article by Avis et al1 titled “Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition,” from the Study of Women Across the Nation (SWAN) gives further insight into the complexities of estrogen action. Vasomotor symptoms signal to the woman and those around her that her body is not functioning as it has in earlier reproductive years. Vasomotor symptoms possibly arise because of transient hypoestrogenemia at estrogen receptor (ER) α coexpressed with kisspeptin/neurokinin B/dynorphin (KNDy) neurons in the arcuate nucleus of the brain.2 If vasomotor symptoms are the canary in the coal mine of hypoestrogenemia, we could ask which of the many other ERs and ER signaling pathways might be experiencing a degree of malfunction. For example, ER-α in brain mitochondria enhance use of glucose preferentially to ketones.3 Is the “brain fog” of menopausal transition a question of mitochondrial bioenergetics? Hypoestrogenemia that is sufficient to cause thermoregulatory dysfunction for up to 7 years before the last menstrual period is another manifestation of Clarkson’s hypothalamically mediated ovulatory dysfunction as widely reported in the mid-1990s.4 Clarkson studied nondominant cynomolgous monkeys and observed the effects of hypoestrogenemia, including increased central obesity, decreased high-density lipoprotein concentration, vasoconstriction to acetylcholine administration, and increased atherosclerotic plaque formation. These changes were preventable with the timing hypothesis, a timely administration of exogenous estradiol. Timely administration of estrogen is crucial to this hypothesis for optimal ER function.4 It is now time to consider that hypoestrogenemia in the menopausal transition may also apply to many other estrogen signaling pathways. This question of maintaining proper estrogen receptor function refocuses the indication for hormone therapy from serum estradiol concentration to optimal estrogen receptor function in all tissues, that is euestrogenemia or the concentration of estradiol at which all ERs function optimally.5 Irwin J. Kerber, MD Ralph J. Turner, MD 1586
Author Affiliations: Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School, Dallas (Kerber); Department of Surgery, University of Texas Health Northeast, Tyler (Turner).
2. Mittelman-Smith MA, Williams H, Krajewski-Hall SJ, McMullen NT, Rance NE. Role for kisspeptin/neurokinin B/dynorphin (KNDy) neurons in cutaneous vasodilatation and the estrogen modulation of body temperature. Proc Natl Acad Sci U S A. 2012;109(48):19846-19851. 3. Yao J, Hamilton RT, Cadenas E, Brinton RD. Decline in mitochondrial bioenergetics and shift to ketogenic profile in brain during reproductive senescence. Biochim Biophys Acta. 2010;1800(10):1121-1126. 4. Clarkson TB, Kaplan JR, Shively CA, Klein KP. Benefits of exogenous oestrogen in inhibiting stress-related coronary artery atherosclerosis. Br J Obstet Gynaecol. 1996;103(suppl 13):73-78. 5. Kerber IJ, Turner RJ. Eu-estrogenemia. J Appl Physiol (1985). 2005;99(6):24712472.
Better Choices Concerning Rheumatoid Factor Testing To the Editor I agree with Kerr et al1 that an aspect of the Choosing Wisely (CW) campaign should be choosing a target wisely. Their concerns that unaggressive recommendations are being made that do not target wasteful testing may be valid. For this reason, the Canadian Rheumatology Association (CRA) CW recommendations were based on a specific methodology that adequately targeted problem areas.2 The CRA surveyed its society members to find tests or treatments that were deemed common and wasteful. Using this methodology, a Top 5 list was formed.2 Regional data confirm that the right choices were being made. One of the CRA’s recommendations urges avoiding antinuclear antibody (ANA) testing to screen patients without specific symptoms of systemic lupus erythematosus or another connective tissue disease. In Alberta, for example, unpublished data show that 63 000 ANA tests are done each year in a province with a population of 4 million. This means that 1 in 60 people in the province have an ANA test every year. Considering that the incidence of systemic lupus erythematosus is likely less than 0.02% of the population,3 this is a startling waste of testing. The spirit of the CRA CW recommendations for ANA could easily be duplicated in the form of a similar recommendation for rheumatoid factor (RF) testing, where 83 000 tests (1 in 48 people in Alberta) are done each year. It is clear that there is waste, but as Kerr et al1 suggest, it is important methods that target the most wasteful testing are used before making recommendations that may be otherwise less effective. Doing so, along with analyzing the actual testing frequencies at the population level, can provide useful insights. For example, a second recommendation of the CRA discourages ordering a human leukocyte
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Copyright 2015 American Medical Association. All rights reserved.
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ries; everyday interactions with chairs produce 95 times more hospital visits; and injuries from unintentional bites and stings are over 380 times more prevalent in emergency departments than tanning bed mishaps.4 These comparisons to traumas caused by physical objects are relevant because many of the reported tanning bed injuries were not related to UV light but to physical equipment. It is disappointing that the CDC will not release its data when all appearances suggest that the research may not have been accurately portrayed. Gregory Kohs, MA Author Affiliation: MyWikiBiz, West Chester, Pennsylvania. Corresponding Author: Gregory Kohs, MA, Founder, MyWikiBiz, 489 Lake George Circle, West Chester, PA 19382 ([email protected]). Conflict of Interest Disclosures: Mr Kohs was a paid consultant in 2007-2008 for research studies related to consumer attitudes about indoor tanning. No other conflicts are reported. 1. Guy GP Jr, Watson M, Haileyesus T, Annest JL. Indoor tanning-related injuries treated in a national sample of US hospital emergency departments. JAMA Intern Med. 2015;175(2):309-311. 2. National Electronic Injury Surveillance System (NEISS). NEISS Estimates Query Builder CPSC Case #70452756, recorded April 27, 2007. http://www.cpsc .gov/cgibin/NEISSQuery/home.aspx. Accessed July 15, 2015. 3. Lawrence BA, Spicer RS, Miller TR. A fresh look at the costs of non-fatal consumer product injuries. Inj Prev. 2015;21(1):23-29. 4. Centers for Disease Control and Prevention. National Estimates of the 10 Leading Causes of Nonfatal Injuries Treated In Hospital Emergency Departments, United States. 2011. http://www.cdc.gov/injury/wisqars/pdf/10lci _nonfatal_injurytreated_in_hospital-emergency_dept_2011-a.pdf. Accessed April 30, 2015.
In Reply In our study in the February issue of JAMA Internal Medicine,1 we found that an average of 3234 indoor tanning– related injuries were treated annually in hospital emergency departments in the United States from 2003-2012. The majority of injuries were directly related to ultraviolet radiation (UV) from indoor tanning devices: skin burns comprised 79.5% of injuries; and injuries to the eye, primarily burns, 5.8%. Additional injuries (eg, lacerations and broken bones) often related to fainting during or directly following indoor tanning, or being hit by a device’s lid or door, were reported. In his letter, Mr Kohs mentions a narrative from the Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) data set. This is not the data set that we used. Instead, we used the NEISS-All Injury Program (NEISS-AIP). The data set that Mr Kohs mentions, the NEISS, only retains records for consumer products. Since indoor tanning devices are classified as medical devices, not consumer products, indoor tanning device injuries are not included in the NEISS data. The CPSC removes the tanning bed product code from cases with more than 1 product code and removes the case completely if the tanning bed product code was the only code used. The data set we used, the NEISS-AIP, collects information on all injuries rather than just consumer product–related injuries.2 Mr Kohs mentions concerns related to public access to the data included in our analysis. The NEISS-AIP public use data 1584
set, and related documentation, is available to the general public.3 The patient case narratives we used are not available on the public use data set because of preexisting rules of nondisclosure and confidentiality provisions agreed upon by all federal participants funding the NEISS-AIP. As noted in our article, we used a text mining process on the patient case narratives with explicit and objective inclusion and exclusion criteria to ensure that included cases represented injuries attributable to indoor tanning. Cases were initially selected using a keyword search. Each case narrative was reviewed and classified by 3 study researchers to confirm that the injuries were attributable to indoor tanning, with classification differences resolved by consensus. Cases not involving the use of an indoor tanning device were excluded, such as injuries resulting from sun exposure, moving or cleaning an indoor tanning device, and working at a tanning salon. Thus, the narrative provided by Mr Kohs would have been initially selected based on the keyword search but excluded upon case narrative review since the injury was not directly related to the use of an indoor tanning device. Our study provides national estimates of indoor tanning– related injuries treated in emergency departments in the United States. Although indoor tanning–related injuries might account for a small portion of the total injuries treated in US hospital departments, it is clear that these are avoidable injuries that result in harm to the injured person and cost to treat the injuries. In addition to causing acute injuries, indoor tanning, a known carcinogen, increases the risk of skin cancer.4 Gery P. Guy Jr, PhD, MPH Meg Watson, MPH Tadesse Haileyesus, MS Author Affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia. Corresponding Author: Gery P. Guy Jr, PhD, MPH, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mail Stop K-76, Atlanta, GA 30341 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Guy GP Jr, Watson M, Haileyesus T, Annest JL. Indoor tanning-related injuries treated in a national sample of US hospital emergency departments. JAMA Intern Med. 2015;175(2):309-311. 2. NEISS. The National Electronic Injury Surveillance System: A Tool for Researchers. http://www.cpsc.gov/PageFiles/106626/2000d015.pdf. Accessed May 14, 2015. 3. National Electronic Injury Surveillance System All Injury Program, 2011 (ICPSR 35233). Inter-university Consortium for Political and Social Research [distributor]; Ann Arbor, MI. 2014. http://www.icpsr.umich.edu/icpsrweb/NACJD /studies/35233/version/1. Accessed July 10, 2015. 4. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2014.
In Defense of Documentary Cameras To The Editor Neal Baer and I have sparred before on the issue of documentary cameras being allowed into emergent settings.1,2 Alas, I find this latest jeremiad3 shows him to be just as willfully subjective about which facts he includes this time as last. As a viewer, Dr Baer is entitled to his opinion. How-
JAMA Internal Medicine September 2015 Volume 175, Number 9 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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ever, let us be clear about his agenda and the lack of context for his assertions. Dr Baer devalues the legal and ethical assessments made by our nation’s leading academic medical centers (eg, Johns Hopkins, New York-Presbyterian, Brigham and Women’s, Massachusetts General, and Boston Medical Center) when they decided to let our camera into emergent care areas. He assumes they cast ethics, legality, and patient interests aside. One might ask why Dr Baer thinks he is better positioned to be a patient advocate than the clinical departments we work with in the actual hospitals where we film. He patronizes patients, assuming they can't understand the implications of consenting to be on television when they agree to have their care portrayed. In our experience, many patients are avid consumers of media, have seen our program, and are worldly about our mission. For someone who touts his experience in network television, Dr Baer is strangely ignorant of the work that must go on behind the scenes to make our program. He ignores what must obviously be diligent consent protocol, careful vetting of footage by risk management, and countless preparatory meetings with medical staff, not to mention specialized training of our own staff to allow them to be in this environment. He casually mislabels our program a “reality show” rather than a documentary, even though we have been making this show since 2000, when Hopkins 24/7 first aired. Nowhere does Dr Baer mention the many positive aspects of this kind of programming. In fairness, how could he know of the hundreds of individuals who have written and approached us over the years, telling us the program inspired them to train as paramedics, go to medical school, or specialize in emergency medicine? I can point to numerous cases where an exchange with doctors has been instructive to the patient and the audience. For instance, they have learned when to call an ambulance or what behaviors are risky. People suffering from anaphylaxis learn to carry epinephrine autoinjectors, women learn the sometimes confusing symptoms of a heart attack, and the audience learns generally what expertise and tools are available at a Level 1 Trauma Center as opposed to a community hospital emergency room. For better or worse, television is the broadest medium available for educating the public. What should be obvious to Dr Baer is that programs contain a great deal of valuable medical information that the public can use. Terence Wrong Author Affiliation: ABC News, Documentary, New York, New York. Corresponding Author: Terence Wrong, ABC News, Documentary, 125 W End Ave, New York, NY 10023 ([email protected]). Conflict of Interest Disclosures: None reported. Additional Information: Terence Wrong was the producer of Hopkins 24/7, a 6-part documentary series that aired in 2000 on ABC. He also was the executive producer of Hopkins, a 7-part documentary series that aired in 2008; Boston Med, an 8-part documentary series that aired in 2010; NY MED: Season 1, an 8-part documentary series that aired in 2012; and NY MED: Season 2, an 8-part documentary series that aired in 2014.
3. Baer N. The circus comes to the emergency department. JAMA Intern Med. 2015;175(6):883-884.
In Reply I certainly have struck a nerve with Terence Wrong in my opinion piece.1 Unfortunately, his defensiveness seems to have blinded him to the critical issues I raise, and he utterly fails to address them. First, and foremost, as difficult as it may be for many of us to accept, the leadership in modern hospitals is not always committed to what is best for patients when marketing goals are at stake, no matter how prestigious the institution. The chance to have one’s hospital featured on network television is enticing, particularly today when there is intense competition for patients. But is it in the best interests of patients to have their most personal and private moments splashed on the screen? Yes, patients on the shows are supposed to give their consent to be filmed. They must in order to protect the television company from legal action. (Note, however, that the widow of Mark Chanko sued ABC after her husband appeared on NY Med—dying before her eyes in the emergency room—without his consent, his face blurred but obviously identifiable to her and her family).2 Contrary to Mr Wrong’s contention, it is not patronizing to ask if patients truly understand the implications of having their medical care team perform under the scrutiny of a camera. Can Mr Wrong guarantee that a camera in the room will not deleteriously affect patient care? Certainly not. For that reason alone cameras should not be allowed in the emergency department. The last thing physicians need to worry about when they are resuscitating a patient is how they will appear to a television audience. And what can patients possibly gain from their illnesses and distress being broadcast to millions of viewers? What is the benefit to that patient or family or to those watching? Mr Wrong fails to answer that except, amusingly, to say that people learn “when to call an ambulance or what behaviors are risky” (he presents no data on what behaviors are learned). If this vague possibility is the best he can offer, he needs to rethink his insistence on the educational value of his shows, which he touts as one of the most important reasons for a hospital to sign on. Finally, Mr Wrong does not address the fundamental question I raise about the conflicting goals of television documentarians and physicians. Filmmakers seek to portray high drama—the “good-bye moments” as Mr Wrong pointedly calls them.3 The focus on grabbing and holding a television audience’s attention has nothing whatsoever to do with the physician’s job of providing the best care possible to the patient and can easily conflict with it. Anything that can interfere with the focus on what’s best for the patient at each moment, including cameras and film crews in the patient’s room or trauma bay, should never be permitted. Mr Wrong’s assertion that the show educates the public cannot disguise itself as justification for making entertainment. There is no sound justification for intruding this way into what are often the most personal and private moments in people’s lives.
1. Wrong T, Baumgart E. Not a “reality” show. J Clin Ethics. 2013;24(1):58-63. 2. Baer N. First, do no harm. J Clin Ethics. 2013;24(1):64-66.
jamainternalmedicine.com
Neal Baer, EdM, AM, MD (Reprinted) JAMA Internal Medicine September 2015 Volume 175, Number 9
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Fudan University User on 08/19/2017
1585
Letters
Author Affiliation: Global Media Center for Social Impact, Fielding School of Public Health, University of California-Los Angeles, Los Angeles. Corresponding Author: Neal Baer, EdM, AM, MD, Global Media Center for Social Impact, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, CA 90095 ([email protected]). Conflict of Interest Disclosures: None reported.
Corresponding Author: Ralph J. Turner, MD, Department of Surgery, University of Texas Health Northeast, 11937 US Hwy 271, Tyler, TX 75708 (RJTURNERTX @aol.com).
1. Baer N. The circus comes to the emergency department. JAMA Intern Med. 2015;175(6):883-884.
Conflict of Interest Disclosures: Dr Turner is on the Speakers Bureau for Pfizer and for Merck (Schering-Plough). No other conflicts are reported.
2. Ornstein C. Dying in the E.R., and on TV. The New York Times. January 4, 2015:MB1.
Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors.
3. The 60-Second interview: Terence Wrong, executive producer of “NY Med” on ABC. Capital New York. June 26, 2014. http://www.capitalnewyork.com /article/media/2014/06/8548028/60-second-interview-terence-wrongexecutive-producer-ny-med-abc. Accessed July 13, 2015.
1. Avis NE, Crawford SL, Greendale G, et al; Study of Women’s Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539.
Eu-estrogenemia, KNDy Neurons, and Vasomotor Symptoms To the Editor The article by Avis et al1 titled “Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition,” from the Study of Women Across the Nation (SWAN) gives further insight into the complexities of estrogen action. Vasomotor symptoms signal to the woman and those around her that her body is not functioning as it has in earlier reproductive years. Vasomotor symptoms possibly arise because of transient hypoestrogenemia at estrogen receptor (ER) α coexpressed with kisspeptin/neurokinin B/dynorphin (KNDy) neurons in the arcuate nucleus of the brain.2 If vasomotor symptoms are the canary in the coal mine of hypoestrogenemia, we could ask which of the many other ERs and ER signaling pathways might be experiencing a degree of malfunction. For example, ER-α in brain mitochondria enhance use of glucose preferentially to ketones.3 Is the “brain fog” of menopausal transition a question of mitochondrial bioenergetics? Hypoestrogenemia that is sufficient to cause thermoregulatory dysfunction for up to 7 years before the last menstrual period is another manifestation of Clarkson’s hypothalamically mediated ovulatory dysfunction as widely reported in the mid-1990s.4 Clarkson studied nondominant cynomolgous monkeys and observed the effects of hypoestrogenemia, including increased central obesity, decreased high-density lipoprotein concentration, vasoconstriction to acetylcholine administration, and increased atherosclerotic plaque formation. These changes were preventable with the timing hypothesis, a timely administration of exogenous estradiol. Timely administration of estrogen is crucial to this hypothesis for optimal ER function.4 It is now time to consider that hypoestrogenemia in the menopausal transition may also apply to many other estrogen signaling pathways. This question of maintaining proper estrogen receptor function refocuses the indication for hormone therapy from serum estradiol concentration to optimal estrogen receptor function in all tissues, that is euestrogenemia or the concentration of estradiol at which all ERs function optimally.5 Irwin J. Kerber, MD Ralph J. Turner, MD 1586
Author Affiliations: Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School, Dallas (Kerber); Department of Surgery, University of Texas Health Northeast, Tyler (Turner).
2. Mittelman-Smith MA, Williams H, Krajewski-Hall SJ, McMullen NT, Rance NE. Role for kisspeptin/neurokinin B/dynorphin (KNDy) neurons in cutaneous vasodilatation and the estrogen modulation of body temperature. Proc Natl Acad Sci U S A. 2012;109(48):19846-19851. 3. Yao J, Hamilton RT, Cadenas E, Brinton RD. Decline in mitochondrial bioenergetics and shift to ketogenic profile in brain during reproductive senescence. Biochim Biophys Acta. 2010;1800(10):1121-1126. 4. Clarkson TB, Kaplan JR, Shively CA, Klein KP. Benefits of exogenous oestrogen in inhibiting stress-related coronary artery atherosclerosis. Br J Obstet Gynaecol. 1996;103(suppl 13):73-78. 5. Kerber IJ, Turner RJ. Eu-estrogenemia. J Appl Physiol (1985). 2005;99(6):24712472.
Better Choices Concerning Rheumatoid Factor Testing To the Editor I agree with Kerr et al1 that an aspect of the Choosing Wisely (CW) campaign should be choosing a target wisely. Their concerns that unaggressive recommendations are being made that do not target wasteful testing may be valid. For this reason, the Canadian Rheumatology Association (CRA) CW recommendations were based on a specific methodology that adequately targeted problem areas.2 The CRA surveyed its society members to find tests or treatments that were deemed common and wasteful. Using this methodology, a Top 5 list was formed.2 Regional data confirm that the right choices were being made. One of the CRA’s recommendations urges avoiding antinuclear antibody (ANA) testing to screen patients without specific symptoms of systemic lupus erythematosus or another connective tissue disease. In Alberta, for example, unpublished data show that 63 000 ANA tests are done each year in a province with a population of 4 million. This means that 1 in 60 people in the province have an ANA test every year. Considering that the incidence of systemic lupus erythematosus is likely less than 0.02% of the population,3 this is a startling waste of testing. The spirit of the CRA CW recommendations for ANA could easily be duplicated in the form of a similar recommendation for rheumatoid factor (RF) testing, where 83 000 tests (1 in 48 people in Alberta) are done each year. It is clear that there is waste, but as Kerr et al1 suggest, it is important methods that target the most wasteful testing are used before making recommendations that may be otherwise less effective. Doing so, along with analyzing the actual testing frequencies at the population level, can provide useful insights. For example, a second recommendation of the CRA discourages ordering a human leukocyte
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