Betsy Bates

LAS VEGAS — The safety, efficacy, and—perhaps most important—tolerability of bowel preparation for colonoscopy came under intense scrutiny at the annual meeting of the American College of Gastroenterology.

“We desperately need to have one regimen that gives us the ideal preparation,” said Dr. Douglas K. Rex, professor of medicine and director of endoscopy at Indiana University Hospital in Indianapolis.

“Bowel preparation is a very, very big deal,” he continued during the Emily Couric Annual Lecture at the meeting. “We already know it's the thing patients complain about most.”

The problems with bowel preparation are twofold: People referred for colonoscopy often don't get it done because they expect the preparation to be inconvenient and uncomfortable, and the difficulties of currently available methods of bowel preparation often lead to incomplete cleansing. The latter problem leads to inadequate visualization in up to 25% of colonoscopies, Dr. Rex added.

“The costs of that over time are enormous,” he said.

One method is the use of aqueous sodium phosphate solutions, which have proven efficacious and reasonably tolerable. But there is some concern about their safety because of problems with electrolyte imbalances, dehydration, and renal failure, he explained.

Polyethylene glycol-electrolyte (PEG-ES) lavage preparations are considered safer but are not as well tolerated, he said.

A third method, hydrotherapy, may offer a reasonable alternative, if early studies can be replicated, he said. In a 45-minute procedure immediately preceding colonoscopy, a trained technician uses a pressure-controlled device to lavage the colon with a constant flow of warm water.

In a study presented at the meeting, the hydrotherapy method was compared with two other methods: 4 L of PEG-ES and aqueous sodium phosphate given in two doses. Patients aged 38–80 years (average age, 61years) were randomized to one of the three procedures.

Hydrotherapy received significantly higher colon cleansing quality scores for every area of the colon (right, transverse, and left) than the sodium phosphate or PEG-Es methods, reported Dr. Joseph J. Fiorito of Danbury (Conn.) Hospital. The ratings were completed by endoscopists blinded to the preparation method used. For example, in the right colon, the quality of cleansing was rated as “good” in 32 of 52 patients (62%) who received aqueous sodium phosphate, 27 of 55 patients (49%) who took PEG-ES, and 49 of 53 (92%) who underwent hydrotherapy.

Patients who received hydrotherapy reported higher scores for ease, convenience, and comfort than patients who underwent the other methods. When asked if they would prefer a different bowel cleansing method if they were to undergo another colonoscopy, 1 of 53 (2%) who had hydrotherapy cleansing said yes, compared with 25 of 52 (48%) of the aqueous sodium phosphate group and 33 of 55 (60%) who had PEG-ES.

One patient (not included in the final analyses) did not complete the hydrotherapy procedure because of discomfort.

Dr. Fiorito said that the patients in the study were not charged for colonoscopy preparation, but that the estimated cost of hydrotherapy ranges from $35 to $75. “It would be nice to have insurance companies or Medicare to look at this as an alternative method of preparation,” he said.

Hydrotherapy Inc. of Las Vegas funded the study.

Another study, which was presented as a poster at the meeting, compared a new, 32-tablet form of sodium phosphate preparation with a bowel preparation kit containing 2 L of PEG and bisacodyl tablets. The study found that less irrigation was necessary during colonoscopy and more polyps were identified when subjects took the tablets. The new tablet formulation, marketed as OsmoPrep, is made by Salix Pharmaceuticals Inc. of Morrisville, N.C., which sponsored the study.

LAS VEGAS — The safety, efficacy, and—perhaps most important—tolerability of bowel preparation for colonoscopy came under intense scrutiny at the annual meeting of the American College of Gastroenterology.

“We desperately need to have one regimen that gives us the ideal preparation,” said Dr. Douglas K. Rex, professor of medicine and director of endoscopy at Indiana University Hospital in Indianapolis.

“Bowel preparation is a very, very big deal,” he continued during the Emily Couric Annual Lecture at the meeting. “We already know it's the thing patients complain about most.”

The problems with bowel preparation are twofold: People referred for colonoscopy often don't get it done because they expect the preparation to be inconvenient and uncomfortable, and the difficulties of currently available methods of bowel preparation often lead to incomplete cleansing. The latter problem leads to inadequate visualization in up to 25% of colonoscopies, Dr. Rex added.

“The costs of that over time are enormous,” he said.

One method is the use of aqueous sodium phosphate solutions, which have proven efficacious and reasonably tolerable. But there is some concern about their safety because of problems with electrolyte imbalances, dehydration, and renal failure, he explained.

Polyethylene glycol-electrolyte (PEG-ES) lavage preparations are considered safer but are not as well tolerated, he said.

A third method, hydrotherapy, may offer a reasonable alternative, if early studies can be replicated, he said. In a 45-minute procedure immediately preceding colonoscopy, a trained technician uses a pressure-controlled device to lavage the colon with a constant flow of warm water.

In a study presented at the meeting, the hydrotherapy method was compared with two other methods: 4 L of PEG-ES and aqueous sodium phosphate given in two doses. Patients aged 38–80 years (average age, 61years) were randomized to one of the three procedures.

Hydrotherapy received significantly higher colon cleansing quality scores for every area of the colon (right, transverse, and left) than the sodium phosphate or PEG-Es methods, reported Dr. Joseph J. Fiorito of Danbury (Conn.) Hospital. The ratings were completed by endoscopists blinded to the preparation method used. For example, in the right colon, the quality of cleansing was rated as “good” in 32 of 52 patients (62%) who received aqueous sodium phosphate, 27 of 55 patients (49%) who took PEG-ES, and 49 of 53 (92%) who underwent hydrotherapy.

Patients who received hydrotherapy reported higher scores for ease, convenience, and comfort than patients who underwent the other methods. When asked if they would prefer a different bowel cleansing method if they were to undergo another colonoscopy, 1 of 53 (2%) who had hydrotherapy cleansing said yes, compared with 25 of 52 (48%) of the aqueous sodium phosphate group and 33 of 55 (60%) who had PEG-ES.

One patient (not included in the final analyses) did not complete the hydrotherapy procedure because of discomfort.

Dr. Fiorito said that the patients in the study were not charged for colonoscopy preparation, but that the estimated cost of hydrotherapy ranges from $35 to $75. “It would be nice to have insurance companies or Medicare to look at this as an alternative method of preparation,” he said.

Hydrotherapy Inc. of Las Vegas funded the study.

Another study, which was presented as a poster at the meeting, compared a new, 32-tablet form of sodium phosphate preparation with a bowel preparation kit containing 2 L of PEG and bisacodyl tablets. The study found that less irrigation was necessary during colonoscopy and more polyps were identified when subjects took the tablets. The new tablet formulation, marketed as OsmoPrep, is made by Salix Pharmaceuticals Inc. of Morrisville, N.C., which sponsored the study.

LAS VEGAS — The safety, efficacy, and—perhaps most important—tolerability of bowel preparation for colonoscopy came under intense scrutiny at the annual meeting of the American College of Gastroenterology.

“We desperately need to have one regimen that gives us the ideal preparation,” said Dr. Douglas K. Rex, professor of medicine and director of endoscopy at Indiana University Hospital in Indianapolis.

“Bowel preparation is a very, very big deal,” he continued during the Emily Couric Annual Lecture at the meeting. “We already know it's the thing patients complain about most.”

The problems with bowel preparation are twofold: People referred for colonoscopy often don't get it done because they expect the preparation to be inconvenient and uncomfortable, and the difficulties of currently available methods of bowel preparation often lead to incomplete cleansing. The latter problem leads to inadequate visualization in up to 25% of colonoscopies, Dr. Rex added.

“The costs of that over time are enormous,” he said.

One method is the use of aqueous sodium phosphate solutions, which have proven efficacious and reasonably tolerable. But there is some concern about their safety because of problems with electrolyte imbalances, dehydration, and renal failure, he explained.

Polyethylene glycol-electrolyte (PEG-ES) lavage preparations are considered safer but are not as well tolerated, he said.

A third method, hydrotherapy, may offer a reasonable alternative, if early studies can be replicated, he said. In a 45-minute procedure immediately preceding colonoscopy, a trained technician uses a pressure-controlled device to lavage the colon with a constant flow of warm water.

In a study presented at the meeting, the hydrotherapy method was compared with two other methods: 4 L of PEG-ES and aqueous sodium phosphate given in two doses. Patients aged 38–80 years (average age, 61years) were randomized to one of the three procedures.

Hydrotherapy received significantly higher colon cleansing quality scores for every area of the colon (right, transverse, and left) than the sodium phosphate or PEG-Es methods, reported Dr. Joseph J. Fiorito of Danbury (Conn.) Hospital. The ratings were completed by endoscopists blinded to the preparation method used. For example, in the right colon, the quality of cleansing was rated as “good” in 32 of 52 patients (62%) who received aqueous sodium phosphate, 27 of 55 patients (49%) who took PEG-ES, and 49 of 53 (92%) who underwent hydrotherapy.

Patients who received hydrotherapy reported higher scores for ease, convenience, and comfort than patients who underwent the other methods. When asked if they would prefer a different bowel cleansing method if they were to undergo another colonoscopy, 1 of 53 (2%) who had hydrotherapy cleansing said yes, compared with 25 of 52 (48%) of the aqueous sodium phosphate group and 33 of 55 (60%) who had PEG-ES.

One patient (not included in the final analyses) did not complete the hydrotherapy procedure because of discomfort.

Dr. Fiorito said that the patients in the study were not charged for colonoscopy preparation, but that the estimated cost of hydrotherapy ranges from $35 to $75. “It would be nice to have insurance companies or Medicare to look at this as an alternative method of preparation,” he said.

Hydrotherapy Inc. of Las Vegas funded the study.

Another study, which was presented as a poster at the meeting, compared a new, 32-tablet form of sodium phosphate preparation with a bowel preparation kit containing 2 L of PEG and bisacodyl tablets. The study found that less irrigation was necessary during colonoscopy and more polyps were identified when subjects took the tablets. The new tablet formulation, marketed as OsmoPrep, is made by Salix Pharmaceuticals Inc. of Morrisville, N.C., which sponsored the study.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These rules include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch what they say. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religion, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” Ms. Peck said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

“You can hide things in a resume,” she said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, Ms. Peck said.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said. Their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense, and it's enough, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These rules include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch what they say. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religion, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” Ms. Peck said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

“You can hide things in a resume,” she said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, Ms. Peck said.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said. Their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense, and it's enough, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These rules include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch what they say. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religion, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” Ms. Peck said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

“You can hide things in a resume,” she said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, Ms. Peck said.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said. Their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense, and it's enough, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

“You can hide things in a resume,” Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, said Ms. Peck.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, “I thought if I gave her positive feedback it might cause her to change,” Ms. Peck explained.

Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said.

An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

“You can hide things in a resume,” Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, said Ms. Peck.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, “I thought if I gave her positive feedback it might cause her to change,” Ms. Peck explained.

Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said.

An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

“You can hide things in a resume,” Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, said Ms. Peck.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, “I thought if I gave her positive feedback it might cause her to change,” Ms. Peck explained.

Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said.

An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

SAN DIEGO — The extra time required for prescribing isotretinoin under the iPLEDGE program need not go unreimbursed, Dr. Allan Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Coordinating a patient's isotretinoin care with the patient, family, and pharmacist, and fulfilling requirements of the federally mandated system often entail more work than the other components of a patient's visit, such as the history and the physical.

“It's important to remember that time can be used for coding when counseling and/or coordination of care constitutes more than 50% of the total physician encounter with patient and/or family,” said Dr. Wirtzer.

Therefore, clinicians should consider billing these visits according to the total time of the encounter, detailing in the patient's chart the type of counseling and coordination of care performed during those minutes, suggested Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., and chair of the American Academy of Dermatology's Task Force on Coding and Reimbursement.

He offered two chart notes that would justify a CPT billing code of 99214, using time as the criteria rather than details of the history, physical examination, and decision-making process:

▸ Extended discussion with mother and patient regarding causes of acne and treatment options—counseling 10 of 15 minutes.

▸ Documentation of pregnancy status and recent blood tests via the iPLEDGE program to coordinate the prescription of Accutane with the pharmacy—15 of 25 minutes.

“We're talking about face-to-face care in the office,” Dr. Wirtzer noted. “When the patient is in the office [and] you're putting information regarding Accutane into the computer [for iPLEDGE], that's time related to coordination of care, and it counts. But you have to document what you've done and how much time you spent.”

Calling a pharmacist after the patient has left the office cannot be included in the time contributing to billing for a visit using the 99214 code, he explained.

Dr. Wirtzer encouraged colleagues to be aware of the level of coding that would be supported by documenting key components of a visit (history, physical examination, decision making, etc.) and to compare that to the level the visit would qualify for if “time” was used as the determining factor.

The times specified for CPT reimbursement levels for established patients include 15 minutes for a 99213, 25 minutes for a 99214, and 40 minutes for a 99215.

SAN DIEGO — The extra time required for prescribing isotretinoin under the iPLEDGE program need not go unreimbursed, Dr. Allan Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Coordinating a patient's isotretinoin care with the patient, family, and pharmacist, and fulfilling requirements of the federally mandated system often entail more work than the other components of a patient's visit, such as the history and the physical.

“It's important to remember that time can be used for coding when counseling and/or coordination of care constitutes more than 50% of the total physician encounter with patient and/or family,” said Dr. Wirtzer.

Therefore, clinicians should consider billing these visits according to the total time of the encounter, detailing in the patient's chart the type of counseling and coordination of care performed during those minutes, suggested Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., and chair of the American Academy of Dermatology's Task Force on Coding and Reimbursement.

He offered two chart notes that would justify a CPT billing code of 99214, using time as the criteria rather than details of the history, physical examination, and decision-making process:

▸ Extended discussion with mother and patient regarding causes of acne and treatment options—counseling 10 of 15 minutes.

▸ Documentation of pregnancy status and recent blood tests via the iPLEDGE program to coordinate the prescription of Accutane with the pharmacy—15 of 25 minutes.

“We're talking about face-to-face care in the office,” Dr. Wirtzer noted. “When the patient is in the office [and] you're putting information regarding Accutane into the computer [for iPLEDGE], that's time related to coordination of care, and it counts. But you have to document what you've done and how much time you spent.”

Calling a pharmacist after the patient has left the office cannot be included in the time contributing to billing for a visit using the 99214 code, he explained.

Dr. Wirtzer encouraged colleagues to be aware of the level of coding that would be supported by documenting key components of a visit (history, physical examination, decision making, etc.) and to compare that to the level the visit would qualify for if “time” was used as the determining factor.

The times specified for CPT reimbursement levels for established patients include 15 minutes for a 99213, 25 minutes for a 99214, and 40 minutes for a 99215.

SAN DIEGO — The extra time required for prescribing isotretinoin under the iPLEDGE program need not go unreimbursed, Dr. Allan Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Coordinating a patient's isotretinoin care with the patient, family, and pharmacist, and fulfilling requirements of the federally mandated system often entail more work than the other components of a patient's visit, such as the history and the physical.

“It's important to remember that time can be used for coding when counseling and/or coordination of care constitutes more than 50% of the total physician encounter with patient and/or family,” said Dr. Wirtzer.

Therefore, clinicians should consider billing these visits according to the total time of the encounter, detailing in the patient's chart the type of counseling and coordination of care performed during those minutes, suggested Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., and chair of the American Academy of Dermatology's Task Force on Coding and Reimbursement.

He offered two chart notes that would justify a CPT billing code of 99214, using time as the criteria rather than details of the history, physical examination, and decision-making process:

▸ Extended discussion with mother and patient regarding causes of acne and treatment options—counseling 10 of 15 minutes.

▸ Documentation of pregnancy status and recent blood tests via the iPLEDGE program to coordinate the prescription of Accutane with the pharmacy—15 of 25 minutes.

“We're talking about face-to-face care in the office,” Dr. Wirtzer noted. “When the patient is in the office [and] you're putting information regarding Accutane into the computer [for iPLEDGE], that's time related to coordination of care, and it counts. But you have to document what you've done and how much time you spent.”

Calling a pharmacist after the patient has left the office cannot be included in the time contributing to billing for a visit using the 99214 code, he explained.

Dr. Wirtzer encouraged colleagues to be aware of the level of coding that would be supported by documenting key components of a visit (history, physical examination, decision making, etc.) and to compare that to the level the visit would qualify for if “time” was used as the determining factor.

The times specified for CPT reimbursement levels for established patients include 15 minutes for a 99213, 25 minutes for a 99214, and 40 minutes for a 99215.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said. Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Decisions regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said.

An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said. Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Decisions regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said.

An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said. Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Decisions regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said.

An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

SAN DEIGO — An accurate diagnosis of melanoma in situ is often lifesaving, but its histology can be difficult to distinguish from benign histologic findings, Dr. Philip E. LeBoit said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Numerous and prominent melano-cytes on sun-damaged facial skin, particularly those that are near the eyelids, can easily be confused with those seen in melanoma in situ, as can enlarged melanocytes stimulated by a recent excision, said Dr. LeBoit, professor of clinical pathology and dermatology at the University of California, San Francisco.

Dr. Barbara Gilchrest and her associates first highlighted the presence of “actinic melanocytosis” when they reported many years ago that the basal layer of sun-damaged skin in patients of all ages contains twice the expected number of melanocytes (J. Invest. Dermatol. 1979;73:141–3). That finding was recently confirmed and elaborated upon in a recent study by Dr. Ali Hendi and associates.

“So it's not just an increase in the prominence or an increase in the size of melanocytes due to the macules around them in sun-damaged skin. There's actually an increase in number,” Dr. LeBoit said.

If dyschromia or solar lentigos further confuse the picture on facial skin, where there are more melanocytes than on other parts of the body, “nature is confounding you,” he said.

Dr. LeBoit offered the following clues, which he said should heighten the suspicion that a lesion is a melanoma in situ, rather than an artifact of skin that has been damaged by the sun:

▸ The presence of irregular intervals between melanocytes.

▸ Nests, which may be present in melanoma in situ, but not in actinic melanocytosis. Levels may be required to show them.

▸ Pagetoid spread, which also may require levels to be visualized.

▸ Prominent dendrites, which are sometimes, though not necessarily always, present in melanoma in situ. Dr. LeBoit cautioned, however, that dendrites may be seen more prominently in dark-skinned patients.

▸ More irregular pigmentation.

▸ More marked adnexal involvement, except in the case of lentigo melanoma. (In actinic melanocytosis, large melanocytes may extend more deeply or symmetrically in the follicular infundibula and acrosyringia.)

Immunohistochemical studies using HMB-45 or Ki-67(MIB-1) stains are of little use in distinguishing melanoma in situ from actinic melanocytosis, he pointed out.

The results of recent studies from Italy also suggest that the use of immunoperoxidase stains in this context can lead to the “overdiagnosis” of melanoma in situ, said Dr. LeBoit, who founded and codirects the university's dermatopathology service.

A more reliable alternative is to simply biopsy the contralateral side of sun-exposed facial skin, he suggested.

“If you find the exact same picture, then that's just what the patient's face looks like,” he said.

The second dilemma he posed—that is, distinguishing melanoma in situ from recently excised skin—also has a fairly simple solution, as it turns out.

Dr. LeBoit explained that all biopsies stimulate a release of cytokines during the wound-healing process, which in turn activates melanocytes, especially on facial skin.

“Even the best dermatopathologists in the world sometimes cannot tell melanocyte activation by the wound-healing process from the very edge of a melanoma in situ,” he asserted.

His solution? Wait to reexcise.

“Once you've gotten a clinically evident melanoma in situ out, although the patient may be anxious, there is no medical reason to bring them in the next day to do a reexcision,” Dr. LeBoit said.

“You can wait a month. At that point, you will have no enlargement of melanocytes to confuse the picture,” he commented.

SAN DEIGO — An accurate diagnosis of melanoma in situ is often lifesaving, but its histology can be difficult to distinguish from benign histologic findings, Dr. Philip E. LeBoit said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Numerous and prominent melano-cytes on sun-damaged facial skin, particularly those that are near the eyelids, can easily be confused with those seen in melanoma in situ, as can enlarged melanocytes stimulated by a recent excision, said Dr. LeBoit, professor of clinical pathology and dermatology at the University of California, San Francisco.

Dr. Barbara Gilchrest and her associates first highlighted the presence of “actinic melanocytosis” when they reported many years ago that the basal layer of sun-damaged skin in patients of all ages contains twice the expected number of melanocytes (J. Invest. Dermatol. 1979;73:141–3). That finding was recently confirmed and elaborated upon in a recent study by Dr. Ali Hendi and associates.

“So it's not just an increase in the prominence or an increase in the size of melanocytes due to the macules around them in sun-damaged skin. There's actually an increase in number,” Dr. LeBoit said.

If dyschromia or solar lentigos further confuse the picture on facial skin, where there are more melanocytes than on other parts of the body, “nature is confounding you,” he said.

Dr. LeBoit offered the following clues, which he said should heighten the suspicion that a lesion is a melanoma in situ, rather than an artifact of skin that has been damaged by the sun:

▸ The presence of irregular intervals between melanocytes.

▸ Nests, which may be present in melanoma in situ, but not in actinic melanocytosis. Levels may be required to show them.

▸ Pagetoid spread, which also may require levels to be visualized.

▸ Prominent dendrites, which are sometimes, though not necessarily always, present in melanoma in situ. Dr. LeBoit cautioned, however, that dendrites may be seen more prominently in dark-skinned patients.

▸ More irregular pigmentation.

▸ More marked adnexal involvement, except in the case of lentigo melanoma. (In actinic melanocytosis, large melanocytes may extend more deeply or symmetrically in the follicular infundibula and acrosyringia.)

Immunohistochemical studies using HMB-45 or Ki-67(MIB-1) stains are of little use in distinguishing melanoma in situ from actinic melanocytosis, he pointed out.

The results of recent studies from Italy also suggest that the use of immunoperoxidase stains in this context can lead to the “overdiagnosis” of melanoma in situ, said Dr. LeBoit, who founded and codirects the university's dermatopathology service.

A more reliable alternative is to simply biopsy the contralateral side of sun-exposed facial skin, he suggested.

“If you find the exact same picture, then that's just what the patient's face looks like,” he said.

The second dilemma he posed—that is, distinguishing melanoma in situ from recently excised skin—also has a fairly simple solution, as it turns out.

Dr. LeBoit explained that all biopsies stimulate a release of cytokines during the wound-healing process, which in turn activates melanocytes, especially on facial skin.

“Even the best dermatopathologists in the world sometimes cannot tell melanocyte activation by the wound-healing process from the very edge of a melanoma in situ,” he asserted.

His solution? Wait to reexcise.

“Once you've gotten a clinically evident melanoma in situ out, although the patient may be anxious, there is no medical reason to bring them in the next day to do a reexcision,” Dr. LeBoit said.

“You can wait a month. At that point, you will have no enlargement of melanocytes to confuse the picture,” he commented.

SAN DEIGO — An accurate diagnosis of melanoma in situ is often lifesaving, but its histology can be difficult to distinguish from benign histologic findings, Dr. Philip E. LeBoit said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Numerous and prominent melano-cytes on sun-damaged facial skin, particularly those that are near the eyelids, can easily be confused with those seen in melanoma in situ, as can enlarged melanocytes stimulated by a recent excision, said Dr. LeBoit, professor of clinical pathology and dermatology at the University of California, San Francisco.

Dr. Barbara Gilchrest and her associates first highlighted the presence of “actinic melanocytosis” when they reported many years ago that the basal layer of sun-damaged skin in patients of all ages contains twice the expected number of melanocytes (J. Invest. Dermatol. 1979;73:141–3). That finding was recently confirmed and elaborated upon in a recent study by Dr. Ali Hendi and associates.

“So it's not just an increase in the prominence or an increase in the size of melanocytes due to the macules around them in sun-damaged skin. There's actually an increase in number,” Dr. LeBoit said.

If dyschromia or solar lentigos further confuse the picture on facial skin, where there are more melanocytes than on other parts of the body, “nature is confounding you,” he said.

Dr. LeBoit offered the following clues, which he said should heighten the suspicion that a lesion is a melanoma in situ, rather than an artifact of skin that has been damaged by the sun:

▸ The presence of irregular intervals between melanocytes.

▸ Nests, which may be present in melanoma in situ, but not in actinic melanocytosis. Levels may be required to show them.

▸ Pagetoid spread, which also may require levels to be visualized.

▸ Prominent dendrites, which are sometimes, though not necessarily always, present in melanoma in situ. Dr. LeBoit cautioned, however, that dendrites may be seen more prominently in dark-skinned patients.

▸ More irregular pigmentation.

▸ More marked adnexal involvement, except in the case of lentigo melanoma. (In actinic melanocytosis, large melanocytes may extend more deeply or symmetrically in the follicular infundibula and acrosyringia.)

Immunohistochemical studies using HMB-45 or Ki-67(MIB-1) stains are of little use in distinguishing melanoma in situ from actinic melanocytosis, he pointed out.

The results of recent studies from Italy also suggest that the use of immunoperoxidase stains in this context can lead to the “overdiagnosis” of melanoma in situ, said Dr. LeBoit, who founded and codirects the university's dermatopathology service.

A more reliable alternative is to simply biopsy the contralateral side of sun-exposed facial skin, he suggested.

“If you find the exact same picture, then that's just what the patient's face looks like,” he said.

The second dilemma he posed—that is, distinguishing melanoma in situ from recently excised skin—also has a fairly simple solution, as it turns out.

Dr. LeBoit explained that all biopsies stimulate a release of cytokines during the wound-healing process, which in turn activates melanocytes, especially on facial skin.

“Even the best dermatopathologists in the world sometimes cannot tell melanocyte activation by the wound-healing process from the very edge of a melanoma in situ,” he asserted.

His solution? Wait to reexcise.

“Once you've gotten a clinically evident melanoma in situ out, although the patient may be anxious, there is no medical reason to bring them in the next day to do a reexcision,” Dr. LeBoit said.

“You can wait a month. At that point, you will have no enlargement of melanocytes to confuse the picture,” he commented.

SAN DIEGO — Melanoma of the foot and ankle occurred far more commonly in women than it did in men, but men were more likely to have thicker tumors that were associated with a worse prognosis, Dr. Hugh T. Greenway said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

In a review of 63 cases seen over 20 years at the Scripps Clinic in La Jolla, Calif., patients were the first to draw attention to melanoma lesions in 44 cases. Physicians spotted them in seven cases, and both were credited in five, Dr. Greenway reported.

There was no association between trauma and melanoma in the series.

Possible factors contributing to the disease remain unclear, said Dr. Greenway, who heads the clinic's division of Mohs/dermatologic surgery.

Sunburns, the binding pressure of shoes, and perhaps exposure to unfiltered radiation from fitting devices at Buster Brown shoe stores in the 1950s and 1960s may be contributing to melanoma of the lower extremities.

In all, foot and ankle melanoma constituted 4% of all melanoma cases diagnosed at Scripps over 2 decades, occurring in 47 women and 16 men. The mean age at diagnosis was 58 years.

Melanomas occurring on the foot and ankle are more often misdiagnosed than melanomas on any other anatomic site, Dr. Greenway said. In his series, 10 cases, or 16%, were originally misdiagnosed.

“We're used to seeing benign conditions of the foot,” he said, noting that some melanoma lesions may be dismissed as verrucae, toenail onychomycosis, subungual hematomas, tinea pedis, or ischemic ulcers.

“For the most part, prognosis is not good,” with 5-year survival ranging from 52% to 71% in previous series, noted Dr. Greenway.

The Scripps series showed a 4-year survival of 80%, with disease-free survival in 73% (46 patients). One reason for the high survival of Scripps patients could be that 24 of the 63 cases were melanoma in situ.

“The real key [to generally poor survival statistics] is that we don't pick these up as early as we do melanoma on other parts of the skin surface,” he said.

People don't regularly examine their feet, and the process becomes even more difficult with age and infirmities. In addition, some clinicians don't even have patients remove their socks during skin examinations, said Dr. Greenway.

Women may be diagnosed with less-thick melanomas because they pay more attention to their feet than men do and they are also more likely to get pedicures, he speculated.

Presumably these cases are diagnosed earlier.

Many patients, however, have trouble remembering how long the lesions have been on their feet or ankles, perhaps accounting for the failure of Dr. Greenway's group to find an association between tumor thickness and duration.

In 10 cases, a biopsy underestimated the Breslow thickness of the tumor. Seven of these cases were upstaged during the treatment process, which consists of surgery, consideration of sentinel node examination, a metastatic and oncology evaluation, and follow-up.

Disease-free survival was significantly worse in the Scripps series for thicker tumors, a higher stage, males, and tumors initially misdiagnosed.

Increased surveillance did not improve survival in the series, he noted.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Melanoma of the foot and ankle occurred far more commonly in women than it did in men, but men were more likely to have thicker tumors that were associated with a worse prognosis, Dr. Hugh T. Greenway said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

In a review of 63 cases seen over 20 years at the Scripps Clinic in La Jolla, Calif., patients were the first to draw attention to melanoma lesions in 44 cases. Physicians spotted them in seven cases, and both were credited in five, Dr. Greenway reported.

There was no association between trauma and melanoma in the series.

Possible factors contributing to the disease remain unclear, said Dr. Greenway, who heads the clinic's division of Mohs/dermatologic surgery.

Sunburns, the binding pressure of shoes, and perhaps exposure to unfiltered radiation from fitting devices at Buster Brown shoe stores in the 1950s and 1960s may be contributing to melanoma of the lower extremities.

In all, foot and ankle melanoma constituted 4% of all melanoma cases diagnosed at Scripps over 2 decades, occurring in 47 women and 16 men. The mean age at diagnosis was 58 years.

Melanomas occurring on the foot and ankle are more often misdiagnosed than melanomas on any other anatomic site, Dr. Greenway said. In his series, 10 cases, or 16%, were originally misdiagnosed.

“We're used to seeing benign conditions of the foot,” he said, noting that some melanoma lesions may be dismissed as verrucae, toenail onychomycosis, subungual hematomas, tinea pedis, or ischemic ulcers.

“For the most part, prognosis is not good,” with 5-year survival ranging from 52% to 71% in previous series, noted Dr. Greenway.

The Scripps series showed a 4-year survival of 80%, with disease-free survival in 73% (46 patients). One reason for the high survival of Scripps patients could be that 24 of the 63 cases were melanoma in situ.

“The real key [to generally poor survival statistics] is that we don't pick these up as early as we do melanoma on other parts of the skin surface,” he said.

People don't regularly examine their feet, and the process becomes even more difficult with age and infirmities. In addition, some clinicians don't even have patients remove their socks during skin examinations, said Dr. Greenway.

Women may be diagnosed with less-thick melanomas because they pay more attention to their feet than men do and they are also more likely to get pedicures, he speculated.

Presumably these cases are diagnosed earlier.

Many patients, however, have trouble remembering how long the lesions have been on their feet or ankles, perhaps accounting for the failure of Dr. Greenway's group to find an association between tumor thickness and duration.

In 10 cases, a biopsy underestimated the Breslow thickness of the tumor. Seven of these cases were upstaged during the treatment process, which consists of surgery, consideration of sentinel node examination, a metastatic and oncology evaluation, and follow-up.

Disease-free survival was significantly worse in the Scripps series for thicker tumors, a higher stage, males, and tumors initially misdiagnosed.

Increased surveillance did not improve survival in the series, he noted.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Melanoma of the foot and ankle occurred far more commonly in women than it did in men, but men were more likely to have thicker tumors that were associated with a worse prognosis, Dr. Hugh T. Greenway said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

In a review of 63 cases seen over 20 years at the Scripps Clinic in La Jolla, Calif., patients were the first to draw attention to melanoma lesions in 44 cases. Physicians spotted them in seven cases, and both were credited in five, Dr. Greenway reported.

There was no association between trauma and melanoma in the series.

Possible factors contributing to the disease remain unclear, said Dr. Greenway, who heads the clinic's division of Mohs/dermatologic surgery.

Sunburns, the binding pressure of shoes, and perhaps exposure to unfiltered radiation from fitting devices at Buster Brown shoe stores in the 1950s and 1960s may be contributing to melanoma of the lower extremities.

In all, foot and ankle melanoma constituted 4% of all melanoma cases diagnosed at Scripps over 2 decades, occurring in 47 women and 16 men. The mean age at diagnosis was 58 years.

Melanomas occurring on the foot and ankle are more often misdiagnosed than melanomas on any other anatomic site, Dr. Greenway said. In his series, 10 cases, or 16%, were originally misdiagnosed.

“We're used to seeing benign conditions of the foot,” he said, noting that some melanoma lesions may be dismissed as verrucae, toenail onychomycosis, subungual hematomas, tinea pedis, or ischemic ulcers.

“For the most part, prognosis is not good,” with 5-year survival ranging from 52% to 71% in previous series, noted Dr. Greenway.

The Scripps series showed a 4-year survival of 80%, with disease-free survival in 73% (46 patients). One reason for the high survival of Scripps patients could be that 24 of the 63 cases were melanoma in situ.

“The real key [to generally poor survival statistics] is that we don't pick these up as early as we do melanoma on other parts of the skin surface,” he said.

People don't regularly examine their feet, and the process becomes even more difficult with age and infirmities. In addition, some clinicians don't even have patients remove their socks during skin examinations, said Dr. Greenway.

Women may be diagnosed with less-thick melanomas because they pay more attention to their feet than men do and they are also more likely to get pedicures, he speculated.

Presumably these cases are diagnosed earlier.

Many patients, however, have trouble remembering how long the lesions have been on their feet or ankles, perhaps accounting for the failure of Dr. Greenway's group to find an association between tumor thickness and duration.

In 10 cases, a biopsy underestimated the Breslow thickness of the tumor. Seven of these cases were upstaged during the treatment process, which consists of surgery, consideration of sentinel node examination, a metastatic and oncology evaluation, and follow-up.

Disease-free survival was significantly worse in the Scripps series for thicker tumors, a higher stage, males, and tumors initially misdiagnosed.

Increased surveillance did not improve survival in the series, he noted.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES – Adherence to a self-care action plan helped primary care patients exceed national goals for reducing their depression, reported Dr. Doriane C. Miller, associate division chief of general internal medicine at Stroger Hospital of Cook County in Chicago.

The study of 403 depressed adults in rural South Carolina has implications for improving outcomes for patients with diabetes, whose depression undermines their ability to manage a complex disease, she said at the annual meeting of the American Association of Diabetes Educators.

Patients at CareSouth, a series of federally qualified health centers serving mostly minority, low-income residents, were screened using the Patient Health Questionnaire-9 (PHQ-9), an instrument made available by Pfizer (www.pfizer.com/pfizer/phq-9/index.jsp

Those patients whose scores indicated they had clinically significant depression were enrolled in a collaborative self-management program that included the Depression Self-Care Action Plan (www.collaborativeselfmanagement.org/uploads/ManagingDepression.pdf

Focusing on “simple goals and small steps,” the plan helps patients establish concrete ways to stay physically active, engage in pleasurable activities, spend time with supportive people, incorporate relaxation into their daily lives, and identify life stresses and ways to deal with them.

It's a “living process document,” reviewed at appointments and adapted to the reality of patients' often troubled lives, Dr. Miller said.

After 1 year, 56% of patients had reduced their depression scores by more than 50%, compared with a national goal of 40%. Fully 85% of patients had documented their self-management of depression, compared with a national goal of 70%. About one-fourth of patients participating in the depression collaborative, sponsored by the Health Resources and Services Administration's Bureau of Primary Health Care, had diabetes as a comorbidity.

Perhaps most dramatically, 53% of patients no longer met the PHQ-9 threshold for depression, compared with a national goal of 40%.

“We find this kind of self-care action plan can be a very useful tool for people who have depression and, particularly, people with diabetes [who have depression],” said Dr. Miller, who also serves as national program director of Quality Allies, an effort aimed at improving ambulatory care that is sponsored by the Robert Wood Johnson Foundation and the California HealthCare Foundation.

As many as one in four patients with diabetes have depression, but it can be missed in quick office visits or disguised as hostility, apathetic noncompliance, or a seeming inability to concentrate and follow directions.

People with diabetes are especially burdened by a sense of hopelessness and helplessness about downstream consequences of their disease, such as amputation, blindness, myocardial infarction, or stroke, Dr. Miller said.

“It can have a strong influence on their thinking,” she said. “[They start thinking] 'if it happened to my brother, my grandfather, my mother, it's going to happen to me. It's just a hopeless situation and something I need to bear.'”

Dr. Miller said primary care physicians often don't even want to ask about depression, since they feel unable to deal with it in the 15-minute time slots allotted to appointments for chronic conditions.

But diabetes care can be severely impacted by depression, on many levels. “Patients oftentimes will self-medicate their depression by eating more. They won't check their blood sugar [levels],” she said.

When concentration is hampered by depression, patients will return to the office failing to recall even a simple care plan they agreed to on a previous visit.

“If you're not able to address some of the underlying causes for medication nonadherence, you're not going to get anywhere in terms of clinical treatment,” she said.

Dr. Miller currently screens all of her patients with diabetes using the PHQ-9 at least once a year. When patients screen positive, she sees them more often than usual–at least three times in 90 days if they are receiving an antidepressant–and rescreens them with the PHQ-9 every 4–6 weeks.

She has seen clear benefits of this approach in her own practice, she said.

She described a patient in her late 50s whose diabetes control was falling apart even as she coped with the loss of a job and ensuing financial difficulties and weight gain. By identifying her depression and helping her to implement a self-care plan, Dr. Miller was able to watch as her patient became more physically active and lost weight, began an earnest job search, and returned to HbA_1c levels in the range of 7%–8%, down from a level of 10%.

Dr. Miller has no financial ties to Pfizer, sponsor of the PHQ-9.

Addressing some of the underlying causes for medication nonadherence is critical. DR. MILLER

LOS ANGELES – Adherence to a self-care action plan helped primary care patients exceed national goals for reducing their depression, reported Dr. Doriane C. Miller, associate division chief of general internal medicine at Stroger Hospital of Cook County in Chicago.

The study of 403 depressed adults in rural South Carolina has implications for improving outcomes for patients with diabetes, whose depression undermines their ability to manage a complex disease, she said at the annual meeting of the American Association of Diabetes Educators.

Patients at CareSouth, a series of federally qualified health centers serving mostly minority, low-income residents, were screened using the Patient Health Questionnaire-9 (PHQ-9), an instrument made available by Pfizer (www.pfizer.com/pfizer/phq-9/index.jsp

Those patients whose scores indicated they had clinically significant depression were enrolled in a collaborative self-management program that included the Depression Self-Care Action Plan (www.collaborativeselfmanagement.org/uploads/ManagingDepression.pdf

Focusing on “simple goals and small steps,” the plan helps patients establish concrete ways to stay physically active, engage in pleasurable activities, spend time with supportive people, incorporate relaxation into their daily lives, and identify life stresses and ways to deal with them.

It's a “living process document,” reviewed at appointments and adapted to the reality of patients' often troubled lives, Dr. Miller said.

After 1 year, 56% of patients had reduced their depression scores by more than 50%, compared with a national goal of 40%. Fully 85% of patients had documented their self-management of depression, compared with a national goal of 70%. About one-fourth of patients participating in the depression collaborative, sponsored by the Health Resources and Services Administration's Bureau of Primary Health Care, had diabetes as a comorbidity.

Perhaps most dramatically, 53% of patients no longer met the PHQ-9 threshold for depression, compared with a national goal of 40%.

“We find this kind of self-care action plan can be a very useful tool for people who have depression and, particularly, people with diabetes [who have depression],” said Dr. Miller, who also serves as national program director of Quality Allies, an effort aimed at improving ambulatory care that is sponsored by the Robert Wood Johnson Foundation and the California HealthCare Foundation.

As many as one in four patients with diabetes have depression, but it can be missed in quick office visits or disguised as hostility, apathetic noncompliance, or a seeming inability to concentrate and follow directions.

People with diabetes are especially burdened by a sense of hopelessness and helplessness about downstream consequences of their disease, such as amputation, blindness, myocardial infarction, or stroke, Dr. Miller said.

“It can have a strong influence on their thinking,” she said. “[They start thinking] 'if it happened to my brother, my grandfather, my mother, it's going to happen to me. It's just a hopeless situation and something I need to bear.'”

Dr. Miller said primary care physicians often don't even want to ask about depression, since they feel unable to deal with it in the 15-minute time slots allotted to appointments for chronic conditions.

But diabetes care can be severely impacted by depression, on many levels. “Patients oftentimes will self-medicate their depression by eating more. They won't check their blood sugar [levels],” she said.

When concentration is hampered by depression, patients will return to the office failing to recall even a simple care plan they agreed to on a previous visit.

“If you're not able to address some of the underlying causes for medication nonadherence, you're not going to get anywhere in terms of clinical treatment,” she said.

Dr. Miller currently screens all of her patients with diabetes using the PHQ-9 at least once a year. When patients screen positive, she sees them more often than usual–at least three times in 90 days if they are receiving an antidepressant–and rescreens them with the PHQ-9 every 4–6 weeks.

She has seen clear benefits of this approach in her own practice, she said.

She described a patient in her late 50s whose diabetes control was falling apart even as she coped with the loss of a job and ensuing financial difficulties and weight gain. By identifying her depression and helping her to implement a self-care plan, Dr. Miller was able to watch as her patient became more physically active and lost weight, began an earnest job search, and returned to HbA_1c levels in the range of 7%–8%, down from a level of 10%.

Dr. Miller has no financial ties to Pfizer, sponsor of the PHQ-9.

Addressing some of the underlying causes for medication nonadherence is critical. DR. MILLER

LOS ANGELES – Adherence to a self-care action plan helped primary care patients exceed national goals for reducing their depression, reported Dr. Doriane C. Miller, associate division chief of general internal medicine at Stroger Hospital of Cook County in Chicago.

The study of 403 depressed adults in rural South Carolina has implications for improving outcomes for patients with diabetes, whose depression undermines their ability to manage a complex disease, she said at the annual meeting of the American Association of Diabetes Educators.

Patients at CareSouth, a series of federally qualified health centers serving mostly minority, low-income residents, were screened using the Patient Health Questionnaire-9 (PHQ-9), an instrument made available by Pfizer (www.pfizer.com/pfizer/phq-9/index.jsp

Those patients whose scores indicated they had clinically significant depression were enrolled in a collaborative self-management program that included the Depression Self-Care Action Plan (www.collaborativeselfmanagement.org/uploads/ManagingDepression.pdf

Focusing on “simple goals and small steps,” the plan helps patients establish concrete ways to stay physically active, engage in pleasurable activities, spend time with supportive people, incorporate relaxation into their daily lives, and identify life stresses and ways to deal with them.

It's a “living process document,” reviewed at appointments and adapted to the reality of patients' often troubled lives, Dr. Miller said.

After 1 year, 56% of patients had reduced their depression scores by more than 50%, compared with a national goal of 40%. Fully 85% of patients had documented their self-management of depression, compared with a national goal of 70%. About one-fourth of patients participating in the depression collaborative, sponsored by the Health Resources and Services Administration's Bureau of Primary Health Care, had diabetes as a comorbidity.

Perhaps most dramatically, 53% of patients no longer met the PHQ-9 threshold for depression, compared with a national goal of 40%.

“We find this kind of self-care action plan can be a very useful tool for people who have depression and, particularly, people with diabetes [who have depression],” said Dr. Miller, who also serves as national program director of Quality Allies, an effort aimed at improving ambulatory care that is sponsored by the Robert Wood Johnson Foundation and the California HealthCare Foundation.

As many as one in four patients with diabetes have depression, but it can be missed in quick office visits or disguised as hostility, apathetic noncompliance, or a seeming inability to concentrate and follow directions.

People with diabetes are especially burdened by a sense of hopelessness and helplessness about downstream consequences of their disease, such as amputation, blindness, myocardial infarction, or stroke, Dr. Miller said.

“It can have a strong influence on their thinking,” she said. “[They start thinking] 'if it happened to my brother, my grandfather, my mother, it's going to happen to me. It's just a hopeless situation and something I need to bear.'”

Dr. Miller said primary care physicians often don't even want to ask about depression, since they feel unable to deal with it in the 15-minute time slots allotted to appointments for chronic conditions.

But diabetes care can be severely impacted by depression, on many levels. “Patients oftentimes will self-medicate their depression by eating more. They won't check their blood sugar [levels],” she said.

When concentration is hampered by depression, patients will return to the office failing to recall even a simple care plan they agreed to on a previous visit.

“If you're not able to address some of the underlying causes for medication nonadherence, you're not going to get anywhere in terms of clinical treatment,” she said.

Dr. Miller currently screens all of her patients with diabetes using the PHQ-9 at least once a year. When patients screen positive, she sees them more often than usual–at least three times in 90 days if they are receiving an antidepressant–and rescreens them with the PHQ-9 every 4–6 weeks.

She has seen clear benefits of this approach in her own practice, she said.

She described a patient in her late 50s whose diabetes control was falling apart even as she coped with the loss of a job and ensuing financial difficulties and weight gain. By identifying her depression and helping her to implement a self-care plan, Dr. Miller was able to watch as her patient became more physically active and lost weight, began an earnest job search, and returned to HbA_1c levels in the range of 7%–8%, down from a level of 10%.

Dr. Miller has no financial ties to Pfizer, sponsor of the PHQ-9.

Addressing some of the underlying causes for medication nonadherence is critical. DR. MILLER

LOS ANGELES – In any given year, 6% of adolescents aged 12–19 years experience at least one migraine headache, according to the American Migraine Prevalence and Prevention Study released at the annual meeting of the American Headache Society.

Nearly a third of those teenagers have migraines so frequent and severe that they should be offered preventive therapy or at least be considered potential candidates for a prevention regimen, based on thresholds set by a consensus of headache specialists, according to Dr. Paul Winner, director of the Palm Beach Headache Center in West Palm Beach, Fla. Yet only 11% of teenage migraineurs receive such treatment.

The national prevalence study drew from results of validated questionnaires sent to 120,000 households representative of the U.S. population. Among 18,714 respondents whose descriptions of their headaches met the International Headache Society criteria for migraine, 1,178 were adolescents.

The 1-year prevalence for migraine among these respondents was 5% of males and 7.7% of females, with a female predominance that rose through early adolescence to peak in those aged 15–16 years, when 8.1% of females reported migraines.

Nearly 60% of the adolescents used over-the-counter (OTC) medications to treat their migraines, 16.5% relied on prescription medications, and 22% used a combination of OTC and prescription medications for their acute headaches.

An expert panel linked to the study determined by consensus the factors that should warrant consideration or an offer of a medication that could be taken on a regular basis to reduce the number or severity of migraines. The preventive medications noted include anticonvulsants, blood pressure medications, and antidepressants shown to reduce the frequency of migraines.

For example, the panel's consensus was that preventive therapy should be offered to any patient with six or more migraines per month, when some of those migraines involve severe impairment of activities and require bedrest.

Among the adolescents in the study, 21% met consensus threshold for an offer of preventive therapy and 10% would be considered potential candidates for such therapy, said Dr. Winner. There was no indication for preventive therapy in 69%.

Some adolescents who were candidates for preventive therapy had used it in the past or were using such a medication for another indication. But one in four candidates for a preventive medication had never used one.

Dr. Winner noted that up to 40% of adolescents “cycle in and out of migraines,” with gaps in time when they suffer no such headaches. Another 30% suffer one migraine and never develop another.

However, within the remaining population with migraines, there is a vulnerable group of adolescents who risk progression to transformed migraine, sometimes within just 2 years.

Future research is underway to determine whether adolescent patients who appropriately receive preventive medications for frequent and severe migraines will be less likely than others to develop transformed migraines, Dr. Winner said.

The study was sponsored by an unrestricted grant from Ortho-McNeil Inc.

LOS ANGELES – In any given year, 6% of adolescents aged 12–19 years experience at least one migraine headache, according to the American Migraine Prevalence and Prevention Study released at the annual meeting of the American Headache Society.

Nearly a third of those teenagers have migraines so frequent and severe that they should be offered preventive therapy or at least be considered potential candidates for a prevention regimen, based on thresholds set by a consensus of headache specialists, according to Dr. Paul Winner, director of the Palm Beach Headache Center in West Palm Beach, Fla. Yet only 11% of teenage migraineurs receive such treatment.

The national prevalence study drew from results of validated questionnaires sent to 120,000 households representative of the U.S. population. Among 18,714 respondents whose descriptions of their headaches met the International Headache Society criteria for migraine, 1,178 were adolescents.

The 1-year prevalence for migraine among these respondents was 5% of males and 7.7% of females, with a female predominance that rose through early adolescence to peak in those aged 15–16 years, when 8.1% of females reported migraines.

Nearly 60% of the adolescents used over-the-counter (OTC) medications to treat their migraines, 16.5% relied on prescription medications, and 22% used a combination of OTC and prescription medications for their acute headaches.

An expert panel linked to the study determined by consensus the factors that should warrant consideration or an offer of a medication that could be taken on a regular basis to reduce the number or severity of migraines. The preventive medications noted include anticonvulsants, blood pressure medications, and antidepressants shown to reduce the frequency of migraines.

For example, the panel's consensus was that preventive therapy should be offered to any patient with six or more migraines per month, when some of those migraines involve severe impairment of activities and require bedrest.

Among the adolescents in the study, 21% met consensus threshold for an offer of preventive therapy and 10% would be considered potential candidates for such therapy, said Dr. Winner. There was no indication for preventive therapy in 69%.

Some adolescents who were candidates for preventive therapy had used it in the past or were using such a medication for another indication. But one in four candidates for a preventive medication had never used one.

Dr. Winner noted that up to 40% of adolescents “cycle in and out of migraines,” with gaps in time when they suffer no such headaches. Another 30% suffer one migraine and never develop another.

However, within the remaining population with migraines, there is a vulnerable group of adolescents who risk progression to transformed migraine, sometimes within just 2 years.

Future research is underway to determine whether adolescent patients who appropriately receive preventive medications for frequent and severe migraines will be less likely than others to develop transformed migraines, Dr. Winner said.

The study was sponsored by an unrestricted grant from Ortho-McNeil Inc.

LOS ANGELES – In any given year, 6% of adolescents aged 12–19 years experience at least one migraine headache, according to the American Migraine Prevalence and Prevention Study released at the annual meeting of the American Headache Society.

Nearly a third of those teenagers have migraines so frequent and severe that they should be offered preventive therapy or at least be considered potential candidates for a prevention regimen, based on thresholds set by a consensus of headache specialists, according to Dr. Paul Winner, director of the Palm Beach Headache Center in West Palm Beach, Fla. Yet only 11% of teenage migraineurs receive such treatment.

The national prevalence study drew from results of validated questionnaires sent to 120,000 households representative of the U.S. population. Among 18,714 respondents whose descriptions of their headaches met the International Headache Society criteria for migraine, 1,178 were adolescents.

The 1-year prevalence for migraine among these respondents was 5% of males and 7.7% of females, with a female predominance that rose through early adolescence to peak in those aged 15–16 years, when 8.1% of females reported migraines.

Nearly 60% of the adolescents used over-the-counter (OTC) medications to treat their migraines, 16.5% relied on prescription medications, and 22% used a combination of OTC and prescription medications for their acute headaches.

An expert panel linked to the study determined by consensus the factors that should warrant consideration or an offer of a medication that could be taken on a regular basis to reduce the number or severity of migraines. The preventive medications noted include anticonvulsants, blood pressure medications, and antidepressants shown to reduce the frequency of migraines.

For example, the panel's consensus was that preventive therapy should be offered to any patient with six or more migraines per month, when some of those migraines involve severe impairment of activities and require bedrest.

Among the adolescents in the study, 21% met consensus threshold for an offer of preventive therapy and 10% would be considered potential candidates for such therapy, said Dr. Winner. There was no indication for preventive therapy in 69%.

Some adolescents who were candidates for preventive therapy had used it in the past or were using such a medication for another indication. But one in four candidates for a preventive medication had never used one.

Dr. Winner noted that up to 40% of adolescents “cycle in and out of migraines,” with gaps in time when they suffer no such headaches. Another 30% suffer one migraine and never develop another.

However, within the remaining population with migraines, there is a vulnerable group of adolescents who risk progression to transformed migraine, sometimes within just 2 years.

Future research is underway to determine whether adolescent patients who appropriately receive preventive medications for frequent and severe migraines will be less likely than others to develop transformed migraines, Dr. Winner said.

The study was sponsored by an unrestricted grant from Ortho-McNeil Inc.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history. “You can hide things in a resume,” Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, Ms. Peck said.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, “I thought if I gave her positive feedback it might cause her to change,” Ms. Peck explained. Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, Ms. Peck said.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history. “You can hide things in a resume,” Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, Ms. Peck said.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, “I thought if I gave her positive feedback it might cause her to change,” Ms. Peck explained. Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, Ms. Peck said.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the “golden rules” of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by “unwelcome conduct,” she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history. “You can hide things in a resume,” Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an “at will” clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee “at will.” The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

“There are huge exceptions” to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, Ms. Peck said.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with “posturing princesses” or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow “soft” evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, “I thought if I gave her positive feedback it might cause her to change,” Ms. Peck explained. Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, Ms. Peck said.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get “into trouble with employment law,” she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a “clean” reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.