Betsy Bates

LOS CABOS, MEXICO — Every community dermatologist dreads the phrase, "Oh, by the way … "

It comes, all too often at the end of a harried day, spoken by the young mother with rosacea who waits until the last millisecond to point out her teenager's acne and her 8-year-old's hair loss.

To survive, clinicians often come up with creative, effective, and amusing strategies to cope with real-world dilemmas, but they rarely sit down and compare notes.

That's why Dr. Michael A. Greenberg, a dermatologist in Elk Grove Village, Ill., codirected a workshop entitled, Bring Us Your Office Problems, at the annual meeting of the Noah Worcester Dermatological Society.

The problems raged, but solutions abounded at the lively session. Here are some of the more thorny issues presented, as well as the attendees' suggestions.

"Oh, By the Way …"

All dermatologists who attended the session said they stop what they are doing and take a look only if the last-minute issue involves a black or otherwise suspicious lesion. If not, they delay. Some explain to patients that medicolegal rules require that any visit be documented in a chart. They send the patient and his or her entourage back to the front desk so a chart can be established or retrieved, and then offer to work the new patient into the schedule.

"It may be 5 minutes; it may be an hour," Dr. Charles Zugerman of Chicago tells his patients.

Dr. Lee J. Vesper of Cincinnati emphasized the complexity of what may seem like a simple issue: "There are 52 kinds of hair loss. I need to take a good history."

Dr. Greenberg quipped, "I don't take quick looks. I only take careful looks."

"I Have a List"

"Carpe registrar: Seize the list," advised Dr. Alan M. Ruben of Wheeling, W.Va.

The strategy has two rationales. First, patients often begin with the least important issue first. Second, many of the items on the list may be related to one condition, so reviewing the list may aid in diagnosis and treatment.

If the list is long and complex, prioritize the problems and assign the rest to a new appointment, attendees suggested.

"Why Did I Have to Wait So Long?"

The worst horror story came from Dr. Zugerman, who once faced a revolution in his waiting room when four or five patients united to demand that he come out to explain the "obscene" amount of time they had been waiting.

Many dermatologists said they have had to revise the way they schedule to alleviate waiting times. Dr. Stuart M. Brown of Dallas suggested stretching most appointment slots to 30 minutes and leaving open the last hour of the morning and the afternoon.

"I think it's a sin to keep people waiting a long time, but then act rushed," said Dr. Ruben. As he enters a room, he apologizes, first thing.

Dr. Greenberg keeps a plaque in his waiting room that explains delays, noting that emergencies arise and dermatologic cases sometimes prove to be unexpectedly complex. He also reminds people that they'll receive special attention on the day they need it.

Dr. Brett M. Coldiron of Cincinnati said he reduced his waiting times by dropping his two worst-paying insurance carriers. He also uses his lunch hour to catch up with charting and phone calls.

"Patients don't wait; charts do," he said.

"Can You Remove an Irritated Skin Tag?"

Most dermatologists remove a few skin tags or benign lesions for free. If there are many, and the patient wants them all off, some physicians explain that insurance won't cover their removal and ask if the patient wants to pay cash.

Dr. Ruben asks the patient to sign a note that goes into the chart and to the insurance company. It states the following:

▸ The patient has been reassured all lesions are benign and normal.

▸ The patient has identified lesions that are symptomatic.

▸ Only these symptomatic lesions were treated at the patient's request.

Given this information, some companies reimburse for their removal, he said.

What Bill?!

Sometimes a patient owes a significant amount and it becomes clear that they never intend to pay. Dr. Greenberg offered a possible solution: forgiveness of the debt. The physician writes off the debt. A Form 1099 is issued and referred to the Internal Revenue Service, which will demand that the debtor pay social security, Medicare fees, and taxes on the amount.

Rep Raps

Dermatologists voiced several complaints about pharmaceutical representatives, especially those who show up on a busy day to hype a "third-generation, me-too drug."

Many physicians require that reps schedule an appointment for routine business. One requests "payment" for the visit in the form of a donation to a charity. Another has salespeople wait in a "rep room" until the physicians have a break in their schedules.

Dr. Peter J. Muelleman of Independence, Mo., will speak to reps who show up unannounced, but only for a "socially appropriate amount of time—not 10 minutes."

"They don't have to buy lunch," he explained. "The staff knows which ones I want to see."

Virtually all of the dermatologists said they appreciate pharmaceutical samples, which enable them to treat Medicare patients who would do best on an expensive drug, to see if a patient reacts to a drug before prescribing it, and to conduct split-face studies to see which of two agents is best for an individual patient.

LOS CABOS, MEXICO — Every community dermatologist dreads the phrase, "Oh, by the way … "

It comes, all too often at the end of a harried day, spoken by the young mother with rosacea who waits until the last millisecond to point out her teenager's acne and her 8-year-old's hair loss.

To survive, clinicians often come up with creative, effective, and amusing strategies to cope with real-world dilemmas, but they rarely sit down and compare notes.

That's why Dr. Michael A. Greenberg, a dermatologist in Elk Grove Village, Ill., codirected a workshop entitled, Bring Us Your Office Problems, at the annual meeting of the Noah Worcester Dermatological Society.

The problems raged, but solutions abounded at the lively session. Here are some of the more thorny issues presented, as well as the attendees' suggestions.

"Oh, By the Way …"

All dermatologists who attended the session said they stop what they are doing and take a look only if the last-minute issue involves a black or otherwise suspicious lesion. If not, they delay. Some explain to patients that medicolegal rules require that any visit be documented in a chart. They send the patient and his or her entourage back to the front desk so a chart can be established or retrieved, and then offer to work the new patient into the schedule.

"It may be 5 minutes; it may be an hour," Dr. Charles Zugerman of Chicago tells his patients.

Dr. Lee J. Vesper of Cincinnati emphasized the complexity of what may seem like a simple issue: "There are 52 kinds of hair loss. I need to take a good history."

Dr. Greenberg quipped, "I don't take quick looks. I only take careful looks."

"I Have a List"

"Carpe registrar: Seize the list," advised Dr. Alan M. Ruben of Wheeling, W.Va.

The strategy has two rationales. First, patients often begin with the least important issue first. Second, many of the items on the list may be related to one condition, so reviewing the list may aid in diagnosis and treatment.

If the list is long and complex, prioritize the problems and assign the rest to a new appointment, attendees suggested.

"Why Did I Have to Wait So Long?"

The worst horror story came from Dr. Zugerman, who once faced a revolution in his waiting room when four or five patients united to demand that he come out to explain the "obscene" amount of time they had been waiting.

Many dermatologists said they have had to revise the way they schedule to alleviate waiting times. Dr. Stuart M. Brown of Dallas suggested stretching most appointment slots to 30 minutes and leaving open the last hour of the morning and the afternoon.

"I think it's a sin to keep people waiting a long time, but then act rushed," said Dr. Ruben. As he enters a room, he apologizes, first thing.

Dr. Greenberg keeps a plaque in his waiting room that explains delays, noting that emergencies arise and dermatologic cases sometimes prove to be unexpectedly complex. He also reminds people that they'll receive special attention on the day they need it.

Dr. Brett M. Coldiron of Cincinnati said he reduced his waiting times by dropping his two worst-paying insurance carriers. He also uses his lunch hour to catch up with charting and phone calls.

"Patients don't wait; charts do," he said.

"Can You Remove an Irritated Skin Tag?"

Most dermatologists remove a few skin tags or benign lesions for free. If there are many, and the patient wants them all off, some physicians explain that insurance won't cover their removal and ask if the patient wants to pay cash.

Dr. Ruben asks the patient to sign a note that goes into the chart and to the insurance company. It states the following:

▸ The patient has been reassured all lesions are benign and normal.

▸ The patient has identified lesions that are symptomatic.

▸ Only these symptomatic lesions were treated at the patient's request.

Given this information, some companies reimburse for their removal, he said.

What Bill?!

Sometimes a patient owes a significant amount and it becomes clear that they never intend to pay. Dr. Greenberg offered a possible solution: forgiveness of the debt. The physician writes off the debt. A Form 1099 is issued and referred to the Internal Revenue Service, which will demand that the debtor pay social security, Medicare fees, and taxes on the amount.

Rep Raps

Dermatologists voiced several complaints about pharmaceutical representatives, especially those who show up on a busy day to hype a "third-generation, me-too drug."

Many physicians require that reps schedule an appointment for routine business. One requests "payment" for the visit in the form of a donation to a charity. Another has salespeople wait in a "rep room" until the physicians have a break in their schedules.

Dr. Peter J. Muelleman of Independence, Mo., will speak to reps who show up unannounced, but only for a "socially appropriate amount of time—not 10 minutes."

"They don't have to buy lunch," he explained. "The staff knows which ones I want to see."

Virtually all of the dermatologists said they appreciate pharmaceutical samples, which enable them to treat Medicare patients who would do best on an expensive drug, to see if a patient reacts to a drug before prescribing it, and to conduct split-face studies to see which of two agents is best for an individual patient.

LOS CABOS, MEXICO — Every community dermatologist dreads the phrase, "Oh, by the way … "

It comes, all too often at the end of a harried day, spoken by the young mother with rosacea who waits until the last millisecond to point out her teenager's acne and her 8-year-old's hair loss.

To survive, clinicians often come up with creative, effective, and amusing strategies to cope with real-world dilemmas, but they rarely sit down and compare notes.

That's why Dr. Michael A. Greenberg, a dermatologist in Elk Grove Village, Ill., codirected a workshop entitled, Bring Us Your Office Problems, at the annual meeting of the Noah Worcester Dermatological Society.

The problems raged, but solutions abounded at the lively session. Here are some of the more thorny issues presented, as well as the attendees' suggestions.

"Oh, By the Way …"

All dermatologists who attended the session said they stop what they are doing and take a look only if the last-minute issue involves a black or otherwise suspicious lesion. If not, they delay. Some explain to patients that medicolegal rules require that any visit be documented in a chart. They send the patient and his or her entourage back to the front desk so a chart can be established or retrieved, and then offer to work the new patient into the schedule.

"It may be 5 minutes; it may be an hour," Dr. Charles Zugerman of Chicago tells his patients.

Dr. Lee J. Vesper of Cincinnati emphasized the complexity of what may seem like a simple issue: "There are 52 kinds of hair loss. I need to take a good history."

Dr. Greenberg quipped, "I don't take quick looks. I only take careful looks."

"I Have a List"

"Carpe registrar: Seize the list," advised Dr. Alan M. Ruben of Wheeling, W.Va.

The strategy has two rationales. First, patients often begin with the least important issue first. Second, many of the items on the list may be related to one condition, so reviewing the list may aid in diagnosis and treatment.

If the list is long and complex, prioritize the problems and assign the rest to a new appointment, attendees suggested.

"Why Did I Have to Wait So Long?"

The worst horror story came from Dr. Zugerman, who once faced a revolution in his waiting room when four or five patients united to demand that he come out to explain the "obscene" amount of time they had been waiting.

Many dermatologists said they have had to revise the way they schedule to alleviate waiting times. Dr. Stuart M. Brown of Dallas suggested stretching most appointment slots to 30 minutes and leaving open the last hour of the morning and the afternoon.

"I think it's a sin to keep people waiting a long time, but then act rushed," said Dr. Ruben. As he enters a room, he apologizes, first thing.

Dr. Greenberg keeps a plaque in his waiting room that explains delays, noting that emergencies arise and dermatologic cases sometimes prove to be unexpectedly complex. He also reminds people that they'll receive special attention on the day they need it.

Dr. Brett M. Coldiron of Cincinnati said he reduced his waiting times by dropping his two worst-paying insurance carriers. He also uses his lunch hour to catch up with charting and phone calls.

"Patients don't wait; charts do," he said.

"Can You Remove an Irritated Skin Tag?"

Most dermatologists remove a few skin tags or benign lesions for free. If there are many, and the patient wants them all off, some physicians explain that insurance won't cover their removal and ask if the patient wants to pay cash.

Dr. Ruben asks the patient to sign a note that goes into the chart and to the insurance company. It states the following:

▸ The patient has been reassured all lesions are benign and normal.

▸ The patient has identified lesions that are symptomatic.

▸ Only these symptomatic lesions were treated at the patient's request.

Given this information, some companies reimburse for their removal, he said.

What Bill?!

Sometimes a patient owes a significant amount and it becomes clear that they never intend to pay. Dr. Greenberg offered a possible solution: forgiveness of the debt. The physician writes off the debt. A Form 1099 is issued and referred to the Internal Revenue Service, which will demand that the debtor pay social security, Medicare fees, and taxes on the amount.

Rep Raps

Dermatologists voiced several complaints about pharmaceutical representatives, especially those who show up on a busy day to hype a "third-generation, me-too drug."

Many physicians require that reps schedule an appointment for routine business. One requests "payment" for the visit in the form of a donation to a charity. Another has salespeople wait in a "rep room" until the physicians have a break in their schedules.

Dr. Peter J. Muelleman of Independence, Mo., will speak to reps who show up unannounced, but only for a "socially appropriate amount of time—not 10 minutes."

"They don't have to buy lunch," he explained. "The staff knows which ones I want to see."

Virtually all of the dermatologists said they appreciate pharmaceutical samples, which enable them to treat Medicare patients who would do best on an expensive drug, to see if a patient reacts to a drug before prescribing it, and to conduct split-face studies to see which of two agents is best for an individual patient.

SAN FRANCISCO — Fair-skinned volunteers injected with synthetic α-melanin-stimulating hormone readily acquired tans and showed minimal epidermal damage following exposure to ultraviolet light, in a study unveiled at the annual meeting of the American Academy of Dermatology.

Dr. Ross Barnetson, the Raymond E. Purvess Professor of Dermatology at the University of Sydney (Australia) and the Royal Prince Alfred Hospital, both in Camperdown, New South Wales, reported on the experimental approach to sun protection during a special session highlighting exciting new trial data.

In his presentation, Dr. Barnetson explained that 79 Australian subjects, most of them fair-skinned women, were enrolled in a 3-month trial comparing subcutaneous abdominal injections of Melanotan, which is an analog of α-melanocyte-stimulating hormone (α-MSH), with a placebo.

Melanin density, which was measured in the skin of subjects by using spectrophotometry, was found to increase significantly in patients who received the α-MSH injections for 10 days a month for 3 months.

“What was fascinating was that … the patients with low baseline MED [minimal erythema dose]—that is, [Fitzpatrick] skin type I or skin type II—had much better responses than those with high MED,” Dr. Barnetson said during the session.

“It was a big surprise to us that, suddenly, people with red hair were getting a tan,” he added.

The patients who had low baseline MED scores demonstrated a 40% increase in melanin density over eight separate skin sites after being administered the hormone, compared with a 12% increase in those with high baseline MED scores.

Melanin density increases were seen not only in skin that was exposed to the sun but also in skin that was unexposed.

The investigators went on to measure epidermal changes following exposure of subjects to three times their baseline MED of solar-simulated ultraviolet rays, 90 days into the trial.

Compared with placebo, individuals with low baseline MED who were administered the hormone demonstrated a 50% reduction in epidermal sunburned (apoptotic) cells and nearly a 60% reduction in DNA damage, as measured by thymine dimer formation.

“Melanotan results in an increase in skin pigmentation, with the greatest increases in those with low MED, [for example] type I and II skin types,” Dr. Barnetson said in his conclusion.

“Clearly, it has the propensity to prevent cellular damage, as measured by sunburned cells and thymine dimers.”

In the short term, he said that the synthetic hormone may prove to be useful as a means of preventing photosensitizing diseases such as polymorphic light eruption. Early studies of the effect of the synthetic hormone on those diseases have been “very encouraging,” he noted.

In the long term, a product might be developed that could be used to prevent the development of skin cancer in individuals who are fair-skinned.

There are wrinkles that must be worked out before a commercial product can become a reality in the marketplace, however.

Dr. Barnetson noted that 12 of 59 patients assigned to the active treatment arm of the investigation dropped out because of flushing and nausea, which were adverse events associated with the Melanotan injections. A depot form of injection that was administered to subjects in a subsequent study appears to have ameliorated those side effects, he said.

An audience member asked Dr. Barnetson about the possibility of melanocyte proliferation in response to the injections.

Although that has not proven to be an issue, “there is some suggestion [Melanotan] could be immunosuppressive, so we have to think of the long term,” Dr. Barnetson replied.

In trials involving “quite a lot of subjects” who were administered the synthetic hormone, no case of melanoma has been diagnosed.

Melanotan is manufactured by the Melbourne (Australia)-based company Clinuvel Pharmaceuticals Ltd. (formerly Epitan Ltd.). Dr. Barnetson disclosed that he serves on the firm's medical advisory board.

SAN FRANCISCO — Fair-skinned volunteers injected with synthetic α-melanin-stimulating hormone readily acquired tans and showed minimal epidermal damage following exposure to ultraviolet light, in a study unveiled at the annual meeting of the American Academy of Dermatology.

Dr. Ross Barnetson, the Raymond E. Purvess Professor of Dermatology at the University of Sydney (Australia) and the Royal Prince Alfred Hospital, both in Camperdown, New South Wales, reported on the experimental approach to sun protection during a special session highlighting exciting new trial data.

In his presentation, Dr. Barnetson explained that 79 Australian subjects, most of them fair-skinned women, were enrolled in a 3-month trial comparing subcutaneous abdominal injections of Melanotan, which is an analog of α-melanocyte-stimulating hormone (α-MSH), with a placebo.

Melanin density, which was measured in the skin of subjects by using spectrophotometry, was found to increase significantly in patients who received the α-MSH injections for 10 days a month for 3 months.

“What was fascinating was that … the patients with low baseline MED [minimal erythema dose]—that is, [Fitzpatrick] skin type I or skin type II—had much better responses than those with high MED,” Dr. Barnetson said during the session.

“It was a big surprise to us that, suddenly, people with red hair were getting a tan,” he added.

The patients who had low baseline MED scores demonstrated a 40% increase in melanin density over eight separate skin sites after being administered the hormone, compared with a 12% increase in those with high baseline MED scores.

Melanin density increases were seen not only in skin that was exposed to the sun but also in skin that was unexposed.

The investigators went on to measure epidermal changes following exposure of subjects to three times their baseline MED of solar-simulated ultraviolet rays, 90 days into the trial.

Compared with placebo, individuals with low baseline MED who were administered the hormone demonstrated a 50% reduction in epidermal sunburned (apoptotic) cells and nearly a 60% reduction in DNA damage, as measured by thymine dimer formation.

“Melanotan results in an increase in skin pigmentation, with the greatest increases in those with low MED, [for example] type I and II skin types,” Dr. Barnetson said in his conclusion.

“Clearly, it has the propensity to prevent cellular damage, as measured by sunburned cells and thymine dimers.”

In the short term, he said that the synthetic hormone may prove to be useful as a means of preventing photosensitizing diseases such as polymorphic light eruption. Early studies of the effect of the synthetic hormone on those diseases have been “very encouraging,” he noted.

In the long term, a product might be developed that could be used to prevent the development of skin cancer in individuals who are fair-skinned.

There are wrinkles that must be worked out before a commercial product can become a reality in the marketplace, however.

Dr. Barnetson noted that 12 of 59 patients assigned to the active treatment arm of the investigation dropped out because of flushing and nausea, which were adverse events associated with the Melanotan injections. A depot form of injection that was administered to subjects in a subsequent study appears to have ameliorated those side effects, he said.

An audience member asked Dr. Barnetson about the possibility of melanocyte proliferation in response to the injections.

Although that has not proven to be an issue, “there is some suggestion [Melanotan] could be immunosuppressive, so we have to think of the long term,” Dr. Barnetson replied.

In trials involving “quite a lot of subjects” who were administered the synthetic hormone, no case of melanoma has been diagnosed.

Melanotan is manufactured by the Melbourne (Australia)-based company Clinuvel Pharmaceuticals Ltd. (formerly Epitan Ltd.). Dr. Barnetson disclosed that he serves on the firm's medical advisory board.

SAN FRANCISCO — Fair-skinned volunteers injected with synthetic α-melanin-stimulating hormone readily acquired tans and showed minimal epidermal damage following exposure to ultraviolet light, in a study unveiled at the annual meeting of the American Academy of Dermatology.

Dr. Ross Barnetson, the Raymond E. Purvess Professor of Dermatology at the University of Sydney (Australia) and the Royal Prince Alfred Hospital, both in Camperdown, New South Wales, reported on the experimental approach to sun protection during a special session highlighting exciting new trial data.

In his presentation, Dr. Barnetson explained that 79 Australian subjects, most of them fair-skinned women, were enrolled in a 3-month trial comparing subcutaneous abdominal injections of Melanotan, which is an analog of α-melanocyte-stimulating hormone (α-MSH), with a placebo.

Melanin density, which was measured in the skin of subjects by using spectrophotometry, was found to increase significantly in patients who received the α-MSH injections for 10 days a month for 3 months.

“What was fascinating was that … the patients with low baseline MED [minimal erythema dose]—that is, [Fitzpatrick] skin type I or skin type II—had much better responses than those with high MED,” Dr. Barnetson said during the session.

“It was a big surprise to us that, suddenly, people with red hair were getting a tan,” he added.

The patients who had low baseline MED scores demonstrated a 40% increase in melanin density over eight separate skin sites after being administered the hormone, compared with a 12% increase in those with high baseline MED scores.

Melanin density increases were seen not only in skin that was exposed to the sun but also in skin that was unexposed.

The investigators went on to measure epidermal changes following exposure of subjects to three times their baseline MED of solar-simulated ultraviolet rays, 90 days into the trial.

Compared with placebo, individuals with low baseline MED who were administered the hormone demonstrated a 50% reduction in epidermal sunburned (apoptotic) cells and nearly a 60% reduction in DNA damage, as measured by thymine dimer formation.

“Melanotan results in an increase in skin pigmentation, with the greatest increases in those with low MED, [for example] type I and II skin types,” Dr. Barnetson said in his conclusion.

“Clearly, it has the propensity to prevent cellular damage, as measured by sunburned cells and thymine dimers.”

In the short term, he said that the synthetic hormone may prove to be useful as a means of preventing photosensitizing diseases such as polymorphic light eruption. Early studies of the effect of the synthetic hormone on those diseases have been “very encouraging,” he noted.

In the long term, a product might be developed that could be used to prevent the development of skin cancer in individuals who are fair-skinned.

There are wrinkles that must be worked out before a commercial product can become a reality in the marketplace, however.

Dr. Barnetson noted that 12 of 59 patients assigned to the active treatment arm of the investigation dropped out because of flushing and nausea, which were adverse events associated with the Melanotan injections. A depot form of injection that was administered to subjects in a subsequent study appears to have ameliorated those side effects, he said.

An audience member asked Dr. Barnetson about the possibility of melanocyte proliferation in response to the injections.

Although that has not proven to be an issue, “there is some suggestion [Melanotan] could be immunosuppressive, so we have to think of the long term,” Dr. Barnetson replied.

In trials involving “quite a lot of subjects” who were administered the synthetic hormone, no case of melanoma has been diagnosed.

Melanotan is manufactured by the Melbourne (Australia)-based company Clinuvel Pharmaceuticals Ltd. (formerly Epitan Ltd.). Dr. Barnetson disclosed that he serves on the firm's medical advisory board.

PASADENA, CALIF. — Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with state medical board representatives.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in medical malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators. But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, Mr. Osinoff said.

“I want to assure you that the vast majority of cases [in California] are resolved without an accusation,” once the facts are known. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well-prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria.

However, there are common themes. Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they often look for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career. Yet a surprising number of medical board cases are based on the care and treatment of a single patient.

Dishonesty, illegal conduct, and psychological or physical problems often generate interest among state boards. Finally, in quality of care cases, boards look for such things as gross negligence or an “extreme departure” from standard of care or repeated negligent acts.

As in medical malpractice cases, inadequate record-keeping can be a serious problem for a physician under investigation, Mr. Osinoff said.

One category of red-flag incidents can be grouped as “Sex, Lies, and Videotape.” Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries.

Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Videotape most often comes into play in obstetric cases, when the excited father films what may be interpreted as “too vigorous” use of forceps or some other event that may or may not represent any medical error. Some hospitals currently forbid videotaping during labor and delivery.

Mr. Osinoff said he is frequently asked whether a physician should report a medical board investigation to his or her insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

Nonetheless, he repeated his basic advice: “Call a lawyer first,” he said.

PASADENA, CALIF. — Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with state medical board representatives.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in medical malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators. But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, Mr. Osinoff said.

“I want to assure you that the vast majority of cases [in California] are resolved without an accusation,” once the facts are known. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well-prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria.

However, there are common themes. Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they often look for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career. Yet a surprising number of medical board cases are based on the care and treatment of a single patient.

Dishonesty, illegal conduct, and psychological or physical problems often generate interest among state boards. Finally, in quality of care cases, boards look for such things as gross negligence or an “extreme departure” from standard of care or repeated negligent acts.

As in medical malpractice cases, inadequate record-keeping can be a serious problem for a physician under investigation, Mr. Osinoff said.

One category of red-flag incidents can be grouped as “Sex, Lies, and Videotape.” Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries.

Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Videotape most often comes into play in obstetric cases, when the excited father films what may be interpreted as “too vigorous” use of forceps or some other event that may or may not represent any medical error. Some hospitals currently forbid videotaping during labor and delivery.

Mr. Osinoff said he is frequently asked whether a physician should report a medical board investigation to his or her insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

Nonetheless, he repeated his basic advice: “Call a lawyer first,” he said.

PASADENA, CALIF. — Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with state medical board representatives.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in medical malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators. But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, Mr. Osinoff said.

“I want to assure you that the vast majority of cases [in California] are resolved without an accusation,” once the facts are known. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well-prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria.

However, there are common themes. Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they often look for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career. Yet a surprising number of medical board cases are based on the care and treatment of a single patient.

Dishonesty, illegal conduct, and psychological or physical problems often generate interest among state boards. Finally, in quality of care cases, boards look for such things as gross negligence or an “extreme departure” from standard of care or repeated negligent acts.

As in medical malpractice cases, inadequate record-keeping can be a serious problem for a physician under investigation, Mr. Osinoff said.

One category of red-flag incidents can be grouped as “Sex, Lies, and Videotape.” Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries.

Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Videotape most often comes into play in obstetric cases, when the excited father films what may be interpreted as “too vigorous” use of forceps or some other event that may or may not represent any medical error. Some hospitals currently forbid videotaping during labor and delivery.

Mr. Osinoff said he is frequently asked whether a physician should report a medical board investigation to his or her insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

Nonetheless, he repeated his basic advice: “Call a lawyer first,” he said.

SAN FRANCISCO — Patients with underlying viral hepatitis B are likely to present with hepatocellular carcinoma at a younger age and in better overall health than are patients with hepatitis C, but their tumors tend to be larger and more aggressive.

Important distinctions in the characteristics of liver cancer patients emerged when Dr. Spiros P. Hiotis of the department of surgery at New York University and associates examined the records of 127 patients diagnosed at the university medical center during a 12-year period.

Dr. Hiotis presented the results at a symposium sponsored by the American Society of Clinical Oncology.

Of 89 patients with underlying hepatitis B, 22 presented with hepatocellular cancer before age 40. None of the 38 patients with hepatitis C presented with cancer at such an early age. Among the 119 patients whose cirrhosis status was known, all 35 hepatitis C patients (100%) had cirrhosis at the time of diagnosis, compared with 50 of 84 hepatitis B patients (60%). Serum α-fetoprotein was more than 2,000 ng/mL in nearly half of the hepatitis B patients and in 5 of 35 hepatitis C patients.

Two-thirds of hepatitis B patients had tumors larger than 5 cm at their greatest diameter, compared with 14 of 37 hepatitis C patients (38%). Tumor size determines if a patient meets the Milan criteria, which are used to decide if a patient is a good candidate for a liver transplant. These criteria include having no solitary tumor more than 5 cm in diameter, or, in patients with multiple tumors, having no more than three tumors, none of which is larger than 3 cm.

On one hand, fewer hepatitis B patients met the Milan criteria than did hepatitis C patients (14% vs. 34%). On the other hand, nearly all hepatitis C patients had at least one comorbidity, compared with less than one-fourth of hepatitis B patients.

The typical presentation of advanced disease in hepatitis B patients heightens the need for more aggressive screening, Dr. Hiotis said at the meeting, which was also sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiology and Oncology, and the Society of Surgical Oncology.

He referred to new screening guidelines from the American Association for the Study of Liver Diseases, which were published by Dr. Jordi Bruix of the University of Barcelona and Dr. Morris Sherman of the University of Toronto. (See box.)

Screening for Hepatocellular Carcinoma

Patients at high risk for developing hepatocellular carcinoma (HCC) should be entered into surveillance programs.

The following groups of patients should be screened:

▸ Certain hepatitis B carriers. These carriers will also have either cirrhosis or a family history of HCC, or are Asian males 40 years and older or Asian females 50 years and older.

▸ Other noncirrhotic hepatitis B carriers. The risk of HCC depends on the severity of the underlying liver disease and the current and past hepatic inflammatory activity. Patients with high DNA concentrations of hepatitis B and those with hepatitic inflammatory activity remain at risk for HCC.

▸ Certain patients with nonhepatitis B cirrhosis. Those who should be screened will also have hepatitis C, alcoholic cirrhosis, genetic hemochromatosis, or primary biliary cirrhosis.

▸ Patients with α1-antitrypsin deficiency, nonalcoholic steatohepatitis, and autoimmune hepatitis. These patients are at elevated risk for HCC, but not enough data exist to justify a recommendation for surveillance.

▸ Patients on the transplant waiting list. The development of HCC advances patients on the waiting list. In addition, failure to screen for HCC could mean that the disease progresses beyond listing criteria.

Recommended screening methods and schedules are as follows:

▸ Surveillance for HCC should be performed using ultrasound. AFP levels alone should not be used for screening unless ultrasound is unavailable, because AFP as a screening tool has a high false-positive rate and is much less sensitive than is well-performed ultrasound.

▸ Patients should be screened at 6− to 12-month intervals. Dr. Sherman recommends 6-month intervals. The surveillance interval does not need to be shortened for patients at higher risk of HCC.

Source: American Association for the Study of Liver Diseases Practice Guidelines: Management of Hepatocellular Carcinoma (Hepatology 2005;42:1208–36).

SAN FRANCISCO — Patients with underlying viral hepatitis B are likely to present with hepatocellular carcinoma at a younger age and in better overall health than are patients with hepatitis C, but their tumors tend to be larger and more aggressive.

Important distinctions in the characteristics of liver cancer patients emerged when Dr. Spiros P. Hiotis of the department of surgery at New York University and associates examined the records of 127 patients diagnosed at the university medical center during a 12-year period.

Dr. Hiotis presented the results at a symposium sponsored by the American Society of Clinical Oncology.

Of 89 patients with underlying hepatitis B, 22 presented with hepatocellular cancer before age 40. None of the 38 patients with hepatitis C presented with cancer at such an early age. Among the 119 patients whose cirrhosis status was known, all 35 hepatitis C patients (100%) had cirrhosis at the time of diagnosis, compared with 50 of 84 hepatitis B patients (60%). Serum α-fetoprotein was more than 2,000 ng/mL in nearly half of the hepatitis B patients and in 5 of 35 hepatitis C patients.

Two-thirds of hepatitis B patients had tumors larger than 5 cm at their greatest diameter, compared with 14 of 37 hepatitis C patients (38%). Tumor size determines if a patient meets the Milan criteria, which are used to decide if a patient is a good candidate for a liver transplant. These criteria include having no solitary tumor more than 5 cm in diameter, or, in patients with multiple tumors, having no more than three tumors, none of which is larger than 3 cm.

On one hand, fewer hepatitis B patients met the Milan criteria than did hepatitis C patients (14% vs. 34%). On the other hand, nearly all hepatitis C patients had at least one comorbidity, compared with less than one-fourth of hepatitis B patients.

The typical presentation of advanced disease in hepatitis B patients heightens the need for more aggressive screening, Dr. Hiotis said at the meeting, which was also sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiology and Oncology, and the Society of Surgical Oncology.

He referred to new screening guidelines from the American Association for the Study of Liver Diseases, which were published by Dr. Jordi Bruix of the University of Barcelona and Dr. Morris Sherman of the University of Toronto. (See box.)

Screening for Hepatocellular Carcinoma

Patients at high risk for developing hepatocellular carcinoma (HCC) should be entered into surveillance programs.

The following groups of patients should be screened:

▸ Certain hepatitis B carriers. These carriers will also have either cirrhosis or a family history of HCC, or are Asian males 40 years and older or Asian females 50 years and older.

▸ Other noncirrhotic hepatitis B carriers. The risk of HCC depends on the severity of the underlying liver disease and the current and past hepatic inflammatory activity. Patients with high DNA concentrations of hepatitis B and those with hepatitic inflammatory activity remain at risk for HCC.

▸ Certain patients with nonhepatitis B cirrhosis. Those who should be screened will also have hepatitis C, alcoholic cirrhosis, genetic hemochromatosis, or primary biliary cirrhosis.

▸ Patients with α1-antitrypsin deficiency, nonalcoholic steatohepatitis, and autoimmune hepatitis. These patients are at elevated risk for HCC, but not enough data exist to justify a recommendation for surveillance.

▸ Patients on the transplant waiting list. The development of HCC advances patients on the waiting list. In addition, failure to screen for HCC could mean that the disease progresses beyond listing criteria.

Recommended screening methods and schedules are as follows:

▸ Surveillance for HCC should be performed using ultrasound. AFP levels alone should not be used for screening unless ultrasound is unavailable, because AFP as a screening tool has a high false-positive rate and is much less sensitive than is well-performed ultrasound.

▸ Patients should be screened at 6− to 12-month intervals. Dr. Sherman recommends 6-month intervals. The surveillance interval does not need to be shortened for patients at higher risk of HCC.

Source: American Association for the Study of Liver Diseases Practice Guidelines: Management of Hepatocellular Carcinoma (Hepatology 2005;42:1208–36).

SAN FRANCISCO — Patients with underlying viral hepatitis B are likely to present with hepatocellular carcinoma at a younger age and in better overall health than are patients with hepatitis C, but their tumors tend to be larger and more aggressive.

Important distinctions in the characteristics of liver cancer patients emerged when Dr. Spiros P. Hiotis of the department of surgery at New York University and associates examined the records of 127 patients diagnosed at the university medical center during a 12-year period.

Dr. Hiotis presented the results at a symposium sponsored by the American Society of Clinical Oncology.

Of 89 patients with underlying hepatitis B, 22 presented with hepatocellular cancer before age 40. None of the 38 patients with hepatitis C presented with cancer at such an early age. Among the 119 patients whose cirrhosis status was known, all 35 hepatitis C patients (100%) had cirrhosis at the time of diagnosis, compared with 50 of 84 hepatitis B patients (60%). Serum α-fetoprotein was more than 2,000 ng/mL in nearly half of the hepatitis B patients and in 5 of 35 hepatitis C patients.

Two-thirds of hepatitis B patients had tumors larger than 5 cm at their greatest diameter, compared with 14 of 37 hepatitis C patients (38%). Tumor size determines if a patient meets the Milan criteria, which are used to decide if a patient is a good candidate for a liver transplant. These criteria include having no solitary tumor more than 5 cm in diameter, or, in patients with multiple tumors, having no more than three tumors, none of which is larger than 3 cm.

On one hand, fewer hepatitis B patients met the Milan criteria than did hepatitis C patients (14% vs. 34%). On the other hand, nearly all hepatitis C patients had at least one comorbidity, compared with less than one-fourth of hepatitis B patients.

The typical presentation of advanced disease in hepatitis B patients heightens the need for more aggressive screening, Dr. Hiotis said at the meeting, which was also sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiology and Oncology, and the Society of Surgical Oncology.

He referred to new screening guidelines from the American Association for the Study of Liver Diseases, which were published by Dr. Jordi Bruix of the University of Barcelona and Dr. Morris Sherman of the University of Toronto. (See box.)

Screening for Hepatocellular Carcinoma

Patients at high risk for developing hepatocellular carcinoma (HCC) should be entered into surveillance programs.

The following groups of patients should be screened:

▸ Certain hepatitis B carriers. These carriers will also have either cirrhosis or a family history of HCC, or are Asian males 40 years and older or Asian females 50 years and older.

▸ Other noncirrhotic hepatitis B carriers. The risk of HCC depends on the severity of the underlying liver disease and the current and past hepatic inflammatory activity. Patients with high DNA concentrations of hepatitis B and those with hepatitic inflammatory activity remain at risk for HCC.

▸ Certain patients with nonhepatitis B cirrhosis. Those who should be screened will also have hepatitis C, alcoholic cirrhosis, genetic hemochromatosis, or primary biliary cirrhosis.

▸ Patients with α1-antitrypsin deficiency, nonalcoholic steatohepatitis, and autoimmune hepatitis. These patients are at elevated risk for HCC, but not enough data exist to justify a recommendation for surveillance.

▸ Patients on the transplant waiting list. The development of HCC advances patients on the waiting list. In addition, failure to screen for HCC could mean that the disease progresses beyond listing criteria.

Recommended screening methods and schedules are as follows:

▸ Surveillance for HCC should be performed using ultrasound. AFP levels alone should not be used for screening unless ultrasound is unavailable, because AFP as a screening tool has a high false-positive rate and is much less sensitive than is well-performed ultrasound.

▸ Patients should be screened at 6− to 12-month intervals. Dr. Sherman recommends 6-month intervals. The surveillance interval does not need to be shortened for patients at higher risk of HCC.

Source: American Association for the Study of Liver Diseases Practice Guidelines: Management of Hepatocellular Carcinoma (Hepatology 2005;42:1208–36).

PASADENA, CALIF. — The Heimlich maneuver becomes unwieldy during the late stages of pregnancy, requiring adaptations, Dr. J. Gerald Quirk said at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

Breast enlargement, diaphragm displacement, and the size and weight of a pregnant woman all contribute to difficulty in performing the traditional emergency maneuver to prevent choking during late pregnancy.

First described in 1974 by Dr. Henry Heimlich, a thoracic surgeon, the Heimlich maneuver involves standing behind a choking victim and placing a fist, thumb side in, underneath the diaphragm. With the other hand used to push against the fist, a series of abrupt upward thrusts are made; these motions can usually dislodge a piece of food from the airway.

Not only is it difficult to hold a woman in this position during late pregnancy, it is also hard to exert the force necessary to perform the maneuver correctly, said Dr. Quirk, professor and chair of obstetrics, gynecology, and reproductive medicine at Stony Brook (N.Y.) University.

“The best thing to do is lay her on the floor and press down on the lower part of the sternum,” he said.

The woman should be tilted slightly to one side to prevent aortocaval compression.

Dr. Quirk said several case reports suggest that this adaptation is effective for use in late pregnancy.

PASADENA, CALIF. — The Heimlich maneuver becomes unwieldy during the late stages of pregnancy, requiring adaptations, Dr. J. Gerald Quirk said at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

Breast enlargement, diaphragm displacement, and the size and weight of a pregnant woman all contribute to difficulty in performing the traditional emergency maneuver to prevent choking during late pregnancy.

First described in 1974 by Dr. Henry Heimlich, a thoracic surgeon, the Heimlich maneuver involves standing behind a choking victim and placing a fist, thumb side in, underneath the diaphragm. With the other hand used to push against the fist, a series of abrupt upward thrusts are made; these motions can usually dislodge a piece of food from the airway.

Not only is it difficult to hold a woman in this position during late pregnancy, it is also hard to exert the force necessary to perform the maneuver correctly, said Dr. Quirk, professor and chair of obstetrics, gynecology, and reproductive medicine at Stony Brook (N.Y.) University.

“The best thing to do is lay her on the floor and press down on the lower part of the sternum,” he said.

The woman should be tilted slightly to one side to prevent aortocaval compression.

Dr. Quirk said several case reports suggest that this adaptation is effective for use in late pregnancy.

PASADENA, CALIF. — The Heimlich maneuver becomes unwieldy during the late stages of pregnancy, requiring adaptations, Dr. J. Gerald Quirk said at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

Breast enlargement, diaphragm displacement, and the size and weight of a pregnant woman all contribute to difficulty in performing the traditional emergency maneuver to prevent choking during late pregnancy.

First described in 1974 by Dr. Henry Heimlich, a thoracic surgeon, the Heimlich maneuver involves standing behind a choking victim and placing a fist, thumb side in, underneath the diaphragm. With the other hand used to push against the fist, a series of abrupt upward thrusts are made; these motions can usually dislodge a piece of food from the airway.

Not only is it difficult to hold a woman in this position during late pregnancy, it is also hard to exert the force necessary to perform the maneuver correctly, said Dr. Quirk, professor and chair of obstetrics, gynecology, and reproductive medicine at Stony Brook (N.Y.) University.

“The best thing to do is lay her on the floor and press down on the lower part of the sternum,” he said.

The woman should be tilted slightly to one side to prevent aortocaval compression.

Dr. Quirk said several case reports suggest that this adaptation is effective for use in late pregnancy.

PASADENA, CALIF. — Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with state medical board representatives.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in medical malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators. But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, said Mr. Osinoff. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria, but there are common themes.

Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they are often looking for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career.

However, a surprising number of medical board cases are based on the care and treatment of a single patient. Dishonesty, illegal conduct, and psychological or physical problems often generate interest within state boards. Finally, in quality of care cases, boards look for such things as gross negligence, an “extreme departure” from standard of care, or repeated negligent acts.

As in medical malpractice cases, inadequate record keeping can be a serious problem for a physician under investigation, said Mr. Osinoff.

For obstetricians and gynecologists, red-flag incidents can be grouped under the heading, “Sex, Lies, and Videotape.”

Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries.

Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Videotape most often comes into play in obstetric cases, when the excited father films what may be interpreted as “too vigorous” use of forceps or some other event that may or may not represent any medical error. Some hospitals currently forbid videotaping during labor and delivery.

Mr. Osinoff said he is frequently asked whether a physician should report a medical board investigation to his or her insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

However, he repeated his basic advice.

“Call a lawyer first,” he said.

Going it alone 'is like walking into the police station as the prime suspect in a case.' MR. OSINOFF

PASADENA, CALIF. — Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with state medical board representatives.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in medical malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators. But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, said Mr. Osinoff. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria, but there are common themes.

Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they are often looking for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career.

However, a surprising number of medical board cases are based on the care and treatment of a single patient. Dishonesty, illegal conduct, and psychological or physical problems often generate interest within state boards. Finally, in quality of care cases, boards look for such things as gross negligence, an “extreme departure” from standard of care, or repeated negligent acts.

As in medical malpractice cases, inadequate record keeping can be a serious problem for a physician under investigation, said Mr. Osinoff.

For obstetricians and gynecologists, red-flag incidents can be grouped under the heading, “Sex, Lies, and Videotape.”

Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries.

Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Videotape most often comes into play in obstetric cases, when the excited father films what may be interpreted as “too vigorous” use of forceps or some other event that may or may not represent any medical error. Some hospitals currently forbid videotaping during labor and delivery.

Mr. Osinoff said he is frequently asked whether a physician should report a medical board investigation to his or her insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

However, he repeated his basic advice.

“Call a lawyer first,” he said.

Going it alone 'is like walking into the police station as the prime suspect in a case.' MR. OSINOFF

PASADENA, CALIF. — Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with state medical board representatives.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in medical malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators. But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, said Mr. Osinoff. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria, but there are common themes.

Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they are often looking for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career.

However, a surprising number of medical board cases are based on the care and treatment of a single patient. Dishonesty, illegal conduct, and psychological or physical problems often generate interest within state boards. Finally, in quality of care cases, boards look for such things as gross negligence, an “extreme departure” from standard of care, or repeated negligent acts.

As in medical malpractice cases, inadequate record keeping can be a serious problem for a physician under investigation, said Mr. Osinoff.

For obstetricians and gynecologists, red-flag incidents can be grouped under the heading, “Sex, Lies, and Videotape.”

Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries.

Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Videotape most often comes into play in obstetric cases, when the excited father films what may be interpreted as “too vigorous” use of forceps or some other event that may or may not represent any medical error. Some hospitals currently forbid videotaping during labor and delivery.

Mr. Osinoff said he is frequently asked whether a physician should report a medical board investigation to his or her insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

However, he repeated his basic advice.

“Call a lawyer first,” he said.

Going it alone 'is like walking into the police station as the prime suspect in a case.' MR. OSINOFF

PASADENA, CALIF. — Imaging for gynecologic cancer has been greatly improved with techniques combining structural and anatomic data from ultrasound, MRI, and CT with metabolic clues shown by PET scans, Dr. Robin Farias-Eisner said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Prior advances in traditional techniques were “great, but not good enough,” in their sensitivity, specificity, and accuracy, said Dr. Farias-Eisner, chief of gynecology at the University of California, Los Angeles.

It is in identifying microscopic disease in lymph nodes by depicting anatomy and structure that PET with

In many of his cases, the fused image completes the picture, demonstrating metabolic tumor activity in a precise location. Incorporating FDG-PET into the work-up also provides an evaluation of the whole body and can point to disease in patients whose normal anatomic landmarks have been lost to surgery or radiation.

PASADENA, CALIF. — Imaging for gynecologic cancer has been greatly improved with techniques combining structural and anatomic data from ultrasound, MRI, and CT with metabolic clues shown by PET scans, Dr. Robin Farias-Eisner said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Prior advances in traditional techniques were “great, but not good enough,” in their sensitivity, specificity, and accuracy, said Dr. Farias-Eisner, chief of gynecology at the University of California, Los Angeles.

It is in identifying microscopic disease in lymph nodes by depicting anatomy and structure that PET with

In many of his cases, the fused image completes the picture, demonstrating metabolic tumor activity in a precise location. Incorporating FDG-PET into the work-up also provides an evaluation of the whole body and can point to disease in patients whose normal anatomic landmarks have been lost to surgery or radiation.

PASADENA, CALIF. — Imaging for gynecologic cancer has been greatly improved with techniques combining structural and anatomic data from ultrasound, MRI, and CT with metabolic clues shown by PET scans, Dr. Robin Farias-Eisner said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Prior advances in traditional techniques were “great, but not good enough,” in their sensitivity, specificity, and accuracy, said Dr. Farias-Eisner, chief of gynecology at the University of California, Los Angeles.

It is in identifying microscopic disease in lymph nodes by depicting anatomy and structure that PET with

In many of his cases, the fused image completes the picture, demonstrating metabolic tumor activity in a precise location. Incorporating FDG-PET into the work-up also provides an evaluation of the whole body and can point to disease in patients whose normal anatomic landmarks have been lost to surgery or radiation.

SAN FRANCISCO — Negative-pressure vacuum therapy appears to speed healing and increase the likelihood of complete closure of nonhealing diabetic foot ulcers, Dr. David G. Armstrong said at the annual meeting of the American Academy of Dermatology.

But negative pressure, like any therapy for nonhealing wounds, should be “married with good common sense” and the critical steps of debridement and pressure offloading.

“In my opinion, what this device does is make complicated wounds [simpler]. Once you get a nice carpet of granulation tissue, then stop,” advised Dr. Armstrong, professor of surgery and chair of research at Rosalind Franklin University of Medicine and Science in North Chicago, Ill.

In negative-pressure wound therapy, subatmospheric pressure is delivered to the wound through a pump attached to a foam dressing. A canister collects exudate wicked from the wound.

Dr. Armstrong recommends that a stoma paste or hydrocolloid be placed around the periphery of the wound to prevent maceration from exudate collected during the process.

Although the exact mechanism of action is unknown, negative-pressure therapy reduces edema, uniformly draws wound edges together, and may promote cytokine elaboration and angiogenesis.

The therapy can be performed on an outpatient basis, although the set-up is bulky, Dr. Armstrong said.

At a cost that he likened to a moderately priced hotel stay—$70–$100 a day—the therapy is not cheap, but it could reduce the overall cost of healing diabetic foot ulcers if it keeps patients out of the hospital. Diabetic foot ulcer treatment averages $28,000; 75% of those costs are related to the hospital stay.

In a recently published randomized trial, Dr. Armstrong and Dr. Lawrence A. Lavery of Scott and White Memorial Hospital in Temple, Tex., found that large, deep diabetic foot wounds secondary to amputation healed faster and more completely with negative-pressure therapy than with standard wound care (Lancet 2005;366:1704–10).

Wounds closed completely in more than half of the patients (43 of 77) receiving continuous treatment with the vacuum-assisted closure (VAC) system for the 112-day study period. Just 33 of 85 patients receiving standard moist wound care healed completely.

“Rapid granulation tissue formation provided a clinical 'wow!' factor,” in the VAC group, Dr. Armstrong said.

There was a trend to fewer reamputations in patients receiving VAC, although the study was not powered to demonstrate that end point.

Although the study received criticism for allowing clinical judgment to guide therapeutic interventions, Dr. Armstrong said such a design was necessary for studies to have “real world” relevance.

His study enrolled patients with wounds eight times larger than those in previous trials of negative-pressure therapy.

“It may be that in some trials, the less you need [interventions], the better they work,” Dr. Armstrong said.

The study used the VAC therapy system made by Kinetic Concepts Inc., which sponsored the research.

Dr. Armstrong stressed throughout his talk the need for matching wound therapies to the right patients and wounds. Not every nonhealing wound needs negative-pressure therapy, for example. Referring to the oft-quoted phrase, “Don't just do something, stand there,” Dr. Armstrong noted that physicians are sometimes reluctant to follow that advice.

“You feel like squirting something, spraying something, applying something to the wound. Much of this really helps people, but some of it won't,” he said.

Well-designed trials with appropriately selected patients will point the way to “keeping a few more limbs on a few more bodies,” he said.

SAN FRANCISCO — Negative-pressure vacuum therapy appears to speed healing and increase the likelihood of complete closure of nonhealing diabetic foot ulcers, Dr. David G. Armstrong said at the annual meeting of the American Academy of Dermatology.

But negative pressure, like any therapy for nonhealing wounds, should be “married with good common sense” and the critical steps of debridement and pressure offloading.

“In my opinion, what this device does is make complicated wounds [simpler]. Once you get a nice carpet of granulation tissue, then stop,” advised Dr. Armstrong, professor of surgery and chair of research at Rosalind Franklin University of Medicine and Science in North Chicago, Ill.

In negative-pressure wound therapy, subatmospheric pressure is delivered to the wound through a pump attached to a foam dressing. A canister collects exudate wicked from the wound.

Dr. Armstrong recommends that a stoma paste or hydrocolloid be placed around the periphery of the wound to prevent maceration from exudate collected during the process.

Although the exact mechanism of action is unknown, negative-pressure therapy reduces edema, uniformly draws wound edges together, and may promote cytokine elaboration and angiogenesis.

The therapy can be performed on an outpatient basis, although the set-up is bulky, Dr. Armstrong said.

At a cost that he likened to a moderately priced hotel stay—$70–$100 a day—the therapy is not cheap, but it could reduce the overall cost of healing diabetic foot ulcers if it keeps patients out of the hospital. Diabetic foot ulcer treatment averages $28,000; 75% of those costs are related to the hospital stay.

In a recently published randomized trial, Dr. Armstrong and Dr. Lawrence A. Lavery of Scott and White Memorial Hospital in Temple, Tex., found that large, deep diabetic foot wounds secondary to amputation healed faster and more completely with negative-pressure therapy than with standard wound care (Lancet 2005;366:1704–10).

Wounds closed completely in more than half of the patients (43 of 77) receiving continuous treatment with the vacuum-assisted closure (VAC) system for the 112-day study period. Just 33 of 85 patients receiving standard moist wound care healed completely.

“Rapid granulation tissue formation provided a clinical 'wow!' factor,” in the VAC group, Dr. Armstrong said.

There was a trend to fewer reamputations in patients receiving VAC, although the study was not powered to demonstrate that end point.

Although the study received criticism for allowing clinical judgment to guide therapeutic interventions, Dr. Armstrong said such a design was necessary for studies to have “real world” relevance.

His study enrolled patients with wounds eight times larger than those in previous trials of negative-pressure therapy.

“It may be that in some trials, the less you need [interventions], the better they work,” Dr. Armstrong said.

The study used the VAC therapy system made by Kinetic Concepts Inc., which sponsored the research.

Dr. Armstrong stressed throughout his talk the need for matching wound therapies to the right patients and wounds. Not every nonhealing wound needs negative-pressure therapy, for example. Referring to the oft-quoted phrase, “Don't just do something, stand there,” Dr. Armstrong noted that physicians are sometimes reluctant to follow that advice.

“You feel like squirting something, spraying something, applying something to the wound. Much of this really helps people, but some of it won't,” he said.

Well-designed trials with appropriately selected patients will point the way to “keeping a few more limbs on a few more bodies,” he said.

SAN FRANCISCO — Negative-pressure vacuum therapy appears to speed healing and increase the likelihood of complete closure of nonhealing diabetic foot ulcers, Dr. David G. Armstrong said at the annual meeting of the American Academy of Dermatology.

But negative pressure, like any therapy for nonhealing wounds, should be “married with good common sense” and the critical steps of debridement and pressure offloading.

“In my opinion, what this device does is make complicated wounds [simpler]. Once you get a nice carpet of granulation tissue, then stop,” advised Dr. Armstrong, professor of surgery and chair of research at Rosalind Franklin University of Medicine and Science in North Chicago, Ill.

In negative-pressure wound therapy, subatmospheric pressure is delivered to the wound through a pump attached to a foam dressing. A canister collects exudate wicked from the wound.

Dr. Armstrong recommends that a stoma paste or hydrocolloid be placed around the periphery of the wound to prevent maceration from exudate collected during the process.

Although the exact mechanism of action is unknown, negative-pressure therapy reduces edema, uniformly draws wound edges together, and may promote cytokine elaboration and angiogenesis.

The therapy can be performed on an outpatient basis, although the set-up is bulky, Dr. Armstrong said.

At a cost that he likened to a moderately priced hotel stay—$70–$100 a day—the therapy is not cheap, but it could reduce the overall cost of healing diabetic foot ulcers if it keeps patients out of the hospital. Diabetic foot ulcer treatment averages $28,000; 75% of those costs are related to the hospital stay.

In a recently published randomized trial, Dr. Armstrong and Dr. Lawrence A. Lavery of Scott and White Memorial Hospital in Temple, Tex., found that large, deep diabetic foot wounds secondary to amputation healed faster and more completely with negative-pressure therapy than with standard wound care (Lancet 2005;366:1704–10).

Wounds closed completely in more than half of the patients (43 of 77) receiving continuous treatment with the vacuum-assisted closure (VAC) system for the 112-day study period. Just 33 of 85 patients receiving standard moist wound care healed completely.

“Rapid granulation tissue formation provided a clinical 'wow!' factor,” in the VAC group, Dr. Armstrong said.

There was a trend to fewer reamputations in patients receiving VAC, although the study was not powered to demonstrate that end point.

Although the study received criticism for allowing clinical judgment to guide therapeutic interventions, Dr. Armstrong said such a design was necessary for studies to have “real world” relevance.

His study enrolled patients with wounds eight times larger than those in previous trials of negative-pressure therapy.

“It may be that in some trials, the less you need [interventions], the better they work,” Dr. Armstrong said.

The study used the VAC therapy system made by Kinetic Concepts Inc., which sponsored the research.

Dr. Armstrong stressed throughout his talk the need for matching wound therapies to the right patients and wounds. Not every nonhealing wound needs negative-pressure therapy, for example. Referring to the oft-quoted phrase, “Don't just do something, stand there,” Dr. Armstrong noted that physicians are sometimes reluctant to follow that advice.

“You feel like squirting something, spraying something, applying something to the wound. Much of this really helps people, but some of it won't,” he said.

Well-designed trials with appropriately selected patients will point the way to “keeping a few more limbs on a few more bodies,” he said.

SAN FRANCISCO — A stepwise algorithm favoring medical alternatives can spare many patients from surgery for chronic anal fissure, Dr. Andreas M. Kaiser and his associates reported in a poster at the annual clinical congress of the American College of Surgeons.

The study, conducted at the University of Southern California, Los Angeles, looked at patients who had experienced chronic anal fissure for a median duration of 16 weeks.

The patients voluntarily agreed to participate in a sequenced protocol involving anywhere from one to three treatment strategies. The prospective cohort of 72 patients included 30 males and 42 females.

Criteria that were used to exclude potential participants included cardiac disease, use of a prescription muscle relaxant for another diagnosis, pregnancy, HIV ulcers, inflammatory bowel disease, current chemotherapy, and a history of receiving pelvic radiation therapy.

The treatment protocol called for initial therapy with topical nitroglycerin in a concentration of 0.2%. If that approach failed, two injections of 20 U of botulinum toxin type A (Botox) were administered.

The last resort treatment in the study protocol was surgical: lateral internal sphincterotomy. Two-week intervals were built into the algorithm to allow time for each successive therapy to work.

Five eligible patients refused to follow the treatment protocol. Three of these five desired immediate therapy with Botox, and two requested immediate surgery.

Among the 67 patients who agreed to follow the algorithm, 31 had healing of their chronic anal fissures with nitroglycerin alone. Two developed recurrent fissures, and Botox successfully resolved both cases.

Of 36 patients who failed initial nitroglycerin therapy, 3 required surgery as the next step. The other 33 went on to receive Botox per the algorithm; 5 of them failed to heal with Botox and went on to surgery.

The overall surgery rate was 13.9% (10 of 72 patients). Among patients who agreed to be treated according to the algorithm, just 11% (8 of 67) required surgery.

Lateral internal sphincterotomy, while effective in treating chronic anal fissure, is irreversible and has been associated with a 5%–10% rate of incontinence of stool or gas, Dr. Kaiser noted in an interview after the meeting.

The algorithm “is a very practical approach,” he said. “Our approach was to observe what happens if we try to maximize the conservative approach. How often can we get to a successful result, starting with the cheapest, most simple treatment and working from there?” said Dr. Kaiser, a faculty member in the colorectal surgery department.

“We already knew beforehand it [the simplest approach] was not going to be 100% effective in all patients,” he said, adding that most patients are willing to try something else first before resorting to surgery.

“Based on our prospective data, we suggest that the treatment algorithm for chronic anal fissure with stepwise escalation is an effective tool in achieving fissure healing and avoiding irreversible surgical sphincterotomy in [almost] 85% of the patients,” Dr. Kaiser and his associates concluded.

Medical therapy “should be considered the first-line treatment and surgery be reserved for refractory cases,” they said.

SAN FRANCISCO — A stepwise algorithm favoring medical alternatives can spare many patients from surgery for chronic anal fissure, Dr. Andreas M. Kaiser and his associates reported in a poster at the annual clinical congress of the American College of Surgeons.

The study, conducted at the University of Southern California, Los Angeles, looked at patients who had experienced chronic anal fissure for a median duration of 16 weeks.

The patients voluntarily agreed to participate in a sequenced protocol involving anywhere from one to three treatment strategies. The prospective cohort of 72 patients included 30 males and 42 females.

Criteria that were used to exclude potential participants included cardiac disease, use of a prescription muscle relaxant for another diagnosis, pregnancy, HIV ulcers, inflammatory bowel disease, current chemotherapy, and a history of receiving pelvic radiation therapy.

The treatment protocol called for initial therapy with topical nitroglycerin in a concentration of 0.2%. If that approach failed, two injections of 20 U of botulinum toxin type A (Botox) were administered.

The last resort treatment in the study protocol was surgical: lateral internal sphincterotomy. Two-week intervals were built into the algorithm to allow time for each successive therapy to work.

Five eligible patients refused to follow the treatment protocol. Three of these five desired immediate therapy with Botox, and two requested immediate surgery.

Among the 67 patients who agreed to follow the algorithm, 31 had healing of their chronic anal fissures with nitroglycerin alone. Two developed recurrent fissures, and Botox successfully resolved both cases.

Of 36 patients who failed initial nitroglycerin therapy, 3 required surgery as the next step. The other 33 went on to receive Botox per the algorithm; 5 of them failed to heal with Botox and went on to surgery.

The overall surgery rate was 13.9% (10 of 72 patients). Among patients who agreed to be treated according to the algorithm, just 11% (8 of 67) required surgery.

Lateral internal sphincterotomy, while effective in treating chronic anal fissure, is irreversible and has been associated with a 5%–10% rate of incontinence of stool or gas, Dr. Kaiser noted in an interview after the meeting.

The algorithm “is a very practical approach,” he said. “Our approach was to observe what happens if we try to maximize the conservative approach. How often can we get to a successful result, starting with the cheapest, most simple treatment and working from there?” said Dr. Kaiser, a faculty member in the colorectal surgery department.

“We already knew beforehand it [the simplest approach] was not going to be 100% effective in all patients,” he said, adding that most patients are willing to try something else first before resorting to surgery.

“Based on our prospective data, we suggest that the treatment algorithm for chronic anal fissure with stepwise escalation is an effective tool in achieving fissure healing and avoiding irreversible surgical sphincterotomy in [almost] 85% of the patients,” Dr. Kaiser and his associates concluded.

Medical therapy “should be considered the first-line treatment and surgery be reserved for refractory cases,” they said.

SAN FRANCISCO — A stepwise algorithm favoring medical alternatives can spare many patients from surgery for chronic anal fissure, Dr. Andreas M. Kaiser and his associates reported in a poster at the annual clinical congress of the American College of Surgeons.

The study, conducted at the University of Southern California, Los Angeles, looked at patients who had experienced chronic anal fissure for a median duration of 16 weeks.

The patients voluntarily agreed to participate in a sequenced protocol involving anywhere from one to three treatment strategies. The prospective cohort of 72 patients included 30 males and 42 females.

Criteria that were used to exclude potential participants included cardiac disease, use of a prescription muscle relaxant for another diagnosis, pregnancy, HIV ulcers, inflammatory bowel disease, current chemotherapy, and a history of receiving pelvic radiation therapy.

The treatment protocol called for initial therapy with topical nitroglycerin in a concentration of 0.2%. If that approach failed, two injections of 20 U of botulinum toxin type A (Botox) were administered.

The last resort treatment in the study protocol was surgical: lateral internal sphincterotomy. Two-week intervals were built into the algorithm to allow time for each successive therapy to work.

Five eligible patients refused to follow the treatment protocol. Three of these five desired immediate therapy with Botox, and two requested immediate surgery.

Among the 67 patients who agreed to follow the algorithm, 31 had healing of their chronic anal fissures with nitroglycerin alone. Two developed recurrent fissures, and Botox successfully resolved both cases.

Of 36 patients who failed initial nitroglycerin therapy, 3 required surgery as the next step. The other 33 went on to receive Botox per the algorithm; 5 of them failed to heal with Botox and went on to surgery.

The overall surgery rate was 13.9% (10 of 72 patients). Among patients who agreed to be treated according to the algorithm, just 11% (8 of 67) required surgery.

Lateral internal sphincterotomy, while effective in treating chronic anal fissure, is irreversible and has been associated with a 5%–10% rate of incontinence of stool or gas, Dr. Kaiser noted in an interview after the meeting.

The algorithm “is a very practical approach,” he said. “Our approach was to observe what happens if we try to maximize the conservative approach. How often can we get to a successful result, starting with the cheapest, most simple treatment and working from there?” said Dr. Kaiser, a faculty member in the colorectal surgery department.

“We already knew beforehand it [the simplest approach] was not going to be 100% effective in all patients,” he said, adding that most patients are willing to try something else first before resorting to surgery.

“Based on our prospective data, we suggest that the treatment algorithm for chronic anal fissure with stepwise escalation is an effective tool in achieving fissure healing and avoiding irreversible surgical sphincterotomy in [almost] 85% of the patients,” Dr. Kaiser and his associates concluded.

Medical therapy “should be considered the first-line treatment and surgery be reserved for refractory cases,” they said.

SAN FRANCISCO — Treating early-stage rectal cancer with local resection alone has become increasingly common but poses a considerable long-term risk of local recurrence, even in patients with T1 tumors, according to the results of a large retrospective cohort study.

Dr. Y. Nancy You, of the Mayo Clinic in Rochester, Minn., reported follow-up data from the National Cancer Data Base on 765 patients who underwent local excision and 1,359 patients who underwent standard resection for stage I rectal cancer between 1994 and 1996. She presented the data at a symposium sponsored by the American Society of Clinical Oncology.

The 5-year local recurrence rates among patients with complete resection (R0; no residual tumor) were substantially higher among patients who had local excision alone, compared with standard abdominal resection. For patients with T1 tumors, defined as those that invade only the submucosa, recurrence rates were 13% for local excision alone versus 7% for standard abdominal resection. For patients with T2 tumors, defined as those extending into the muscularis propria, recurrence rates were 22% versus 15%, respectively.

At 8 years post diagnosis, the local recurrence rate for completely resected T1 tumors had climbed to 14.3% among patients who underwent local excision alone, Dr. You said.

The type of surgery did not significantly affect overall 5-year survival rates for patients with T1 tumors, although patients with T2 tumors were more likely to survive if they underwent the more radical surgery rather than local excision (77% vs. 68%, respectively).

A multivariate analysis found that overall survival was independently associated with age at diagnosis, number of comorbidities, and number of postoperative complications for patients with T1 or T2 tumors.

Local excision alone spares most patients perioperative morbidity and preserves the sphincter, Dr. You said. Her review found that patients selected for local excision tended to have low-lying, small, low-grade tumors.

Lower rates of rehospitalization and perioperative complications were found in the patients who underwent local excision than in those who underwent complete resection for stage I disease.

Dr. You and associates concluded that appropriately selected patients with T1 tumors, including the elderly and patients with comorbid conditions that would increase surgical risk, can expect “acceptable overall survival” from local excision. “However, they do face increased risk for a local recurrence in the long term, in exchange for a favorable perioperative course,” she said at the meeting.

Caution should be used in treating patients with T2 tumors with local resection alone, she advised. “I would reserve local excision alone only for those patients [with T2 tumors] whose medical risks are prohibitive,” Dr. You emphasized.

In an interview after the meeting, she said the gold standard for patients with T2 tumors remains a standard abdominal resection, which she generally recommends to her patients when discussing the risks and benefits of either procedure.

“However, if the tumor characteristics are favorable for local excision and [the] patient is reluctant to undergo a large procedure, I would strongly consider a clinical trial,” she said.

Trials are underway to see whether chemoradiation in combination with local excision lowers the risk of local recurrence in patients with stage I disease.

Dr. Heidi Nelson, chair of the colon and rectal surgery division at the Mayo Clinic, was a coinvestigator on the study. Researchers from the University of Minnesota and the American College of Surgeons also contributed. The meeting was co-sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiation and Oncology, and the Society of Surgical Oncology.

At 8 years post diagnosis, the local recurrence rate for resected T1 tumors had climbed to 14.3%. DR. YOU

SAN FRANCISCO — Treating early-stage rectal cancer with local resection alone has become increasingly common but poses a considerable long-term risk of local recurrence, even in patients with T1 tumors, according to the results of a large retrospective cohort study.

Dr. Y. Nancy You, of the Mayo Clinic in Rochester, Minn., reported follow-up data from the National Cancer Data Base on 765 patients who underwent local excision and 1,359 patients who underwent standard resection for stage I rectal cancer between 1994 and 1996. She presented the data at a symposium sponsored by the American Society of Clinical Oncology.

The 5-year local recurrence rates among patients with complete resection (R0; no residual tumor) were substantially higher among patients who had local excision alone, compared with standard abdominal resection. For patients with T1 tumors, defined as those that invade only the submucosa, recurrence rates were 13% for local excision alone versus 7% for standard abdominal resection. For patients with T2 tumors, defined as those extending into the muscularis propria, recurrence rates were 22% versus 15%, respectively.

At 8 years post diagnosis, the local recurrence rate for completely resected T1 tumors had climbed to 14.3% among patients who underwent local excision alone, Dr. You said.

The type of surgery did not significantly affect overall 5-year survival rates for patients with T1 tumors, although patients with T2 tumors were more likely to survive if they underwent the more radical surgery rather than local excision (77% vs. 68%, respectively).

A multivariate analysis found that overall survival was independently associated with age at diagnosis, number of comorbidities, and number of postoperative complications for patients with T1 or T2 tumors.

Local excision alone spares most patients perioperative morbidity and preserves the sphincter, Dr. You said. Her review found that patients selected for local excision tended to have low-lying, small, low-grade tumors.

Lower rates of rehospitalization and perioperative complications were found in the patients who underwent local excision than in those who underwent complete resection for stage I disease.

Dr. You and associates concluded that appropriately selected patients with T1 tumors, including the elderly and patients with comorbid conditions that would increase surgical risk, can expect “acceptable overall survival” from local excision. “However, they do face increased risk for a local recurrence in the long term, in exchange for a favorable perioperative course,” she said at the meeting.

Caution should be used in treating patients with T2 tumors with local resection alone, she advised. “I would reserve local excision alone only for those patients [with T2 tumors] whose medical risks are prohibitive,” Dr. You emphasized.

In an interview after the meeting, she said the gold standard for patients with T2 tumors remains a standard abdominal resection, which she generally recommends to her patients when discussing the risks and benefits of either procedure.

“However, if the tumor characteristics are favorable for local excision and [the] patient is reluctant to undergo a large procedure, I would strongly consider a clinical trial,” she said.

Trials are underway to see whether chemoradiation in combination with local excision lowers the risk of local recurrence in patients with stage I disease.

Dr. Heidi Nelson, chair of the colon and rectal surgery division at the Mayo Clinic, was a coinvestigator on the study. Researchers from the University of Minnesota and the American College of Surgeons also contributed. The meeting was co-sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiation and Oncology, and the Society of Surgical Oncology.

At 8 years post diagnosis, the local recurrence rate for resected T1 tumors had climbed to 14.3%. DR. YOU

SAN FRANCISCO — Treating early-stage rectal cancer with local resection alone has become increasingly common but poses a considerable long-term risk of local recurrence, even in patients with T1 tumors, according to the results of a large retrospective cohort study.

Dr. Y. Nancy You, of the Mayo Clinic in Rochester, Minn., reported follow-up data from the National Cancer Data Base on 765 patients who underwent local excision and 1,359 patients who underwent standard resection for stage I rectal cancer between 1994 and 1996. She presented the data at a symposium sponsored by the American Society of Clinical Oncology.

The 5-year local recurrence rates among patients with complete resection (R0; no residual tumor) were substantially higher among patients who had local excision alone, compared with standard abdominal resection. For patients with T1 tumors, defined as those that invade only the submucosa, recurrence rates were 13% for local excision alone versus 7% for standard abdominal resection. For patients with T2 tumors, defined as those extending into the muscularis propria, recurrence rates were 22% versus 15%, respectively.

At 8 years post diagnosis, the local recurrence rate for completely resected T1 tumors had climbed to 14.3% among patients who underwent local excision alone, Dr. You said.

The type of surgery did not significantly affect overall 5-year survival rates for patients with T1 tumors, although patients with T2 tumors were more likely to survive if they underwent the more radical surgery rather than local excision (77% vs. 68%, respectively).

A multivariate analysis found that overall survival was independently associated with age at diagnosis, number of comorbidities, and number of postoperative complications for patients with T1 or T2 tumors.

Local excision alone spares most patients perioperative morbidity and preserves the sphincter, Dr. You said. Her review found that patients selected for local excision tended to have low-lying, small, low-grade tumors.

Lower rates of rehospitalization and perioperative complications were found in the patients who underwent local excision than in those who underwent complete resection for stage I disease.

Dr. You and associates concluded that appropriately selected patients with T1 tumors, including the elderly and patients with comorbid conditions that would increase surgical risk, can expect “acceptable overall survival” from local excision. “However, they do face increased risk for a local recurrence in the long term, in exchange for a favorable perioperative course,” she said at the meeting.

Caution should be used in treating patients with T2 tumors with local resection alone, she advised. “I would reserve local excision alone only for those patients [with T2 tumors] whose medical risks are prohibitive,” Dr. You emphasized.

In an interview after the meeting, she said the gold standard for patients with T2 tumors remains a standard abdominal resection, which she generally recommends to her patients when discussing the risks and benefits of either procedure.

“However, if the tumor characteristics are favorable for local excision and [the] patient is reluctant to undergo a large procedure, I would strongly consider a clinical trial,” she said.

Trials are underway to see whether chemoradiation in combination with local excision lowers the risk of local recurrence in patients with stage I disease.

Dr. Heidi Nelson, chair of the colon and rectal surgery division at the Mayo Clinic, was a coinvestigator on the study. Researchers from the University of Minnesota and the American College of Surgeons also contributed. The meeting was co-sponsored by the American Gastroenterological Association, the American Society for Therapeutic Radiation and Oncology, and the Society of Surgical Oncology.

At 8 years post diagnosis, the local recurrence rate for resected T1 tumors had climbed to 14.3%. DR. YOU