Clinical question

Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?

Bottom line

Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)

Reference

Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.

Study design

Other

Funding source

Unknown/not stated

Allocation

Uncertain

Setting

Inpatient (any location)

Synopsis

Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?

Bottom line

Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)

Reference

Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.

Study design

Other

Funding source

Unknown/not stated

Allocation

Uncertain

Setting

Inpatient (any location)

Synopsis

Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does implementation of the I COUGH strategy improve pulmonary outcomes in postoperative patients?

Bottom line

Although not statistically significant, data from this before-and-after trial shows that the I COUGH strategy (emphasizing lung expansion, early mobilization, oral hygiene, and patient and provider education) may decrease postoperative pulmonary complications in hospitalized patients. (LOE = 2c)

Reference

Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013;148(8):740-745.

Study design

Other

Funding source

Unknown/not stated

Allocation

Uncertain

Setting

Inpatient (any location)

Synopsis

Data from the National Surgical Quality Improvement Program (NQSIP) showed that the Boston Medical Center was a high outlier for postoperative pulmonary complications. To address this, a pulmonary care working group including surgeons, internists, nurses, and respiratory therapists was formed. The group reviewed the literature on preventing postoperative pulmonary complications and devised the I COUGH strategy: (1) Incentive spirometry, (2) Coughing and deep breathing, (3) Oral care, (4) Understanding (patient and family education), (5) Getting out of bed, and (6) Head-of-bed elevation. Postoperative pain control was also emphasized. Educational materials including videos and brochures were developed for patients and families and distributed in surgery and perioperative clinics. Incentive spirometry technique was taught and reinforced in the preoperative setting. Frontline nurses and physicians also received education regarding the baseline outcomes data and the reasons for developing the program. Finally, standardized order sets outlining the components of I COUGH were created. The I COUGH strategy was implemented for all hospitalized general and vascular surgery patients in the institution. More patients were out of bed postintervention than preintervention (70% vs 20%; P < .001). Similarly, more patients had incentive spirometry available and within reach postintervention (77% vs 53%; P < .001). Note, however, that the preintervention audits were unannounced observations of nursing practices whereas postintervention audits were by review of nursing documentation only. Although not statistically significant, the NSQIP data revealed trends toward decreased incidences of postoperative pneumonia (2.6% vs 1.6%; P = .09) and unplanned intubations (2.0% vs 1.2%; P = .09) after I COUGH implementation. National averages for postoperative pneumonias and unplanned intubations for comparable hospitals during this period were 1.4% to 1.7% and 1.4% to 1.6%, respectively.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

How effective is intensive smoking cessation support for hospitalized patients?

Bottom line

Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)

Reference

Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ 2013;347:f4004.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

How effective is intensive smoking cessation support for hospitalized patients?

Bottom line

Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)

Reference

Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ 2013;347:f4004.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

How effective is intensive smoking cessation support for hospitalized patients?

Bottom line

Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)

Reference

Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ 2013;347:f4004.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

The diagnosis of otitis media absolutely requires visualization of the tympanic membrane. So it may be time to upgrade your tools to do a better job in diagnosing. Think about how often you use your otoscope. Are you using the best available technology, or are you using the otoscope you got in medical school, perhaps quite a few years ago? It may be time for an upgrade. Considering how often you might use an otoscope, you can afford it. You deserve it.

The improved features of new otoscopes include remarkably better illumination. The quality of the light not only has to do with the lumens, but also the color of the light. Also there is a version of an otoscope called a Macro View (Welch Allyn, Skaneateles Falls, N.Y.). It allows you to increase the magnification on the tympanic membrane (TM) as needed. There is an option to purchase a lighter and smaller handle for the scope, and that can improve ease of use for persons with small hands.

For all otoscopes, the bulb should be replaced when illumination begins to fade and you cannot get back the intensity of light with a battery recharge. For most primary care practitioners, bulbs usually require replacement annually.

Speculum size is key to getting the most light onto the TM; the bigger the speculum, the better. Advancing the speculum as far into the external ear canal as you can without causing discomfort helps improve the intensity of the light shone on the TM. While it is convenient to use disposable specula, they are not as good as reusable ones because the finish on the inside of disposable specula is duller than on reusable specula, thus decreasing the amount of light shone on the TM. Also, disposable specula often are too short, and that too reduces the light shone on the TM.

Many clinicians have not been trained on using pneumatic otoscopy, or even if trained, they find it inconvenient and/or problematic to use because it requires a seal of the speculum against the external auditory canal; this makes children cry. The problem is that you really need to use pneumatic otoscopy in some cases to determine if the TM is retracted (no acute infection) or bulging (acute infection, or AOM). I use pneumatic otoscopy in about one-third of cases, and to this day I am surprised sometimes when the negative pressure pulls a retracted TM forward when I was pretty sure the TM more likely was bulging. There are specula with a semisoft sleeve midway down the shaft, but I have not found they are any less likely to cause the child to cry, because as anyone knows who has stuck a Q-tip swab into their ear canal, it is sensitive skin.

Then there is the wax! Clinical studies show that about half of children have wax in their external auditory canal blocking 25% of the view, and one-quarter have wax blocking 50% of the view. The best tool I have found to clear the wax is a plastic cerumen spoon (called a safe ear curette) made by Bionix Medical Technologies (Toledo, Ohio). I use the white ones as they are the most flexible. Ninety percent of the time I can scoop the wax out of the way and get a good view. For the remaining difficult cases, the ear canal needs to be irrigated with warm water (code 69210), and then the remaining wax can be scooped out.

Tympanometry (code 92567) is another tool to aid in accurate diagnosis and follow-up of otitis media. A key aspect of the diagnostic algorithm advocated by the American Academy of Pediatrics is a determination of whether the TM is bulging (AOM) or not (no AOM). A retracted TM is inconsistent with the diagnosis of AOM. Tympanometry requires a seal with the external auditory canal because a pressure is applied to the TM to determine TM movement. After positive and negative pressure are applied by the instrument, the readout will be a positive peaked curve (bulging), a negative peaked curve (retracted), a normal peaked curve (normal), or flat, no curve (stiff TM).

The first three readouts are very helpful in distinguishing AOM from no AOM. The flat curve indicates three possibilities: The TM is stiff, perhaps due to thickening; the TM is not moving because the middle ear space is filled with pus behind it, meaning it is AOM; or the TM is not moving because the middle ear space is filled with effusion fluid behind it, meaning the patient has otitis media with effusion. In the case of a flat readout, the tie breaker should come from the visual exam and/or the use of spectral gradient acoustic reflectometry (code 92567).

These better tools and techniques should improve your diagnosis of otitis media.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester General Hospital, N.Y. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].

The diagnosis of otitis media absolutely requires visualization of the tympanic membrane. So it may be time to upgrade your tools to do a better job in diagnosing. Think about how often you use your otoscope. Are you using the best available technology, or are you using the otoscope you got in medical school, perhaps quite a few years ago? It may be time for an upgrade. Considering how often you might use an otoscope, you can afford it. You deserve it.

The improved features of new otoscopes include remarkably better illumination. The quality of the light not only has to do with the lumens, but also the color of the light. Also there is a version of an otoscope called a Macro View (Welch Allyn, Skaneateles Falls, N.Y.). It allows you to increase the magnification on the tympanic membrane (TM) as needed. There is an option to purchase a lighter and smaller handle for the scope, and that can improve ease of use for persons with small hands.

For all otoscopes, the bulb should be replaced when illumination begins to fade and you cannot get back the intensity of light with a battery recharge. For most primary care practitioners, bulbs usually require replacement annually.

Speculum size is key to getting the most light onto the TM; the bigger the speculum, the better. Advancing the speculum as far into the external ear canal as you can without causing discomfort helps improve the intensity of the light shone on the TM. While it is convenient to use disposable specula, they are not as good as reusable ones because the finish on the inside of disposable specula is duller than on reusable specula, thus decreasing the amount of light shone on the TM. Also, disposable specula often are too short, and that too reduces the light shone on the TM.

Many clinicians have not been trained on using pneumatic otoscopy, or even if trained, they find it inconvenient and/or problematic to use because it requires a seal of the speculum against the external auditory canal; this makes children cry. The problem is that you really need to use pneumatic otoscopy in some cases to determine if the TM is retracted (no acute infection) or bulging (acute infection, or AOM). I use pneumatic otoscopy in about one-third of cases, and to this day I am surprised sometimes when the negative pressure pulls a retracted TM forward when I was pretty sure the TM more likely was bulging. There are specula with a semisoft sleeve midway down the shaft, but I have not found they are any less likely to cause the child to cry, because as anyone knows who has stuck a Q-tip swab into their ear canal, it is sensitive skin.

Then there is the wax! Clinical studies show that about half of children have wax in their external auditory canal blocking 25% of the view, and one-quarter have wax blocking 50% of the view. The best tool I have found to clear the wax is a plastic cerumen spoon (called a safe ear curette) made by Bionix Medical Technologies (Toledo, Ohio). I use the white ones as they are the most flexible. Ninety percent of the time I can scoop the wax out of the way and get a good view. For the remaining difficult cases, the ear canal needs to be irrigated with warm water (code 69210), and then the remaining wax can be scooped out.

Tympanometry (code 92567) is another tool to aid in accurate diagnosis and follow-up of otitis media. A key aspect of the diagnostic algorithm advocated by the American Academy of Pediatrics is a determination of whether the TM is bulging (AOM) or not (no AOM). A retracted TM is inconsistent with the diagnosis of AOM. Tympanometry requires a seal with the external auditory canal because a pressure is applied to the TM to determine TM movement. After positive and negative pressure are applied by the instrument, the readout will be a positive peaked curve (bulging), a negative peaked curve (retracted), a normal peaked curve (normal), or flat, no curve (stiff TM).

The first three readouts are very helpful in distinguishing AOM from no AOM. The flat curve indicates three possibilities: The TM is stiff, perhaps due to thickening; the TM is not moving because the middle ear space is filled with pus behind it, meaning it is AOM; or the TM is not moving because the middle ear space is filled with effusion fluid behind it, meaning the patient has otitis media with effusion. In the case of a flat readout, the tie breaker should come from the visual exam and/or the use of spectral gradient acoustic reflectometry (code 92567).

These better tools and techniques should improve your diagnosis of otitis media.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester General Hospital, N.Y. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].

The diagnosis of otitis media absolutely requires visualization of the tympanic membrane. So it may be time to upgrade your tools to do a better job in diagnosing. Think about how often you use your otoscope. Are you using the best available technology, or are you using the otoscope you got in medical school, perhaps quite a few years ago? It may be time for an upgrade. Considering how often you might use an otoscope, you can afford it. You deserve it.

The improved features of new otoscopes include remarkably better illumination. The quality of the light not only has to do with the lumens, but also the color of the light. Also there is a version of an otoscope called a Macro View (Welch Allyn, Skaneateles Falls, N.Y.). It allows you to increase the magnification on the tympanic membrane (TM) as needed. There is an option to purchase a lighter and smaller handle for the scope, and that can improve ease of use for persons with small hands.

For all otoscopes, the bulb should be replaced when illumination begins to fade and you cannot get back the intensity of light with a battery recharge. For most primary care practitioners, bulbs usually require replacement annually.

Speculum size is key to getting the most light onto the TM; the bigger the speculum, the better. Advancing the speculum as far into the external ear canal as you can without causing discomfort helps improve the intensity of the light shone on the TM. While it is convenient to use disposable specula, they are not as good as reusable ones because the finish on the inside of disposable specula is duller than on reusable specula, thus decreasing the amount of light shone on the TM. Also, disposable specula often are too short, and that too reduces the light shone on the TM.

Many clinicians have not been trained on using pneumatic otoscopy, or even if trained, they find it inconvenient and/or problematic to use because it requires a seal of the speculum against the external auditory canal; this makes children cry. The problem is that you really need to use pneumatic otoscopy in some cases to determine if the TM is retracted (no acute infection) or bulging (acute infection, or AOM). I use pneumatic otoscopy in about one-third of cases, and to this day I am surprised sometimes when the negative pressure pulls a retracted TM forward when I was pretty sure the TM more likely was bulging. There are specula with a semisoft sleeve midway down the shaft, but I have not found they are any less likely to cause the child to cry, because as anyone knows who has stuck a Q-tip swab into their ear canal, it is sensitive skin.

Then there is the wax! Clinical studies show that about half of children have wax in their external auditory canal blocking 25% of the view, and one-quarter have wax blocking 50% of the view. The best tool I have found to clear the wax is a plastic cerumen spoon (called a safe ear curette) made by Bionix Medical Technologies (Toledo, Ohio). I use the white ones as they are the most flexible. Ninety percent of the time I can scoop the wax out of the way and get a good view. For the remaining difficult cases, the ear canal needs to be irrigated with warm water (code 69210), and then the remaining wax can be scooped out.

Tympanometry (code 92567) is another tool to aid in accurate diagnosis and follow-up of otitis media. A key aspect of the diagnostic algorithm advocated by the American Academy of Pediatrics is a determination of whether the TM is bulging (AOM) or not (no AOM). A retracted TM is inconsistent with the diagnosis of AOM. Tympanometry requires a seal with the external auditory canal because a pressure is applied to the TM to determine TM movement. After positive and negative pressure are applied by the instrument, the readout will be a positive peaked curve (bulging), a negative peaked curve (retracted), a normal peaked curve (normal), or flat, no curve (stiff TM).

The first three readouts are very helpful in distinguishing AOM from no AOM. The flat curve indicates three possibilities: The TM is stiff, perhaps due to thickening; the TM is not moving because the middle ear space is filled with pus behind it, meaning it is AOM; or the TM is not moving because the middle ear space is filled with effusion fluid behind it, meaning the patient has otitis media with effusion. In the case of a flat readout, the tie breaker should come from the visual exam and/or the use of spectral gradient acoustic reflectometry (code 92567).

These better tools and techniques should improve your diagnosis of otitis media.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester General Hospital, N.Y. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no financial disclosures relevant to this article. To comment, e-mail him at [email protected].

Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.

Some tips for treating PFB:

If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.

If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.

Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.

If shaving is a must, advise patients to:

• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.

• Use shaving gel and a sharp razor each time.

• Do not pull the skin taut.

• Do not shave against the direction of hair growth.

• Take short strokes and do not shave back and forth over the same areas.

• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.

Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.

If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.

Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.

For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.

What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.

Some tips for treating PFB:

If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.

If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.

Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.

If shaving is a must, advise patients to:

• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.

• Use shaving gel and a sharp razor each time.

• Do not pull the skin taut.

• Do not shave against the direction of hair growth.

• Take short strokes and do not shave back and forth over the same areas.

• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.

Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.

If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.

Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.

For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.

What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.

Some tips for treating PFB:

If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.

If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.

Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.

If shaving is a must, advise patients to:

• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.

• Use shaving gel and a sharp razor each time.

• Do not pull the skin taut.

• Do not shave against the direction of hair growth.

• Take short strokes and do not shave back and forth over the same areas.

• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.

Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.

If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.

Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.

For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.

What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

The doctors’ lounge: A hallowed space for sharing challenging cases and discussing the Affordable Care Act or a place to catch a nap and commiserate? It can (and likely should) be both. Unfortunately, doctors’ lounges are a thing of the past for many of today’s physicians. Whether you’re in private practice or work in a place that simply has no social space for physicians, it can be difficult to connect and share professional and personal information with colleagues.

Technology is offering a solution. In the last few years, physician-only online communities have burgeoned. Sermo, the largest of these communities, boasts more than 125,000 licensed physicians from more than 65 specialties as members. Other big players include Medscape Physician Connect and Doximity. Many smaller specialty-specific communities have surfaced as well, such as OrthoMind.com and MomMD.com, social networks exclusively for orthopedic surgeons and women in medicine (including nurses and residents), respectively.

Unlike open social forums such as Facebook and Twitter, these physician communities are closed social networks, which means that only credentialed members can join and participate. This exclusivity has been a large draw for physicians otherwise skeptical of using social networks. However, it’s worth noting that several sites allow access to other health care providers, including nurses, residents, and medical students.

Ideally, these close social networks exist to help physicians maximize benefits (collaborating and networking) and reduce risks (liability and online reputation). To allay concerns of risk, some sites, including Sermo and Medscape, allow confirmed physicians to choose an alias. On the upside, such anonymous posting allows for franker discussions; on the downside, it can lend itself to unprofessionalism, such as posting inappropriate or incendiary comments.

How many physicians are using these online physician communities? Between 25% and 28%, according to a 2011 study from QuantialMD, and a 2012 study from the Journal of Medical Internet Research. These numbers continue to grow.

If you’ve wondered whether to join a physician-only online community, here are six potential benefits:

• Curbside consults. These communities provide access to thousands of physicians, including specialists, which offers you a tremendous opportunity to get a curbside consult for that difficult patient. Often you can get both diagnostic and treatment suggestions quickly and cost free.

• Current event information. Missed a journal or a conference? These communities are great ways for you to stay informed. You can ask questions or simply follow conversations based on particular topics.

• Help with patient management. We’ve all had to work with difficult patients; the truth is some of us are better at it than others. These communities allow you to ask for advice (anonymously if you’re more comfortable with that) from other professionals who have navigated similar situations successfully and wish to help.

• The ability to share best practice information. Whether it’s a new medication or an office management solution, online communities are rich resources for sharing best practices. Many sites also allow you to poll fellow members, which yields personalized, instantaneous, real feedback.

• The ability to become a thought leader/expert. Whether you’re an established expert in your field or are building your reputation, these communities are effective vehicles for identifying people who stand out from the pack. Establishing yourself as a respected leader in a community can also lead to professional opportunities such as speaking invitations or other leadership roles.

• Networking. Sometimes we physicians forget that it’s beneficial to simply be social. These communities don’t always have to be about improving office efficiency or diagnosing difficult cases; sometimes they can simply be a place to hang out and connect with like-minded people. It’s not uncommon for online relationships to develop into real-life ones, such as connecting at a conference or collaborating on a volunteer project.

Remember, like any worthwhile network, these sites are only as valuable as your participation in them. And before posting questionable material, make sure it’s content that you would be comfortable sharing with a physician in person.

If you belong to a physician-only online community, please share your thoughts with us online, via the Skin & Allergy News Facebook page, or via e-mail ([email protected]). What benefits or drawbacks have you encountered?

The next time you need advice on a challenging case or simply feel like connecting with colleagues, consider joining a physician online community. Just realize that there won’t be any hot coffee and donuts.

Dr. Jeffrey Benabio is a practicing dermatologist and Physician Director of Healthcare Transformation at Kaiser Permanente in San Diego. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].

The doctors’ lounge: A hallowed space for sharing challenging cases and discussing the Affordable Care Act or a place to catch a nap and commiserate? It can (and likely should) be both. Unfortunately, doctors’ lounges are a thing of the past for many of today’s physicians. Whether you’re in private practice or work in a place that simply has no social space for physicians, it can be difficult to connect and share professional and personal information with colleagues.

Technology is offering a solution. In the last few years, physician-only online communities have burgeoned. Sermo, the largest of these communities, boasts more than 125,000 licensed physicians from more than 65 specialties as members. Other big players include Medscape Physician Connect and Doximity. Many smaller specialty-specific communities have surfaced as well, such as OrthoMind.com and MomMD.com, social networks exclusively for orthopedic surgeons and women in medicine (including nurses and residents), respectively.

Unlike open social forums such as Facebook and Twitter, these physician communities are closed social networks, which means that only credentialed members can join and participate. This exclusivity has been a large draw for physicians otherwise skeptical of using social networks. However, it’s worth noting that several sites allow access to other health care providers, including nurses, residents, and medical students.

Ideally, these close social networks exist to help physicians maximize benefits (collaborating and networking) and reduce risks (liability and online reputation). To allay concerns of risk, some sites, including Sermo and Medscape, allow confirmed physicians to choose an alias. On the upside, such anonymous posting allows for franker discussions; on the downside, it can lend itself to unprofessionalism, such as posting inappropriate or incendiary comments.

How many physicians are using these online physician communities? Between 25% and 28%, according to a 2011 study from QuantialMD, and a 2012 study from the Journal of Medical Internet Research. These numbers continue to grow.

If you’ve wondered whether to join a physician-only online community, here are six potential benefits:

• Curbside consults. These communities provide access to thousands of physicians, including specialists, which offers you a tremendous opportunity to get a curbside consult for that difficult patient. Often you can get both diagnostic and treatment suggestions quickly and cost free.

• Current event information. Missed a journal or a conference? These communities are great ways for you to stay informed. You can ask questions or simply follow conversations based on particular topics.

• Help with patient management. We’ve all had to work with difficult patients; the truth is some of us are better at it than others. These communities allow you to ask for advice (anonymously if you’re more comfortable with that) from other professionals who have navigated similar situations successfully and wish to help.

• The ability to share best practice information. Whether it’s a new medication or an office management solution, online communities are rich resources for sharing best practices. Many sites also allow you to poll fellow members, which yields personalized, instantaneous, real feedback.

• The ability to become a thought leader/expert. Whether you’re an established expert in your field or are building your reputation, these communities are effective vehicles for identifying people who stand out from the pack. Establishing yourself as a respected leader in a community can also lead to professional opportunities such as speaking invitations or other leadership roles.

• Networking. Sometimes we physicians forget that it’s beneficial to simply be social. These communities don’t always have to be about improving office efficiency or diagnosing difficult cases; sometimes they can simply be a place to hang out and connect with like-minded people. It’s not uncommon for online relationships to develop into real-life ones, such as connecting at a conference or collaborating on a volunteer project.

Remember, like any worthwhile network, these sites are only as valuable as your participation in them. And before posting questionable material, make sure it’s content that you would be comfortable sharing with a physician in person.

If you belong to a physician-only online community, please share your thoughts with us online, via the Skin & Allergy News Facebook page, or via e-mail ([email protected]). What benefits or drawbacks have you encountered?

The next time you need advice on a challenging case or simply feel like connecting with colleagues, consider joining a physician online community. Just realize that there won’t be any hot coffee and donuts.

Dr. Jeffrey Benabio is a practicing dermatologist and Physician Director of Healthcare Transformation at Kaiser Permanente in San Diego. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].

The doctors’ lounge: A hallowed space for sharing challenging cases and discussing the Affordable Care Act or a place to catch a nap and commiserate? It can (and likely should) be both. Unfortunately, doctors’ lounges are a thing of the past for many of today’s physicians. Whether you’re in private practice or work in a place that simply has no social space for physicians, it can be difficult to connect and share professional and personal information with colleagues.

Technology is offering a solution. In the last few years, physician-only online communities have burgeoned. Sermo, the largest of these communities, boasts more than 125,000 licensed physicians from more than 65 specialties as members. Other big players include Medscape Physician Connect and Doximity. Many smaller specialty-specific communities have surfaced as well, such as OrthoMind.com and MomMD.com, social networks exclusively for orthopedic surgeons and women in medicine (including nurses and residents), respectively.

Unlike open social forums such as Facebook and Twitter, these physician communities are closed social networks, which means that only credentialed members can join and participate. This exclusivity has been a large draw for physicians otherwise skeptical of using social networks. However, it’s worth noting that several sites allow access to other health care providers, including nurses, residents, and medical students.

Ideally, these close social networks exist to help physicians maximize benefits (collaborating and networking) and reduce risks (liability and online reputation). To allay concerns of risk, some sites, including Sermo and Medscape, allow confirmed physicians to choose an alias. On the upside, such anonymous posting allows for franker discussions; on the downside, it can lend itself to unprofessionalism, such as posting inappropriate or incendiary comments.

How many physicians are using these online physician communities? Between 25% and 28%, according to a 2011 study from QuantialMD, and a 2012 study from the Journal of Medical Internet Research. These numbers continue to grow.

If you’ve wondered whether to join a physician-only online community, here are six potential benefits:

• Curbside consults. These communities provide access to thousands of physicians, including specialists, which offers you a tremendous opportunity to get a curbside consult for that difficult patient. Often you can get both diagnostic and treatment suggestions quickly and cost free.

• Current event information. Missed a journal or a conference? These communities are great ways for you to stay informed. You can ask questions or simply follow conversations based on particular topics.

• Help with patient management. We’ve all had to work with difficult patients; the truth is some of us are better at it than others. These communities allow you to ask for advice (anonymously if you’re more comfortable with that) from other professionals who have navigated similar situations successfully and wish to help.

• The ability to share best practice information. Whether it’s a new medication or an office management solution, online communities are rich resources for sharing best practices. Many sites also allow you to poll fellow members, which yields personalized, instantaneous, real feedback.

• The ability to become a thought leader/expert. Whether you’re an established expert in your field or are building your reputation, these communities are effective vehicles for identifying people who stand out from the pack. Establishing yourself as a respected leader in a community can also lead to professional opportunities such as speaking invitations or other leadership roles.

• Networking. Sometimes we physicians forget that it’s beneficial to simply be social. These communities don’t always have to be about improving office efficiency or diagnosing difficult cases; sometimes they can simply be a place to hang out and connect with like-minded people. It’s not uncommon for online relationships to develop into real-life ones, such as connecting at a conference or collaborating on a volunteer project.

Remember, like any worthwhile network, these sites are only as valuable as your participation in them. And before posting questionable material, make sure it’s content that you would be comfortable sharing with a physician in person.

If you belong to a physician-only online community, please share your thoughts with us online, via the Skin & Allergy News Facebook page, or via e-mail ([email protected]). What benefits or drawbacks have you encountered?

The next time you need advice on a challenging case or simply feel like connecting with colleagues, consider joining a physician online community. Just realize that there won’t be any hot coffee and donuts.

Dr. Jeffrey Benabio is a practicing dermatologist and Physician Director of Healthcare Transformation at Kaiser Permanente in San Diego. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].

Insurance – so goes the hoary cliché – is the one product you buy hoping never to use. While no one enjoys foreseeing unforeseeable calamities, regular meetings with your insurance broker are important. Overinsuring is a waste of money, but underinsuring can prove even more costly, should the unforeseeable happen.

Malpractice premiums continue to rise. If yours are getting out of hand, ask your broker about alternatives.

"Occurrence" policies remain the coverage of choice where they are available and affordable, but they are becoming an endangered species as fewer insurers are willing to write them. "Claims-made" policies are usually cheaper, and provide the same coverage as long as you remain in practice. You will need "tail" coverage against belated claims after you retire, but many companies provide free tail coverage after you’ve been insured for a minimum period (usually 5 years).

Other alternatives are gaining popularity as the demand for more reasonably priced insurance increases. The most common, known as reciprocal exchanges, are very similar to traditional insurers, but differ in certain aspects of funding and operations. For example, most exchanges require policyholders to make capital contributions in addition to payment of premiums, at least in their early stages. You get your investment back, with interest, when (if) the exchange becomes solvent.

Another option, called a captive, is an insurance company formed by several noninsurance entities (such as medical practices) to write their own insurance policies. All participants are shareholders, and all premiums (less administrative expenses) go toward building the security of the captive. Most captives purchase reinsurance to protect against catastrophic losses. If all goes well, individual owners sell their shares at retirement for a nice profit, which has grown tax free in the interim.

Risk Retention Groups (RRGs) are a combination of exchanges and captives, in that capital investments are usually required, and the owners are the insureds themselves; but all responsibility for management and adequate funding falls on the insureds’ shoulders, and reinsurance is rarely an option. Most medical malpractice RRGs are licensed in Vermont or South Carolina, because of favorable laws in those states, but they can be based in any state that allows them.

Exchanges, captives, and RRGs all carry risk: A few large claims can eat up all the profits, and may even put you in a financial hole. But of course, traditional malpractice policies offer zero profit opportunity.

If your financial situation has changed since your last insurance review, your life insurance needs have probably changed, too. As your retirement savings accumulate, less insurance is necessary. And if you own any expensive whole life policies, you can probably convert them to much cheaper term insurance.

Disability insurance is not something to skimp on, but if you are approaching retirement age, you may be able to decrease your coverage, or even eliminate it entirely, if your retirement plan is far enough along.

Liability insurance is likewise no place to pinch pennies, but you might be able to add an umbrella policy providing comprehensive catastrophic coverage, which may allow you to decrease your regular coverage, or raise your deductible limits.

One additional policy to consider is Employment Practices Liability Insurance, which protects you from lawsuits brought by militant or disgruntled employees. More on that next month.

Health insurance premiums continue to soar; Obamacare might offer a favorable alternative for your office policy. Open enrollment began Oct. 1, with coverage scheduled to begin Jan. 1, 2014. If you are considering such an option, go to the Center for Consumer Information and Insurance Oversight and pick a plan for your employees to enroll in.

Workers’ compensation insurance is mandatory in most states, and heavily regulated, so there is little room for cutting expenses. However, some states do not require you, as the employer, to cover yourself, and eliminating that coverage could save you a substantial amount. This is only worth considering, of course, if you have adequate health and disability policies in place.

If you’re over 50 years old, look into long-term care insurance as well. It’s relatively inexpensive if you buy it while you’re still healthy, and it could save you and your heirs a load of money on the other end. If you have shouldered the expense of a chronically ill parent or grandparent, you know what I’m talking about.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J., and has been a long-time monthly columnist for Dermatology News.

Insurance – so goes the hoary cliché – is the one product you buy hoping never to use. While no one enjoys foreseeing unforeseeable calamities, regular meetings with your insurance broker are important. Overinsuring is a waste of money, but underinsuring can prove even more costly, should the unforeseeable happen.

Malpractice premiums continue to rise. If yours are getting out of hand, ask your broker about alternatives.

"Occurrence" policies remain the coverage of choice where they are available and affordable, but they are becoming an endangered species as fewer insurers are willing to write them. "Claims-made" policies are usually cheaper, and provide the same coverage as long as you remain in practice. You will need "tail" coverage against belated claims after you retire, but many companies provide free tail coverage after you’ve been insured for a minimum period (usually 5 years).

Other alternatives are gaining popularity as the demand for more reasonably priced insurance increases. The most common, known as reciprocal exchanges, are very similar to traditional insurers, but differ in certain aspects of funding and operations. For example, most exchanges require policyholders to make capital contributions in addition to payment of premiums, at least in their early stages. You get your investment back, with interest, when (if) the exchange becomes solvent.

Another option, called a captive, is an insurance company formed by several noninsurance entities (such as medical practices) to write their own insurance policies. All participants are shareholders, and all premiums (less administrative expenses) go toward building the security of the captive. Most captives purchase reinsurance to protect against catastrophic losses. If all goes well, individual owners sell their shares at retirement for a nice profit, which has grown tax free in the interim.

Risk Retention Groups (RRGs) are a combination of exchanges and captives, in that capital investments are usually required, and the owners are the insureds themselves; but all responsibility for management and adequate funding falls on the insureds’ shoulders, and reinsurance is rarely an option. Most medical malpractice RRGs are licensed in Vermont or South Carolina, because of favorable laws in those states, but they can be based in any state that allows them.

Exchanges, captives, and RRGs all carry risk: A few large claims can eat up all the profits, and may even put you in a financial hole. But of course, traditional malpractice policies offer zero profit opportunity.

If your financial situation has changed since your last insurance review, your life insurance needs have probably changed, too. As your retirement savings accumulate, less insurance is necessary. And if you own any expensive whole life policies, you can probably convert them to much cheaper term insurance.

Disability insurance is not something to skimp on, but if you are approaching retirement age, you may be able to decrease your coverage, or even eliminate it entirely, if your retirement plan is far enough along.

Liability insurance is likewise no place to pinch pennies, but you might be able to add an umbrella policy providing comprehensive catastrophic coverage, which may allow you to decrease your regular coverage, or raise your deductible limits.

One additional policy to consider is Employment Practices Liability Insurance, which protects you from lawsuits brought by militant or disgruntled employees. More on that next month.

Health insurance premiums continue to soar; Obamacare might offer a favorable alternative for your office policy. Open enrollment began Oct. 1, with coverage scheduled to begin Jan. 1, 2014. If you are considering such an option, go to the Center for Consumer Information and Insurance Oversight and pick a plan for your employees to enroll in.

Workers’ compensation insurance is mandatory in most states, and heavily regulated, so there is little room for cutting expenses. However, some states do not require you, as the employer, to cover yourself, and eliminating that coverage could save you a substantial amount. This is only worth considering, of course, if you have adequate health and disability policies in place.

If you’re over 50 years old, look into long-term care insurance as well. It’s relatively inexpensive if you buy it while you’re still healthy, and it could save you and your heirs a load of money on the other end. If you have shouldered the expense of a chronically ill parent or grandparent, you know what I’m talking about.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J., and has been a long-time monthly columnist for Dermatology News.

Insurance – so goes the hoary cliché – is the one product you buy hoping never to use. While no one enjoys foreseeing unforeseeable calamities, regular meetings with your insurance broker are important. Overinsuring is a waste of money, but underinsuring can prove even more costly, should the unforeseeable happen.

Malpractice premiums continue to rise. If yours are getting out of hand, ask your broker about alternatives.

"Occurrence" policies remain the coverage of choice where they are available and affordable, but they are becoming an endangered species as fewer insurers are willing to write them. "Claims-made" policies are usually cheaper, and provide the same coverage as long as you remain in practice. You will need "tail" coverage against belated claims after you retire, but many companies provide free tail coverage after you’ve been insured for a minimum period (usually 5 years).

Other alternatives are gaining popularity as the demand for more reasonably priced insurance increases. The most common, known as reciprocal exchanges, are very similar to traditional insurers, but differ in certain aspects of funding and operations. For example, most exchanges require policyholders to make capital contributions in addition to payment of premiums, at least in their early stages. You get your investment back, with interest, when (if) the exchange becomes solvent.

Another option, called a captive, is an insurance company formed by several noninsurance entities (such as medical practices) to write their own insurance policies. All participants are shareholders, and all premiums (less administrative expenses) go toward building the security of the captive. Most captives purchase reinsurance to protect against catastrophic losses. If all goes well, individual owners sell their shares at retirement for a nice profit, which has grown tax free in the interim.

Risk Retention Groups (RRGs) are a combination of exchanges and captives, in that capital investments are usually required, and the owners are the insureds themselves; but all responsibility for management and adequate funding falls on the insureds’ shoulders, and reinsurance is rarely an option. Most medical malpractice RRGs are licensed in Vermont or South Carolina, because of favorable laws in those states, but they can be based in any state that allows them.

Exchanges, captives, and RRGs all carry risk: A few large claims can eat up all the profits, and may even put you in a financial hole. But of course, traditional malpractice policies offer zero profit opportunity.

If your financial situation has changed since your last insurance review, your life insurance needs have probably changed, too. As your retirement savings accumulate, less insurance is necessary. And if you own any expensive whole life policies, you can probably convert them to much cheaper term insurance.

Disability insurance is not something to skimp on, but if you are approaching retirement age, you may be able to decrease your coverage, or even eliminate it entirely, if your retirement plan is far enough along.

Liability insurance is likewise no place to pinch pennies, but you might be able to add an umbrella policy providing comprehensive catastrophic coverage, which may allow you to decrease your regular coverage, or raise your deductible limits.

One additional policy to consider is Employment Practices Liability Insurance, which protects you from lawsuits brought by militant or disgruntled employees. More on that next month.

Health insurance premiums continue to soar; Obamacare might offer a favorable alternative for your office policy. Open enrollment began Oct. 1, with coverage scheduled to begin Jan. 1, 2014. If you are considering such an option, go to the Center for Consumer Information and Insurance Oversight and pick a plan for your employees to enroll in.

Workers’ compensation insurance is mandatory in most states, and heavily regulated, so there is little room for cutting expenses. However, some states do not require you, as the employer, to cover yourself, and eliminating that coverage could save you a substantial amount. This is only worth considering, of course, if you have adequate health and disability policies in place.

If you’re over 50 years old, look into long-term care insurance as well. It’s relatively inexpensive if you buy it while you’re still healthy, and it could save you and your heirs a load of money on the other end. If you have shouldered the expense of a chronically ill parent or grandparent, you know what I’m talking about.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J., and has been a long-time monthly columnist for Dermatology News.

A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.

By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.

Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.

First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.

I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.

I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.

For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)

But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.

Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.

If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).

But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.

Dr. Chan practices rheumatology in Pawtucket, R.I.

A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.

By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.

Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.

First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.

I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.

I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.

For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)

But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.

Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.

If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).

But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.

Dr. Chan practices rheumatology in Pawtucket, R.I.

A few weeks ago I had to take some days off work because I was sick. I had just come back from visiting family in Las Vegas and I suspect I caught something from my brother-in-law. The brief vacation, plus sick days and two weekends in between, meant that I did not work for 10 days.

By the end of that period, I was ready to go back to work. It did not matter that I was not 100% better. I was better, and as grateful as I was for the rest, I couldn’t wait to get back.

Now, I often joke about feeling burnt out (and, as I am very fond of saying, jokes are half-meant), so for me to feel that way came as a surprise to me.

First, let me explain why, after only 4 years of full-time practice, I am feeling a bit burnt out. Frustration seems to be an almost daily occurrence now. I get frustrated when there are delays in the treatment I prescribe because of insurance companies. I am frustrated by patients who are habitually late or noncompliant, or worse, drug seeking. I get frustrated when I think my office staff is not doing things efficiently.

I get frustrated when my judgment is questioned not on the basis of its lack of merit, but on the basis of a mistrust of my age, gender, race, and stature. I’ll bet neither one of my bosses gets called "honey" or "little girl," nor, I suspect, are they regularly asked for their age. My guess is that I get more overt signs of disrespect than they do as well. A patient once said that I could not wear heels and not expect people to stare, as if my fashion sense negates my medical degree and training.

I get frustrated when I can’t help patients: When their osteoarthritis is so far advanced that nothing helps; when I’ve tried every single approved biologic but their psoriatic arthritis is not responding; when those with polymyalgia rheumatica can’t get below 9 mg of prednisone; and when they somatize and have hyperbolic symptoms that are wildly disproportionate to the degree of arthritis.

For all the vagaries of our chosen profession, I have more than once wondered at my boss’s resilience and admired his ability to let things slide off his back when I constantly find myself at the brink of collapsing under the weight of the world’s expectations of me, including my expectations of myself. (Who’s being hyperbolic now?)

But when I missed those 10 days of work and was so eager to return, I realized the inescapable reality that, to a degree that I had not previously appreciated, my doctorhood defines me.

Doctoring is a privilege. We would not be here if we didn’t possess the gifts of intellect, talent, industry, and altruism. Because we have those qualities, we are in a unique position to belong to such a noble profession, to belong to the ranks of people making other people better, to stand on the shoulders of the giants who came before us, looking at a horizon that they could not have imagined.

If you consume pop culture like I do, you are familiar with the injunction to "find your happiness," as if happiness is a good that can be acquired. I’ve long struggled with this concept. I’ve wondered what, if anything, I was missing. I wondered if I was being disingenuous by not pursuing an appropriately low-paying-but-oh-so-antiestablishment job that was purportedly my passion (writer, musician, artist, organic farmer?).

But I think I’ve finally figured it out. Happiness is not a good, it is a byproduct of a life well-lived: to make a difference in our patients’ lives, to earn the trust of colleagues whom we respect, and to treat people with kindness and generosity. This is a meaningful life from which happiness derives.

Dr. Chan practices rheumatology in Pawtucket, R.I.