Commentary

The Digital Revolution has invaded the House of Medicine, which is not really news since the invasion has been long-standing, but it seems to be generating more interest and concern in recent months. The American Medical Association recently created the Digital Health Implementation Playbook to lend guidance in developing technologies that are fundamentally altering the manner in which patients interact with health care providers.¹ The playbook lays out specific steps for developing and implementing digital health technologies such as remote patient monitoring devices. The goal of the playbook is to make certain that such devices are accurate, reliable, and validated as valuable additions to high-quality patient care.¹

In the February 2018 issue of Cutis, Masud et al² evaluated 44 patient-directed mobile applications (apps) for dermatologic conditions and developed a schematic for evaluating their value in providing valid usable information for patients. They found that most of the apps failed to live up to their purported usefulness in patient education.² I am certain we have all seen numerous examples on the Internet, many times brought to us by patients, of fallacious and inaccurate information about the diagnosis and treatment of dermatologic conditions that are actually harmful to the care of our patients.

A more upsetting trend in recent years is the proliferation of open-access journals. Although such digital journals can result in more rapid dissemination of valid scientific information, many of them do not follow a true peer-review process. So-called predatory journals from for-profit unethical publishers are increasing at an alarming rate.³

Furthermore, there is a need to present data more accurately and in formats that provide more meaningful interpretation, according to a recent Letter From the Editor in the Journal of the American Academy of Dermatology.⁴ Elston⁴ wrote: “Be honest about your data and the limitations of the study design.” He cautioned further about the proper use of statistical analysis.

As dermatologists, how do we make certain that the Digital Revolution results in better care of our patients? The answer, of course, is in education of the practitioner and our young colleagues in training. Although most Cutis readers still access the print version of our journal, more and more readers are accessing our digital format. Online we are able to offer readers the peer-reviewed content you have known to trust and rely on to improve your care of patients as well as other educational tools. Furthermore, we can provide readers access to additional charts and tables pertaining to research published in the print journal.

In January 2019 the Cutis website will merge with Dermatology News, our sister news publication, to become MDedge Dermatology (www.mdedge.com/dermatology). This site will be your new one-stop destination for timely news and clinical content you can trust from both publications. This interactive site is designed to help clinicians quickly find the information they need to improve the treatment and care of patients with conditions affecting the hair, skin, and nails. You will have free access to digital resources such as procedural videos, podcasts, image quizzes, board review, and resident resources, as well as an archive of Cutis content dating back to 2000.

As we at Cutis broaden our digital footprint, we look forward to providing our readers with a larger volume of clinically relevant content in more easily accessed formats while maintaining our commitment to valid trustworthy information. In the coming months we look forward to joining with you in this new digital endeavor, and as always, we appreciate the input of our readers during this process.

The Digital Revolution has invaded the House of Medicine, which is not really news since the invasion has been long-standing, but it seems to be generating more interest and concern in recent months. The American Medical Association recently created the Digital Health Implementation Playbook to lend guidance in developing technologies that are fundamentally altering the manner in which patients interact with health care providers.¹ The playbook lays out specific steps for developing and implementing digital health technologies such as remote patient monitoring devices. The goal of the playbook is to make certain that such devices are accurate, reliable, and validated as valuable additions to high-quality patient care.¹

In the February 2018 issue of Cutis, Masud et al² evaluated 44 patient-directed mobile applications (apps) for dermatologic conditions and developed a schematic for evaluating their value in providing valid usable information for patients. They found that most of the apps failed to live up to their purported usefulness in patient education.² I am certain we have all seen numerous examples on the Internet, many times brought to us by patients, of fallacious and inaccurate information about the diagnosis and treatment of dermatologic conditions that are actually harmful to the care of our patients.

A more upsetting trend in recent years is the proliferation of open-access journals. Although such digital journals can result in more rapid dissemination of valid scientific information, many of them do not follow a true peer-review process. So-called predatory journals from for-profit unethical publishers are increasing at an alarming rate.³

Furthermore, there is a need to present data more accurately and in formats that provide more meaningful interpretation, according to a recent Letter From the Editor in the Journal of the American Academy of Dermatology.⁴ Elston⁴ wrote: “Be honest about your data and the limitations of the study design.” He cautioned further about the proper use of statistical analysis.

As dermatologists, how do we make certain that the Digital Revolution results in better care of our patients? The answer, of course, is in education of the practitioner and our young colleagues in training. Although most Cutis readers still access the print version of our journal, more and more readers are accessing our digital format. Online we are able to offer readers the peer-reviewed content you have known to trust and rely on to improve your care of patients as well as other educational tools. Furthermore, we can provide readers access to additional charts and tables pertaining to research published in the print journal.

In January 2019 the Cutis website will merge with Dermatology News, our sister news publication, to become MDedge Dermatology (www.mdedge.com/dermatology). This site will be your new one-stop destination for timely news and clinical content you can trust from both publications. This interactive site is designed to help clinicians quickly find the information they need to improve the treatment and care of patients with conditions affecting the hair, skin, and nails. You will have free access to digital resources such as procedural videos, podcasts, image quizzes, board review, and resident resources, as well as an archive of Cutis content dating back to 2000.

As we at Cutis broaden our digital footprint, we look forward to providing our readers with a larger volume of clinically relevant content in more easily accessed formats while maintaining our commitment to valid trustworthy information. In the coming months we look forward to joining with you in this new digital endeavor, and as always, we appreciate the input of our readers during this process.

The Digital Revolution has invaded the House of Medicine, which is not really news since the invasion has been long-standing, but it seems to be generating more interest and concern in recent months. The American Medical Association recently created the Digital Health Implementation Playbook to lend guidance in developing technologies that are fundamentally altering the manner in which patients interact with health care providers.¹ The playbook lays out specific steps for developing and implementing digital health technologies such as remote patient monitoring devices. The goal of the playbook is to make certain that such devices are accurate, reliable, and validated as valuable additions to high-quality patient care.¹

In the February 2018 issue of Cutis, Masud et al² evaluated 44 patient-directed mobile applications (apps) for dermatologic conditions and developed a schematic for evaluating their value in providing valid usable information for patients. They found that most of the apps failed to live up to their purported usefulness in patient education.² I am certain we have all seen numerous examples on the Internet, many times brought to us by patients, of fallacious and inaccurate information about the diagnosis and treatment of dermatologic conditions that are actually harmful to the care of our patients.

A more upsetting trend in recent years is the proliferation of open-access journals. Although such digital journals can result in more rapid dissemination of valid scientific information, many of them do not follow a true peer-review process. So-called predatory journals from for-profit unethical publishers are increasing at an alarming rate.³

Furthermore, there is a need to present data more accurately and in formats that provide more meaningful interpretation, according to a recent Letter From the Editor in the Journal of the American Academy of Dermatology.⁴ Elston⁴ wrote: “Be honest about your data and the limitations of the study design.” He cautioned further about the proper use of statistical analysis.

As dermatologists, how do we make certain that the Digital Revolution results in better care of our patients? The answer, of course, is in education of the practitioner and our young colleagues in training. Although most Cutis readers still access the print version of our journal, more and more readers are accessing our digital format. Online we are able to offer readers the peer-reviewed content you have known to trust and rely on to improve your care of patients as well as other educational tools. Furthermore, we can provide readers access to additional charts and tables pertaining to research published in the print journal.

In January 2019 the Cutis website will merge with Dermatology News, our sister news publication, to become MDedge Dermatology (www.mdedge.com/dermatology). This site will be your new one-stop destination for timely news and clinical content you can trust from both publications. This interactive site is designed to help clinicians quickly find the information they need to improve the treatment and care of patients with conditions affecting the hair, skin, and nails. You will have free access to digital resources such as procedural videos, podcasts, image quizzes, board review, and resident resources, as well as an archive of Cutis content dating back to 2000.

As we at Cutis broaden our digital footprint, we look forward to providing our readers with a larger volume of clinically relevant content in more easily accessed formats while maintaining our commitment to valid trustworthy information. In the coming months we look forward to joining with you in this new digital endeavor, and as always, we appreciate the input of our readers during this process.

As I reflect upon the past year, 2018 has certainly made a mark for addressing burnout among medical professionals, enforcing wellness, and targeting implicit and explicit gender bias in medicine and surgery.

Looking back, I entered surgery with a dream to change the culture of surgery. I knew I didn’t fit the traditional mold of an aggressive or arrogant surgeon. But I thought that my empathetic, open, and compassionate ways may spark a change in paradigm for that traditional surgical ideology. However, what I encountered as I made my way on this long, ever-winding journey was a system, culture, and tradition that beats you down, and what I thought were my strengths were quickly turned into weaknesses. As I grew and matured, this loss of identity in a culture of depersonalization surrounded by gender bias, for me, was a perfect recipe leading straight to burnout. However, this was an impetus for change, to be that voice and spark for a cultural transformation of surgery and for the women who work in the specialty.

More women are entering medical and surgical specialties. However, despite the advances made there are still clear gender-based disparities influencing overall wellness and work satisfaction. For instance, a study by Meyerson et al. demonstrated that female residents receive less operating room autonomy than male ones. I see it daily within my own curriculum and in observing other female residents in other surgical specialties. Furthermore, female residents are less often introduced by their physician titles, compared with their male counterparts, are often confused as nonphysicians, and are perceived as being less competent. This influences, to no small extent, overall confidence. It’s discouraging and disheartening to have worked so hard and yet still be treated in a sexist paradigm. And to top it all off, female physicians face a motherhood penalty.

In a recent study by Magudia et al., out of 12 top medical institutions that provided maternity leave, only 8 did so for residents with a grant total of 6.6 weeks on average. Furthermore, women with children or women who plan to have children have constrained career opportunities and are less likely to get full professorship or leadership positions. Anecdotally, a surgeon in passing semijokingly told me that if I were to take a specific academic vascular position, I may have to sign an agreement not to get pregnant ... probably not the job for me.

It’s appalling that, in this day and age, these explicit beliefs still exist, but what scares me more are all the implicit unconscious biases that affect all women not only in surgery but in medicine as well.

Looking back, 2018 is a year of beginning difficult conversations about physician and surgeon wellness, burnout, and gender bias. What’s obvious is that there is a hell of a lot of work to do. But change is slowly starting. We are now recognizing what the issues are, and the next step is to take action. It’s difficult to steer big ships, but there is an active community investing in strategies to improve the cultural scope of surgery and supporting and valuing women and what they have to offer.

References

Magudia K et al. JAMA. 2018;320(22):2372-4.

Meyerson SL et al. J Surg Educ. 2017;74(6):e111-18.

Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.

As I reflect upon the past year, 2018 has certainly made a mark for addressing burnout among medical professionals, enforcing wellness, and targeting implicit and explicit gender bias in medicine and surgery.

Looking back, I entered surgery with a dream to change the culture of surgery. I knew I didn’t fit the traditional mold of an aggressive or arrogant surgeon. But I thought that my empathetic, open, and compassionate ways may spark a change in paradigm for that traditional surgical ideology. However, what I encountered as I made my way on this long, ever-winding journey was a system, culture, and tradition that beats you down, and what I thought were my strengths were quickly turned into weaknesses. As I grew and matured, this loss of identity in a culture of depersonalization surrounded by gender bias, for me, was a perfect recipe leading straight to burnout. However, this was an impetus for change, to be that voice and spark for a cultural transformation of surgery and for the women who work in the specialty.

More women are entering medical and surgical specialties. However, despite the advances made there are still clear gender-based disparities influencing overall wellness and work satisfaction. For instance, a study by Meyerson et al. demonstrated that female residents receive less operating room autonomy than male ones. I see it daily within my own curriculum and in observing other female residents in other surgical specialties. Furthermore, female residents are less often introduced by their physician titles, compared with their male counterparts, are often confused as nonphysicians, and are perceived as being less competent. This influences, to no small extent, overall confidence. It’s discouraging and disheartening to have worked so hard and yet still be treated in a sexist paradigm. And to top it all off, female physicians face a motherhood penalty.

In a recent study by Magudia et al., out of 12 top medical institutions that provided maternity leave, only 8 did so for residents with a grant total of 6.6 weeks on average. Furthermore, women with children or women who plan to have children have constrained career opportunities and are less likely to get full professorship or leadership positions. Anecdotally, a surgeon in passing semijokingly told me that if I were to take a specific academic vascular position, I may have to sign an agreement not to get pregnant ... probably not the job for me.

It’s appalling that, in this day and age, these explicit beliefs still exist, but what scares me more are all the implicit unconscious biases that affect all women not only in surgery but in medicine as well.

Looking back, 2018 is a year of beginning difficult conversations about physician and surgeon wellness, burnout, and gender bias. What’s obvious is that there is a hell of a lot of work to do. But change is slowly starting. We are now recognizing what the issues are, and the next step is to take action. It’s difficult to steer big ships, but there is an active community investing in strategies to improve the cultural scope of surgery and supporting and valuing women and what they have to offer.

References

Magudia K et al. JAMA. 2018;320(22):2372-4.

Meyerson SL et al. J Surg Educ. 2017;74(6):e111-18.

Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.

As I reflect upon the past year, 2018 has certainly made a mark for addressing burnout among medical professionals, enforcing wellness, and targeting implicit and explicit gender bias in medicine and surgery.

Looking back, I entered surgery with a dream to change the culture of surgery. I knew I didn’t fit the traditional mold of an aggressive or arrogant surgeon. But I thought that my empathetic, open, and compassionate ways may spark a change in paradigm for that traditional surgical ideology. However, what I encountered as I made my way on this long, ever-winding journey was a system, culture, and tradition that beats you down, and what I thought were my strengths were quickly turned into weaknesses. As I grew and matured, this loss of identity in a culture of depersonalization surrounded by gender bias, for me, was a perfect recipe leading straight to burnout. However, this was an impetus for change, to be that voice and spark for a cultural transformation of surgery and for the women who work in the specialty.

More women are entering medical and surgical specialties. However, despite the advances made there are still clear gender-based disparities influencing overall wellness and work satisfaction. For instance, a study by Meyerson et al. demonstrated that female residents receive less operating room autonomy than male ones. I see it daily within my own curriculum and in observing other female residents in other surgical specialties. Furthermore, female residents are less often introduced by their physician titles, compared with their male counterparts, are often confused as nonphysicians, and are perceived as being less competent. This influences, to no small extent, overall confidence. It’s discouraging and disheartening to have worked so hard and yet still be treated in a sexist paradigm. And to top it all off, female physicians face a motherhood penalty.

In a recent study by Magudia et al., out of 12 top medical institutions that provided maternity leave, only 8 did so for residents with a grant total of 6.6 weeks on average. Furthermore, women with children or women who plan to have children have constrained career opportunities and are less likely to get full professorship or leadership positions. Anecdotally, a surgeon in passing semijokingly told me that if I were to take a specific academic vascular position, I may have to sign an agreement not to get pregnant ... probably not the job for me.

It’s appalling that, in this day and age, these explicit beliefs still exist, but what scares me more are all the implicit unconscious biases that affect all women not only in surgery but in medicine as well.

Looking back, 2018 is a year of beginning difficult conversations about physician and surgeon wellness, burnout, and gender bias. What’s obvious is that there is a hell of a lot of work to do. But change is slowly starting. We are now recognizing what the issues are, and the next step is to take action. It’s difficult to steer big ships, but there is an active community investing in strategies to improve the cultural scope of surgery and supporting and valuing women and what they have to offer.

References

Magudia K et al. JAMA. 2018;320(22):2372-4.

Meyerson SL et al. J Surg Educ. 2017;74(6):e111-18.

Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.

Life is short, art long, opportunity fleeting. – Hippocrates

The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.

Many younger physicians have not ever seen a paper chart. The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.

In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.

While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.

Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.

We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.

Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.

A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.

Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”

On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).

Life is short, art long, opportunity fleeting. – Hippocrates

The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.

Many younger physicians have not ever seen a paper chart. The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.

In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.

While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.

Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.

We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.

Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.

A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.

Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”

On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).

Life is short, art long, opportunity fleeting. – Hippocrates

The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.

Many younger physicians have not ever seen a paper chart. The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.

In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.

While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.

Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.

We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.

Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.

A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.

Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”

On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).

This month’s issue is packed with important science – nice to get back to medicine and not focus on politics. On page one, we highlight important new clinical guidance on the use of thiopurines in inflammatory bowel disease. This clinical practice update has some very specific and clear recommendations about thiopurines, especially in combination with biologic agents. As any clinician knowns, treatment of IBD has become complex from both a biologic standpoint and because we now recognize the importance of social determinants of health in our management of chronic diseases. We have seen an enormous outpouring of work that helps gastroenterologists develop multidisciplinary “homes” for IBD patients. These programs are now becoming best practice standards. Such approaches are practical for both academic and community GI practices. Best practice for our IBD patients now involves following clinical guidelines, understanding the impact of IBD on patients’ social and behavioral health and the incorporation of support services (or referral), and outcomes measurement. This clinical practice update will help us enhance our medical therapy for patients with both Crohn’s disease and ulcerative colitis.

Other stories include a review of the new AGA clinical practice update on endoscopic submucosal dissection for early stage cancers with important information about technique, indications, and management of complications. Questions about our approach to prevention of GI bleeding for patients in the ICU are raised by a new multicentered trial of PPI use in over 3,500 patients. Essentially, PPI prophylaxis should be reserved for seriously ill patients at high risk for bleeding – prophylaxis may not be needed in other ICU patients. Finally, another study does not support use of probiotics (at least in the current formulation) in children with gastroenteritis.

I hope you enjoy the issue and that you had a wonderful year’s end. We look forward to more excitement in 2019.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This month’s issue is packed with important science – nice to get back to medicine and not focus on politics. On page one, we highlight important new clinical guidance on the use of thiopurines in inflammatory bowel disease. This clinical practice update has some very specific and clear recommendations about thiopurines, especially in combination with biologic agents. As any clinician knowns, treatment of IBD has become complex from both a biologic standpoint and because we now recognize the importance of social determinants of health in our management of chronic diseases. We have seen an enormous outpouring of work that helps gastroenterologists develop multidisciplinary “homes” for IBD patients. These programs are now becoming best practice standards. Such approaches are practical for both academic and community GI practices. Best practice for our IBD patients now involves following clinical guidelines, understanding the impact of IBD on patients’ social and behavioral health and the incorporation of support services (or referral), and outcomes measurement. This clinical practice update will help us enhance our medical therapy for patients with both Crohn’s disease and ulcerative colitis.

Other stories include a review of the new AGA clinical practice update on endoscopic submucosal dissection for early stage cancers with important information about technique, indications, and management of complications. Questions about our approach to prevention of GI bleeding for patients in the ICU are raised by a new multicentered trial of PPI use in over 3,500 patients. Essentially, PPI prophylaxis should be reserved for seriously ill patients at high risk for bleeding – prophylaxis may not be needed in other ICU patients. Finally, another study does not support use of probiotics (at least in the current formulation) in children with gastroenteritis.

I hope you enjoy the issue and that you had a wonderful year’s end. We look forward to more excitement in 2019.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This month’s issue is packed with important science – nice to get back to medicine and not focus on politics. On page one, we highlight important new clinical guidance on the use of thiopurines in inflammatory bowel disease. This clinical practice update has some very specific and clear recommendations about thiopurines, especially in combination with biologic agents. As any clinician knowns, treatment of IBD has become complex from both a biologic standpoint and because we now recognize the importance of social determinants of health in our management of chronic diseases. We have seen an enormous outpouring of work that helps gastroenterologists develop multidisciplinary “homes” for IBD patients. These programs are now becoming best practice standards. Such approaches are practical for both academic and community GI practices. Best practice for our IBD patients now involves following clinical guidelines, understanding the impact of IBD on patients’ social and behavioral health and the incorporation of support services (or referral), and outcomes measurement. This clinical practice update will help us enhance our medical therapy for patients with both Crohn’s disease and ulcerative colitis.

Other stories include a review of the new AGA clinical practice update on endoscopic submucosal dissection for early stage cancers with important information about technique, indications, and management of complications. Questions about our approach to prevention of GI bleeding for patients in the ICU are raised by a new multicentered trial of PPI use in over 3,500 patients. Essentially, PPI prophylaxis should be reserved for seriously ill patients at high risk for bleeding – prophylaxis may not be needed in other ICU patients. Finally, another study does not support use of probiotics (at least in the current formulation) in children with gastroenteritis.

I hope you enjoy the issue and that you had a wonderful year’s end. We look forward to more excitement in 2019.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Having taken the SVS “burnout” survey, I felt that it really never got into the “whys” of what was making individuals burn out. It dealt more with the consequences of the whys rather than the whys themselves, and it is these whys that must be addressed to assist in the prevention of burnout. I would like to comment on my experience of some, certainly not all, of the possible whys related to both inherent stressors and “administrator induced stressors” encountered in my 42-year vascular surgery practice that can easily cause burnout.

I believe there are several major areas that need to be evaluated to understand the causes of burnout because the complexities of today’s practice environment demand a different approach to the practice of vascular surgery for the well-being of the vascular surgeon. These complexities include the emotional baggage inherent in a practice, practice structure, unpredictable time management issues of running a practice, and hospital administration’s decisions creating unintended consequences for the vascular surgeon.

By its very nature, vascular surgery is a difficult field with many inherent stressors, endovascular innovations not withstanding. The initial emotional stressors may well be those of dealing with elderly patients with multiple severe comorbidities, poor outcomes, and the ensuing consequences. With the aging of the population, these stressors will only increase, yet compensation to treat these feeble patients has yet to rise to a level commensurate with the risk factors and complications the surgeon must deal with. Over time this will take its toll on some.

Which practice pattern one chooses to utilize – solo, group, or employed – also plays an important part. The presence or absence of appropriate help and backup for difficult cases, call coverage, and partnership financial packages can be either very stress producing or stress relieving. Are practice responsibilities and finances equally split so as to achieve a reasonable lifestyle, or is there a hierarchy of work and financial gain by which some must shoulder more of the burden for less pay than others? This is the beginning of the income versus lifestyle conflict and becomes a seriously stressful trap when one is short sighted and does not go for the long term. In our practice, we rotate the work and split the gain equally in return for the most valuable commodity of all: free time.

Time management is of paramount importance in completing a schedule, yet the paradox of the vascular world is its inherent unpredictability. There are difficult, time-consuming cases; unexpected, recurrent vascular problems in the same patient; urgent consults needing treatment within a few days; and the inevitable emergency room call for immediate treatment, day or night, for an embolism, vascular trauma, or ruptured aneurysm – not to mention the hospital committees or other responsibilities in the everyday life of a vascular surgeon.

One’s schedule requires dedicated time and attention yet the urgent/emergent issues interrupting one’s daily schedule ensures that the only predictability is unpredictability. This is a source of burnout. My experience over the years has been that about 25% of our practice load comes on an urgent to emergent basis, often causing considerable scheduling problems both in the operating room and at the office – again, issues that can cause tremendous stress for many. Without a large group, these constant stressors become difficult to shoulder.

Then there are the hospital-induced stressors caused by poorly conceived administrative decrees. One example is when emergency rooms need vascular services but no contracts are offered to secure these services, in which physicians are merely expected to provide 24/7 services. Once a physician has been called in for a case in the middle of the night, the stress of carrying on the next day becomes greater for that physician unless a system is in place for designated calls, which some larger groups have worked out.

Another example is the tendency to grant interventional privileges to those incapable of treating their operative complications without any consideration for who would reimburse those who come in after and how. Why is it assumed that vascular surgeons would/should take time out of their practice to answer the call without any additional compensation? If the compensation from these service lines is so lucrative, then compensation in the form of contracts needs to be offered to those who can provide the necessary services to treat the inevitable complications. This will in some way help compensate for time lost in the vascular surgeons’ practices.

The contracts should reflect the value to an institution vascular surgeons bring for their presence, including ED coverage for most if not all of the service lines, such as cardiology, radiology, orthopedics, gynecology, and general surgery. This also includes issues arising from the house staff inserting lines and from subsequent renal failure, as well as for angio-access patients who need immediate vascular backup to treat the vascular complications encountered.

In addition, these contracts should acknowledge the revenue generated by the presence of a vascular service line. With the burnout rate and unpredictable lifestyle, one would be concerned that vascular surgeons could be on the endangered species list; and given the current shortage of vascular surgeons, don’t our numbers reflect this concern?

There are no easy solutions because the field is a difficult one and is undercompensated for the risks assumed and services provided, which makes it an unattractive specialty, especially in today’s lifestyle-conscious generation. The vascular specialty is embattled, and the human toll extracted in the field speaks for itself. The rewards must improve to make things more appealing, and this will lead to an increase in the number of vascular surgeons, and more will join in groups to mitigate the effects of the stressors of the field. Until then, vascular surgeons need to demand that they receive fair compensation for their availability and the coverage they provide, which allows many other departments and specialties to function. This reality must be acknowledged and compensated.

Carlo A. Dall’Olmo, MD
Michigan Vascular Center
Flint, Michigan

Having taken the SVS “burnout” survey, I felt that it really never got into the “whys” of what was making individuals burn out. It dealt more with the consequences of the whys rather than the whys themselves, and it is these whys that must be addressed to assist in the prevention of burnout. I would like to comment on my experience of some, certainly not all, of the possible whys related to both inherent stressors and “administrator induced stressors” encountered in my 42-year vascular surgery practice that can easily cause burnout.

I believe there are several major areas that need to be evaluated to understand the causes of burnout because the complexities of today’s practice environment demand a different approach to the practice of vascular surgery for the well-being of the vascular surgeon. These complexities include the emotional baggage inherent in a practice, practice structure, unpredictable time management issues of running a practice, and hospital administration’s decisions creating unintended consequences for the vascular surgeon.

By its very nature, vascular surgery is a difficult field with many inherent stressors, endovascular innovations not withstanding. The initial emotional stressors may well be those of dealing with elderly patients with multiple severe comorbidities, poor outcomes, and the ensuing consequences. With the aging of the population, these stressors will only increase, yet compensation to treat these feeble patients has yet to rise to a level commensurate with the risk factors and complications the surgeon must deal with. Over time this will take its toll on some.

Which practice pattern one chooses to utilize – solo, group, or employed – also plays an important part. The presence or absence of appropriate help and backup for difficult cases, call coverage, and partnership financial packages can be either very stress producing or stress relieving. Are practice responsibilities and finances equally split so as to achieve a reasonable lifestyle, or is there a hierarchy of work and financial gain by which some must shoulder more of the burden for less pay than others? This is the beginning of the income versus lifestyle conflict and becomes a seriously stressful trap when one is short sighted and does not go for the long term. In our practice, we rotate the work and split the gain equally in return for the most valuable commodity of all: free time.

Time management is of paramount importance in completing a schedule, yet the paradox of the vascular world is its inherent unpredictability. There are difficult, time-consuming cases; unexpected, recurrent vascular problems in the same patient; urgent consults needing treatment within a few days; and the inevitable emergency room call for immediate treatment, day or night, for an embolism, vascular trauma, or ruptured aneurysm – not to mention the hospital committees or other responsibilities in the everyday life of a vascular surgeon.

One’s schedule requires dedicated time and attention yet the urgent/emergent issues interrupting one’s daily schedule ensures that the only predictability is unpredictability. This is a source of burnout. My experience over the years has been that about 25% of our practice load comes on an urgent to emergent basis, often causing considerable scheduling problems both in the operating room and at the office – again, issues that can cause tremendous stress for many. Without a large group, these constant stressors become difficult to shoulder.

Then there are the hospital-induced stressors caused by poorly conceived administrative decrees. One example is when emergency rooms need vascular services but no contracts are offered to secure these services, in which physicians are merely expected to provide 24/7 services. Once a physician has been called in for a case in the middle of the night, the stress of carrying on the next day becomes greater for that physician unless a system is in place for designated calls, which some larger groups have worked out.

Another example is the tendency to grant interventional privileges to those incapable of treating their operative complications without any consideration for who would reimburse those who come in after and how. Why is it assumed that vascular surgeons would/should take time out of their practice to answer the call without any additional compensation? If the compensation from these service lines is so lucrative, then compensation in the form of contracts needs to be offered to those who can provide the necessary services to treat the inevitable complications. This will in some way help compensate for time lost in the vascular surgeons’ practices.

The contracts should reflect the value to an institution vascular surgeons bring for their presence, including ED coverage for most if not all of the service lines, such as cardiology, radiology, orthopedics, gynecology, and general surgery. This also includes issues arising from the house staff inserting lines and from subsequent renal failure, as well as for angio-access patients who need immediate vascular backup to treat the vascular complications encountered.

In addition, these contracts should acknowledge the revenue generated by the presence of a vascular service line. With the burnout rate and unpredictable lifestyle, one would be concerned that vascular surgeons could be on the endangered species list; and given the current shortage of vascular surgeons, don’t our numbers reflect this concern?

There are no easy solutions because the field is a difficult one and is undercompensated for the risks assumed and services provided, which makes it an unattractive specialty, especially in today’s lifestyle-conscious generation. The vascular specialty is embattled, and the human toll extracted in the field speaks for itself. The rewards must improve to make things more appealing, and this will lead to an increase in the number of vascular surgeons, and more will join in groups to mitigate the effects of the stressors of the field. Until then, vascular surgeons need to demand that they receive fair compensation for their availability and the coverage they provide, which allows many other departments and specialties to function. This reality must be acknowledged and compensated.

Carlo A. Dall’Olmo, MD
Michigan Vascular Center
Flint, Michigan

Having taken the SVS “burnout” survey, I felt that it really never got into the “whys” of what was making individuals burn out. It dealt more with the consequences of the whys rather than the whys themselves, and it is these whys that must be addressed to assist in the prevention of burnout. I would like to comment on my experience of some, certainly not all, of the possible whys related to both inherent stressors and “administrator induced stressors” encountered in my 42-year vascular surgery practice that can easily cause burnout.

I believe there are several major areas that need to be evaluated to understand the causes of burnout because the complexities of today’s practice environment demand a different approach to the practice of vascular surgery for the well-being of the vascular surgeon. These complexities include the emotional baggage inherent in a practice, practice structure, unpredictable time management issues of running a practice, and hospital administration’s decisions creating unintended consequences for the vascular surgeon.

By its very nature, vascular surgery is a difficult field with many inherent stressors, endovascular innovations not withstanding. The initial emotional stressors may well be those of dealing with elderly patients with multiple severe comorbidities, poor outcomes, and the ensuing consequences. With the aging of the population, these stressors will only increase, yet compensation to treat these feeble patients has yet to rise to a level commensurate with the risk factors and complications the surgeon must deal with. Over time this will take its toll on some.

Which practice pattern one chooses to utilize – solo, group, or employed – also plays an important part. The presence or absence of appropriate help and backup for difficult cases, call coverage, and partnership financial packages can be either very stress producing or stress relieving. Are practice responsibilities and finances equally split so as to achieve a reasonable lifestyle, or is there a hierarchy of work and financial gain by which some must shoulder more of the burden for less pay than others? This is the beginning of the income versus lifestyle conflict and becomes a seriously stressful trap when one is short sighted and does not go for the long term. In our practice, we rotate the work and split the gain equally in return for the most valuable commodity of all: free time.

Time management is of paramount importance in completing a schedule, yet the paradox of the vascular world is its inherent unpredictability. There are difficult, time-consuming cases; unexpected, recurrent vascular problems in the same patient; urgent consults needing treatment within a few days; and the inevitable emergency room call for immediate treatment, day or night, for an embolism, vascular trauma, or ruptured aneurysm – not to mention the hospital committees or other responsibilities in the everyday life of a vascular surgeon.

One’s schedule requires dedicated time and attention yet the urgent/emergent issues interrupting one’s daily schedule ensures that the only predictability is unpredictability. This is a source of burnout. My experience over the years has been that about 25% of our practice load comes on an urgent to emergent basis, often causing considerable scheduling problems both in the operating room and at the office – again, issues that can cause tremendous stress for many. Without a large group, these constant stressors become difficult to shoulder.

Then there are the hospital-induced stressors caused by poorly conceived administrative decrees. One example is when emergency rooms need vascular services but no contracts are offered to secure these services, in which physicians are merely expected to provide 24/7 services. Once a physician has been called in for a case in the middle of the night, the stress of carrying on the next day becomes greater for that physician unless a system is in place for designated calls, which some larger groups have worked out.

Another example is the tendency to grant interventional privileges to those incapable of treating their operative complications without any consideration for who would reimburse those who come in after and how. Why is it assumed that vascular surgeons would/should take time out of their practice to answer the call without any additional compensation? If the compensation from these service lines is so lucrative, then compensation in the form of contracts needs to be offered to those who can provide the necessary services to treat the inevitable complications. This will in some way help compensate for time lost in the vascular surgeons’ practices.

The contracts should reflect the value to an institution vascular surgeons bring for their presence, including ED coverage for most if not all of the service lines, such as cardiology, radiology, orthopedics, gynecology, and general surgery. This also includes issues arising from the house staff inserting lines and from subsequent renal failure, as well as for angio-access patients who need immediate vascular backup to treat the vascular complications encountered.

In addition, these contracts should acknowledge the revenue generated by the presence of a vascular service line. With the burnout rate and unpredictable lifestyle, one would be concerned that vascular surgeons could be on the endangered species list; and given the current shortage of vascular surgeons, don’t our numbers reflect this concern?

There are no easy solutions because the field is a difficult one and is undercompensated for the risks assumed and services provided, which makes it an unattractive specialty, especially in today’s lifestyle-conscious generation. The vascular specialty is embattled, and the human toll extracted in the field speaks for itself. The rewards must improve to make things more appealing, and this will lead to an increase in the number of vascular surgeons, and more will join in groups to mitigate the effects of the stressors of the field. Until then, vascular surgeons need to demand that they receive fair compensation for their availability and the coverage they provide, which allows many other departments and specialties to function. This reality must be acknowledged and compensated.

Carlo A. Dall’Olmo, MD
Michigan Vascular Center
Flint, Michigan

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”

“How’s it going?” I asked.

Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”

I too, dear colleagues, have had a life’s ambition, secret until right now: I wanted to eliminate erroneous fungal diagnosis. Or, to put it more pungently, to help nondermatologists stop treating every roundish scaly rash as ringworm.

Alas, like Ed’s, my work is not yet done.

I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.

1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.

2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.

3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.

4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.

5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.

6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!

7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.

8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.

9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.

10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?

And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.

In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.

Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”

I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.

Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.

But then, there always is.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”

“How’s it going?” I asked.

Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”

I too, dear colleagues, have had a life’s ambition, secret until right now: I wanted to eliminate erroneous fungal diagnosis. Or, to put it more pungently, to help nondermatologists stop treating every roundish scaly rash as ringworm.

Alas, like Ed’s, my work is not yet done.

I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.

1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.

2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.

3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.

4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.

5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.

6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!

7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.

8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.

9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.

10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?

And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.

In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.

Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”

I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.

Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.

But then, there always is.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”

“How’s it going?” I asked.

Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”

I too, dear colleagues, have had a life’s ambition, secret until right now: I wanted to eliminate erroneous fungal diagnosis. Or, to put it more pungently, to help nondermatologists stop treating every roundish scaly rash as ringworm.

Alas, like Ed’s, my work is not yet done.

I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.

1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.

2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.

3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.

4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.

5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.

6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!

7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.

8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.

9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.

10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?

And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.

In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.

Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”

I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.

Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.

But then, there always is.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.