Commentary

This month's article by Dr. Yuen and colleagues on cognitive biases and the diagnostic errors that can result is a humbling reminder of the limitations of our brains and the need for us to be ever vigilant about the accuracy of our clinical diagnoses.

According to the article, at least 8 different kinds of bias can unintentionally derail our efforts to make the correct diagnosis. In my editorial last month (J Fam Pract. 2018;67:268), I presented data showing that up to 30% of patients with a physician’s diagnosis of asthma do not, in fact, have asthma. These mistaken diagnoses are most likely due to the bias known as “diagnostic momentum,” which is the tendency of physicians to accept a diagnosis without questioning its validity.

We are also prone to anchoring. Because family physicians (FPs) are very busy and use type 1 reasoning (pattern recognition or intuitive reasoning) more frequently than type 2 reasoning (analytical thinking, which requires more time), I suspect we are most susceptible to the bias of premature closure of the diagnostic process, also called anchoring. At times we attach too much weight to preliminary findings and don’t dig deep enough into the history or physical findings to confirm or support our diagnoses.

A memorable example of my own cognitive bias was my treatment of a middle-aged woman with hyperlipidemia. I thought I was being a good doctor, treating her appropriately with a statin. Luckily for her, she saw one of my partners when I was on vacation. My partner walked into the room and immediately recognized her myxedematous face as a sign of hypothyroidism. Her thyroid stimulating hormone level was 124 mIU/L! She was cured with thyroid hormone replacement and did not need a statin at all. I had not taken the time to think through the case carefully. And I had not noticed her gradual weight gain or the changes to her face.

My partner saw the patient's myxedematous face and knew she had hypothyroidism—not hyperlipidemia.

Lulled by common diagnoses. Another difficulty for FPs and other primary care practitioners is that most of the patients we see have a common illness that is easy to diagnose. Recognizing shingles, eczema, acute appendicitis, and viral respiratory infections and managing chronic illnesses such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD) is second nature to us. But we must constantly be on the lookout for uncommon and potentially serious conditions. A classic example is not considering alpha-1 antitrypsin deficiency in a patient with COPD who does not smoke.

The bottom line: Take an extra minute or 2 to think through every diagnosis carefully—especially when one or more of the puzzle pieces do not fit together properly.

This month's article by Dr. Yuen and colleagues on cognitive biases and the diagnostic errors that can result is a humbling reminder of the limitations of our brains and the need for us to be ever vigilant about the accuracy of our clinical diagnoses.

According to the article, at least 8 different kinds of bias can unintentionally derail our efforts to make the correct diagnosis. In my editorial last month (J Fam Pract. 2018;67:268), I presented data showing that up to 30% of patients with a physician’s diagnosis of asthma do not, in fact, have asthma. These mistaken diagnoses are most likely due to the bias known as “diagnostic momentum,” which is the tendency of physicians to accept a diagnosis without questioning its validity.

We are also prone to anchoring. Because family physicians (FPs) are very busy and use type 1 reasoning (pattern recognition or intuitive reasoning) more frequently than type 2 reasoning (analytical thinking, which requires more time), I suspect we are most susceptible to the bias of premature closure of the diagnostic process, also called anchoring. At times we attach too much weight to preliminary findings and don’t dig deep enough into the history or physical findings to confirm or support our diagnoses.

A memorable example of my own cognitive bias was my treatment of a middle-aged woman with hyperlipidemia. I thought I was being a good doctor, treating her appropriately with a statin. Luckily for her, she saw one of my partners when I was on vacation. My partner walked into the room and immediately recognized her myxedematous face as a sign of hypothyroidism. Her thyroid stimulating hormone level was 124 mIU/L! She was cured with thyroid hormone replacement and did not need a statin at all. I had not taken the time to think through the case carefully. And I had not noticed her gradual weight gain or the changes to her face.

My partner saw the patient's myxedematous face and knew she had hypothyroidism—not hyperlipidemia.

Lulled by common diagnoses. Another difficulty for FPs and other primary care practitioners is that most of the patients we see have a common illness that is easy to diagnose. Recognizing shingles, eczema, acute appendicitis, and viral respiratory infections and managing chronic illnesses such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD) is second nature to us. But we must constantly be on the lookout for uncommon and potentially serious conditions. A classic example is not considering alpha-1 antitrypsin deficiency in a patient with COPD who does not smoke.

The bottom line: Take an extra minute or 2 to think through every diagnosis carefully—especially when one or more of the puzzle pieces do not fit together properly.

This month's article by Dr. Yuen and colleagues on cognitive biases and the diagnostic errors that can result is a humbling reminder of the limitations of our brains and the need for us to be ever vigilant about the accuracy of our clinical diagnoses.

According to the article, at least 8 different kinds of bias can unintentionally derail our efforts to make the correct diagnosis. In my editorial last month (J Fam Pract. 2018;67:268), I presented data showing that up to 30% of patients with a physician’s diagnosis of asthma do not, in fact, have asthma. These mistaken diagnoses are most likely due to the bias known as “diagnostic momentum,” which is the tendency of physicians to accept a diagnosis without questioning its validity.

We are also prone to anchoring. Because family physicians (FPs) are very busy and use type 1 reasoning (pattern recognition or intuitive reasoning) more frequently than type 2 reasoning (analytical thinking, which requires more time), I suspect we are most susceptible to the bias of premature closure of the diagnostic process, also called anchoring. At times we attach too much weight to preliminary findings and don’t dig deep enough into the history or physical findings to confirm or support our diagnoses.

A memorable example of my own cognitive bias was my treatment of a middle-aged woman with hyperlipidemia. I thought I was being a good doctor, treating her appropriately with a statin. Luckily for her, she saw one of my partners when I was on vacation. My partner walked into the room and immediately recognized her myxedematous face as a sign of hypothyroidism. Her thyroid stimulating hormone level was 124 mIU/L! She was cured with thyroid hormone replacement and did not need a statin at all. I had not taken the time to think through the case carefully. And I had not noticed her gradual weight gain or the changes to her face.

My partner saw the patient's myxedematous face and knew she had hypothyroidism—not hyperlipidemia.

Lulled by common diagnoses. Another difficulty for FPs and other primary care practitioners is that most of the patients we see have a common illness that is easy to diagnose. Recognizing shingles, eczema, acute appendicitis, and viral respiratory infections and managing chronic illnesses such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD) is second nature to us. But we must constantly be on the lookout for uncommon and potentially serious conditions. A classic example is not considering alpha-1 antitrypsin deficiency in a patient with COPD who does not smoke.

The bottom line: Take an extra minute or 2 to think through every diagnosis carefully—especially when one or more of the puzzle pieces do not fit together properly.

Sexual harassment hit a peak of cultural awareness over the past year. Will medicine be the next field to experience a reckoning?

In 2017, Time magazine’s Person of the Year Award went to the Silence Breakers who spoke out against sexual assault and harassment.¹ The exposure of predatory behavior exhibited by once-celebrated movie producers, newscasters, and actors has given rise to a powerful change. The #MeToo movement has risen to support survivors and end sexual violence.

Just like show business, other industries have rich histories of discrimination and power. Think Wall Street, Silicon Valley, hospitality services, and the list goes on and on.² But what about medicine? To answer this question, this article aims to:

• review the dilemma
• explore our duty to our patients and each other
• discuss solutions to address the problem.

Sexual harassment: A brief history

Decades ago, Anita Hill accused U.S. Supreme Court nominee Clarence Thomas, her boss at the U.S. Department of Education and the Equal Employment Opportunity Commission (EEOC), of sexual harassment.³

The year was 1991, and President George H. W. Bush had nominated Thomas, a federal Circuit Judge, to succeed retiring Associate Supreme Court Justice Thurgood Marshall. With Thomas’s good character presented as a primary qualification, he appeared to be a sure thing.

Continue to: That was until an FBI interview...

That was until an FBI interview of Hill was leaked to the press. Hill asserted that Thomas had sexually harassed her while he was her supervisor at the Department of Education and the EEOC.⁴ Heavily scrutinized for her choice to follow Thomas to a second job after he had already allegedly harassed her, Hill was in a conundrum shared by many women—putting up with abuse in exchange for a reputable position and the opportunity to fulfill a career ambition.

Hill is a trailblazer for women yearning to speak the truth, and she brought national attention to sexual harassment in the early 1990s. On December 16, 2017, the Commission on Sexual Harassment and Advancing Equality in the Workplace was formed. Hill was selected to lead the charge against sexual harassment in the entertainment industry.⁵

A forensic assessment of harassment

Hill’s courageous story is one of many touched upon in the 2016 book Because of Sex.⁶ Author Gillian Thomas, a senior staff attorney with the American Civil Liberties Union’s Women’s Rights Project, explores how Title VII of the Civil Rights Act of 1964 made it illegal to discriminate “because of sex.”

The field of forensic psychiatry has long been attentive to themes of sexual harassment and discrimination. The American Academy of Psychiatry and Law has a robust list of landmark cases thought to be especially important and significant for forensic psychiatry.⁷ This list includes cases brought forth by tenacious, yet ordinary women who used the law to advocate, and some have taken their fight all the way to the Supreme Court. Let’s consider 2 such cases:

Meritor Savings Bank, FSB v Vinson (1986).⁸ This was a U.S. labor law case. Michelle Vinson rose through the ranks at Meritor Savings Bank, only to be fired for excessive sick leave. She filed a Title VII suit against the bank. Vinson alleged that the bank was liable for sexual harassment perpetrated by its employee and vice president, Sidney Taylor. Vinson claimed that there had been 40 to 50 sexual encounters over 4 years, ranging from fondling to indecent exposure to rape. Vinson asserted that she never reported these events for fear of losing her job. The Supreme Court, in a 9-to-0 decision, recognized sexual harassment as a violation of Title VII of the Civil Rights Act of 1964.

Continue to: Harris v Forklift Systems, Inc. (1993)

Harris v Forklift Systems, Inc. (1993).⁹ Teresa Harris, a manager at Forklift Systems, Inc., claimed that the company’s president frequently directed offensive remarks at her that were sexual and discriminatory. The Supreme Court clarified the definition of a “hostile” or “abusive” work environment under Title VII of the Civil Rights Act of 1964. Associate Justice Sandra Day O’Connor was joined by a unanimous majority opinion in agreement with Harris.

Physicians are not immune

Clinicians are affected by sexual harassment, too. We have a duty to protect our patients, colleagues, and ourselves. Psychiatrists in particular often are on the frontlines of helping victims process their trauma.¹⁰

But will the field of medicine also face a reckoning when it comes to perpetrating harassment? It seems likely that the medical field would be ripe with harassment when you consider its history of male domination and a hierarchical structure with strong power differentials—not to mention the late nights, exhaustion, easy access to beds, and late-night encounters where inhibitions may be lowered.¹¹

A shocking number of female doctors are sexually harassed. Thirty percent of the top female clinician-researchers have experienced blatant sexual harassment on the job, according to a survey of 573 men and 493 women who received career development awards from the National Institutes of Health in 2006 to 2009.¹² In this survey, harassment covered the scope of sexist remarks or behavior, unwanted sexual advances, bribery, threats, and coercion. The majority of those affected said the experience undermined their confidence as professionals, and many said the harassment negatively affected their career advancement.¹²

Continue to: But what about the progress women have made...

But what about the progress women have made in medicine? Women are surpassing men in terms of admittance to medical school. Last year, for the first time, women accounted for more than half of the enrollees in U.S. medical schools, according to the Association of American Medical Colleges.¹³ Yet there has been a stalling in terms of change when it comes to harassment.¹² Women may be more vulnerable to harassment, both when they’re perceived as weak and when they’re so strong that they challenge traditional hierarchies.

Perpetuating the problem is the trouble with reporting sexual harassment. Victims do not fare well in our society. Even in the #MeToo era, reporting such behavior is far from straightforward.¹¹ Women fear that reporting any harassment will make them a target. Think of Anita Hill—her testimony against Clarence Thomas during his confirmation hearings for the Supreme Court showed that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse.

The result is that medical professionals tend to suppress the recognition of harassment. We make excuses for it, blame ourselves, or just take it on the chin and move on. There’s also confusion regarding what constitutes harassment. As doctors, especially psychiatrists, we hear harrowing stories. It’s reasonable to downplay our own experiences. Turning everyone into a victim of sexual harassment could detract from the stories of women who were raped, molested, and severely taken advantage of. There is a reasonable fear that diluting their message could be further damaging.¹⁴

Time for action

The field of medicine needs to do better in terms of education, support, anticipation, prevention, and reaction to harassment. We have the awareness. Now, we need action.

Continue to: One way to change any culture...

One way to change any culture of harassment or discrimination would be the advancement of more female physicians into leadership positions. The Association of American Medical Colleges has reported that fewer women than men hold faculty positions and full professorships.^15,16 There’s also a striking imbalance among fields of medicine practiced by men and women, with more women seen in pediatrics, obstetrics, and gynecology as opposed to surgery. Advancement into policy-setting echelons of medicine is essential for change. Sexual harassment can be a silent problem that will be corrected only when institutions and leaders put it on the forefront of discussions.¹⁷

Another possible solution would be to shift problem-solving from punishment to prevention. Many institutions set expectations about intolerance of sexual harassment and conduct occasional lectures about it. However, enforcing protocols and safeguards that support and enforce policy are difficult on the ground level. In any event, punishment alone won’t change a culture.¹⁷

Working with students until they are comfortable disclosing details of incidents can be helpful. For example, the University of Wisconsin-Madison employs an ombuds to help with this process.¹⁸ All institutions should encourage reporting along confidential pathways and have multiple ways to report.¹⁷ Tracking complaints, even seemingly minor infractions, can help identify patterns of behavior and anticipate future incidents.

Some solutions seem obvious, such as informal and retaliation-free reporting that allows institutions to track perpetrators’ behavior; mandatory training that includes bystander training; and disciplining and monitoring transgressors and terminating their employment when appropriate—something along the lines of a zero-tolerance policy. There needs to be more research on the prevalence, severity, and outcomes of sexual harassment, and subsequent investigations, along with research into evidence-based prevention and intervention strategies.¹⁷

Continue to: Although this article focuses...

Although this article focuses on harassment of women, men are equally important to this conversation because they, too, can be victims. Men also can serve a pivotal role in mentoring and championing their female counterparts as they strive for advancement, equality, and respect.

The task ahead is large, and this discussion is not over.

Sexual harassment hit a peak of cultural awareness over the past year. Will medicine be the next field to experience a reckoning?

In 2017, Time magazine’s Person of the Year Award went to the Silence Breakers who spoke out against sexual assault and harassment.¹ The exposure of predatory behavior exhibited by once-celebrated movie producers, newscasters, and actors has given rise to a powerful change. The #MeToo movement has risen to support survivors and end sexual violence.

Just like show business, other industries have rich histories of discrimination and power. Think Wall Street, Silicon Valley, hospitality services, and the list goes on and on.² But what about medicine? To answer this question, this article aims to:

• review the dilemma
• explore our duty to our patients and each other
• discuss solutions to address the problem.

Sexual harassment: A brief history

Decades ago, Anita Hill accused U.S. Supreme Court nominee Clarence Thomas, her boss at the U.S. Department of Education and the Equal Employment Opportunity Commission (EEOC), of sexual harassment.³

The year was 1991, and President George H. W. Bush had nominated Thomas, a federal Circuit Judge, to succeed retiring Associate Supreme Court Justice Thurgood Marshall. With Thomas’s good character presented as a primary qualification, he appeared to be a sure thing.

Continue to: That was until an FBI interview...

That was until an FBI interview of Hill was leaked to the press. Hill asserted that Thomas had sexually harassed her while he was her supervisor at the Department of Education and the EEOC.⁴ Heavily scrutinized for her choice to follow Thomas to a second job after he had already allegedly harassed her, Hill was in a conundrum shared by many women—putting up with abuse in exchange for a reputable position and the opportunity to fulfill a career ambition.

Hill is a trailblazer for women yearning to speak the truth, and she brought national attention to sexual harassment in the early 1990s. On December 16, 2017, the Commission on Sexual Harassment and Advancing Equality in the Workplace was formed. Hill was selected to lead the charge against sexual harassment in the entertainment industry.⁵

A forensic assessment of harassment

Hill’s courageous story is one of many touched upon in the 2016 book Because of Sex.⁶ Author Gillian Thomas, a senior staff attorney with the American Civil Liberties Union’s Women’s Rights Project, explores how Title VII of the Civil Rights Act of 1964 made it illegal to discriminate “because of sex.”

The field of forensic psychiatry has long been attentive to themes of sexual harassment and discrimination. The American Academy of Psychiatry and Law has a robust list of landmark cases thought to be especially important and significant for forensic psychiatry.⁷ This list includes cases brought forth by tenacious, yet ordinary women who used the law to advocate, and some have taken their fight all the way to the Supreme Court. Let’s consider 2 such cases:

Meritor Savings Bank, FSB v Vinson (1986).⁸ This was a U.S. labor law case. Michelle Vinson rose through the ranks at Meritor Savings Bank, only to be fired for excessive sick leave. She filed a Title VII suit against the bank. Vinson alleged that the bank was liable for sexual harassment perpetrated by its employee and vice president, Sidney Taylor. Vinson claimed that there had been 40 to 50 sexual encounters over 4 years, ranging from fondling to indecent exposure to rape. Vinson asserted that she never reported these events for fear of losing her job. The Supreme Court, in a 9-to-0 decision, recognized sexual harassment as a violation of Title VII of the Civil Rights Act of 1964.

Continue to: Harris v Forklift Systems, Inc. (1993)

Harris v Forklift Systems, Inc. (1993).⁹ Teresa Harris, a manager at Forklift Systems, Inc., claimed that the company’s president frequently directed offensive remarks at her that were sexual and discriminatory. The Supreme Court clarified the definition of a “hostile” or “abusive” work environment under Title VII of the Civil Rights Act of 1964. Associate Justice Sandra Day O’Connor was joined by a unanimous majority opinion in agreement with Harris.

Physicians are not immune

Clinicians are affected by sexual harassment, too. We have a duty to protect our patients, colleagues, and ourselves. Psychiatrists in particular often are on the frontlines of helping victims process their trauma.¹⁰

But will the field of medicine also face a reckoning when it comes to perpetrating harassment? It seems likely that the medical field would be ripe with harassment when you consider its history of male domination and a hierarchical structure with strong power differentials—not to mention the late nights, exhaustion, easy access to beds, and late-night encounters where inhibitions may be lowered.¹¹

A shocking number of female doctors are sexually harassed. Thirty percent of the top female clinician-researchers have experienced blatant sexual harassment on the job, according to a survey of 573 men and 493 women who received career development awards from the National Institutes of Health in 2006 to 2009.¹² In this survey, harassment covered the scope of sexist remarks or behavior, unwanted sexual advances, bribery, threats, and coercion. The majority of those affected said the experience undermined their confidence as professionals, and many said the harassment negatively affected their career advancement.¹²

Continue to: But what about the progress women have made...

But what about the progress women have made in medicine? Women are surpassing men in terms of admittance to medical school. Last year, for the first time, women accounted for more than half of the enrollees in U.S. medical schools, according to the Association of American Medical Colleges.¹³ Yet there has been a stalling in terms of change when it comes to harassment.¹² Women may be more vulnerable to harassment, both when they’re perceived as weak and when they’re so strong that they challenge traditional hierarchies.

Perpetuating the problem is the trouble with reporting sexual harassment. Victims do not fare well in our society. Even in the #MeToo era, reporting such behavior is far from straightforward.¹¹ Women fear that reporting any harassment will make them a target. Think of Anita Hill—her testimony against Clarence Thomas during his confirmation hearings for the Supreme Court showed that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse.

The result is that medical professionals tend to suppress the recognition of harassment. We make excuses for it, blame ourselves, or just take it on the chin and move on. There’s also confusion regarding what constitutes harassment. As doctors, especially psychiatrists, we hear harrowing stories. It’s reasonable to downplay our own experiences. Turning everyone into a victim of sexual harassment could detract from the stories of women who were raped, molested, and severely taken advantage of. There is a reasonable fear that diluting their message could be further damaging.¹⁴

Time for action

The field of medicine needs to do better in terms of education, support, anticipation, prevention, and reaction to harassment. We have the awareness. Now, we need action.

Continue to: One way to change any culture...

One way to change any culture of harassment or discrimination would be the advancement of more female physicians into leadership positions. The Association of American Medical Colleges has reported that fewer women than men hold faculty positions and full professorships.^15,16 There’s also a striking imbalance among fields of medicine practiced by men and women, with more women seen in pediatrics, obstetrics, and gynecology as opposed to surgery. Advancement into policy-setting echelons of medicine is essential for change. Sexual harassment can be a silent problem that will be corrected only when institutions and leaders put it on the forefront of discussions.¹⁷

Another possible solution would be to shift problem-solving from punishment to prevention. Many institutions set expectations about intolerance of sexual harassment and conduct occasional lectures about it. However, enforcing protocols and safeguards that support and enforce policy are difficult on the ground level. In any event, punishment alone won’t change a culture.¹⁷

Working with students until they are comfortable disclosing details of incidents can be helpful. For example, the University of Wisconsin-Madison employs an ombuds to help with this process.¹⁸ All institutions should encourage reporting along confidential pathways and have multiple ways to report.¹⁷ Tracking complaints, even seemingly minor infractions, can help identify patterns of behavior and anticipate future incidents.

Some solutions seem obvious, such as informal and retaliation-free reporting that allows institutions to track perpetrators’ behavior; mandatory training that includes bystander training; and disciplining and monitoring transgressors and terminating their employment when appropriate—something along the lines of a zero-tolerance policy. There needs to be more research on the prevalence, severity, and outcomes of sexual harassment, and subsequent investigations, along with research into evidence-based prevention and intervention strategies.¹⁷

Continue to: Although this article focuses...

Although this article focuses on harassment of women, men are equally important to this conversation because they, too, can be victims. Men also can serve a pivotal role in mentoring and championing their female counterparts as they strive for advancement, equality, and respect.

The task ahead is large, and this discussion is not over.

Sexual harassment hit a peak of cultural awareness over the past year. Will medicine be the next field to experience a reckoning?

In 2017, Time magazine’s Person of the Year Award went to the Silence Breakers who spoke out against sexual assault and harassment.¹ The exposure of predatory behavior exhibited by once-celebrated movie producers, newscasters, and actors has given rise to a powerful change. The #MeToo movement has risen to support survivors and end sexual violence.

Just like show business, other industries have rich histories of discrimination and power. Think Wall Street, Silicon Valley, hospitality services, and the list goes on and on.² But what about medicine? To answer this question, this article aims to:

• review the dilemma
• explore our duty to our patients and each other
• discuss solutions to address the problem.

Sexual harassment: A brief history

Decades ago, Anita Hill accused U.S. Supreme Court nominee Clarence Thomas, her boss at the U.S. Department of Education and the Equal Employment Opportunity Commission (EEOC), of sexual harassment.³

The year was 1991, and President George H. W. Bush had nominated Thomas, a federal Circuit Judge, to succeed retiring Associate Supreme Court Justice Thurgood Marshall. With Thomas’s good character presented as a primary qualification, he appeared to be a sure thing.

Continue to: That was until an FBI interview...

That was until an FBI interview of Hill was leaked to the press. Hill asserted that Thomas had sexually harassed her while he was her supervisor at the Department of Education and the EEOC.⁴ Heavily scrutinized for her choice to follow Thomas to a second job after he had already allegedly harassed her, Hill was in a conundrum shared by many women—putting up with abuse in exchange for a reputable position and the opportunity to fulfill a career ambition.

Hill is a trailblazer for women yearning to speak the truth, and she brought national attention to sexual harassment in the early 1990s. On December 16, 2017, the Commission on Sexual Harassment and Advancing Equality in the Workplace was formed. Hill was selected to lead the charge against sexual harassment in the entertainment industry.⁵

A forensic assessment of harassment

Hill’s courageous story is one of many touched upon in the 2016 book Because of Sex.⁶ Author Gillian Thomas, a senior staff attorney with the American Civil Liberties Union’s Women’s Rights Project, explores how Title VII of the Civil Rights Act of 1964 made it illegal to discriminate “because of sex.”

The field of forensic psychiatry has long been attentive to themes of sexual harassment and discrimination. The American Academy of Psychiatry and Law has a robust list of landmark cases thought to be especially important and significant for forensic psychiatry.⁷ This list includes cases brought forth by tenacious, yet ordinary women who used the law to advocate, and some have taken their fight all the way to the Supreme Court. Let’s consider 2 such cases:

Meritor Savings Bank, FSB v Vinson (1986).⁸ This was a U.S. labor law case. Michelle Vinson rose through the ranks at Meritor Savings Bank, only to be fired for excessive sick leave. She filed a Title VII suit against the bank. Vinson alleged that the bank was liable for sexual harassment perpetrated by its employee and vice president, Sidney Taylor. Vinson claimed that there had been 40 to 50 sexual encounters over 4 years, ranging from fondling to indecent exposure to rape. Vinson asserted that she never reported these events for fear of losing her job. The Supreme Court, in a 9-to-0 decision, recognized sexual harassment as a violation of Title VII of the Civil Rights Act of 1964.

Continue to: Harris v Forklift Systems, Inc. (1993)

Harris v Forklift Systems, Inc. (1993).⁹ Teresa Harris, a manager at Forklift Systems, Inc., claimed that the company’s president frequently directed offensive remarks at her that were sexual and discriminatory. The Supreme Court clarified the definition of a “hostile” or “abusive” work environment under Title VII of the Civil Rights Act of 1964. Associate Justice Sandra Day O’Connor was joined by a unanimous majority opinion in agreement with Harris.

Physicians are not immune

Clinicians are affected by sexual harassment, too. We have a duty to protect our patients, colleagues, and ourselves. Psychiatrists in particular often are on the frontlines of helping victims process their trauma.¹⁰

But will the field of medicine also face a reckoning when it comes to perpetrating harassment? It seems likely that the medical field would be ripe with harassment when you consider its history of male domination and a hierarchical structure with strong power differentials—not to mention the late nights, exhaustion, easy access to beds, and late-night encounters where inhibitions may be lowered.¹¹

A shocking number of female doctors are sexually harassed. Thirty percent of the top female clinician-researchers have experienced blatant sexual harassment on the job, according to a survey of 573 men and 493 women who received career development awards from the National Institutes of Health in 2006 to 2009.¹² In this survey, harassment covered the scope of sexist remarks or behavior, unwanted sexual advances, bribery, threats, and coercion. The majority of those affected said the experience undermined their confidence as professionals, and many said the harassment negatively affected their career advancement.¹²

Continue to: But what about the progress women have made...

But what about the progress women have made in medicine? Women are surpassing men in terms of admittance to medical school. Last year, for the first time, women accounted for more than half of the enrollees in U.S. medical schools, according to the Association of American Medical Colleges.¹³ Yet there has been a stalling in terms of change when it comes to harassment.¹² Women may be more vulnerable to harassment, both when they’re perceived as weak and when they’re so strong that they challenge traditional hierarchies.

Perpetuating the problem is the trouble with reporting sexual harassment. Victims do not fare well in our society. Even in the #MeToo era, reporting such behavior is far from straightforward.¹¹ Women fear that reporting any harassment will make them a target. Think of Anita Hill—her testimony against Clarence Thomas during his confirmation hearings for the Supreme Court showed that women who report sexual harassment experience marginalization, retaliation, stigmatization, and worse.

The result is that medical professionals tend to suppress the recognition of harassment. We make excuses for it, blame ourselves, or just take it on the chin and move on. There’s also confusion regarding what constitutes harassment. As doctors, especially psychiatrists, we hear harrowing stories. It’s reasonable to downplay our own experiences. Turning everyone into a victim of sexual harassment could detract from the stories of women who were raped, molested, and severely taken advantage of. There is a reasonable fear that diluting their message could be further damaging.¹⁴

Time for action

The field of medicine needs to do better in terms of education, support, anticipation, prevention, and reaction to harassment. We have the awareness. Now, we need action.

Continue to: One way to change any culture...

One way to change any culture of harassment or discrimination would be the advancement of more female physicians into leadership positions. The Association of American Medical Colleges has reported that fewer women than men hold faculty positions and full professorships.^15,16 There’s also a striking imbalance among fields of medicine practiced by men and women, with more women seen in pediatrics, obstetrics, and gynecology as opposed to surgery. Advancement into policy-setting echelons of medicine is essential for change. Sexual harassment can be a silent problem that will be corrected only when institutions and leaders put it on the forefront of discussions.¹⁷

Another possible solution would be to shift problem-solving from punishment to prevention. Many institutions set expectations about intolerance of sexual harassment and conduct occasional lectures about it. However, enforcing protocols and safeguards that support and enforce policy are difficult on the ground level. In any event, punishment alone won’t change a culture.¹⁷

Working with students until they are comfortable disclosing details of incidents can be helpful. For example, the University of Wisconsin-Madison employs an ombuds to help with this process.¹⁸ All institutions should encourage reporting along confidential pathways and have multiple ways to report.¹⁷ Tracking complaints, even seemingly minor infractions, can help identify patterns of behavior and anticipate future incidents.

Some solutions seem obvious, such as informal and retaliation-free reporting that allows institutions to track perpetrators’ behavior; mandatory training that includes bystander training; and disciplining and monitoring transgressors and terminating their employment when appropriate—something along the lines of a zero-tolerance policy. There needs to be more research on the prevalence, severity, and outcomes of sexual harassment, and subsequent investigations, along with research into evidence-based prevention and intervention strategies.¹⁷

Continue to: Although this article focuses...

Although this article focuses on harassment of women, men are equally important to this conversation because they, too, can be victims. Men also can serve a pivotal role in mentoring and championing their female counterparts as they strive for advancement, equality, and respect.

The task ahead is large, and this discussion is not over.

She was my 3:45 p.m. return visit. She had been a new patient with dyspepsia and I had found Helicobacter pylori–gastritis on endoscopy. She had marketplace-based coverage (silver, high-deductible plan), which was why she had to travel from her community to our university for care. That she did not look like me (older white male) was an understatement. She was so enthusiastic as she thanked me for helping her. Then she described how she, her husband (both hourly-wage, working adults) and their two young kids had gathered around the dinner table to discuss how they could reduce their food allowance for 2 months to have money for mom’s H. pylori medication. She said her entire family was grateful for the help to get her well. It was a moment of grace. She is why I keep fighting to make our health system great again.

Our cover articles this month discuss HCV treatment in patients with special risk factors or co-conditions. Fascinating information will emerge from studies like the article about artificial sweeteners. Scientists studied hunger-related enzyme levels and brain blood flow with functional MRI’s in obese and lean individuals after ingesting placebo and sucralose-containing solutions. Results might influence our weight loss advice to patients. Worried about malpractice? See our third front page article.

Additional articles discuss a reversal agent for one of the direct-acting oral anticoagulants and a hemospray for GI bleeding. Clinically impactful articles from the AGA journals are highlighted.

Finally, I would like to thank all of you who filled out the readership survey last fall. We are proud that you identified GI & Hepatology News as the best overall source for news information in gastroenterology.
 

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

She was my 3:45 p.m. return visit. She had been a new patient with dyspepsia and I had found Helicobacter pylori–gastritis on endoscopy. She had marketplace-based coverage (silver, high-deductible plan), which was why she had to travel from her community to our university for care. That she did not look like me (older white male) was an understatement. She was so enthusiastic as she thanked me for helping her. Then she described how she, her husband (both hourly-wage, working adults) and their two young kids had gathered around the dinner table to discuss how they could reduce their food allowance for 2 months to have money for mom’s H. pylori medication. She said her entire family was grateful for the help to get her well. It was a moment of grace. She is why I keep fighting to make our health system great again.

Our cover articles this month discuss HCV treatment in patients with special risk factors or co-conditions. Fascinating information will emerge from studies like the article about artificial sweeteners. Scientists studied hunger-related enzyme levels and brain blood flow with functional MRI’s in obese and lean individuals after ingesting placebo and sucralose-containing solutions. Results might influence our weight loss advice to patients. Worried about malpractice? See our third front page article.

Additional articles discuss a reversal agent for one of the direct-acting oral anticoagulants and a hemospray for GI bleeding. Clinically impactful articles from the AGA journals are highlighted.

Finally, I would like to thank all of you who filled out the readership survey last fall. We are proud that you identified GI & Hepatology News as the best overall source for news information in gastroenterology.
 

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

She was my 3:45 p.m. return visit. She had been a new patient with dyspepsia and I had found Helicobacter pylori–gastritis on endoscopy. She had marketplace-based coverage (silver, high-deductible plan), which was why she had to travel from her community to our university for care. That she did not look like me (older white male) was an understatement. She was so enthusiastic as she thanked me for helping her. Then she described how she, her husband (both hourly-wage, working adults) and their two young kids had gathered around the dinner table to discuss how they could reduce their food allowance for 2 months to have money for mom’s H. pylori medication. She said her entire family was grateful for the help to get her well. It was a moment of grace. She is why I keep fighting to make our health system great again.

Our cover articles this month discuss HCV treatment in patients with special risk factors or co-conditions. Fascinating information will emerge from studies like the article about artificial sweeteners. Scientists studied hunger-related enzyme levels and brain blood flow with functional MRI’s in obese and lean individuals after ingesting placebo and sucralose-containing solutions. Results might influence our weight loss advice to patients. Worried about malpractice? See our third front page article.

Additional articles discuss a reversal agent for one of the direct-acting oral anticoagulants and a hemospray for GI bleeding. Clinically impactful articles from the AGA journals are highlighted.

Finally, I would like to thank all of you who filled out the readership survey last fall. We are proud that you identified GI & Hepatology News as the best overall source for news information in gastroenterology.
 

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

The recent release of three Americans from North Korea has raised the question of how to bring back those who have been incarcerated abroad.

Jason Rezaian is the Iranian-American journalist who was detained in Iran for a year and a half. He recently discussed how beneficial it was for him to have time away from the spotlight after his release. He also expressed concern that the current administration’s tendency to parade former hostages before cameras right after their release could interfere with their ability to heal from their ordeal.

Dr. Ritchie, a forensic psychiatrist with expertise in military and veteran’s issues, is chief of psychiatry at MedStar Washington Hospital Center.

The recent release of three Americans from North Korea has raised the question of how to bring back those who have been incarcerated abroad.

Jason Rezaian is the Iranian-American journalist who was detained in Iran for a year and a half. He recently discussed how beneficial it was for him to have time away from the spotlight after his release. He also expressed concern that the current administration’s tendency to parade former hostages before cameras right after their release could interfere with their ability to heal from their ordeal.

Dr. Ritchie, a forensic psychiatrist with expertise in military and veteran’s issues, is chief of psychiatry at MedStar Washington Hospital Center.

The recent release of three Americans from North Korea has raised the question of how to bring back those who have been incarcerated abroad.

Jason Rezaian is the Iranian-American journalist who was detained in Iran for a year and a half. He recently discussed how beneficial it was for him to have time away from the spotlight after his release. He also expressed concern that the current administration’s tendency to parade former hostages before cameras right after their release could interfere with their ability to heal from their ordeal.

Dr. Ritchie, a forensic psychiatrist with expertise in military and veteran’s issues, is chief of psychiatry at MedStar Washington Hospital Center.

While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.

It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.

javi_indy/ Thinkstock

Depression

Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.

Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.

Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.

Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.

Traumatic stress

Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected]

While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.

It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.

javi_indy/ Thinkstock

Depression

Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.

Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.

Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.

Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.

Traumatic stress

Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected]

While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.

It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.

javi_indy/ Thinkstock

Depression

Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.

Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.

Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.

Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.

Traumatic stress

Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected]

The world has surely changed in recent years, leading television and Hollywood to recreate many former works of postapocalyptic fiction. Watching the recent Hulu drama “The Handmaid’s Tale” leads many to make modern-day comparisons, but to this hematologist the connection is bone deep.

Hematopoietic stem cells face a century of carefully regulated symmetric division. They are tasked with the mission to generate the heterogeneous and environmentally responsive progenitor populations that will undergo coordinated differentiation and maturation.¹

Dr. Viny is with the Memorial Sloan-Kettering Cancer Center, N.Y., where he is a clinical instructor, is on the staff of the leukemia service, and is a clinical researcher in the Ross Levine Lab.

References

1. Orkin SH and Zon L. Cell. 2008 Feb 22;132(4):631-44.

2. Jongen-Lavrencic M et al. N Engl J Med 2018; 378:1189-99.

3. Bhatnagar B et al. Br J Haematol. 2016 Oct;175(2):226-36.

4. Shlush LI et al. Nature. 2017;547:104-8.

5. Bowman RL et al. Cell Stem Cell. 2018 Feb 1;22(2):157-70.

The world has surely changed in recent years, leading television and Hollywood to recreate many former works of postapocalyptic fiction. Watching the recent Hulu drama “The Handmaid’s Tale” leads many to make modern-day comparisons, but to this hematologist the connection is bone deep.

Hematopoietic stem cells face a century of carefully regulated symmetric division. They are tasked with the mission to generate the heterogeneous and environmentally responsive progenitor populations that will undergo coordinated differentiation and maturation.¹

Dr. Viny is with the Memorial Sloan-Kettering Cancer Center, N.Y., where he is a clinical instructor, is on the staff of the leukemia service, and is a clinical researcher in the Ross Levine Lab.

References

1. Orkin SH and Zon L. Cell. 2008 Feb 22;132(4):631-44.

2. Jongen-Lavrencic M et al. N Engl J Med 2018; 378:1189-99.

3. Bhatnagar B et al. Br J Haematol. 2016 Oct;175(2):226-36.

4. Shlush LI et al. Nature. 2017;547:104-8.

5. Bowman RL et al. Cell Stem Cell. 2018 Feb 1;22(2):157-70.

The world has surely changed in recent years, leading television and Hollywood to recreate many former works of postapocalyptic fiction. Watching the recent Hulu drama “The Handmaid’s Tale” leads many to make modern-day comparisons, but to this hematologist the connection is bone deep.

Hematopoietic stem cells face a century of carefully regulated symmetric division. They are tasked with the mission to generate the heterogeneous and environmentally responsive progenitor populations that will undergo coordinated differentiation and maturation.¹

Dr. Viny is with the Memorial Sloan-Kettering Cancer Center, N.Y., where he is a clinical instructor, is on the staff of the leukemia service, and is a clinical researcher in the Ross Levine Lab.

References

1. Orkin SH and Zon L. Cell. 2008 Feb 22;132(4):631-44.

2. Jongen-Lavrencic M et al. N Engl J Med 2018; 378:1189-99.

3. Bhatnagar B et al. Br J Haematol. 2016 Oct;175(2):226-36.

4. Shlush LI et al. Nature. 2017;547:104-8.

5. Bowman RL et al. Cell Stem Cell. 2018 Feb 1;22(2):157-70.

Most U.S. mainland pediatric practitioners will see only one or two cases of Kawasaki disease (KD) in their careers, but no one wants to miss even one case.

Making the diagnosis as early as possible is important to reduce the chance of sequelae, particularly the coronary artery aneurysms that will eventually lead to 5% of overall acute coronary syndromes in adults. And because there is no “KD test,” we must rely on a constellation of clinical and laboratory findings to develop over a period of days in order to cobble together a diagnosis of KD, or sometimes incomplete KD. And there are some new data that complicate this. Despite the recently updated 2017 guideline,¹ most cases end up being confirmed and managed by regional “experts.” But nearly all of the approximately 6,000 KD cases/year in U.S. children younger than 5 years old start out with one or more primary care, urgent care, or ED visits.

This means that every clinician in the trenches not only needs a high index of suspicion but also needs to be at least a partial expert, too. What raises our index of suspicion? Classic data tell us we need 5 consecutive days of fever plus four or five other principal clinical findings for a KD diagnosis. The principal findings are:

1. Eyes: Bilateral bulbar nonexudative conjunctival injection.

2. Mouth: Erythema of oral/pharyngeal mucosa or cracked lips or strawberry tongue or oral mucositis.

3. Rash.

4. Hands or feet findings: Swelling/erythema or later periungual desquamation.

5. Cervical adenopathy greater than 1.4 cm, usually unilateral.

Other factors that have classically increased suspicion are winter/early spring presentation in North America, male gender (1.5:1 ratio to females), and Asian (particularly Japanese) ancestry. The importance of genetics was initially based on epidemiology (Japan/Asian risk) but lately has been further associated with six gene polymorphisms. However, molecular genetic testing is not currently a practical tool.

Fuzzy KD math

Current guidelines list an exception to the 5-day fever requirement in that only 4 days of fever are needed with four or more principal clinical features, particularly when hand and feet findings exist. Some call this the “4X4 exception.” Then there is a sub-caveat: “Experienced clinicians who have treated many patients with KD may establish the diagnosis with 3 days of fever in rare cases.”¹

Incomplete KD

This is another exception, which seems to be a more frequent diagnosis in the past decade. Incomplete KD requires the 5 days of fever duration plus an elevated C-reactive protein or erythrocyte sedimentation rate. But one needs only two or three of the five principal clinical KD criteria plus three or more of six other laboratory findings (anemia, low albumin, leukocytosis, thrombocytosis, pyuria, or elevated alanine aminotransferase). Incomplete KD can be confirmed by an abnormal echocardiogram – usually not until after 7 days of KD symptoms.¹

New KD nuances

In a recent report on 20 years of data from Japan (n = 1,945 KD cases), more granularity on age, seasonal epidemiology, and outcome were seen.² There was an inverse correlation of male predominance to age, i.e. as age groups got older, there was a gradual shift to female predominance by 7 years of age. The winter/spring predominance (60% of overall cases) did not hold true in younger age groups where summer/fall was the peak season (65% of cases).

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Circulation. 2017 Mar 29. doi: 10.1161/CIR.0000000000000484

2. N Engl J Med. 2018 May 24. doi: 10.1056/NEJMc1804312.

Most U.S. mainland pediatric practitioners will see only one or two cases of Kawasaki disease (KD) in their careers, but no one wants to miss even one case.

Making the diagnosis as early as possible is important to reduce the chance of sequelae, particularly the coronary artery aneurysms that will eventually lead to 5% of overall acute coronary syndromes in adults. And because there is no “KD test,” we must rely on a constellation of clinical and laboratory findings to develop over a period of days in order to cobble together a diagnosis of KD, or sometimes incomplete KD. And there are some new data that complicate this. Despite the recently updated 2017 guideline,¹ most cases end up being confirmed and managed by regional “experts.” But nearly all of the approximately 6,000 KD cases/year in U.S. children younger than 5 years old start out with one or more primary care, urgent care, or ED visits.

This means that every clinician in the trenches not only needs a high index of suspicion but also needs to be at least a partial expert, too. What raises our index of suspicion? Classic data tell us we need 5 consecutive days of fever plus four or five other principal clinical findings for a KD diagnosis. The principal findings are:

1. Eyes: Bilateral bulbar nonexudative conjunctival injection.

2. Mouth: Erythema of oral/pharyngeal mucosa or cracked lips or strawberry tongue or oral mucositis.

3. Rash.

4. Hands or feet findings: Swelling/erythema or later periungual desquamation.

5. Cervical adenopathy greater than 1.4 cm, usually unilateral.

Other factors that have classically increased suspicion are winter/early spring presentation in North America, male gender (1.5:1 ratio to females), and Asian (particularly Japanese) ancestry. The importance of genetics was initially based on epidemiology (Japan/Asian risk) but lately has been further associated with six gene polymorphisms. However, molecular genetic testing is not currently a practical tool.

Fuzzy KD math

Current guidelines list an exception to the 5-day fever requirement in that only 4 days of fever are needed with four or more principal clinical features, particularly when hand and feet findings exist. Some call this the “4X4 exception.” Then there is a sub-caveat: “Experienced clinicians who have treated many patients with KD may establish the diagnosis with 3 days of fever in rare cases.”¹

Incomplete KD

This is another exception, which seems to be a more frequent diagnosis in the past decade. Incomplete KD requires the 5 days of fever duration plus an elevated C-reactive protein or erythrocyte sedimentation rate. But one needs only two or three of the five principal clinical KD criteria plus three or more of six other laboratory findings (anemia, low albumin, leukocytosis, thrombocytosis, pyuria, or elevated alanine aminotransferase). Incomplete KD can be confirmed by an abnormal echocardiogram – usually not until after 7 days of KD symptoms.¹

New KD nuances

In a recent report on 20 years of data from Japan (n = 1,945 KD cases), more granularity on age, seasonal epidemiology, and outcome were seen.² There was an inverse correlation of male predominance to age, i.e. as age groups got older, there was a gradual shift to female predominance by 7 years of age. The winter/spring predominance (60% of overall cases) did not hold true in younger age groups where summer/fall was the peak season (65% of cases).

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Circulation. 2017 Mar 29. doi: 10.1161/CIR.0000000000000484

2. N Engl J Med. 2018 May 24. doi: 10.1056/NEJMc1804312.

Most U.S. mainland pediatric practitioners will see only one or two cases of Kawasaki disease (KD) in their careers, but no one wants to miss even one case.

Making the diagnosis as early as possible is important to reduce the chance of sequelae, particularly the coronary artery aneurysms that will eventually lead to 5% of overall acute coronary syndromes in adults. And because there is no “KD test,” we must rely on a constellation of clinical and laboratory findings to develop over a period of days in order to cobble together a diagnosis of KD, or sometimes incomplete KD. And there are some new data that complicate this. Despite the recently updated 2017 guideline,¹ most cases end up being confirmed and managed by regional “experts.” But nearly all of the approximately 6,000 KD cases/year in U.S. children younger than 5 years old start out with one or more primary care, urgent care, or ED visits.

This means that every clinician in the trenches not only needs a high index of suspicion but also needs to be at least a partial expert, too. What raises our index of suspicion? Classic data tell us we need 5 consecutive days of fever plus four or five other principal clinical findings for a KD diagnosis. The principal findings are:

1. Eyes: Bilateral bulbar nonexudative conjunctival injection.

2. Mouth: Erythema of oral/pharyngeal mucosa or cracked lips or strawberry tongue or oral mucositis.

3. Rash.

4. Hands or feet findings: Swelling/erythema or later periungual desquamation.

5. Cervical adenopathy greater than 1.4 cm, usually unilateral.

Other factors that have classically increased suspicion are winter/early spring presentation in North America, male gender (1.5:1 ratio to females), and Asian (particularly Japanese) ancestry. The importance of genetics was initially based on epidemiology (Japan/Asian risk) but lately has been further associated with six gene polymorphisms. However, molecular genetic testing is not currently a practical tool.

Fuzzy KD math

Current guidelines list an exception to the 5-day fever requirement in that only 4 days of fever are needed with four or more principal clinical features, particularly when hand and feet findings exist. Some call this the “4X4 exception.” Then there is a sub-caveat: “Experienced clinicians who have treated many patients with KD may establish the diagnosis with 3 days of fever in rare cases.”¹

Incomplete KD

This is another exception, which seems to be a more frequent diagnosis in the past decade. Incomplete KD requires the 5 days of fever duration plus an elevated C-reactive protein or erythrocyte sedimentation rate. But one needs only two or three of the five principal clinical KD criteria plus three or more of six other laboratory findings (anemia, low albumin, leukocytosis, thrombocytosis, pyuria, or elevated alanine aminotransferase). Incomplete KD can be confirmed by an abnormal echocardiogram – usually not until after 7 days of KD symptoms.¹

New KD nuances

In a recent report on 20 years of data from Japan (n = 1,945 KD cases), more granularity on age, seasonal epidemiology, and outcome were seen.² There was an inverse correlation of male predominance to age, i.e. as age groups got older, there was a gradual shift to female predominance by 7 years of age. The winter/spring predominance (60% of overall cases) did not hold true in younger age groups where summer/fall was the peak season (65% of cases).

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Circulation. 2017 Mar 29. doi: 10.1161/CIR.0000000000000484

2. N Engl J Med. 2018 May 24. doi: 10.1056/NEJMc1804312.

The notion that residency training falls short when it comes to preparing residents and doctors for starting their own practice is a common thread across the board, whether you’re just getting started or have been managing your own practice for years. I did a survey on LinkedIn and over 50 dermatology and plastic surgery colleagues generously provided their own personal insights and words of wisdom to help young doctors avoid common practice management problems.

I could not quote everyone, but here are some of the best tips that I received:
 

Choose your staff carefully – and invest in the right candidates

One of the biggest pieces of practice management advice that doctors had to offer was to hire the right employees from the beginning, even if that means spending a little more time in the hiring process. This will eliminate headaches and frustration later.

Foster teamwork

Another important aspect of managing your practice is building a sense of teamwork and camaraderie among employees and other doctors. Sean Weiss, MD, a facial plastic surgeon in New Orleans, has a great team-building tip that he uses daily.

“I plan a daily morning huddle with my staff. During the huddle, we review the prior day’s performance, those patients that need following up on, and whether or not the prior day’s goals were met. We then review the patient list for the current day to identify patient needs. We look specifically for ways to improve efficiency and avoid slowing down the work flow. We also try to identify opportunities to cross-promote our offerings to increase awareness of our services. In about 10 minutes, the entire team becomes focused and ready for a productive day.”

For Lacey Elwyn, DO, making staff feel appreciated can be as simple as telling them thank you on a regular basis. “The success of a dermatology practice encompasses every staff member of the team,” Dr. Elwyn, a medical and cosmetic dermatologist in South Florida, said. “The physician should respect and value all staff members. Tell them when they are doing a great job and tell them that you appreciate them every day, but also let them know right away when something is wrong.”
 

Don’t forget about patient education

Janet Trowbridge, MD, PhD, who practices in Edmond, Wash., expressed a great point that not only do patients need to be educated about their medical or cosmetic concerns, but they also need to be educated about the way that health care works in general. “I would say that 50% of my time as a physician is spent educating patients not about their disease, but about how medicine works – or doesn’t work,” she said. “I am constantly amazed by how little the average person understands about how health care is delivered. I talk about copays, coinsurance, annual deductibles, and why their prescriptions are not being covered. Patients feel that the system has let them down.”

Play the dual role of doctor and businessperson

At the end of the day, if you are managing your own practice, you must be able to split your time and skill set between being a physician and being a businessperson. Having realized the importance of the business aspect of running a practice, Justin Bryant, DO, a plastic and reconstructive surgeon in Walled Lake, Mich., enrolled in a dual-degree program during medical school in order to obtain his MBA.

“That investment already has proven priceless, as I’ve helped attendings and colleagues with their practice in marketing, finance, technology, and simply in translating business terms and contracts with physicians,” he said. “Although I don’t think it’s necessary for all physicians to pursue an MBA, and it’s not the answer to every business problem in the field of medicine, when applied, it can be very powerful!”
 

Build and protect your online reputation

Now more than ever, it is imperative to build and protect your online reputation, as online reviews can make or break your business. For plastic surgeon Nirmal Nathan, MD, in Plantation, Fla., managing your reputation is one of the most important considerations when starting a practice. “I would tell residents to start early on reputation management,” he said. “Reviews are so important, even with patients referred by word of mouth. Good reputation management also allows you to quickly ramp up if you decide to move your practice location.”

A large portion of building your online reputation now as to do with what you post (and don’t post) on social media. For Haena Kim, MD, a facial plastic and reconstructive surgeon practicing in Walnut Creek, Calif., figuring out how you would like others to perceive you is the first step.

“In this day and age of social media,” she said, “it’s so hard not to feel the pressure to follow the crowd and be the loudest person out there, and it’s incredibly hard to be patient with your practice growth. It’s important to figure out how you want to present yourself and what you want patients to come away with.”

Sweat the small stuff

Seemingly small administrative and business-related tasks can quickly add up and create much larger problems if not addressed early on. Tito Vasquez, MD, who practices in Southport, Conn., summed this up with an excellent piece of advice to remember: “Sweat the small stuff now, so you don’t have to sweat over the big stuff later.”

In terms of the “small stuff” you’ll need to manage, Dr. Vasquez points to items such as learning local economics and politics, daily finances, office regulations, and documentation, investment and planning, internal and external marketing, and human resources. “While most of us would view this as mundane or at least secondary to the craft we learn,” he said, “it will actually take far greater importance to taking care of patients if you really want your business to succeed and thrive.”

Another essential aspect of business planning that may seem daunting or mundane to many doctors when first starting out is putting together the necessary training manuals to effectively run your practice. Robert Bader, MD, stressed the importance of creating manuals for the front office, back office, Material Safety Data Sheets, and Occupational Safety and Health Administration.

“This is the time, while you have some extra time, to take an active role in forming the foundation of your practice,” Dr. Bader of Deerfield Beach, Fla., said. “Set aside time every year to go over and make necessary changes to these manuals.”

Make decisions now that reflect long-term goals

When you start your practice, deciding on a location might seem like a secondary detail, but the fact of the matter is that location will ultimately play a large role in the future of your business and your life. Beverly Hills, Calif., plastic surgeon John Layke, DO, suggested “choosing where you would like to live, and then building a practice around that location. Being happy in the area you live will make a big difference,” he says. “No one will ultimately be happy making $1 million-plus per year if they are miserable living in the area. In the beginning, share office space with reputable people where you become ‘visible,’ then build the office of your dreams when you are ready.”

Summary

I was amazed at the number of responses that I received in response to this survey. It is my goal to help doctors mentor each other on these important issues so that we do not all have to recreate the wheel. Connect with me on LinkedIn if you want to participate in these surveys or if you want to see the results of them. I want to wish the residents who are graduating and going into their own practice the best of luck. My final advice is to reach out for help – it’s obvious that many people are willing to provide advice.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. She is the author of the monthly “Cosmeceutical Critique” column in Dermatology News.

The notion that residency training falls short when it comes to preparing residents and doctors for starting their own practice is a common thread across the board, whether you’re just getting started or have been managing your own practice for years. I did a survey on LinkedIn and over 50 dermatology and plastic surgery colleagues generously provided their own personal insights and words of wisdom to help young doctors avoid common practice management problems.

I could not quote everyone, but here are some of the best tips that I received:
 

Choose your staff carefully – and invest in the right candidates

One of the biggest pieces of practice management advice that doctors had to offer was to hire the right employees from the beginning, even if that means spending a little more time in the hiring process. This will eliminate headaches and frustration later.

Foster teamwork

Another important aspect of managing your practice is building a sense of teamwork and camaraderie among employees and other doctors. Sean Weiss, MD, a facial plastic surgeon in New Orleans, has a great team-building tip that he uses daily.

“I plan a daily morning huddle with my staff. During the huddle, we review the prior day’s performance, those patients that need following up on, and whether or not the prior day’s goals were met. We then review the patient list for the current day to identify patient needs. We look specifically for ways to improve efficiency and avoid slowing down the work flow. We also try to identify opportunities to cross-promote our offerings to increase awareness of our services. In about 10 minutes, the entire team becomes focused and ready for a productive day.”

For Lacey Elwyn, DO, making staff feel appreciated can be as simple as telling them thank you on a regular basis. “The success of a dermatology practice encompasses every staff member of the team,” Dr. Elwyn, a medical and cosmetic dermatologist in South Florida, said. “The physician should respect and value all staff members. Tell them when they are doing a great job and tell them that you appreciate them every day, but also let them know right away when something is wrong.”
 

Don’t forget about patient education

Janet Trowbridge, MD, PhD, who practices in Edmond, Wash., expressed a great point that not only do patients need to be educated about their medical or cosmetic concerns, but they also need to be educated about the way that health care works in general. “I would say that 50% of my time as a physician is spent educating patients not about their disease, but about how medicine works – or doesn’t work,” she said. “I am constantly amazed by how little the average person understands about how health care is delivered. I talk about copays, coinsurance, annual deductibles, and why their prescriptions are not being covered. Patients feel that the system has let them down.”

Play the dual role of doctor and businessperson

At the end of the day, if you are managing your own practice, you must be able to split your time and skill set between being a physician and being a businessperson. Having realized the importance of the business aspect of running a practice, Justin Bryant, DO, a plastic and reconstructive surgeon in Walled Lake, Mich., enrolled in a dual-degree program during medical school in order to obtain his MBA.

“That investment already has proven priceless, as I’ve helped attendings and colleagues with their practice in marketing, finance, technology, and simply in translating business terms and contracts with physicians,” he said. “Although I don’t think it’s necessary for all physicians to pursue an MBA, and it’s not the answer to every business problem in the field of medicine, when applied, it can be very powerful!”
 

Build and protect your online reputation

Now more than ever, it is imperative to build and protect your online reputation, as online reviews can make or break your business. For plastic surgeon Nirmal Nathan, MD, in Plantation, Fla., managing your reputation is one of the most important considerations when starting a practice. “I would tell residents to start early on reputation management,” he said. “Reviews are so important, even with patients referred by word of mouth. Good reputation management also allows you to quickly ramp up if you decide to move your practice location.”

A large portion of building your online reputation now as to do with what you post (and don’t post) on social media. For Haena Kim, MD, a facial plastic and reconstructive surgeon practicing in Walnut Creek, Calif., figuring out how you would like others to perceive you is the first step.

“In this day and age of social media,” she said, “it’s so hard not to feel the pressure to follow the crowd and be the loudest person out there, and it’s incredibly hard to be patient with your practice growth. It’s important to figure out how you want to present yourself and what you want patients to come away with.”

Sweat the small stuff

Seemingly small administrative and business-related tasks can quickly add up and create much larger problems if not addressed early on. Tito Vasquez, MD, who practices in Southport, Conn., summed this up with an excellent piece of advice to remember: “Sweat the small stuff now, so you don’t have to sweat over the big stuff later.”

In terms of the “small stuff” you’ll need to manage, Dr. Vasquez points to items such as learning local economics and politics, daily finances, office regulations, and documentation, investment and planning, internal and external marketing, and human resources. “While most of us would view this as mundane or at least secondary to the craft we learn,” he said, “it will actually take far greater importance to taking care of patients if you really want your business to succeed and thrive.”

Another essential aspect of business planning that may seem daunting or mundane to many doctors when first starting out is putting together the necessary training manuals to effectively run your practice. Robert Bader, MD, stressed the importance of creating manuals for the front office, back office, Material Safety Data Sheets, and Occupational Safety and Health Administration.

“This is the time, while you have some extra time, to take an active role in forming the foundation of your practice,” Dr. Bader of Deerfield Beach, Fla., said. “Set aside time every year to go over and make necessary changes to these manuals.”

Make decisions now that reflect long-term goals

When you start your practice, deciding on a location might seem like a secondary detail, but the fact of the matter is that location will ultimately play a large role in the future of your business and your life. Beverly Hills, Calif., plastic surgeon John Layke, DO, suggested “choosing where you would like to live, and then building a practice around that location. Being happy in the area you live will make a big difference,” he says. “No one will ultimately be happy making $1 million-plus per year if they are miserable living in the area. In the beginning, share office space with reputable people where you become ‘visible,’ then build the office of your dreams when you are ready.”

Summary

I was amazed at the number of responses that I received in response to this survey. It is my goal to help doctors mentor each other on these important issues so that we do not all have to recreate the wheel. Connect with me on LinkedIn if you want to participate in these surveys or if you want to see the results of them. I want to wish the residents who are graduating and going into their own practice the best of luck. My final advice is to reach out for help – it’s obvious that many people are willing to provide advice.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. She is the author of the monthly “Cosmeceutical Critique” column in Dermatology News.

The notion that residency training falls short when it comes to preparing residents and doctors for starting their own practice is a common thread across the board, whether you’re just getting started or have been managing your own practice for years. I did a survey on LinkedIn and over 50 dermatology and plastic surgery colleagues generously provided their own personal insights and words of wisdom to help young doctors avoid common practice management problems.

I could not quote everyone, but here are some of the best tips that I received:
 

Choose your staff carefully – and invest in the right candidates

One of the biggest pieces of practice management advice that doctors had to offer was to hire the right employees from the beginning, even if that means spending a little more time in the hiring process. This will eliminate headaches and frustration later.

Foster teamwork

Another important aspect of managing your practice is building a sense of teamwork and camaraderie among employees and other doctors. Sean Weiss, MD, a facial plastic surgeon in New Orleans, has a great team-building tip that he uses daily.

“I plan a daily morning huddle with my staff. During the huddle, we review the prior day’s performance, those patients that need following up on, and whether or not the prior day’s goals were met. We then review the patient list for the current day to identify patient needs. We look specifically for ways to improve efficiency and avoid slowing down the work flow. We also try to identify opportunities to cross-promote our offerings to increase awareness of our services. In about 10 minutes, the entire team becomes focused and ready for a productive day.”

For Lacey Elwyn, DO, making staff feel appreciated can be as simple as telling them thank you on a regular basis. “The success of a dermatology practice encompasses every staff member of the team,” Dr. Elwyn, a medical and cosmetic dermatologist in South Florida, said. “The physician should respect and value all staff members. Tell them when they are doing a great job and tell them that you appreciate them every day, but also let them know right away when something is wrong.”
 

Don’t forget about patient education

Janet Trowbridge, MD, PhD, who practices in Edmond, Wash., expressed a great point that not only do patients need to be educated about their medical or cosmetic concerns, but they also need to be educated about the way that health care works in general. “I would say that 50% of my time as a physician is spent educating patients not about their disease, but about how medicine works – or doesn’t work,” she said. “I am constantly amazed by how little the average person understands about how health care is delivered. I talk about copays, coinsurance, annual deductibles, and why their prescriptions are not being covered. Patients feel that the system has let them down.”

Play the dual role of doctor and businessperson

At the end of the day, if you are managing your own practice, you must be able to split your time and skill set between being a physician and being a businessperson. Having realized the importance of the business aspect of running a practice, Justin Bryant, DO, a plastic and reconstructive surgeon in Walled Lake, Mich., enrolled in a dual-degree program during medical school in order to obtain his MBA.

“That investment already has proven priceless, as I’ve helped attendings and colleagues with their practice in marketing, finance, technology, and simply in translating business terms and contracts with physicians,” he said. “Although I don’t think it’s necessary for all physicians to pursue an MBA, and it’s not the answer to every business problem in the field of medicine, when applied, it can be very powerful!”
 

Build and protect your online reputation

Now more than ever, it is imperative to build and protect your online reputation, as online reviews can make or break your business. For plastic surgeon Nirmal Nathan, MD, in Plantation, Fla., managing your reputation is one of the most important considerations when starting a practice. “I would tell residents to start early on reputation management,” he said. “Reviews are so important, even with patients referred by word of mouth. Good reputation management also allows you to quickly ramp up if you decide to move your practice location.”

A large portion of building your online reputation now as to do with what you post (and don’t post) on social media. For Haena Kim, MD, a facial plastic and reconstructive surgeon practicing in Walnut Creek, Calif., figuring out how you would like others to perceive you is the first step.

“In this day and age of social media,” she said, “it’s so hard not to feel the pressure to follow the crowd and be the loudest person out there, and it’s incredibly hard to be patient with your practice growth. It’s important to figure out how you want to present yourself and what you want patients to come away with.”

Sweat the small stuff

Seemingly small administrative and business-related tasks can quickly add up and create much larger problems if not addressed early on. Tito Vasquez, MD, who practices in Southport, Conn., summed this up with an excellent piece of advice to remember: “Sweat the small stuff now, so you don’t have to sweat over the big stuff later.”

In terms of the “small stuff” you’ll need to manage, Dr. Vasquez points to items such as learning local economics and politics, daily finances, office regulations, and documentation, investment and planning, internal and external marketing, and human resources. “While most of us would view this as mundane or at least secondary to the craft we learn,” he said, “it will actually take far greater importance to taking care of patients if you really want your business to succeed and thrive.”

Another essential aspect of business planning that may seem daunting or mundane to many doctors when first starting out is putting together the necessary training manuals to effectively run your practice. Robert Bader, MD, stressed the importance of creating manuals for the front office, back office, Material Safety Data Sheets, and Occupational Safety and Health Administration.

“This is the time, while you have some extra time, to take an active role in forming the foundation of your practice,” Dr. Bader of Deerfield Beach, Fla., said. “Set aside time every year to go over and make necessary changes to these manuals.”

Make decisions now that reflect long-term goals

When you start your practice, deciding on a location might seem like a secondary detail, but the fact of the matter is that location will ultimately play a large role in the future of your business and your life. Beverly Hills, Calif., plastic surgeon John Layke, DO, suggested “choosing where you would like to live, and then building a practice around that location. Being happy in the area you live will make a big difference,” he says. “No one will ultimately be happy making $1 million-plus per year if they are miserable living in the area. In the beginning, share office space with reputable people where you become ‘visible,’ then build the office of your dreams when you are ready.”

Summary

I was amazed at the number of responses that I received in response to this survey. It is my goal to help doctors mentor each other on these important issues so that we do not all have to recreate the wheel. Connect with me on LinkedIn if you want to participate in these surveys or if you want to see the results of them. I want to wish the residents who are graduating and going into their own practice the best of luck. My final advice is to reach out for help – it’s obvious that many people are willing to provide advice.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems. She is the author of the monthly “Cosmeceutical Critique” column in Dermatology News.

In 2013, the emergency contraception containing levonorgestrel, most commonly known as Plan B, became available for purchase without prescription or age restriction. Yet, 5 years later, many adolescents and teens remain misinformed or uninformed completely. For the scope of this article, only levonorgestrel will be discussed, acknowledging that ulipristal acetate (Ella) is also an emergency contraception by prescription.

As providers we all recognize the challenges of engaging a teen patient long enough to have a meaningful conversation on health and wellness. There are even greater challenges when it comes to discussing sexual activity and sexually transmitted diseases. So the thought of discussing prevention of unwanted pregnancy may be daunting for most of us.

Thinkstockphotos.com

This topic has many layers. First and foremost, it touches on a hotly debated topic of where life begins, and emergency contraception may be thought to cross that line. Awareness of the option of emergency contraception is thought to give a free pass to promiscuous behavior. Some just feel there is not enough research to support the safe use of these products in adolescents. As with most things, taking the time to educate ourselves on the facts usually alleviates the conflicts.

Understanding levonorgestrel mechanism of action is important in clarifying its position in the prolife debate. The International Consortium for Emergency Contraception and the International Federation of Gynecologists and Obstetrics consider that inhibition or delay of ovulation is levonorgestrel’s mechanism of action, and that it does not prevent implantation of a fertilized egg. If taken after ovulation has occurred, it is ineffective in preventing pregnancy.^1,2

Levonorgestrel emergency contraception was first approved by the Food and Drug Administration in 1999 under the brand name Plan B by Teva Women’s Health, then later Next Choice (Watson Pharma) was released. Initially, it was prescribed to be taken as a 0.75-mg tab within 72 hours of unprotected intercourse and repeated in 12 hours. Further studies revealed taking a 1.5-mg tab once was just as effective with no significant increase in adverse effects and Plan B One-Step was released.³

The Catholic Health Association presented a paper clarifying that levonorgestrel is not a postfertilization contraceptive (abortifacient), hopefully preventing delay of its use in victims of sexual assault seen in Catholic health care facilities.⁴

Safety for this product since its release has shown no deaths or serious complications.² The most common side effect is nausea, usually without vomiting.² Antinausea medication given 1 hour before can be helpful but is not routinely used. The length of menstrual cycle is shorter if given early in cycle but it may be lengthened by 2 days if taken post ovulation. It is not intended for repeated use, but 11 studies showed no adverse effects when it was used repeatedly in the same ovulatory cycle, and it was shown to be safe.²

For women whose emergency contraception failed, one study of 332 pregnant women who had used levonorgestrel found no teratogenic effect or risk of birth defects.⁵ Although it is not contraindicated in breastfeeding mothers, it was recommended that patients discontinue breastfeeding for 8 hours post ingestion. Recognized contraindications to oral contraceptives do not apply to levonorgestrel, given the temporary and relative low exposure to the hormone.³

As for efficacy, timing is of the essence. As stated previously, if not taken before ovulation has occurred, it is ineffective. If taken within 72 hours of unprotected intercourse, one study showed levonorgestrel would prevent 85% of pregnancies that otherwise might have occurred.³ Although the package insert says it must taken within 72 hours, studies have shown protection up to 120 hours post coitus, but that efficacy declines with every hour. Body mass index also may play a role in effectiveness, but the studies have been varied and more research is required before a determination is made.²

Keep in mind that 10% of all unintended pregnancies occur from nonconsensual intercourse so knowing what options are available is critical. Whether you give a handout with the information or undertake a more in-depth conversation during well visits, this is vital information that can change a person’s life.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. “Emergency Contraception: Questions And Answers For Decision-Makers,” International Consortium for Emergency Contraception, 2013.

2. Clin Obstet Gynecol. 2014 Dec;57(4):741-50.

3. Pediatrics 2012;130:1174-82.

4. Health Progress. 2010 Jan-Feb. 59-61.

5. Hum Reprod. 2009 Jul;24(7):1605-11.

6. Contraception. 2016 Feb;93(2):145-52.

In 2013, the emergency contraception containing levonorgestrel, most commonly known as Plan B, became available for purchase without prescription or age restriction. Yet, 5 years later, many adolescents and teens remain misinformed or uninformed completely. For the scope of this article, only levonorgestrel will be discussed, acknowledging that ulipristal acetate (Ella) is also an emergency contraception by prescription.

As providers we all recognize the challenges of engaging a teen patient long enough to have a meaningful conversation on health and wellness. There are even greater challenges when it comes to discussing sexual activity and sexually transmitted diseases. So the thought of discussing prevention of unwanted pregnancy may be daunting for most of us.

Thinkstockphotos.com

This topic has many layers. First and foremost, it touches on a hotly debated topic of where life begins, and emergency contraception may be thought to cross that line. Awareness of the option of emergency contraception is thought to give a free pass to promiscuous behavior. Some just feel there is not enough research to support the safe use of these products in adolescents. As with most things, taking the time to educate ourselves on the facts usually alleviates the conflicts.

Understanding levonorgestrel mechanism of action is important in clarifying its position in the prolife debate. The International Consortium for Emergency Contraception and the International Federation of Gynecologists and Obstetrics consider that inhibition or delay of ovulation is levonorgestrel’s mechanism of action, and that it does not prevent implantation of a fertilized egg. If taken after ovulation has occurred, it is ineffective in preventing pregnancy.^1,2

Levonorgestrel emergency contraception was first approved by the Food and Drug Administration in 1999 under the brand name Plan B by Teva Women’s Health, then later Next Choice (Watson Pharma) was released. Initially, it was prescribed to be taken as a 0.75-mg tab within 72 hours of unprotected intercourse and repeated in 12 hours. Further studies revealed taking a 1.5-mg tab once was just as effective with no significant increase in adverse effects and Plan B One-Step was released.³

The Catholic Health Association presented a paper clarifying that levonorgestrel is not a postfertilization contraceptive (abortifacient), hopefully preventing delay of its use in victims of sexual assault seen in Catholic health care facilities.⁴

Safety for this product since its release has shown no deaths or serious complications.² The most common side effect is nausea, usually without vomiting.² Antinausea medication given 1 hour before can be helpful but is not routinely used. The length of menstrual cycle is shorter if given early in cycle but it may be lengthened by 2 days if taken post ovulation. It is not intended for repeated use, but 11 studies showed no adverse effects when it was used repeatedly in the same ovulatory cycle, and it was shown to be safe.²

For women whose emergency contraception failed, one study of 332 pregnant women who had used levonorgestrel found no teratogenic effect or risk of birth defects.⁵ Although it is not contraindicated in breastfeeding mothers, it was recommended that patients discontinue breastfeeding for 8 hours post ingestion. Recognized contraindications to oral contraceptives do not apply to levonorgestrel, given the temporary and relative low exposure to the hormone.³

As for efficacy, timing is of the essence. As stated previously, if not taken before ovulation has occurred, it is ineffective. If taken within 72 hours of unprotected intercourse, one study showed levonorgestrel would prevent 85% of pregnancies that otherwise might have occurred.³ Although the package insert says it must taken within 72 hours, studies have shown protection up to 120 hours post coitus, but that efficacy declines with every hour. Body mass index also may play a role in effectiveness, but the studies have been varied and more research is required before a determination is made.²

Keep in mind that 10% of all unintended pregnancies occur from nonconsensual intercourse so knowing what options are available is critical. Whether you give a handout with the information or undertake a more in-depth conversation during well visits, this is vital information that can change a person’s life.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. “Emergency Contraception: Questions And Answers For Decision-Makers,” International Consortium for Emergency Contraception, 2013.

2. Clin Obstet Gynecol. 2014 Dec;57(4):741-50.

3. Pediatrics 2012;130:1174-82.

4. Health Progress. 2010 Jan-Feb. 59-61.

5. Hum Reprod. 2009 Jul;24(7):1605-11.

6. Contraception. 2016 Feb;93(2):145-52.

In 2013, the emergency contraception containing levonorgestrel, most commonly known as Plan B, became available for purchase without prescription or age restriction. Yet, 5 years later, many adolescents and teens remain misinformed or uninformed completely. For the scope of this article, only levonorgestrel will be discussed, acknowledging that ulipristal acetate (Ella) is also an emergency contraception by prescription.

As providers we all recognize the challenges of engaging a teen patient long enough to have a meaningful conversation on health and wellness. There are even greater challenges when it comes to discussing sexual activity and sexually transmitted diseases. So the thought of discussing prevention of unwanted pregnancy may be daunting for most of us.

Thinkstockphotos.com

This topic has many layers. First and foremost, it touches on a hotly debated topic of where life begins, and emergency contraception may be thought to cross that line. Awareness of the option of emergency contraception is thought to give a free pass to promiscuous behavior. Some just feel there is not enough research to support the safe use of these products in adolescents. As with most things, taking the time to educate ourselves on the facts usually alleviates the conflicts.

Understanding levonorgestrel mechanism of action is important in clarifying its position in the prolife debate. The International Consortium for Emergency Contraception and the International Federation of Gynecologists and Obstetrics consider that inhibition or delay of ovulation is levonorgestrel’s mechanism of action, and that it does not prevent implantation of a fertilized egg. If taken after ovulation has occurred, it is ineffective in preventing pregnancy.^1,2

Levonorgestrel emergency contraception was first approved by the Food and Drug Administration in 1999 under the brand name Plan B by Teva Women’s Health, then later Next Choice (Watson Pharma) was released. Initially, it was prescribed to be taken as a 0.75-mg tab within 72 hours of unprotected intercourse and repeated in 12 hours. Further studies revealed taking a 1.5-mg tab once was just as effective with no significant increase in adverse effects and Plan B One-Step was released.³

The Catholic Health Association presented a paper clarifying that levonorgestrel is not a postfertilization contraceptive (abortifacient), hopefully preventing delay of its use in victims of sexual assault seen in Catholic health care facilities.⁴

Safety for this product since its release has shown no deaths or serious complications.² The most common side effect is nausea, usually without vomiting.² Antinausea medication given 1 hour before can be helpful but is not routinely used. The length of menstrual cycle is shorter if given early in cycle but it may be lengthened by 2 days if taken post ovulation. It is not intended for repeated use, but 11 studies showed no adverse effects when it was used repeatedly in the same ovulatory cycle, and it was shown to be safe.²

For women whose emergency contraception failed, one study of 332 pregnant women who had used levonorgestrel found no teratogenic effect or risk of birth defects.⁵ Although it is not contraindicated in breastfeeding mothers, it was recommended that patients discontinue breastfeeding for 8 hours post ingestion. Recognized contraindications to oral contraceptives do not apply to levonorgestrel, given the temporary and relative low exposure to the hormone.³

As for efficacy, timing is of the essence. As stated previously, if not taken before ovulation has occurred, it is ineffective. If taken within 72 hours of unprotected intercourse, one study showed levonorgestrel would prevent 85% of pregnancies that otherwise might have occurred.³ Although the package insert says it must taken within 72 hours, studies have shown protection up to 120 hours post coitus, but that efficacy declines with every hour. Body mass index also may play a role in effectiveness, but the studies have been varied and more research is required before a determination is made.²

Keep in mind that 10% of all unintended pregnancies occur from nonconsensual intercourse so knowing what options are available is critical. Whether you give a handout with the information or undertake a more in-depth conversation during well visits, this is vital information that can change a person’s life.

Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. “Emergency Contraception: Questions And Answers For Decision-Makers,” International Consortium for Emergency Contraception, 2013.

2. Clin Obstet Gynecol. 2014 Dec;57(4):741-50.

3. Pediatrics 2012;130:1174-82.

4. Health Progress. 2010 Jan-Feb. 59-61.

5. Hum Reprod. 2009 Jul;24(7):1605-11.

6. Contraception. 2016 Feb;93(2):145-52.

FP can perform the circumcision

I enjoyed Dr. Lerner's brief review but was puzzled by the question of who should perform the circumcision. The most obvious and one of the most frequent answers was ignored. It should be done by the family physician who delivered the baby, is caring for him in the nursery, and will be caring for him another couple of decades. 

John R. Carroll, MD
Corpus Christi, Texas

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

FP can perform the circumcision

I enjoyed Dr. Lerner's brief review but was puzzled by the question of who should perform the circumcision. The most obvious and one of the most frequent answers was ignored. It should be done by the family physician who delivered the baby, is caring for him in the nursery, and will be caring for him another couple of decades. 

John R. Carroll, MD
Corpus Christi, Texas

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

FP can perform the circumcision

I enjoyed Dr. Lerner's brief review but was puzzled by the question of who should perform the circumcision. The most obvious and one of the most frequent answers was ignored. It should be done by the family physician who delivered the baby, is caring for him in the nursery, and will be caring for him another couple of decades. 

John R. Carroll, MD
Corpus Christi, Texas

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.