Commentary

To the Editor:

Rice and rice products, such as rice cereal and rice snacks, contain inorganic arsenic. Exposure to arsenicin utero and during early life may be associated with adverse fetal growth, adverse infant and child immune response, and adverse neurodevelopmental outcomes. Therefore, the World Health Organization, the Food and Agriculture Organization of the United Nations, the European Union, and the US Food and Drug Administration have suggested maximum arsenic ingestion recommendations for infants: 100 ng/g for inorganic arsenic in products geared toward infants. However, infants consuming only a few servings of rice products may exceed the weekly tolerable intake of arsenic.

Karagas et al¹ obtained dietary data on 759 infants who were enrolled in the New Hampshire Birth Cohort Study from 2011 to 2014. They noted that 80% of the infants had been introduced to rice cereal during the first year. Additional data on diet and total urinary arsenic at 12 months was available for 129 infants: 32.6% of these infants were fed rice snacks. In addition, the total urinary arsenic concentration was higher among infants who ate rice cereal or rice snacks as compared to infants who did not eat rice or rice products.

Chronic arsenic exposure can result in patchy dark brown hyperpigmentation with scattered pale spots referred to as “raindrops on a dusty road.” The axilla, eyelids, groin, neck, nipples, and temples often are affected. However, the hyperpigmentation can extend across the chest, abdomen, and back in severe cases.

Horizontal white lines across the nails (Mees lines) may develop. Keratoses, often on the palms (arsenic keratoses), may appear; they persist and may progress to skin cancers. In addition, patients with arsenic exposure are more susceptible to developing nonmelanoma skin cancers.²

It is unknown if exposure to inorganic arsenic in infancy predisposes these individuals to skin cancer when they become adults. Long-term longitudinal follow-up of the participants in this study may provide additional insight. Perhaps infants should not receive rice cereals and rice snacks or their parents should more carefully monitor the amount of rice and rice products that they ingest.

To the Editor:

Rice and rice products, such as rice cereal and rice snacks, contain inorganic arsenic. Exposure to arsenicin utero and during early life may be associated with adverse fetal growth, adverse infant and child immune response, and adverse neurodevelopmental outcomes. Therefore, the World Health Organization, the Food and Agriculture Organization of the United Nations, the European Union, and the US Food and Drug Administration have suggested maximum arsenic ingestion recommendations for infants: 100 ng/g for inorganic arsenic in products geared toward infants. However, infants consuming only a few servings of rice products may exceed the weekly tolerable intake of arsenic.

Karagas et al¹ obtained dietary data on 759 infants who were enrolled in the New Hampshire Birth Cohort Study from 2011 to 2014. They noted that 80% of the infants had been introduced to rice cereal during the first year. Additional data on diet and total urinary arsenic at 12 months was available for 129 infants: 32.6% of these infants were fed rice snacks. In addition, the total urinary arsenic concentration was higher among infants who ate rice cereal or rice snacks as compared to infants who did not eat rice or rice products.

Chronic arsenic exposure can result in patchy dark brown hyperpigmentation with scattered pale spots referred to as “raindrops on a dusty road.” The axilla, eyelids, groin, neck, nipples, and temples often are affected. However, the hyperpigmentation can extend across the chest, abdomen, and back in severe cases.

Horizontal white lines across the nails (Mees lines) may develop. Keratoses, often on the palms (arsenic keratoses), may appear; they persist and may progress to skin cancers. In addition, patients with arsenic exposure are more susceptible to developing nonmelanoma skin cancers.²

It is unknown if exposure to inorganic arsenic in infancy predisposes these individuals to skin cancer when they become adults. Long-term longitudinal follow-up of the participants in this study may provide additional insight. Perhaps infants should not receive rice cereals and rice snacks or their parents should more carefully monitor the amount of rice and rice products that they ingest.

To the Editor:

Rice and rice products, such as rice cereal and rice snacks, contain inorganic arsenic. Exposure to arsenicin utero and during early life may be associated with adverse fetal growth, adverse infant and child immune response, and adverse neurodevelopmental outcomes. Therefore, the World Health Organization, the Food and Agriculture Organization of the United Nations, the European Union, and the US Food and Drug Administration have suggested maximum arsenic ingestion recommendations for infants: 100 ng/g for inorganic arsenic in products geared toward infants. However, infants consuming only a few servings of rice products may exceed the weekly tolerable intake of arsenic.

Karagas et al¹ obtained dietary data on 759 infants who were enrolled in the New Hampshire Birth Cohort Study from 2011 to 2014. They noted that 80% of the infants had been introduced to rice cereal during the first year. Additional data on diet and total urinary arsenic at 12 months was available for 129 infants: 32.6% of these infants were fed rice snacks. In addition, the total urinary arsenic concentration was higher among infants who ate rice cereal or rice snacks as compared to infants who did not eat rice or rice products.

Chronic arsenic exposure can result in patchy dark brown hyperpigmentation with scattered pale spots referred to as “raindrops on a dusty road.” The axilla, eyelids, groin, neck, nipples, and temples often are affected. However, the hyperpigmentation can extend across the chest, abdomen, and back in severe cases.

Horizontal white lines across the nails (Mees lines) may develop. Keratoses, often on the palms (arsenic keratoses), may appear; they persist and may progress to skin cancers. In addition, patients with arsenic exposure are more susceptible to developing nonmelanoma skin cancers.²

It is unknown if exposure to inorganic arsenic in infancy predisposes these individuals to skin cancer when they become adults. Long-term longitudinal follow-up of the participants in this study may provide additional insight. Perhaps infants should not receive rice cereals and rice snacks or their parents should more carefully monitor the amount of rice and rice products that they ingest.

Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.

Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.

Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.

In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.

The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:

• BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
• CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
• APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations

These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.

The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.¹ Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.

The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification examination and consists of 4 modules: medical, pediatric, surgical, and dermatopathology. Basic science related to these clinical areas is included within each module. Each module consists of 75 to 100 questions and takes 1.5 to 2 hours. Modules are offered on 4 occasions during residency, beginning in the spring of the second year. Modules do not have to be taken in a specific order, and they do not have to be taken in 1 sitting. For example, a resident could choose to take the surgery module during the second year but wait until later in the third year to take the dermatopathology module, depending on when the resident feels prepared. If a module is not passed, it can be retaken at a subsequent offering without prejudice. All 4 modules must be passed to sit for the APPLIED Exam. Travel to a test center is not required; remote proctoring is available online.

The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.

Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.

An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.

It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.²

Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.

Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.

Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.

In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.

The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:

• BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
• CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
• APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations

These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.

The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.¹ Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.

The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification examination and consists of 4 modules: medical, pediatric, surgical, and dermatopathology. Basic science related to these clinical areas is included within each module. Each module consists of 75 to 100 questions and takes 1.5 to 2 hours. Modules are offered on 4 occasions during residency, beginning in the spring of the second year. Modules do not have to be taken in a specific order, and they do not have to be taken in 1 sitting. For example, a resident could choose to take the surgery module during the second year but wait until later in the third year to take the dermatopathology module, depending on when the resident feels prepared. If a module is not passed, it can be retaken at a subsequent offering without prejudice. All 4 modules must be passed to sit for the APPLIED Exam. Travel to a test center is not required; remote proctoring is available online.

The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.

Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.

An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.

It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.²

Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.

Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.

Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.

In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.

The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:

• BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
• CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
• APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations

These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.

The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.¹ Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.

The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification examination and consists of 4 modules: medical, pediatric, surgical, and dermatopathology. Basic science related to these clinical areas is included within each module. Each module consists of 75 to 100 questions and takes 1.5 to 2 hours. Modules are offered on 4 occasions during residency, beginning in the spring of the second year. Modules do not have to be taken in a specific order, and they do not have to be taken in 1 sitting. For example, a resident could choose to take the surgery module during the second year but wait until later in the third year to take the dermatopathology module, depending on when the resident feels prepared. If a module is not passed, it can be retaken at a subsequent offering without prejudice. All 4 modules must be passed to sit for the APPLIED Exam. Travel to a test center is not required; remote proctoring is available online.

The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.

Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.

An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.

It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.²

Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.

In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.¹ Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.²

Methods of repair

The two main methods of bowel repair are primary closure and resection with re-anastamosis. The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.

Simple small bowel closures

Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.

Small bowel resection

Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.

Large bowel repair

Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.⁶

Postoperative management

The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.

The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.⁷ In general, for small and large intestinal injuries, early feeding is considered acceptable.⁸

Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.⁶

Avoiding injury

Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.⁹ However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.¹⁰ Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.

Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.

References

1. Int Surg. 2006 Nov-Dec;91(6):336-40.

2. J Am Coll Surg. 2001 Jun;192(6):677-83.

3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.

4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.

5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.

6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

7. Br J Surg. 2005 Jun;92(6):673-80.

8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.

9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.

10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.


 

Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.

In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.¹ Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.²

Methods of repair

The two main methods of bowel repair are primary closure and resection with re-anastamosis. The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.

Simple small bowel closures

Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.

Small bowel resection

Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.

Large bowel repair

Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.⁶

Postoperative management

The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.

The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.⁷ In general, for small and large intestinal injuries, early feeding is considered acceptable.⁸

Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.⁶

Avoiding injury

Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.⁹ However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.¹⁰ Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.

Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.

References

1. Int Surg. 2006 Nov-Dec;91(6):336-40.

2. J Am Coll Surg. 2001 Jun;192(6):677-83.

3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.

4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.

5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.

6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

7. Br J Surg. 2005 Jun;92(6):673-80.

8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.

9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.

10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.


 

Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.

In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.¹ Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.²

Methods of repair

The two main methods of bowel repair are primary closure and resection with re-anastamosis. The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.

Simple small bowel closures

Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.

Small bowel resection

Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.

Large bowel repair

Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.⁶

Postoperative management

The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.

The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.⁷ In general, for small and large intestinal injuries, early feeding is considered acceptable.⁸

Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.⁶

Avoiding injury

Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.⁹ However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.¹⁰ Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.

Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.

References

1. Int Surg. 2006 Nov-Dec;91(6):336-40.

2. J Am Coll Surg. 2001 Jun;192(6):677-83.

3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.

4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.

5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.

6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

7. Br J Surg. 2005 Jun;92(6):673-80.

8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.

9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.

10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.


 

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

Most physicians are likely familiar with guidelines relating to physician impairment, but they may not be aware that these guidelines typically conflict with the Americans with Disabilities Act (ADA), which protects all employees against unwarranted requests for mental health information or evaluations.

Under the ADA, employers cannot request mental health information from their employees or refer them for mental health evaluations without objective evidence showing that either the employee:

• is unable to perform essential job functions because of a mental health condition
• poses a high risk of substantial, imminent harm to himself (herself) or others in the workplace because of a mental health condition.¹

Employers cannot rely on speculative evidence or generalizations about these conditions when making these determinations,¹ and common mental disorders (eg, depressive disorders, anxiety disorders, attention-­deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.²

In contrast, the American Medical Association (AMA) does not distinguish between the presence of a mental health condition and physician impairment,^3,4 which may result in unwarranted requests and referrals for mental health evaluations. Some state laws on impairment, which all derive from AMA policies,⁵ even state outright that, “‘Impaired’ or ‘impairment’ means the presence of the diseases of alcoholism, drug abuse, or mental illness”⁶ and directly discriminate against physicians with these conditions.

State physician health programs (PHPs) also may describe impairment in problematic ways (eg, “Involvement in litigation against hospital”).⁷ Their descriptions also are overly inclusive in that they could be used to describe most physicians (N.D.L., J.W.B., unpublished data, 2017), and they rarely represent sufficient legal indications for a mental health evaluation under the ADA (N.D.L., J.W.B., unpublished data, 2017). Even the APA’s Clinical Guide to Psychiatric Ethics describes physician impairment as synonymous with mental illness.⁸

Requests for mental health information or evaluations not only can include referrals to state PHPs but also “suggestions” to see a psychologist, professional job coach, or any provider who may ask for mental health information. Under the ADA's guidelines, obtaining “voluntary” consent from an employee who could be fired for not cooperating does not change the involuntary nature of these requests.^2,9

Employers who hire psychiatrists, physicians, and medical residents should comply with the ADA and disregard the AMA’s policies, state laws, PHPs, other institutional guidelines,¹⁰ and guidance from some articles published in Current Psychiatry^11,12 when requesting mental health information, evaluations, and referrals for their employees.

Most physicians are likely familiar with guidelines relating to physician impairment, but they may not be aware that these guidelines typically conflict with the Americans with Disabilities Act (ADA), which protects all employees against unwarranted requests for mental health information or evaluations.

Under the ADA, employers cannot request mental health information from their employees or refer them for mental health evaluations without objective evidence showing that either the employee:

• is unable to perform essential job functions because of a mental health condition
• poses a high risk of substantial, imminent harm to himself (herself) or others in the workplace because of a mental health condition.¹

Employers cannot rely on speculative evidence or generalizations about these conditions when making these determinations,¹ and common mental disorders (eg, depressive disorders, anxiety disorders, attention-­deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.²

In contrast, the American Medical Association (AMA) does not distinguish between the presence of a mental health condition and physician impairment,^3,4 which may result in unwarranted requests and referrals for mental health evaluations. Some state laws on impairment, which all derive from AMA policies,⁵ even state outright that, “‘Impaired’ or ‘impairment’ means the presence of the diseases of alcoholism, drug abuse, or mental illness”⁶ and directly discriminate against physicians with these conditions.

State physician health programs (PHPs) also may describe impairment in problematic ways (eg, “Involvement in litigation against hospital”).⁷ Their descriptions also are overly inclusive in that they could be used to describe most physicians (N.D.L., J.W.B., unpublished data, 2017), and they rarely represent sufficient legal indications for a mental health evaluation under the ADA (N.D.L., J.W.B., unpublished data, 2017). Even the APA’s Clinical Guide to Psychiatric Ethics describes physician impairment as synonymous with mental illness.⁸

Requests for mental health information or evaluations not only can include referrals to state PHPs but also “suggestions” to see a psychologist, professional job coach, or any provider who may ask for mental health information. Under the ADA's guidelines, obtaining “voluntary” consent from an employee who could be fired for not cooperating does not change the involuntary nature of these requests.^2,9

Employers who hire psychiatrists, physicians, and medical residents should comply with the ADA and disregard the AMA’s policies, state laws, PHPs, other institutional guidelines,¹⁰ and guidance from some articles published in Current Psychiatry^11,12 when requesting mental health information, evaluations, and referrals for their employees.

Most physicians are likely familiar with guidelines relating to physician impairment, but they may not be aware that these guidelines typically conflict with the Americans with Disabilities Act (ADA), which protects all employees against unwarranted requests for mental health information or evaluations.

Under the ADA, employers cannot request mental health information from their employees or refer them for mental health evaluations without objective evidence showing that either the employee:

• is unable to perform essential job functions because of a mental health condition
• poses a high risk of substantial, imminent harm to himself (herself) or others in the workplace because of a mental health condition.¹

Employers cannot rely on speculative evidence or generalizations about these conditions when making these determinations,¹ and common mental disorders (eg, depressive disorders, anxiety disorders, attention-­deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.²

In contrast, the American Medical Association (AMA) does not distinguish between the presence of a mental health condition and physician impairment,^3,4 which may result in unwarranted requests and referrals for mental health evaluations. Some state laws on impairment, which all derive from AMA policies,⁵ even state outright that, “‘Impaired’ or ‘impairment’ means the presence of the diseases of alcoholism, drug abuse, or mental illness”⁶ and directly discriminate against physicians with these conditions.

State physician health programs (PHPs) also may describe impairment in problematic ways (eg, “Involvement in litigation against hospital”).⁷ Their descriptions also are overly inclusive in that they could be used to describe most physicians (N.D.L., J.W.B., unpublished data, 2017), and they rarely represent sufficient legal indications for a mental health evaluation under the ADA (N.D.L., J.W.B., unpublished data, 2017). Even the APA’s Clinical Guide to Psychiatric Ethics describes physician impairment as synonymous with mental illness.⁸

Requests for mental health information or evaluations not only can include referrals to state PHPs but also “suggestions” to see a psychologist, professional job coach, or any provider who may ask for mental health information. Under the ADA's guidelines, obtaining “voluntary” consent from an employee who could be fired for not cooperating does not change the involuntary nature of these requests.^2,9

Employers who hire psychiatrists, physicians, and medical residents should comply with the ADA and disregard the AMA’s policies, state laws, PHPs, other institutional guidelines,¹⁰ and guidance from some articles published in Current Psychiatry^11,12 when requesting mental health information, evaluations, and referrals for their employees.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

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

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

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

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

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

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at [email protected].
 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at [email protected].
 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at [email protected].
 

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”