Commentary

August 2016 provided 2 impressive news stories. These stories have far more salience and granularity than I can began to entertain in this brief editorial, but they show that the VA with all its systemic problems has unrivaled potential to promote what Aristotle called human flourishing.

A past director of mine greeted any small success or positive accomplishment of the facility and its employees with the folksy aphorism “You have to celebrate when you can in this outfit.” He was wise, for he knew that taking a respite to recognize a job well done is crucial to the emotional wellness of the workforce. And after that moment of satisfaction, everyone gets back to work at least a little bit recharged. So in this editorial, I will praise a few recent, unique VA achievements that underscore the importance of keeping the organization not only upright, but also doing right.

On August 1, President Obama announced that since 2010 veteran homelessness had been reduced by almost half. VA Secretary Robert A. McDonald also applauded a 56% decrease in unsheltered homeless veterans. Yet just as quickly, he refocused the collaborating agencies on the goal of ending veteran homelessness, which seemed a long shot when initially announced but now seems to have a realistic chance of success. “Although this achievement is noteworthy, we will not rest until every veteran in need is permanently housed,” McDonald said.

Three large government agencies and extensive partnerships cooperated to keep 360,000 veterans and their families from being homeless. But each veteran also had the outreach and support of a HUD-VASH (U.S. Department of Housing and Urban Development and VA Supportive Housing) worker and counterparts in the community. It is hard to see how any other health care organization could leverage this large an effort or would choose to dedicate its federal, state, and city resources to meet a need so basic that without it few persons can move up Maslow’s hierarchy of human actualization.

The same week the VA Research and Development program gave all of us in federal service a reason to hold up our collective heads a little higher announcing that the Million Veteran Program (MVP) had enrolled its 500,000th participant, making it the largest genomic database in the world. Once again, it is difficult to imagine any other health care organization, except another federal agency like the National Institutes of Health, mounting such an ambitious research initiative.

The MVP offers a databank—the likes of which has never been assembled—to study some of the most common and debilitating conditions, such as mental illness, substance use, and kidney and heart disease among many others. The combination of environmental genetics and clinical and psychosocial data will open doors of discoveries for thousands of people, veteran and nonveteran alike. Secretary McDonald applauded the most important ethical aspect of the project, the incomparable altruism of veterans, “Many of our veterans have saved lives on the battlefield and because of their participation in MVP, their participation has the potential to save countless lives—now and for generations to come.”

These 2 amazing initiatives have more in common than may seem apparent at first glance. Besides their intrinsic worth in humanist service and scientific creativity, respectively, putting veterans in homes and constructing a repository of scientific knowledge show that the VA—once accused of being a dinosaur ignoring the plummeting temperatures of its own ice age—has demonstrated remarkable instantiation of the I CARE Core Characteristics of agility and innovation (available at http://www.va.gov/icare) in the campaign to end homelessness and the MVP initiative.

These good-news stories celebrate the immense power of the VA to change the world for the better. This is reason enough to keep the faith that VA will emerge from the hearings and the headlines as a workforce proud of their privilege to care for veterans and contribute to the common good.

August 2016 provided 2 impressive news stories. These stories have far more salience and granularity than I can began to entertain in this brief editorial, but they show that the VA with all its systemic problems has unrivaled potential to promote what Aristotle called human flourishing.

A past director of mine greeted any small success or positive accomplishment of the facility and its employees with the folksy aphorism “You have to celebrate when you can in this outfit.” He was wise, for he knew that taking a respite to recognize a job well done is crucial to the emotional wellness of the workforce. And after that moment of satisfaction, everyone gets back to work at least a little bit recharged. So in this editorial, I will praise a few recent, unique VA achievements that underscore the importance of keeping the organization not only upright, but also doing right.

On August 1, President Obama announced that since 2010 veteran homelessness had been reduced by almost half. VA Secretary Robert A. McDonald also applauded a 56% decrease in unsheltered homeless veterans. Yet just as quickly, he refocused the collaborating agencies on the goal of ending veteran homelessness, which seemed a long shot when initially announced but now seems to have a realistic chance of success. “Although this achievement is noteworthy, we will not rest until every veteran in need is permanently housed,” McDonald said.

Three large government agencies and extensive partnerships cooperated to keep 360,000 veterans and their families from being homeless. But each veteran also had the outreach and support of a HUD-VASH (U.S. Department of Housing and Urban Development and VA Supportive Housing) worker and counterparts in the community. It is hard to see how any other health care organization could leverage this large an effort or would choose to dedicate its federal, state, and city resources to meet a need so basic that without it few persons can move up Maslow’s hierarchy of human actualization.

The same week the VA Research and Development program gave all of us in federal service a reason to hold up our collective heads a little higher announcing that the Million Veteran Program (MVP) had enrolled its 500,000th participant, making it the largest genomic database in the world. Once again, it is difficult to imagine any other health care organization, except another federal agency like the National Institutes of Health, mounting such an ambitious research initiative.

The MVP offers a databank—the likes of which has never been assembled—to study some of the most common and debilitating conditions, such as mental illness, substance use, and kidney and heart disease among many others. The combination of environmental genetics and clinical and psychosocial data will open doors of discoveries for thousands of people, veteran and nonveteran alike. Secretary McDonald applauded the most important ethical aspect of the project, the incomparable altruism of veterans, “Many of our veterans have saved lives on the battlefield and because of their participation in MVP, their participation has the potential to save countless lives—now and for generations to come.”

These 2 amazing initiatives have more in common than may seem apparent at first glance. Besides their intrinsic worth in humanist service and scientific creativity, respectively, putting veterans in homes and constructing a repository of scientific knowledge show that the VA—once accused of being a dinosaur ignoring the plummeting temperatures of its own ice age—has demonstrated remarkable instantiation of the I CARE Core Characteristics of agility and innovation (available at http://www.va.gov/icare) in the campaign to end homelessness and the MVP initiative.

These good-news stories celebrate the immense power of the VA to change the world for the better. This is reason enough to keep the faith that VA will emerge from the hearings and the headlines as a workforce proud of their privilege to care for veterans and contribute to the common good.

August 2016 provided 2 impressive news stories. These stories have far more salience and granularity than I can began to entertain in this brief editorial, but they show that the VA with all its systemic problems has unrivaled potential to promote what Aristotle called human flourishing.

A past director of mine greeted any small success or positive accomplishment of the facility and its employees with the folksy aphorism “You have to celebrate when you can in this outfit.” He was wise, for he knew that taking a respite to recognize a job well done is crucial to the emotional wellness of the workforce. And after that moment of satisfaction, everyone gets back to work at least a little bit recharged. So in this editorial, I will praise a few recent, unique VA achievements that underscore the importance of keeping the organization not only upright, but also doing right.

On August 1, President Obama announced that since 2010 veteran homelessness had been reduced by almost half. VA Secretary Robert A. McDonald also applauded a 56% decrease in unsheltered homeless veterans. Yet just as quickly, he refocused the collaborating agencies on the goal of ending veteran homelessness, which seemed a long shot when initially announced but now seems to have a realistic chance of success. “Although this achievement is noteworthy, we will not rest until every veteran in need is permanently housed,” McDonald said.

Three large government agencies and extensive partnerships cooperated to keep 360,000 veterans and their families from being homeless. But each veteran also had the outreach and support of a HUD-VASH (U.S. Department of Housing and Urban Development and VA Supportive Housing) worker and counterparts in the community. It is hard to see how any other health care organization could leverage this large an effort or would choose to dedicate its federal, state, and city resources to meet a need so basic that without it few persons can move up Maslow’s hierarchy of human actualization.

The same week the VA Research and Development program gave all of us in federal service a reason to hold up our collective heads a little higher announcing that the Million Veteran Program (MVP) had enrolled its 500,000th participant, making it the largest genomic database in the world. Once again, it is difficult to imagine any other health care organization, except another federal agency like the National Institutes of Health, mounting such an ambitious research initiative.

The MVP offers a databank—the likes of which has never been assembled—to study some of the most common and debilitating conditions, such as mental illness, substance use, and kidney and heart disease among many others. The combination of environmental genetics and clinical and psychosocial data will open doors of discoveries for thousands of people, veteran and nonveteran alike. Secretary McDonald applauded the most important ethical aspect of the project, the incomparable altruism of veterans, “Many of our veterans have saved lives on the battlefield and because of their participation in MVP, their participation has the potential to save countless lives—now and for generations to come.”

These 2 amazing initiatives have more in common than may seem apparent at first glance. Besides their intrinsic worth in humanist service and scientific creativity, respectively, putting veterans in homes and constructing a repository of scientific knowledge show that the VA—once accused of being a dinosaur ignoring the plummeting temperatures of its own ice age—has demonstrated remarkable instantiation of the I CARE Core Characteristics of agility and innovation (available at http://www.va.gov/icare) in the campaign to end homelessness and the MVP initiative.

These good-news stories celebrate the immense power of the VA to change the world for the better. This is reason enough to keep the faith that VA will emerge from the hearings and the headlines as a workforce proud of their privilege to care for veterans and contribute to the common good.

Sometimes it seems like cardiac troponin testing has become nearly as ubiquitous as the CBC and the BMP. Concern over atypical presentations of MI has contributed to widespread use in emergency departments and hospitalized patients. But once the test comes back elevated, what do you do with that information?

Typically, the next step is to consult Cardiology, which is a reasonable request with or without a suspicion of MI. Frequently, invasive management is not an option; or perhaps the diagnosis is “type 2 MI.”¹

Courtesy University of Florida

1. Thygesen K, Alpert JS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98.

2. Alcalai R, Planer D, Culhaoglu A, Osman A, Pollak A and Lotan C. Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis. Arch Intern Med. 2007;167:276-81.

3. Winchester DE, Burke L, Agarwal N, Schmalfuss C and Pepine CJ. Predictors of short- and long-term mortality in hospitalized veterans with elevated troponin. J Hosp Med. 2016 Jun 3. doi: 10.1002/jhm.2619.

David Winchester, MD, is assistant professor in the division of cardiovascular medicine at the University of Florida (Gainesville), and practices general cardiology at the Malcom Randall VA Medical Center, Gainesville.

Sometimes it seems like cardiac troponin testing has become nearly as ubiquitous as the CBC and the BMP. Concern over atypical presentations of MI has contributed to widespread use in emergency departments and hospitalized patients. But once the test comes back elevated, what do you do with that information?

Typically, the next step is to consult Cardiology, which is a reasonable request with or without a suspicion of MI. Frequently, invasive management is not an option; or perhaps the diagnosis is “type 2 MI.”¹

Courtesy University of Florida

1. Thygesen K, Alpert JS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98.

2. Alcalai R, Planer D, Culhaoglu A, Osman A, Pollak A and Lotan C. Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis. Arch Intern Med. 2007;167:276-81.

3. Winchester DE, Burke L, Agarwal N, Schmalfuss C and Pepine CJ. Predictors of short- and long-term mortality in hospitalized veterans with elevated troponin. J Hosp Med. 2016 Jun 3. doi: 10.1002/jhm.2619.

David Winchester, MD, is assistant professor in the division of cardiovascular medicine at the University of Florida (Gainesville), and practices general cardiology at the Malcom Randall VA Medical Center, Gainesville.

Sometimes it seems like cardiac troponin testing has become nearly as ubiquitous as the CBC and the BMP. Concern over atypical presentations of MI has contributed to widespread use in emergency departments and hospitalized patients. But once the test comes back elevated, what do you do with that information?

Typically, the next step is to consult Cardiology, which is a reasonable request with or without a suspicion of MI. Frequently, invasive management is not an option; or perhaps the diagnosis is “type 2 MI.”¹

Courtesy University of Florida

1. Thygesen K, Alpert JS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98.

2. Alcalai R, Planer D, Culhaoglu A, Osman A, Pollak A and Lotan C. Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis. Arch Intern Med. 2007;167:276-81.

3. Winchester DE, Burke L, Agarwal N, Schmalfuss C and Pepine CJ. Predictors of short- and long-term mortality in hospitalized veterans with elevated troponin. J Hosp Med. 2016 Jun 3. doi: 10.1002/jhm.2619.

David Winchester, MD, is assistant professor in the division of cardiovascular medicine at the University of Florida (Gainesville), and practices general cardiology at the Malcom Randall VA Medical Center, Gainesville.

Months of extremely high temperatures throughout the United States made the summer of 2016 one of the hottest summers on record. The summer may also be remembered for the excessive amounts of hot air generated in the run-up to the 2016 presidential election. But most oppressive of all has been the failure of Congress to appropriate funds for Zika virus research, prevention, and treatment before it recessed for vacation.

Emergency physicians (EPs) in the United States are already dealing with frightened, symptomatic patients who may have been exposed to the Zika, dengue, or chikungunya viruses, transmitted by the bite of the Aedes aegypti mosquito. In the First EDition section of this issue, dermatologist Iris Z. Ahronowitz, MD, describes some of the similarities in the acute clinical presentations of those infections (see page 438). But among this group of related viruses, only Zika has been positively linked to microcephaly and severely underdeveloped, damaged brains in babies born to women who are infected during pregnancy. An increasing number of newborn babies severely affected by Zika virus in utero began appearing in South America in late 2015. By summer’s end (September 21, 2016), the Centers for Disease Control and Prevention reports of Zika virus disease in the United States included over 3,300 travel-related cases, 43 locally acquired mosquito-borne cases, 28 sexually transmitted cases, and eight cases of Guillain-Barré syndrome (http://www.cdc.gov/zika/geo/united-states.html). Most importantly, as of September 15, 2016, there have been 20 live-born infants with birth defects and five pregnancy losses with birth defects—numbers that do not reflect the outcomes of ongoing pregnancies.

The life expectancy of babies severely affected by Zika virus and the nature and extent of disability in less physically affected babies are presently unknown. But according to The Washington Post (http://wapo.st/29Y5CnR), estimates of the cost of caring for a severely affected Zika baby through adulthood run as high as $10 million or more, and as high a total price as we will pay for the congressional intransigence this summer, such cost estimates do not even consider the terrible human suffering these babies will experience or the anguish their parents may have for the rest of their lives.

Emergency physicians are all too familiar with the emotional and behavioral problems that complicate our efforts to manage acute medical problems of children and adults born with autism or Down syndrome when they present to the ED. Most such congenital illnesses are not preventable, but when one potentially is, delaying needed resources because of partisan politics is unconscionable.

By summer’s end, as the last of leftover Ebola dollars were being spent on Zika-related programs, Democrats and Republicans finally appeared to be reaching a consensus to provide $1.1 billion of the $1.9 billion originally requested by the President long before the long hot summer began. This sudden agreement may be driven by the importance both parties place on winning the Florida vote in the upcoming election. But whatever the reason, Zika funding now will help prevent untold hardships and suffering in the years to come. In the meantime, EPs will continue to evaluate, diagnose, counsel, and, hopefully someday soon, be able to treat all who come to our EDs with Zika infection. 

Months of extremely high temperatures throughout the United States made the summer of 2016 one of the hottest summers on record. The summer may also be remembered for the excessive amounts of hot air generated in the run-up to the 2016 presidential election. But most oppressive of all has been the failure of Congress to appropriate funds for Zika virus research, prevention, and treatment before it recessed for vacation.

Emergency physicians (EPs) in the United States are already dealing with frightened, symptomatic patients who may have been exposed to the Zika, dengue, or chikungunya viruses, transmitted by the bite of the Aedes aegypti mosquito. In the First EDition section of this issue, dermatologist Iris Z. Ahronowitz, MD, describes some of the similarities in the acute clinical presentations of those infections (see page 438). But among this group of related viruses, only Zika has been positively linked to microcephaly and severely underdeveloped, damaged brains in babies born to women who are infected during pregnancy. An increasing number of newborn babies severely affected by Zika virus in utero began appearing in South America in late 2015. By summer’s end (September 21, 2016), the Centers for Disease Control and Prevention reports of Zika virus disease in the United States included over 3,300 travel-related cases, 43 locally acquired mosquito-borne cases, 28 sexually transmitted cases, and eight cases of Guillain-Barré syndrome (http://www.cdc.gov/zika/geo/united-states.html). Most importantly, as of September 15, 2016, there have been 20 live-born infants with birth defects and five pregnancy losses with birth defects—numbers that do not reflect the outcomes of ongoing pregnancies.

The life expectancy of babies severely affected by Zika virus and the nature and extent of disability in less physically affected babies are presently unknown. But according to The Washington Post (http://wapo.st/29Y5CnR), estimates of the cost of caring for a severely affected Zika baby through adulthood run as high as $10 million or more, and as high a total price as we will pay for the congressional intransigence this summer, such cost estimates do not even consider the terrible human suffering these babies will experience or the anguish their parents may have for the rest of their lives.

Emergency physicians are all too familiar with the emotional and behavioral problems that complicate our efforts to manage acute medical problems of children and adults born with autism or Down syndrome when they present to the ED. Most such congenital illnesses are not preventable, but when one potentially is, delaying needed resources because of partisan politics is unconscionable.

By summer’s end, as the last of leftover Ebola dollars were being spent on Zika-related programs, Democrats and Republicans finally appeared to be reaching a consensus to provide $1.1 billion of the $1.9 billion originally requested by the President long before the long hot summer began. This sudden agreement may be driven by the importance both parties place on winning the Florida vote in the upcoming election. But whatever the reason, Zika funding now will help prevent untold hardships and suffering in the years to come. In the meantime, EPs will continue to evaluate, diagnose, counsel, and, hopefully someday soon, be able to treat all who come to our EDs with Zika infection. 

Months of extremely high temperatures throughout the United States made the summer of 2016 one of the hottest summers on record. The summer may also be remembered for the excessive amounts of hot air generated in the run-up to the 2016 presidential election. But most oppressive of all has been the failure of Congress to appropriate funds for Zika virus research, prevention, and treatment before it recessed for vacation.

Emergency physicians (EPs) in the United States are already dealing with frightened, symptomatic patients who may have been exposed to the Zika, dengue, or chikungunya viruses, transmitted by the bite of the Aedes aegypti mosquito. In the First EDition section of this issue, dermatologist Iris Z. Ahronowitz, MD, describes some of the similarities in the acute clinical presentations of those infections (see page 438). But among this group of related viruses, only Zika has been positively linked to microcephaly and severely underdeveloped, damaged brains in babies born to women who are infected during pregnancy. An increasing number of newborn babies severely affected by Zika virus in utero began appearing in South America in late 2015. By summer’s end (September 21, 2016), the Centers for Disease Control and Prevention reports of Zika virus disease in the United States included over 3,300 travel-related cases, 43 locally acquired mosquito-borne cases, 28 sexually transmitted cases, and eight cases of Guillain-Barré syndrome (http://www.cdc.gov/zika/geo/united-states.html). Most importantly, as of September 15, 2016, there have been 20 live-born infants with birth defects and five pregnancy losses with birth defects—numbers that do not reflect the outcomes of ongoing pregnancies.

The life expectancy of babies severely affected by Zika virus and the nature and extent of disability in less physically affected babies are presently unknown. But according to The Washington Post (http://wapo.st/29Y5CnR), estimates of the cost of caring for a severely affected Zika baby through adulthood run as high as $10 million or more, and as high a total price as we will pay for the congressional intransigence this summer, such cost estimates do not even consider the terrible human suffering these babies will experience or the anguish their parents may have for the rest of their lives.

Emergency physicians are all too familiar with the emotional and behavioral problems that complicate our efforts to manage acute medical problems of children and adults born with autism or Down syndrome when they present to the ED. Most such congenital illnesses are not preventable, but when one potentially is, delaying needed resources because of partisan politics is unconscionable.

By summer’s end, as the last of leftover Ebola dollars were being spent on Zika-related programs, Democrats and Republicans finally appeared to be reaching a consensus to provide $1.1 billion of the $1.9 billion originally requested by the President long before the long hot summer began. This sudden agreement may be driven by the importance both parties place on winning the Florida vote in the upcoming election. But whatever the reason, Zika funding now will help prevent untold hardships and suffering in the years to come. In the meantime, EPs will continue to evaluate, diagnose, counsel, and, hopefully someday soon, be able to treat all who come to our EDs with Zika infection. 

In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.¹ Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”²

Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.³ Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.⁴ The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.⁵

The shortage of physicians, which is the focus of this editorial, is especially acute.⁵ The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.⁵ However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.^6,7

Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.

I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.

Fairness

The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.⁸ With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.⁹ Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.⁸

Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.

Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.⁸ While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.⁸ Most of the remaining federal funding for residency programs is provided through Medicare.

Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.

Feasibility

Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.¹⁰ It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.

To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.

How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.

Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.

Altruism

Whether a person is a Republican, Democrat, or independent, we all sincerely appreciate the sacrifice that veterans provide to protect our nation through the ages. Regardless if one agrees with the objective of a particular war or not, our veterans served at the command of the presidents from both major parties. Veterans simply serve their country with their lives on the line. Since World War I, 116,516 World War I, 405,399 World War II, 54,246 Korean War, 90,220 Vietnam War, and 4,424 Operation Iraq Freedom U.S. soldiers and military personnel have died for our country during active duty.^11,12 In addition, many more veterans experienced permanent injuries and illness while protecting our country and our freedom.^11,12 Is it too much to ask our graduated residents, albeit a tiny percentage, to share some of the burden to care for our national heroes for just 1 year? I certainly do not think so.

One possible way to raise national awareness of the need for veteran health care is to make this issue a national service obligation, much like that of military service. We could promote the concept in a slogan, such as “The soldiers’ obligation: Serve the nation in the front lines; the nation’s obligation: Provides care when soldiers return home.” Volunteerism is the preferred method of military recruitment. However, if voluntary enlistment does not fulfill the military need, drafting may be the next necessity. The same logical argument can be used to promote the solution for the VA physician shortage.

Although I’ve focused on the solution for physicians, the same process can be expanded for the shortage of nurses, nurse practitioners, physician assistants, and other health care providers. That way, the VA patient would receive even better care.

I’ve served as a part-time VA physician for 25 consecutive years, and I have gladly provided care for our veterans and would be delighted to welcome our graduating residents in joining me and other dedicated VA physicians in this noble effort. As one Chicago VAMC banner beautifully depicted, “Honored to serve … those who served” (Figure), this is, indeed, the right thing to do.

In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.¹ Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”²

Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.³ Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.⁴ The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.⁵

The shortage of physicians, which is the focus of this editorial, is especially acute.⁵ The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.⁵ However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.^6,7

Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.

I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.

Fairness

The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.⁸ With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.⁹ Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.⁸

Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.

Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.⁸ While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.⁸ Most of the remaining federal funding for residency programs is provided through Medicare.

Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.

Feasibility

Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.¹⁰ It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.

To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.

How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.

Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.

Altruism

Whether a person is a Republican, Democrat, or independent, we all sincerely appreciate the sacrifice that veterans provide to protect our nation through the ages. Regardless if one agrees with the objective of a particular war or not, our veterans served at the command of the presidents from both major parties. Veterans simply serve their country with their lives on the line. Since World War I, 116,516 World War I, 405,399 World War II, 54,246 Korean War, 90,220 Vietnam War, and 4,424 Operation Iraq Freedom U.S. soldiers and military personnel have died for our country during active duty.^11,12 In addition, many more veterans experienced permanent injuries and illness while protecting our country and our freedom.^11,12 Is it too much to ask our graduated residents, albeit a tiny percentage, to share some of the burden to care for our national heroes for just 1 year? I certainly do not think so.

One possible way to raise national awareness of the need for veteran health care is to make this issue a national service obligation, much like that of military service. We could promote the concept in a slogan, such as “The soldiers’ obligation: Serve the nation in the front lines; the nation’s obligation: Provides care when soldiers return home.” Volunteerism is the preferred method of military recruitment. However, if voluntary enlistment does not fulfill the military need, drafting may be the next necessity. The same logical argument can be used to promote the solution for the VA physician shortage.

Although I’ve focused on the solution for physicians, the same process can be expanded for the shortage of nurses, nurse practitioners, physician assistants, and other health care providers. That way, the VA patient would receive even better care.

I’ve served as a part-time VA physician for 25 consecutive years, and I have gladly provided care for our veterans and would be delighted to welcome our graduating residents in joining me and other dedicated VA physicians in this noble effort. As one Chicago VAMC banner beautifully depicted, “Honored to serve … those who served” (Figure), this is, indeed, the right thing to do.

In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.¹ Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”²

Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.³ Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.⁴ The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.⁵

The shortage of physicians, which is the focus of this editorial, is especially acute.⁵ The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.⁵ However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.^6,7

Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.

I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.

Fairness

The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.⁸ With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.⁹ Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.⁸

Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.

Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.⁸ While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.⁸ Most of the remaining federal funding for residency programs is provided through Medicare.

Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.

Feasibility

Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.¹⁰ It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.

To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.

How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.

Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.

Altruism

Whether a person is a Republican, Democrat, or independent, we all sincerely appreciate the sacrifice that veterans provide to protect our nation through the ages. Regardless if one agrees with the objective of a particular war or not, our veterans served at the command of the presidents from both major parties. Veterans simply serve their country with their lives on the line. Since World War I, 116,516 World War I, 405,399 World War II, 54,246 Korean War, 90,220 Vietnam War, and 4,424 Operation Iraq Freedom U.S. soldiers and military personnel have died for our country during active duty.^11,12 In addition, many more veterans experienced permanent injuries and illness while protecting our country and our freedom.^11,12 Is it too much to ask our graduated residents, albeit a tiny percentage, to share some of the burden to care for our national heroes for just 1 year? I certainly do not think so.

One possible way to raise national awareness of the need for veteran health care is to make this issue a national service obligation, much like that of military service. We could promote the concept in a slogan, such as “The soldiers’ obligation: Serve the nation in the front lines; the nation’s obligation: Provides care when soldiers return home.” Volunteerism is the preferred method of military recruitment. However, if voluntary enlistment does not fulfill the military need, drafting may be the next necessity. The same logical argument can be used to promote the solution for the VA physician shortage.

Although I’ve focused on the solution for physicians, the same process can be expanded for the shortage of nurses, nurse practitioners, physician assistants, and other health care providers. That way, the VA patient would receive even better care.

I’ve served as a part-time VA physician for 25 consecutive years, and I have gladly provided care for our veterans and would be delighted to welcome our graduating residents in joining me and other dedicated VA physicians in this noble effort. As one Chicago VAMC banner beautifully depicted, “Honored to serve … those who served” (Figure), this is, indeed, the right thing to do.

Those of us who care for patients with migraine dread seeing patients who come to the office wearing dark sunglasses, even in a dimly lit examination room. In neuro-ophthalmology, the "sunglasses sign" is a predictor of non-organic visual loss and is often associated with a lawsuit, disability, workers' compensation claim, or a highly positive review of systems. While not specifically studied in a headache medicine practice, the sunglasses sign often goes hand in hand with chronic migraine, severe light intolerance to the point of social isolation, comorbid depression, and anxiety. It indicates that the provider is about to tackle a difficult case. Exposure to bright light may trigger a migraine, and heightened light sensitivity may herald a migraine attack. Photophobia is a major source of discomfort and disability for migraine patients during attacks and, in some cases, between attacks. It is often either overlooked or trivialized. The discovery of the melanopsin system clarifies that photophobia has a neurologic basis involving retinothalamic pathways and may be considered similarly to the central sensitization of migraine pain.  

As Dr. Digre points out, dry eyes are a frequent cause of photophobia that is underdiagnosed, even by eye care providers. Patients with dry eyes often experience ocular itching, burning, foreign body sensation, a sense of dryness, reflex tearing, and conjunctival injection. Ocular inflammation, while uncommon, is another potential source of eye pain and photophobia. However, many migraine patients have photophobia that seems to be purely related to having migraine, and they sometimes take extreme measures to live in darkness. Patients with severe light aversion need our support and guidance to help them "come back into the light" gradually by treating any underlying ocular condition and slowly transitioning them to lighter lenses (including FL-41 and other tints). Awareness of the causes and treatments of photophobia, both ocular and central, is an important aspect of headache care that has the potential to vastly improve the quality of life of our patients.  

—Deborah I. Friedman, MD, MPH
Professor of Neurology & Neurotherapeutics and Ophthalmology
University of Texas Southwestern Medical Center
Dallas

Suggested Reading

Bengtzen R, Woodward M, Lynn MJ, et al. The "sunglasses sign" predicts nonorganic visual loss in neuro-ophthalmologic practice. Neurology. 2008;70(3):218-221.

Those of us who care for patients with migraine dread seeing patients who come to the office wearing dark sunglasses, even in a dimly lit examination room. In neuro-ophthalmology, the "sunglasses sign" is a predictor of non-organic visual loss and is often associated with a lawsuit, disability, workers' compensation claim, or a highly positive review of systems. While not specifically studied in a headache medicine practice, the sunglasses sign often goes hand in hand with chronic migraine, severe light intolerance to the point of social isolation, comorbid depression, and anxiety. It indicates that the provider is about to tackle a difficult case. Exposure to bright light may trigger a migraine, and heightened light sensitivity may herald a migraine attack. Photophobia is a major source of discomfort and disability for migraine patients during attacks and, in some cases, between attacks. It is often either overlooked or trivialized. The discovery of the melanopsin system clarifies that photophobia has a neurologic basis involving retinothalamic pathways and may be considered similarly to the central sensitization of migraine pain.  

As Dr. Digre points out, dry eyes are a frequent cause of photophobia that is underdiagnosed, even by eye care providers. Patients with dry eyes often experience ocular itching, burning, foreign body sensation, a sense of dryness, reflex tearing, and conjunctival injection. Ocular inflammation, while uncommon, is another potential source of eye pain and photophobia. However, many migraine patients have photophobia that seems to be purely related to having migraine, and they sometimes take extreme measures to live in darkness. Patients with severe light aversion need our support and guidance to help them "come back into the light" gradually by treating any underlying ocular condition and slowly transitioning them to lighter lenses (including FL-41 and other tints). Awareness of the causes and treatments of photophobia, both ocular and central, is an important aspect of headache care that has the potential to vastly improve the quality of life of our patients.  

—Deborah I. Friedman, MD, MPH
Professor of Neurology & Neurotherapeutics and Ophthalmology
University of Texas Southwestern Medical Center
Dallas

Suggested Reading

Bengtzen R, Woodward M, Lynn MJ, et al. The "sunglasses sign" predicts nonorganic visual loss in neuro-ophthalmologic practice. Neurology. 2008;70(3):218-221.

Those of us who care for patients with migraine dread seeing patients who come to the office wearing dark sunglasses, even in a dimly lit examination room. In neuro-ophthalmology, the "sunglasses sign" is a predictor of non-organic visual loss and is often associated with a lawsuit, disability, workers' compensation claim, or a highly positive review of systems. While not specifically studied in a headache medicine practice, the sunglasses sign often goes hand in hand with chronic migraine, severe light intolerance to the point of social isolation, comorbid depression, and anxiety. It indicates that the provider is about to tackle a difficult case. Exposure to bright light may trigger a migraine, and heightened light sensitivity may herald a migraine attack. Photophobia is a major source of discomfort and disability for migraine patients during attacks and, in some cases, between attacks. It is often either overlooked or trivialized. The discovery of the melanopsin system clarifies that photophobia has a neurologic basis involving retinothalamic pathways and may be considered similarly to the central sensitization of migraine pain.  

As Dr. Digre points out, dry eyes are a frequent cause of photophobia that is underdiagnosed, even by eye care providers. Patients with dry eyes often experience ocular itching, burning, foreign body sensation, a sense of dryness, reflex tearing, and conjunctival injection. Ocular inflammation, while uncommon, is another potential source of eye pain and photophobia. However, many migraine patients have photophobia that seems to be purely related to having migraine, and they sometimes take extreme measures to live in darkness. Patients with severe light aversion need our support and guidance to help them "come back into the light" gradually by treating any underlying ocular condition and slowly transitioning them to lighter lenses (including FL-41 and other tints). Awareness of the causes and treatments of photophobia, both ocular and central, is an important aspect of headache care that has the potential to vastly improve the quality of life of our patients.  

—Deborah I. Friedman, MD, MPH
Professor of Neurology & Neurotherapeutics and Ophthalmology
University of Texas Southwestern Medical Center
Dallas

Suggested Reading

Bengtzen R, Woodward M, Lynn MJ, et al. The "sunglasses sign" predicts nonorganic visual loss in neuro-ophthalmologic practice. Neurology. 2008;70(3):218-221.

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.

Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.

What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.

Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.

So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.

At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.

For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.

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.”

I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.

Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.

What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.

Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.

So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.

At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.

For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.

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.”

I would like to think it was the culmination of a series of clever decisions, but finding myself in a job that I enjoyed was more than likely the result of blind luck. Even as I filled out medical school applications during my senior year in college, I had no intention of actually becoming a physician. I was more focused on not becoming cannon fodder in Vietnam. I am hesitant to use the word love to describe my affection for a job I did for 40 years. But I can’t imagine any work I could have enjoyed more than being a general pediatrician in a small town.

Were there moments when I would have rather been watching one of my children play in a postseason soccer game than see a patient in the office? Sure, but I can’t recall a morning when I dreaded going to work. Having listened to many other people, including my father, complain about their work, I consider myself fortunate to have discovered a job that wasn’t just tolerable and a way to support my family, but one that I actually enjoyed enough to not mind working nights and weekends.

What was it about being a pediatrician that fueled my affection for it? Social scientists have asked the same question, and one of the answers they discovered is that jobs that offer a degree of autonomy and contribute positively to society are more likely to have satisfied workers (“The Incalculable Value of Finding a Job You Love,” by Robert Frank, the New York Times, July 22, 2016). If one assumes that the mission of pediatrics is to help children become and stay healthy, then when I was practicing solo or in a small physician-owned practice, my job easily met these two criteria. But autonomy and a good cause don’t necessarily pay the rent. However, unless I had foolishly chosen to open a practice in an area already saturated with physicians, doing pediatrics meant I would have an adequate income.

Like any craft, practicing pediatrics became easier and more enjoyable as I gained experience. I made fewer time-gobbling errors and had more therapeutic successes. It’s not that more children got better or better quicker under my care. They were going to get better, regardless of what I did. But over time, an increasing number of parents and patients seemed to be appreciative of my role in educating and reassuring them.

So what happened? I retired from office practice 3 years ago. Had I fallen out of love with pediatrics? My physical stamina was and still is good. I just go to bed earlier. But as my practice was swallowed by larger and larger entities, I lost most of the autonomy that had been so appealing. Practicing medicine has always been a business. It has to be unless you are living off an inherited trust fund. But despite praiseworthy mission statements, corporate decisions were being made that were no longer consistent with the kind of individualized care I thought the patients deserved. It was frustrating to hear families who I had been seeing for decades complain that the care delivery system in our office had taken several steps back.

At the risk of whipping the same old tired horse, I must say that it was the impending introduction of a third new and increasingly less-patient and physician-friendly EHR that made it too difficult to accept the accumulation of negatives in exchange for the wonderful feeling at the end of the workday during which at least one person had thanked me or told me I had done a good job.

For those of you that remain on the job, I urge you to fight the good fight to preserve what it is about practicing pediatrics that allows you to get up in the morning and head off to work without grumbling. It won’t be easy, but if you can make it into a job you love, the patients are going to benefit along with you.

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.”

We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:

A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.

Reference

Jakicic JM, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss The IDEA Randomized Clinical Trial. JAMA. 2016;316[11]:1161-71. doi: 10.1001/jama.2016.12858

Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.

We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:

A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.

Reference

Jakicic JM, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss The IDEA Randomized Clinical Trial. JAMA. 2016;316[11]:1161-71. doi: 10.1001/jama.2016.12858

Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.

We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:

A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.

Reference

Jakicic JM, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss The IDEA Randomized Clinical Trial. JAMA. 2016;316[11]:1161-71. doi: 10.1001/jama.2016.12858

Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

As reviewed in Part 1, surgery is indicated for the staging and treatment of endometrial cancer. Lymph node status is one of the most important factors in determining prognosis and the need for adjuvant treatment. The extent of lymph node evaluation is controversial as full lymphadenectomy carries risks, including increased operative time, blood loss, nerve injury, and lymphedema.

Two trials have found no survival benefit from lymphadenectomy for endometrial cancer; however, other evidence suggests that women without known nodal status may be more likely to receive radiotherapy.^1,2,3

Given these issues, the sentinel lymph node technique strikes a balance between the risks and benefits of lymph node evaluation in endometrial cancer.

Sentinel lymph nodes (SLN) are the first nodes to drain a tumor site, and thus, are typically the first to demonstrate occult malignancy. The use of the SLN technique as an alternative to complete lymphadenectomy in endometrial cancer has been well described, although its accuracy and the validity of its use are still debated.

The viability of the SLN technique is predicated on the ability to achieve mapping of dye or tracer from the tumor to the first lymph node to drain the tumor. The lymphatic drainage of the endometrium is complex and unlike vulvar or breast cancer, endometrial cancer is less accessible for peritumoral injection. Several injection techniques have been described; cervical injection is the easiest to achieve and has been found to have similar or higher SLN detection than hysteroscopic or fundal injections.^4,5

There are a number of techniques for SLN detection, each with unique benefits and risks. Visual identification of blue dye, most frequently isosulfan blue, is the “colorimetric method” and has been used most commonly with cervical injection for endometrial cancer. Injection of isosulfan blue does not require specialized equipment, however visualization in obese patients is inferior.⁶

Technetium sulfur colloid (Tc) is a radioactive tracer that can be detected by gamma probes. A preoperative lymphoscintigraphy and a handheld gamma probe are used to map lymphatics. This technique has limitations, including the additional time and coordination of procedures, as well as some evidence of poor correlation between lymphoscintigraphy and surgical SLN mapping.⁷

Indocyanine green (ICG) is a fluorescent dye that has excellent signal penetration and allows for real-time visual identification using near-infrared fluorescence imaging. The bilateral detection rate with ICG appears comparable or better than blue dye.⁸ Combinations of dye, either ICG plus Tc or Tc plus blue dye, may be also used to increase SLN detection.

The accuracy of the SLN technique is the cornerstone to its success. In a prospective multicenter study – Senti-Endo – patients with early-stage disease underwent pelvic SLN assessment with cervical injection of a combination of dyes followed by systematic pelvic node dissection. The overall negative predictive value was 97% with three patients who had positive lymph nodes that were not detected, all of whom had a type 2 endometrial cancer.⁹

With the uptake of the SLN technique, many institutions have protocols surrounding the technique to ensure appropriate SLN detection and evaluation. Physicians using this technique should adhere to protocols supported by National Comprehensive Cancer Network guidelines, taking care to remove any suspicious lymph nodes and perform a full side-specific lymphadenectomy if bilateral mapping is not achieved.

The extent of lymphadenectomy and application of the SLN technique in high-risk endometrial cancer remains controversial. These patients are at higher risk for unsuccessful mapping and isolated para-aortic metastasis. Retrospective series have suggested equivalent oncologic outcomes for women with high-grade cancers who have been staged by SLN biopsy, compared with selective or complete lymphadenectomy.^10,11

We await the results of a large prospective trial in which patients undergo comprehensive lymphadenectomy in addition to SLN biopsy to assess the accuracy of the technique (NCT01673022).

Pathologic evaluation of SLNs is frequently done with ultrastaging, which describes additional sectioning and staining of the node. This technique frequently identifies isolated tumor cells and micrometastasis (collectively called low-volume disease) in addition to macrometastasis. The clinical and prognostic significance of low-volume disease is unknown and additional investigation is urgently needed to determine appropriate adjuvant therapy and follow-up for these patients.

The SLN technique is an acceptable approach to assess clinical stage I endometrial cancer. Physicians should consider adding the SLN biopsy to their routine staging techniques prior to exclusively adopting the new technique. They should take care to adhere to SLN algorithms and monitor outcomes.

References

1. J Natl Cancer Inst. 2008;100(23):1707-16.

2. Lancet. 2009 Jan;373(9658):125-36.

3. Am J Obstet Gynecol. 2011 Dec;205(6):562.e1–9.

4. Gynecol Oncol. 2013 Nov;131(2):299-303.

5. Int J Gynecol Cancer. 2013 Nov;23(9):1704-11.

6. Gynecol Oncol 2014 Aug;134(2):281-6.

7. Gynecol Oncol. 2009 Feb;112(2):348-352.

8. Gynecol Oncol. 2014 May;133(2):274-7.

9. Lancet Oncol. 2011 May;12(5):469-76.

10. Ann Surg Oncol. 2016 Jan;23(1):196-202.

11. Gynecol Oncol. 2016 Mar;140(3):394-9.

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

As reviewed in Part 1, surgery is indicated for the staging and treatment of endometrial cancer. Lymph node status is one of the most important factors in determining prognosis and the need for adjuvant treatment. The extent of lymph node evaluation is controversial as full lymphadenectomy carries risks, including increased operative time, blood loss, nerve injury, and lymphedema.

Two trials have found no survival benefit from lymphadenectomy for endometrial cancer; however, other evidence suggests that women without known nodal status may be more likely to receive radiotherapy.^1,2,3

Given these issues, the sentinel lymph node technique strikes a balance between the risks and benefits of lymph node evaluation in endometrial cancer.

Sentinel lymph nodes (SLN) are the first nodes to drain a tumor site, and thus, are typically the first to demonstrate occult malignancy. The use of the SLN technique as an alternative to complete lymphadenectomy in endometrial cancer has been well described, although its accuracy and the validity of its use are still debated.

The viability of the SLN technique is predicated on the ability to achieve mapping of dye or tracer from the tumor to the first lymph node to drain the tumor. The lymphatic drainage of the endometrium is complex and unlike vulvar or breast cancer, endometrial cancer is less accessible for peritumoral injection. Several injection techniques have been described; cervical injection is the easiest to achieve and has been found to have similar or higher SLN detection than hysteroscopic or fundal injections.^4,5

There are a number of techniques for SLN detection, each with unique benefits and risks. Visual identification of blue dye, most frequently isosulfan blue, is the “colorimetric method” and has been used most commonly with cervical injection for endometrial cancer. Injection of isosulfan blue does not require specialized equipment, however visualization in obese patients is inferior.⁶

Technetium sulfur colloid (Tc) is a radioactive tracer that can be detected by gamma probes. A preoperative lymphoscintigraphy and a handheld gamma probe are used to map lymphatics. This technique has limitations, including the additional time and coordination of procedures, as well as some evidence of poor correlation between lymphoscintigraphy and surgical SLN mapping.⁷

Indocyanine green (ICG) is a fluorescent dye that has excellent signal penetration and allows for real-time visual identification using near-infrared fluorescence imaging. The bilateral detection rate with ICG appears comparable or better than blue dye.⁸ Combinations of dye, either ICG plus Tc or Tc plus blue dye, may be also used to increase SLN detection.

The accuracy of the SLN technique is the cornerstone to its success. In a prospective multicenter study – Senti-Endo – patients with early-stage disease underwent pelvic SLN assessment with cervical injection of a combination of dyes followed by systematic pelvic node dissection. The overall negative predictive value was 97% with three patients who had positive lymph nodes that were not detected, all of whom had a type 2 endometrial cancer.⁹

With the uptake of the SLN technique, many institutions have protocols surrounding the technique to ensure appropriate SLN detection and evaluation. Physicians using this technique should adhere to protocols supported by National Comprehensive Cancer Network guidelines, taking care to remove any suspicious lymph nodes and perform a full side-specific lymphadenectomy if bilateral mapping is not achieved.

The extent of lymphadenectomy and application of the SLN technique in high-risk endometrial cancer remains controversial. These patients are at higher risk for unsuccessful mapping and isolated para-aortic metastasis. Retrospective series have suggested equivalent oncologic outcomes for women with high-grade cancers who have been staged by SLN biopsy, compared with selective or complete lymphadenectomy.^10,11

We await the results of a large prospective trial in which patients undergo comprehensive lymphadenectomy in addition to SLN biopsy to assess the accuracy of the technique (NCT01673022).

Pathologic evaluation of SLNs is frequently done with ultrastaging, which describes additional sectioning and staining of the node. This technique frequently identifies isolated tumor cells and micrometastasis (collectively called low-volume disease) in addition to macrometastasis. The clinical and prognostic significance of low-volume disease is unknown and additional investigation is urgently needed to determine appropriate adjuvant therapy and follow-up for these patients.

The SLN technique is an acceptable approach to assess clinical stage I endometrial cancer. Physicians should consider adding the SLN biopsy to their routine staging techniques prior to exclusively adopting the new technique. They should take care to adhere to SLN algorithms and monitor outcomes.

References

1. J Natl Cancer Inst. 2008;100(23):1707-16.

2. Lancet. 2009 Jan;373(9658):125-36.

3. Am J Obstet Gynecol. 2011 Dec;205(6):562.e1–9.

4. Gynecol Oncol. 2013 Nov;131(2):299-303.

5. Int J Gynecol Cancer. 2013 Nov;23(9):1704-11.

6. Gynecol Oncol 2014 Aug;134(2):281-6.

7. Gynecol Oncol. 2009 Feb;112(2):348-352.

8. Gynecol Oncol. 2014 May;133(2):274-7.

9. Lancet Oncol. 2011 May;12(5):469-76.

10. Ann Surg Oncol. 2016 Jan;23(1):196-202.

11. Gynecol Oncol. 2016 Mar;140(3):394-9.

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

As reviewed in Part 1, surgery is indicated for the staging and treatment of endometrial cancer. Lymph node status is one of the most important factors in determining prognosis and the need for adjuvant treatment. The extent of lymph node evaluation is controversial as full lymphadenectomy carries risks, including increased operative time, blood loss, nerve injury, and lymphedema.

Two trials have found no survival benefit from lymphadenectomy for endometrial cancer; however, other evidence suggests that women without known nodal status may be more likely to receive radiotherapy.^1,2,3

Given these issues, the sentinel lymph node technique strikes a balance between the risks and benefits of lymph node evaluation in endometrial cancer.

Sentinel lymph nodes (SLN) are the first nodes to drain a tumor site, and thus, are typically the first to demonstrate occult malignancy. The use of the SLN technique as an alternative to complete lymphadenectomy in endometrial cancer has been well described, although its accuracy and the validity of its use are still debated.

The viability of the SLN technique is predicated on the ability to achieve mapping of dye or tracer from the tumor to the first lymph node to drain the tumor. The lymphatic drainage of the endometrium is complex and unlike vulvar or breast cancer, endometrial cancer is less accessible for peritumoral injection. Several injection techniques have been described; cervical injection is the easiest to achieve and has been found to have similar or higher SLN detection than hysteroscopic or fundal injections.^4,5

There are a number of techniques for SLN detection, each with unique benefits and risks. Visual identification of blue dye, most frequently isosulfan blue, is the “colorimetric method” and has been used most commonly with cervical injection for endometrial cancer. Injection of isosulfan blue does not require specialized equipment, however visualization in obese patients is inferior.⁶

Technetium sulfur colloid (Tc) is a radioactive tracer that can be detected by gamma probes. A preoperative lymphoscintigraphy and a handheld gamma probe are used to map lymphatics. This technique has limitations, including the additional time and coordination of procedures, as well as some evidence of poor correlation between lymphoscintigraphy and surgical SLN mapping.⁷

Indocyanine green (ICG) is a fluorescent dye that has excellent signal penetration and allows for real-time visual identification using near-infrared fluorescence imaging. The bilateral detection rate with ICG appears comparable or better than blue dye.⁸ Combinations of dye, either ICG plus Tc or Tc plus blue dye, may be also used to increase SLN detection.

The accuracy of the SLN technique is the cornerstone to its success. In a prospective multicenter study – Senti-Endo – patients with early-stage disease underwent pelvic SLN assessment with cervical injection of a combination of dyes followed by systematic pelvic node dissection. The overall negative predictive value was 97% with three patients who had positive lymph nodes that were not detected, all of whom had a type 2 endometrial cancer.⁹

With the uptake of the SLN technique, many institutions have protocols surrounding the technique to ensure appropriate SLN detection and evaluation. Physicians using this technique should adhere to protocols supported by National Comprehensive Cancer Network guidelines, taking care to remove any suspicious lymph nodes and perform a full side-specific lymphadenectomy if bilateral mapping is not achieved.

The extent of lymphadenectomy and application of the SLN technique in high-risk endometrial cancer remains controversial. These patients are at higher risk for unsuccessful mapping and isolated para-aortic metastasis. Retrospective series have suggested equivalent oncologic outcomes for women with high-grade cancers who have been staged by SLN biopsy, compared with selective or complete lymphadenectomy.^10,11

We await the results of a large prospective trial in which patients undergo comprehensive lymphadenectomy in addition to SLN biopsy to assess the accuracy of the technique (NCT01673022).

Pathologic evaluation of SLNs is frequently done with ultrastaging, which describes additional sectioning and staining of the node. This technique frequently identifies isolated tumor cells and micrometastasis (collectively called low-volume disease) in addition to macrometastasis. The clinical and prognostic significance of low-volume disease is unknown and additional investigation is urgently needed to determine appropriate adjuvant therapy and follow-up for these patients.

The SLN technique is an acceptable approach to assess clinical stage I endometrial cancer. Physicians should consider adding the SLN biopsy to their routine staging techniques prior to exclusively adopting the new technique. They should take care to adhere to SLN algorithms and monitor outcomes.

References

1. J Natl Cancer Inst. 2008;100(23):1707-16.

2. Lancet. 2009 Jan;373(9658):125-36.

3. Am J Obstet Gynecol. 2011 Dec;205(6):562.e1–9.

4. Gynecol Oncol. 2013 Nov;131(2):299-303.

5. Int J Gynecol Cancer. 2013 Nov;23(9):1704-11.

6. Gynecol Oncol 2014 Aug;134(2):281-6.

7. Gynecol Oncol. 2009 Feb;112(2):348-352.

8. Gynecol Oncol. 2014 May;133(2):274-7.

9. Lancet Oncol. 2011 May;12(5):469-76.

10. Ann Surg Oncol. 2016 Jan;23(1):196-202.

11. Gynecol Oncol. 2016 Mar;140(3):394-9.

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