Commentary

(This column is the third of a three-part series.)

Question: The state medical board is requesting the medical records of an angry patient who has filed a formal complaint alleging incompetent care. Your immediate impulse is to rush off a letter defending your treatment – and to include a sarcastic remark about ingratitude.

However, you decided not to respond, choosing to await the scheduled interview with the board investigator. To your surprise, he turned out to be warm and friendly, and his relative youth reminded you of your son. Letting your guard down, you spoke freely during the meeting and showed him the medical records. Later, you appeared at the formal board hearing without legal counsel, as the complainant had not suffered any injury while under your care. Under this scenario, which of the following statements is best?

A. You must never respond in writing to any board inquiry.

B. You should have called your insurance carrier immediately.

C. You trusted the investigator because what you told him could not be introduced as evidence.

D. You correctly assumed that, without injuries, there is no liability.

E. You did not insist on having an attorney, because this is not part of your due process rights.

Answer: B. Who gets into trouble with medical disciplinary boards? In a California study,¹ the authors concluded that male physicians were nearly three times as likely to as women physicians, and those who were non–board certified twice as likely to as their board-certified counterparts. Obstetricians, gynecologists, family physicians, general practitioners, and psychiatrists were more likely than internists, whereas pediatricians and radiologists were the least likely. Age had a smaller influence (elevated risk with increasing age), and foreign medical graduates also had an increased risk.

It is true that many board complaints are dismissed and never investigated, but the number of state licensure actions in 2013 was almost four times greater than the number of malpractice payouts. Moreover, board actions against a doctor, unlike a malpractice lawsuit, are premised on substandard or unethical conduct, and do not require a showing of actual patient harm.

A recent news article bemoans the travails of a medical board encounter.² According to a 2009 report, one of every eight physicians in California was being reported to the board each year, with a quarter of complaints leading to an investigation. In turn, a quarter of investigated complaints led to disciplinary proceedings against the physician.

A medical board investigation begins with a complaint lodged by a patient or some other party such as a pharmacist, nurse, or hospital peer review committee. Some states – e.g., California, Georgia, and Maryland – allow complaints to be anonymous, and many states now allow online submissions, whose ease may be expected to increase the number of filings. Oklahoma, for example, saw its board complaints rise by 40% in the 2 years after permitting this option.

Some complaints such as rudeness and disputes over fees may seem like a minor nuisance, but they can mushroom into new and more serious charges. The medical records may reveal other potential misconduct, such as delinquent record keeping or failure to obtain informed consent.

It is therefore prudent to treat all complaints seriously. A written response is necessary, but it must be cowritten with your attorney. Immediately contact your malpractice insurance carrier once an investigator approaches you, or upon notification by the medical board. Most malpractice policies include coverage for medical board investigations.

The simple rule is not to discuss with anyone – including (especially) the complainant – and await a call from the attorney assigned to you. Better yet, ask for an attorney whose skills you are aware of. Make sure he/she is experienced with board proceedings and not just malpractice litigation. There are legal technicalities that may be of importance, such as statutes of limitations barring board actions or the timely filing of an appeal. Everything should flow from here. The lawyer’s advice will most likely be: “Don’t speak to anyone, including your colleagues; don’t contact the patient or family; and don’t release any records without first consulting me.”

You should together draft a response letter. Whereas the attorney will be attentive to the legal ramifications, only you as the doctor can provide the clinical knowledge, context, and empathy. In formulating any written response where patient care is at issue, heed the following principles:

1. Be honest. Truth always surfaces in due course. Candor and trustworthiness are virtues expected of all doctors.

2. Be accurate. Review carefully all relevant medical records. Pay compulsive attention to factual accuracy.

3. Be focused. Do not ramble on and on regarding unrelated or tangential issues. Focus on what the complaint is about. No one is interested in your views regarding your philosophy of medical practice or the health care system – they do not belong in a complaint response letter.

4. Be humble. Arrogance at this stage may prove disastrous. Adopt a contrite and humble tone. Blame no one, especially the patient.

5. Be a patient advocate. Show that patient well-being is always your first and last concern.

In the preliminary stages, a board investigator may call the doctor, typically taking a friendly and casual approach, and this may lull the physician into saying more than is necessary or releasing the medical records. The shared information can come back to haunt the doctor when it is disclosed in a subsequent hearing.

In some situations, the board may offer an informal settlement conference to resolve the issue and obtain a “consent agreement” from the doctor. Depending on the facts – and the proposed settlement terms – your attorney may instead advise proceeding to a formal hearing to present exculpatory evidence and to confront the complainant.

Physicians are guaranteed the right of due process during an investigation. Timely notice, the right to a hearing, to confront the evidence, and to have legal representation are the basic due process rights. And boards must treat the physician fairly and reasonably.

However, where public harm is an imminent risk, boards have the power to immediately institute a temporary suspension of the doctor’s right to practice. Examples warranting such summary suspensions may include sexual misconduct, inappropriate opioid prescriptions, egregious negligent conduct, or impairment from alcohol or drug abuse.

Boards face a dilemma over these cases, because they need to balance depriving a doctor of due process rights, albeit temporarily, against allowing a bad doctor to pose a clear and present threat to the public. In Texas, 32 summary suspensions took place in 2011, a figure that fell to 13 in 2014.

The aggrieved physician typically has the right to appeal an adverse board decision to the courts, although “courts have no inherent appellate jurisdiction over official acts of administrative agencies except where the legislature has made some statutory provision for judicial review.”³

For example, under California’s Code of Civil Procedure section 1094.5, one has the right to have a Superior Court judge review the board’s decision to determine if there has been an abuse of discretion.

Despite the fact that board administrative proceedings are quasi criminal in nature, most states require only a “preponderance of evidence” to find the doctor guilty. This is the evidentiary standard used in civil cases where only monetary damages are at stake, yet it is used in determining whether a doctor would lose the liberty to practice his or her profession.

However, some jurisdictions – such as California, Florida, and Illinois – call for a higher threshold of guilt, requiring proof with “clear and convincing evidence.”

Finally, in the United Kingdom and countries such as Singapore, a guilty decision requires even more evidence – i.e., proof “beyond reasonable doubt” – which is the threshold required in criminal prosecutions.

References

1. Arch Intern Med. 2004 Mar 22;164(6):653-8.

2. Leigh Page. The Black Cloud of a Medical Board Investigation. Medscape, Dec 23, 2015.

3. Crane v. Cont’l Tel. Co. of Cal., 775 P.2d 705 (Nev. 1989).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

(This column is the third of a three-part series.)

Question: The state medical board is requesting the medical records of an angry patient who has filed a formal complaint alleging incompetent care. Your immediate impulse is to rush off a letter defending your treatment – and to include a sarcastic remark about ingratitude.

However, you decided not to respond, choosing to await the scheduled interview with the board investigator. To your surprise, he turned out to be warm and friendly, and his relative youth reminded you of your son. Letting your guard down, you spoke freely during the meeting and showed him the medical records. Later, you appeared at the formal board hearing without legal counsel, as the complainant had not suffered any injury while under your care. Under this scenario, which of the following statements is best?

A. You must never respond in writing to any board inquiry.

B. You should have called your insurance carrier immediately.

C. You trusted the investigator because what you told him could not be introduced as evidence.

D. You correctly assumed that, without injuries, there is no liability.

E. You did not insist on having an attorney, because this is not part of your due process rights.

Answer: B. Who gets into trouble with medical disciplinary boards? In a California study,¹ the authors concluded that male physicians were nearly three times as likely to as women physicians, and those who were non–board certified twice as likely to as their board-certified counterparts. Obstetricians, gynecologists, family physicians, general practitioners, and psychiatrists were more likely than internists, whereas pediatricians and radiologists were the least likely. Age had a smaller influence (elevated risk with increasing age), and foreign medical graduates also had an increased risk.

It is true that many board complaints are dismissed and never investigated, but the number of state licensure actions in 2013 was almost four times greater than the number of malpractice payouts. Moreover, board actions against a doctor, unlike a malpractice lawsuit, are premised on substandard or unethical conduct, and do not require a showing of actual patient harm.

A recent news article bemoans the travails of a medical board encounter.² According to a 2009 report, one of every eight physicians in California was being reported to the board each year, with a quarter of complaints leading to an investigation. In turn, a quarter of investigated complaints led to disciplinary proceedings against the physician.

A medical board investigation begins with a complaint lodged by a patient or some other party such as a pharmacist, nurse, or hospital peer review committee. Some states – e.g., California, Georgia, and Maryland – allow complaints to be anonymous, and many states now allow online submissions, whose ease may be expected to increase the number of filings. Oklahoma, for example, saw its board complaints rise by 40% in the 2 years after permitting this option.

Some complaints such as rudeness and disputes over fees may seem like a minor nuisance, but they can mushroom into new and more serious charges. The medical records may reveal other potential misconduct, such as delinquent record keeping or failure to obtain informed consent.

It is therefore prudent to treat all complaints seriously. A written response is necessary, but it must be cowritten with your attorney. Immediately contact your malpractice insurance carrier once an investigator approaches you, or upon notification by the medical board. Most malpractice policies include coverage for medical board investigations.

The simple rule is not to discuss with anyone – including (especially) the complainant – and await a call from the attorney assigned to you. Better yet, ask for an attorney whose skills you are aware of. Make sure he/she is experienced with board proceedings and not just malpractice litigation. There are legal technicalities that may be of importance, such as statutes of limitations barring board actions or the timely filing of an appeal. Everything should flow from here. The lawyer’s advice will most likely be: “Don’t speak to anyone, including your colleagues; don’t contact the patient or family; and don’t release any records without first consulting me.”

You should together draft a response letter. Whereas the attorney will be attentive to the legal ramifications, only you as the doctor can provide the clinical knowledge, context, and empathy. In formulating any written response where patient care is at issue, heed the following principles:

1. Be honest. Truth always surfaces in due course. Candor and trustworthiness are virtues expected of all doctors.

2. Be accurate. Review carefully all relevant medical records. Pay compulsive attention to factual accuracy.

3. Be focused. Do not ramble on and on regarding unrelated or tangential issues. Focus on what the complaint is about. No one is interested in your views regarding your philosophy of medical practice or the health care system – they do not belong in a complaint response letter.

4. Be humble. Arrogance at this stage may prove disastrous. Adopt a contrite and humble tone. Blame no one, especially the patient.

5. Be a patient advocate. Show that patient well-being is always your first and last concern.

In the preliminary stages, a board investigator may call the doctor, typically taking a friendly and casual approach, and this may lull the physician into saying more than is necessary or releasing the medical records. The shared information can come back to haunt the doctor when it is disclosed in a subsequent hearing.

In some situations, the board may offer an informal settlement conference to resolve the issue and obtain a “consent agreement” from the doctor. Depending on the facts – and the proposed settlement terms – your attorney may instead advise proceeding to a formal hearing to present exculpatory evidence and to confront the complainant.

Physicians are guaranteed the right of due process during an investigation. Timely notice, the right to a hearing, to confront the evidence, and to have legal representation are the basic due process rights. And boards must treat the physician fairly and reasonably.

However, where public harm is an imminent risk, boards have the power to immediately institute a temporary suspension of the doctor’s right to practice. Examples warranting such summary suspensions may include sexual misconduct, inappropriate opioid prescriptions, egregious negligent conduct, or impairment from alcohol or drug abuse.

Boards face a dilemma over these cases, because they need to balance depriving a doctor of due process rights, albeit temporarily, against allowing a bad doctor to pose a clear and present threat to the public. In Texas, 32 summary suspensions took place in 2011, a figure that fell to 13 in 2014.

The aggrieved physician typically has the right to appeal an adverse board decision to the courts, although “courts have no inherent appellate jurisdiction over official acts of administrative agencies except where the legislature has made some statutory provision for judicial review.”³

For example, under California’s Code of Civil Procedure section 1094.5, one has the right to have a Superior Court judge review the board’s decision to determine if there has been an abuse of discretion.

Despite the fact that board administrative proceedings are quasi criminal in nature, most states require only a “preponderance of evidence” to find the doctor guilty. This is the evidentiary standard used in civil cases where only monetary damages are at stake, yet it is used in determining whether a doctor would lose the liberty to practice his or her profession.

However, some jurisdictions – such as California, Florida, and Illinois – call for a higher threshold of guilt, requiring proof with “clear and convincing evidence.”

Finally, in the United Kingdom and countries such as Singapore, a guilty decision requires even more evidence – i.e., proof “beyond reasonable doubt” – which is the threshold required in criminal prosecutions.

References

1. Arch Intern Med. 2004 Mar 22;164(6):653-8.

2. Leigh Page. The Black Cloud of a Medical Board Investigation. Medscape, Dec 23, 2015.

3. Crane v. Cont’l Tel. Co. of Cal., 775 P.2d 705 (Nev. 1989).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

(This column is the third of a three-part series.)

Question: The state medical board is requesting the medical records of an angry patient who has filed a formal complaint alleging incompetent care. Your immediate impulse is to rush off a letter defending your treatment – and to include a sarcastic remark about ingratitude.

However, you decided not to respond, choosing to await the scheduled interview with the board investigator. To your surprise, he turned out to be warm and friendly, and his relative youth reminded you of your son. Letting your guard down, you spoke freely during the meeting and showed him the medical records. Later, you appeared at the formal board hearing without legal counsel, as the complainant had not suffered any injury while under your care. Under this scenario, which of the following statements is best?

A. You must never respond in writing to any board inquiry.

B. You should have called your insurance carrier immediately.

C. You trusted the investigator because what you told him could not be introduced as evidence.

D. You correctly assumed that, without injuries, there is no liability.

E. You did not insist on having an attorney, because this is not part of your due process rights.

Answer: B. Who gets into trouble with medical disciplinary boards? In a California study,¹ the authors concluded that male physicians were nearly three times as likely to as women physicians, and those who were non–board certified twice as likely to as their board-certified counterparts. Obstetricians, gynecologists, family physicians, general practitioners, and psychiatrists were more likely than internists, whereas pediatricians and radiologists were the least likely. Age had a smaller influence (elevated risk with increasing age), and foreign medical graduates also had an increased risk.

It is true that many board complaints are dismissed and never investigated, but the number of state licensure actions in 2013 was almost four times greater than the number of malpractice payouts. Moreover, board actions against a doctor, unlike a malpractice lawsuit, are premised on substandard or unethical conduct, and do not require a showing of actual patient harm.

A recent news article bemoans the travails of a medical board encounter.² According to a 2009 report, one of every eight physicians in California was being reported to the board each year, with a quarter of complaints leading to an investigation. In turn, a quarter of investigated complaints led to disciplinary proceedings against the physician.

A medical board investigation begins with a complaint lodged by a patient or some other party such as a pharmacist, nurse, or hospital peer review committee. Some states – e.g., California, Georgia, and Maryland – allow complaints to be anonymous, and many states now allow online submissions, whose ease may be expected to increase the number of filings. Oklahoma, for example, saw its board complaints rise by 40% in the 2 years after permitting this option.

Some complaints such as rudeness and disputes over fees may seem like a minor nuisance, but they can mushroom into new and more serious charges. The medical records may reveal other potential misconduct, such as delinquent record keeping or failure to obtain informed consent.

It is therefore prudent to treat all complaints seriously. A written response is necessary, but it must be cowritten with your attorney. Immediately contact your malpractice insurance carrier once an investigator approaches you, or upon notification by the medical board. Most malpractice policies include coverage for medical board investigations.

The simple rule is not to discuss with anyone – including (especially) the complainant – and await a call from the attorney assigned to you. Better yet, ask for an attorney whose skills you are aware of. Make sure he/she is experienced with board proceedings and not just malpractice litigation. There are legal technicalities that may be of importance, such as statutes of limitations barring board actions or the timely filing of an appeal. Everything should flow from here. The lawyer’s advice will most likely be: “Don’t speak to anyone, including your colleagues; don’t contact the patient or family; and don’t release any records without first consulting me.”

You should together draft a response letter. Whereas the attorney will be attentive to the legal ramifications, only you as the doctor can provide the clinical knowledge, context, and empathy. In formulating any written response where patient care is at issue, heed the following principles:

1. Be honest. Truth always surfaces in due course. Candor and trustworthiness are virtues expected of all doctors.

2. Be accurate. Review carefully all relevant medical records. Pay compulsive attention to factual accuracy.

3. Be focused. Do not ramble on and on regarding unrelated or tangential issues. Focus on what the complaint is about. No one is interested in your views regarding your philosophy of medical practice or the health care system – they do not belong in a complaint response letter.

4. Be humble. Arrogance at this stage may prove disastrous. Adopt a contrite and humble tone. Blame no one, especially the patient.

5. Be a patient advocate. Show that patient well-being is always your first and last concern.

In the preliminary stages, a board investigator may call the doctor, typically taking a friendly and casual approach, and this may lull the physician into saying more than is necessary or releasing the medical records. The shared information can come back to haunt the doctor when it is disclosed in a subsequent hearing.

In some situations, the board may offer an informal settlement conference to resolve the issue and obtain a “consent agreement” from the doctor. Depending on the facts – and the proposed settlement terms – your attorney may instead advise proceeding to a formal hearing to present exculpatory evidence and to confront the complainant.

Physicians are guaranteed the right of due process during an investigation. Timely notice, the right to a hearing, to confront the evidence, and to have legal representation are the basic due process rights. And boards must treat the physician fairly and reasonably.

However, where public harm is an imminent risk, boards have the power to immediately institute a temporary suspension of the doctor’s right to practice. Examples warranting such summary suspensions may include sexual misconduct, inappropriate opioid prescriptions, egregious negligent conduct, or impairment from alcohol or drug abuse.

Boards face a dilemma over these cases, because they need to balance depriving a doctor of due process rights, albeit temporarily, against allowing a bad doctor to pose a clear and present threat to the public. In Texas, 32 summary suspensions took place in 2011, a figure that fell to 13 in 2014.

The aggrieved physician typically has the right to appeal an adverse board decision to the courts, although “courts have no inherent appellate jurisdiction over official acts of administrative agencies except where the legislature has made some statutory provision for judicial review.”³

For example, under California’s Code of Civil Procedure section 1094.5, one has the right to have a Superior Court judge review the board’s decision to determine if there has been an abuse of discretion.

Despite the fact that board administrative proceedings are quasi criminal in nature, most states require only a “preponderance of evidence” to find the doctor guilty. This is the evidentiary standard used in civil cases where only monetary damages are at stake, yet it is used in determining whether a doctor would lose the liberty to practice his or her profession.

However, some jurisdictions – such as California, Florida, and Illinois – call for a higher threshold of guilt, requiring proof with “clear and convincing evidence.”

Finally, in the United Kingdom and countries such as Singapore, a guilty decision requires even more evidence – i.e., proof “beyond reasonable doubt” – which is the threshold required in criminal prosecutions.

References

1. Arch Intern Med. 2004 Mar 22;164(6):653-8.

2. Leigh Page. The Black Cloud of a Medical Board Investigation. Medscape, Dec 23, 2015.

3. Crane v. Cont’l Tel. Co. of Cal., 775 P.2d 705 (Nev. 1989).

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

The email came with the words, “It is with sadness we report that Frank Moody died. …” I was instantly transported to the last time I saw the man and a flood of emotions swept over me. The name Frank Moody will ring a distant bell or none at all to some in our profession. Like many of the greats of surgery, he belongs to the ages.

I remember the first time I asked a student, “Who is Michael DeBakey?” I was dumbfounded to be greeted with a blank stare. How could a student of medicine not know of Dr. DeBakey? A few years later, the same question prompted a smart aleck reply that he was the man who invented DeBakey forceps. Well, of course he did invent the forceps, but to know nothing further of the man who was the world’s expert on ulcer disease in the 1940s, the progenitor of the National Medical Library, and among the foremost pioneers of heart surgery seemed beyond belief.

Photo credit: Dwight Andrews/UTHealth

My mentor, Ernest Poulos, has long since left the active surgical scene. At times he would note the passing of one of his heroes like Carl Moyer (look it up!) and say, “Sic transit gloria mundi.” At 27 and anxious to get the right to cut into my fellow human beings, I would cock my head like a confounded puppy and wonder what that meant. I looked up the translation and meaning long ago, but now with age I understand the phrase in my bones.

I have long been a hanger-on at surgical meetings, hoping to meet those mighty figures that shaped surgical history. I saw W. Dean Warren once and had a very long hour with the great Mark Ravitch. Oliver Beahrs once performed magic tricks at a dinner I attended. At every surgical meeting there is an old guy (and now occasionally with the change in our profession, an elderly lady) getting on the bus to go to the reception or dinner dance. Often they are alone, their spouses having departed before them. As a young man, I wondered why the heck they came to the meetings. Just like every generation before, ours was eager to grab the reins, and in our ardor for future glory, we were polite but also restless for them to move aside. I hadn’t yet learned the importance of history and of listening.

What I missed while carousing with my young colleagues was an opportunity to hear history first hand and to learn that, what we thought was so cutting edge, these men and women had long ago considered. Many of our living legends imagined some of today’s innovations but they lacked the technology to bring their dreams to fruition, or time and age defeated them before they reached the final chapter of their research. It was when I was about 50 that I wised up and began seeking out living legends like Frank Moody and Frank Spencer.

In the case of Frank Moody, he was quite elderly when I first met him. For some reason, he knew who I was and shook my hand softly. I didn’t recognize him initially, but at the sound of his name, I knew I was in the presence of a major figure in 20th century gastrointestinal surgery. He had been at the University of California, San Francisco, during an historic time when George Sheldon, Donald Trunkey and other great surgeons trained there with J. Englebert Dunphy as their chief. Dr. Moody’s CV lists 141 articles in basic and clinical science that have had a profound impact on how we view the gastrointestinal tract. He was Chief at the University of Utah and the University of Alabama and finished his career as professor at the University of Texas-Houston. His awards and achievements were legion.

Parkinson’s had only recently really begun to affect him when I met him, and as the years went by his voice became so very faint that I had to lean in to hear him. We would sit together at the back of the dinner dance room so that we could hear each other. And while the other guests entertained themselves, Dr. Moody and I would discuss his life, scientific method and philosophy as well as his insights into his own case of Parkinsonism. I would see him at meetings, making his way slowly but steadily along a corridor while others briskly walked by, unaware that the man they just passed was among the most important surgical pioneers of our time. It was not sad that Dr. Moody was elderly and unrecognized, but that we younger surgeons missed knowing a great man in our tendency to rush past history.

History is not facts and dates, but rather, it is people and their lives. Yes, the history of our profession is embodied by pioneers like Frank Moody and the others I’ve mentioned.

We have many Fellows among us who are living history, still contributing – maybe not at the dais but at the dinner table, speaking softly and walking a bit slower than their juniors. Thanks to LaMar McGinnis who started it and Don Nakayama who continues it, the College has a History Community on the ACS Communities, an active Surgical History Group, and a will to acknowledge the history that lives and breathes among us. The Surgical History Group has organized a full program of events at the Clinical Congress and I hope many attendees take the opportunity to attend.

Take a moment at your next meeting or at the Clinical Congress and look for those historic surgeons still with us. Be smarter than I was at a young age and get to know them. You may learn something from them you can’t learn anyplace else.

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

The email came with the words, “It is with sadness we report that Frank Moody died. …” I was instantly transported to the last time I saw the man and a flood of emotions swept over me. The name Frank Moody will ring a distant bell or none at all to some in our profession. Like many of the greats of surgery, he belongs to the ages.

I remember the first time I asked a student, “Who is Michael DeBakey?” I was dumbfounded to be greeted with a blank stare. How could a student of medicine not know of Dr. DeBakey? A few years later, the same question prompted a smart aleck reply that he was the man who invented DeBakey forceps. Well, of course he did invent the forceps, but to know nothing further of the man who was the world’s expert on ulcer disease in the 1940s, the progenitor of the National Medical Library, and among the foremost pioneers of heart surgery seemed beyond belief.

Photo credit: Dwight Andrews/UTHealth

My mentor, Ernest Poulos, has long since left the active surgical scene. At times he would note the passing of one of his heroes like Carl Moyer (look it up!) and say, “Sic transit gloria mundi.” At 27 and anxious to get the right to cut into my fellow human beings, I would cock my head like a confounded puppy and wonder what that meant. I looked up the translation and meaning long ago, but now with age I understand the phrase in my bones.

I have long been a hanger-on at surgical meetings, hoping to meet those mighty figures that shaped surgical history. I saw W. Dean Warren once and had a very long hour with the great Mark Ravitch. Oliver Beahrs once performed magic tricks at a dinner I attended. At every surgical meeting there is an old guy (and now occasionally with the change in our profession, an elderly lady) getting on the bus to go to the reception or dinner dance. Often they are alone, their spouses having departed before them. As a young man, I wondered why the heck they came to the meetings. Just like every generation before, ours was eager to grab the reins, and in our ardor for future glory, we were polite but also restless for them to move aside. I hadn’t yet learned the importance of history and of listening.

What I missed while carousing with my young colleagues was an opportunity to hear history first hand and to learn that, what we thought was so cutting edge, these men and women had long ago considered. Many of our living legends imagined some of today’s innovations but they lacked the technology to bring their dreams to fruition, or time and age defeated them before they reached the final chapter of their research. It was when I was about 50 that I wised up and began seeking out living legends like Frank Moody and Frank Spencer.

In the case of Frank Moody, he was quite elderly when I first met him. For some reason, he knew who I was and shook my hand softly. I didn’t recognize him initially, but at the sound of his name, I knew I was in the presence of a major figure in 20th century gastrointestinal surgery. He had been at the University of California, San Francisco, during an historic time when George Sheldon, Donald Trunkey and other great surgeons trained there with J. Englebert Dunphy as their chief. Dr. Moody’s CV lists 141 articles in basic and clinical science that have had a profound impact on how we view the gastrointestinal tract. He was Chief at the University of Utah and the University of Alabama and finished his career as professor at the University of Texas-Houston. His awards and achievements were legion.

Parkinson’s had only recently really begun to affect him when I met him, and as the years went by his voice became so very faint that I had to lean in to hear him. We would sit together at the back of the dinner dance room so that we could hear each other. And while the other guests entertained themselves, Dr. Moody and I would discuss his life, scientific method and philosophy as well as his insights into his own case of Parkinsonism. I would see him at meetings, making his way slowly but steadily along a corridor while others briskly walked by, unaware that the man they just passed was among the most important surgical pioneers of our time. It was not sad that Dr. Moody was elderly and unrecognized, but that we younger surgeons missed knowing a great man in our tendency to rush past history.

History is not facts and dates, but rather, it is people and their lives. Yes, the history of our profession is embodied by pioneers like Frank Moody and the others I’ve mentioned.

We have many Fellows among us who are living history, still contributing – maybe not at the dais but at the dinner table, speaking softly and walking a bit slower than their juniors. Thanks to LaMar McGinnis who started it and Don Nakayama who continues it, the College has a History Community on the ACS Communities, an active Surgical History Group, and a will to acknowledge the history that lives and breathes among us. The Surgical History Group has organized a full program of events at the Clinical Congress and I hope many attendees take the opportunity to attend.

Take a moment at your next meeting or at the Clinical Congress and look for those historic surgeons still with us. Be smarter than I was at a young age and get to know them. You may learn something from them you can’t learn anyplace else.

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

The email came with the words, “It is with sadness we report that Frank Moody died. …” I was instantly transported to the last time I saw the man and a flood of emotions swept over me. The name Frank Moody will ring a distant bell or none at all to some in our profession. Like many of the greats of surgery, he belongs to the ages.

I remember the first time I asked a student, “Who is Michael DeBakey?” I was dumbfounded to be greeted with a blank stare. How could a student of medicine not know of Dr. DeBakey? A few years later, the same question prompted a smart aleck reply that he was the man who invented DeBakey forceps. Well, of course he did invent the forceps, but to know nothing further of the man who was the world’s expert on ulcer disease in the 1940s, the progenitor of the National Medical Library, and among the foremost pioneers of heart surgery seemed beyond belief.

Photo credit: Dwight Andrews/UTHealth

My mentor, Ernest Poulos, has long since left the active surgical scene. At times he would note the passing of one of his heroes like Carl Moyer (look it up!) and say, “Sic transit gloria mundi.” At 27 and anxious to get the right to cut into my fellow human beings, I would cock my head like a confounded puppy and wonder what that meant. I looked up the translation and meaning long ago, but now with age I understand the phrase in my bones.

I have long been a hanger-on at surgical meetings, hoping to meet those mighty figures that shaped surgical history. I saw W. Dean Warren once and had a very long hour with the great Mark Ravitch. Oliver Beahrs once performed magic tricks at a dinner I attended. At every surgical meeting there is an old guy (and now occasionally with the change in our profession, an elderly lady) getting on the bus to go to the reception or dinner dance. Often they are alone, their spouses having departed before them. As a young man, I wondered why the heck they came to the meetings. Just like every generation before, ours was eager to grab the reins, and in our ardor for future glory, we were polite but also restless for them to move aside. I hadn’t yet learned the importance of history and of listening.

What I missed while carousing with my young colleagues was an opportunity to hear history first hand and to learn that, what we thought was so cutting edge, these men and women had long ago considered. Many of our living legends imagined some of today’s innovations but they lacked the technology to bring their dreams to fruition, or time and age defeated them before they reached the final chapter of their research. It was when I was about 50 that I wised up and began seeking out living legends like Frank Moody and Frank Spencer.

In the case of Frank Moody, he was quite elderly when I first met him. For some reason, he knew who I was and shook my hand softly. I didn’t recognize him initially, but at the sound of his name, I knew I was in the presence of a major figure in 20th century gastrointestinal surgery. He had been at the University of California, San Francisco, during an historic time when George Sheldon, Donald Trunkey and other great surgeons trained there with J. Englebert Dunphy as their chief. Dr. Moody’s CV lists 141 articles in basic and clinical science that have had a profound impact on how we view the gastrointestinal tract. He was Chief at the University of Utah and the University of Alabama and finished his career as professor at the University of Texas-Houston. His awards and achievements were legion.

Parkinson’s had only recently really begun to affect him when I met him, and as the years went by his voice became so very faint that I had to lean in to hear him. We would sit together at the back of the dinner dance room so that we could hear each other. And while the other guests entertained themselves, Dr. Moody and I would discuss his life, scientific method and philosophy as well as his insights into his own case of Parkinsonism. I would see him at meetings, making his way slowly but steadily along a corridor while others briskly walked by, unaware that the man they just passed was among the most important surgical pioneers of our time. It was not sad that Dr. Moody was elderly and unrecognized, but that we younger surgeons missed knowing a great man in our tendency to rush past history.

History is not facts and dates, but rather, it is people and their lives. Yes, the history of our profession is embodied by pioneers like Frank Moody and the others I’ve mentioned.

We have many Fellows among us who are living history, still contributing – maybe not at the dais but at the dinner table, speaking softly and walking a bit slower than their juniors. Thanks to LaMar McGinnis who started it and Don Nakayama who continues it, the College has a History Community on the ACS Communities, an active Surgical History Group, and a will to acknowledge the history that lives and breathes among us. The Surgical History Group has organized a full program of events at the Clinical Congress and I hope many attendees take the opportunity to attend.

Take a moment at your next meeting or at the Clinical Congress and look for those historic surgeons still with us. Be smarter than I was at a young age and get to know them. You may learn something from them you can’t learn anyplace else.

Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.

Carbapenem-resistant Enterobacteriaceae (CRE) are extremely drug-resistant organisms. According to the Centers for Disease Control and Prevention’s National Healthcare Safety Network, in 2014 in the United States, 3.6% of Enterobacteriaceae causing hospital-acquired infections were resistant to carbapenems.¹ Antibiotic treatment options for CRE infections are severely limited, and mortality for invasive infections can be as high as 40%-50%.²

Resistance to carbapenems can be mediated by several mechanisms. From an epidemiologic standpoint, production of carbapenemases is the most-threatening mechanism because Enterobacteriaceae-harboring carbapenemases are highly transmissible.

Carbapenemase-producing CRE (CP-CRE) have caused large outbreaks throughout the world. Israel experienced a nationwide outbreak of CP-CRE, primarily Klebsiella pneumoniae carbapenemase–producing Klebsiella pneumoniae, in the mid-2000s. At the peak of the outbreak in 2007, there were 185 new cases per month (55.5/100,000 patient-days). A successful intervention at the national level dramatically decreased the incidence to 4.8/100,000 patient days in 2012.³

One component of the intervention (which is still ongoing) is active surveillance of high-risk groups using rectal swabs. Upon admission to the hospital, we screen patients who were recently in other hospitals or long-term care facilities. In addition, when a patient is newly diagnosed with CP-CRE (either asymptomatic carriage or clinical infection), we screen patients who had contact with that index case before isolation measures were implemented.

We recently published a study in Infection Control and Hospital Epidemiology that draws on our experience with CP-CRE screening of contacts at Tel Aviv Sourasky Medical Center.⁴ Both Israeli and International guidelines do not precisely define which contacts of a CP-CRE index case warrant screening. For example, should only roommates of index cases be screened or should we screen all patients on the same ward as the index case? Likewise, is there a minimum time of contact that should trigger screening?

Identifying which contacts are at high risk of acquiring CP-CRE is important for two reasons: We want to detect contacts who acquired CP-CRE so that they can be isolated before further transmission occurs, and we don’t want to waste resources and screen those at low risk. In our hospital, the criteria for being a contact are staying in the same ward and being treated by the same nursing staff as a newly identified CP-CRE patient.

This strategy appears to lead to overscreening, as we found that from October 2008 to June 2012, 3,158 screening tests were performed to detect 53 positive contacts (a yield of less than 2%). In order to screen more efficiently, our study aimed to determine risk factors for CP-CRE acquisition among patients exposed to a CP-CRE index patient.

We used a matched case-control design. The case group consisted of the 53 contacts who screened positive for CP-CRE. For each case we chose 2 controls: contacts who screened negative for CP-CRE. The basis for matching between the case and the 2 controls was that they were exposed to the same index patient. The benefit of matching this way was that it eliminated the question of whether a contact became positive because the index patient was more likely to transmit CP-CRE (e.g., because of diarrhea), and not because of characteristics of the contact patients themselves.

We found three factors that increased the risk that a contact would screen positive:

• Contact period of at least 3 days with the index case.

• Being on mechanical ventilation.

• Having a history of carriage or infection with another multidrug-resistant organism (such as methicillin-resistant Staphylococcus aureus).

Unexpectedly, sharing a room with the index patient or being debilitated did not significantly increase the risk of acquiring CP-CRE.

Many studies have identified antibiotic use as a risk factor for acquiring CP-CRE. In our study, no class of antibiotic increased the risk of CP-CRE acquisition, probably because only a small number of patients received each class. We were surprised to find that contacts who had taken cephalosporins were less likely to acquire CP-CRE. On further examination, when we compared patients who received only cephalosporins with patients who received no antibiotic, this protective effect disappeared. Nevertheless, compared with other antibiotics, it appears that cephalosporins might pose less of a risk for CP-CRE acquisition. More studies are needed to confirm our findings.

Our findings have practical implications for infection control. Using the risk factors we identified could help us to avoid excessive screening. We calculated that selective screening, based on our three risk factors, would have decreased the number of contacts screened by 30%, but 2 out of 53 positive contacts would have been missed. Institutions need to decide whether that is a trade-off they are willing to make.

Another way to apply our findings could be to add an additional layer of infection control by preemptively implementing contact precautions for patients at highest risk, for example, those with more than one risk factor.
 

1. Weiner LM, Fridkin SK, Aponte-Torres Z, Avery L, Coffin N, Dudeck MA, Edwards JR, Jernigan JA, Konnor R, Soe MM, Peterson K, Clifford McDonald L. Vital signs: preventing antibiotic-resistant infections in hospitals - United States, 2014. Am J Transplant. 2016 Jul;16(7):2224-30.

2. Centers for Disease Control and Prevention. Facility guidance for control of carbapenem-resistant Enterobacteriaceae (CRE): November 2015 update – CRE Toolkit.

3. Schwaber MJ, Carmeli Y. An ongoing national intervention to contain the spread of carbapenem-resistant enterobacteriaceae. Clin Infect Dis. 2014 Mar;58(5):697-703.

Schwartz-Neiderman A, Braun T, Fallach N, Schwartz D, Carmeli Y, Schechner V. Risk factors for carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) acquisition among contacts of newly diagnosed CP-CRE patients. Infect Control Hosp Epidemiol. 2016 Jul 25:1-7.
 

Vered Schechner, MD, MSc, is an infection control physician in the department of epidemiology at Tel Aviv Sourasky Medical Center.

Carbapenem-resistant Enterobacteriaceae (CRE) are extremely drug-resistant organisms. According to the Centers for Disease Control and Prevention’s National Healthcare Safety Network, in 2014 in the United States, 3.6% of Enterobacteriaceae causing hospital-acquired infections were resistant to carbapenems.¹ Antibiotic treatment options for CRE infections are severely limited, and mortality for invasive infections can be as high as 40%-50%.²

Resistance to carbapenems can be mediated by several mechanisms. From an epidemiologic standpoint, production of carbapenemases is the most-threatening mechanism because Enterobacteriaceae-harboring carbapenemases are highly transmissible.

Carbapenemase-producing CRE (CP-CRE) have caused large outbreaks throughout the world. Israel experienced a nationwide outbreak of CP-CRE, primarily Klebsiella pneumoniae carbapenemase–producing Klebsiella pneumoniae, in the mid-2000s. At the peak of the outbreak in 2007, there were 185 new cases per month (55.5/100,000 patient-days). A successful intervention at the national level dramatically decreased the incidence to 4.8/100,000 patient days in 2012.³

One component of the intervention (which is still ongoing) is active surveillance of high-risk groups using rectal swabs. Upon admission to the hospital, we screen patients who were recently in other hospitals or long-term care facilities. In addition, when a patient is newly diagnosed with CP-CRE (either asymptomatic carriage or clinical infection), we screen patients who had contact with that index case before isolation measures were implemented.

We recently published a study in Infection Control and Hospital Epidemiology that draws on our experience with CP-CRE screening of contacts at Tel Aviv Sourasky Medical Center.⁴ Both Israeli and International guidelines do not precisely define which contacts of a CP-CRE index case warrant screening. For example, should only roommates of index cases be screened or should we screen all patients on the same ward as the index case? Likewise, is there a minimum time of contact that should trigger screening?

Identifying which contacts are at high risk of acquiring CP-CRE is important for two reasons: We want to detect contacts who acquired CP-CRE so that they can be isolated before further transmission occurs, and we don’t want to waste resources and screen those at low risk. In our hospital, the criteria for being a contact are staying in the same ward and being treated by the same nursing staff as a newly identified CP-CRE patient.

This strategy appears to lead to overscreening, as we found that from October 2008 to June 2012, 3,158 screening tests were performed to detect 53 positive contacts (a yield of less than 2%). In order to screen more efficiently, our study aimed to determine risk factors for CP-CRE acquisition among patients exposed to a CP-CRE index patient.

We used a matched case-control design. The case group consisted of the 53 contacts who screened positive for CP-CRE. For each case we chose 2 controls: contacts who screened negative for CP-CRE. The basis for matching between the case and the 2 controls was that they were exposed to the same index patient. The benefit of matching this way was that it eliminated the question of whether a contact became positive because the index patient was more likely to transmit CP-CRE (e.g., because of diarrhea), and not because of characteristics of the contact patients themselves.

We found three factors that increased the risk that a contact would screen positive:

• Contact period of at least 3 days with the index case.

• Being on mechanical ventilation.

• Having a history of carriage or infection with another multidrug-resistant organism (such as methicillin-resistant Staphylococcus aureus).

Unexpectedly, sharing a room with the index patient or being debilitated did not significantly increase the risk of acquiring CP-CRE.

Many studies have identified antibiotic use as a risk factor for acquiring CP-CRE. In our study, no class of antibiotic increased the risk of CP-CRE acquisition, probably because only a small number of patients received each class. We were surprised to find that contacts who had taken cephalosporins were less likely to acquire CP-CRE. On further examination, when we compared patients who received only cephalosporins with patients who received no antibiotic, this protective effect disappeared. Nevertheless, compared with other antibiotics, it appears that cephalosporins might pose less of a risk for CP-CRE acquisition. More studies are needed to confirm our findings.

Our findings have practical implications for infection control. Using the risk factors we identified could help us to avoid excessive screening. We calculated that selective screening, based on our three risk factors, would have decreased the number of contacts screened by 30%, but 2 out of 53 positive contacts would have been missed. Institutions need to decide whether that is a trade-off they are willing to make.

Another way to apply our findings could be to add an additional layer of infection control by preemptively implementing contact precautions for patients at highest risk, for example, those with more than one risk factor.
 

1. Weiner LM, Fridkin SK, Aponte-Torres Z, Avery L, Coffin N, Dudeck MA, Edwards JR, Jernigan JA, Konnor R, Soe MM, Peterson K, Clifford McDonald L. Vital signs: preventing antibiotic-resistant infections in hospitals - United States, 2014. Am J Transplant. 2016 Jul;16(7):2224-30.

2. Centers for Disease Control and Prevention. Facility guidance for control of carbapenem-resistant Enterobacteriaceae (CRE): November 2015 update – CRE Toolkit.

3. Schwaber MJ, Carmeli Y. An ongoing national intervention to contain the spread of carbapenem-resistant enterobacteriaceae. Clin Infect Dis. 2014 Mar;58(5):697-703.

Schwartz-Neiderman A, Braun T, Fallach N, Schwartz D, Carmeli Y, Schechner V. Risk factors for carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) acquisition among contacts of newly diagnosed CP-CRE patients. Infect Control Hosp Epidemiol. 2016 Jul 25:1-7.
 

Vered Schechner, MD, MSc, is an infection control physician in the department of epidemiology at Tel Aviv Sourasky Medical Center.

Carbapenem-resistant Enterobacteriaceae (CRE) are extremely drug-resistant organisms. According to the Centers for Disease Control and Prevention’s National Healthcare Safety Network, in 2014 in the United States, 3.6% of Enterobacteriaceae causing hospital-acquired infections were resistant to carbapenems.¹ Antibiotic treatment options for CRE infections are severely limited, and mortality for invasive infections can be as high as 40%-50%.²

Resistance to carbapenems can be mediated by several mechanisms. From an epidemiologic standpoint, production of carbapenemases is the most-threatening mechanism because Enterobacteriaceae-harboring carbapenemases are highly transmissible.

Carbapenemase-producing CRE (CP-CRE) have caused large outbreaks throughout the world. Israel experienced a nationwide outbreak of CP-CRE, primarily Klebsiella pneumoniae carbapenemase–producing Klebsiella pneumoniae, in the mid-2000s. At the peak of the outbreak in 2007, there were 185 new cases per month (55.5/100,000 patient-days). A successful intervention at the national level dramatically decreased the incidence to 4.8/100,000 patient days in 2012.³

One component of the intervention (which is still ongoing) is active surveillance of high-risk groups using rectal swabs. Upon admission to the hospital, we screen patients who were recently in other hospitals or long-term care facilities. In addition, when a patient is newly diagnosed with CP-CRE (either asymptomatic carriage or clinical infection), we screen patients who had contact with that index case before isolation measures were implemented.

We recently published a study in Infection Control and Hospital Epidemiology that draws on our experience with CP-CRE screening of contacts at Tel Aviv Sourasky Medical Center.⁴ Both Israeli and International guidelines do not precisely define which contacts of a CP-CRE index case warrant screening. For example, should only roommates of index cases be screened or should we screen all patients on the same ward as the index case? Likewise, is there a minimum time of contact that should trigger screening?

Identifying which contacts are at high risk of acquiring CP-CRE is important for two reasons: We want to detect contacts who acquired CP-CRE so that they can be isolated before further transmission occurs, and we don’t want to waste resources and screen those at low risk. In our hospital, the criteria for being a contact are staying in the same ward and being treated by the same nursing staff as a newly identified CP-CRE patient.

This strategy appears to lead to overscreening, as we found that from October 2008 to June 2012, 3,158 screening tests were performed to detect 53 positive contacts (a yield of less than 2%). In order to screen more efficiently, our study aimed to determine risk factors for CP-CRE acquisition among patients exposed to a CP-CRE index patient.

We used a matched case-control design. The case group consisted of the 53 contacts who screened positive for CP-CRE. For each case we chose 2 controls: contacts who screened negative for CP-CRE. The basis for matching between the case and the 2 controls was that they were exposed to the same index patient. The benefit of matching this way was that it eliminated the question of whether a contact became positive because the index patient was more likely to transmit CP-CRE (e.g., because of diarrhea), and not because of characteristics of the contact patients themselves.

We found three factors that increased the risk that a contact would screen positive:

• Contact period of at least 3 days with the index case.

• Being on mechanical ventilation.

• Having a history of carriage or infection with another multidrug-resistant organism (such as methicillin-resistant Staphylococcus aureus).

Unexpectedly, sharing a room with the index patient or being debilitated did not significantly increase the risk of acquiring CP-CRE.

Many studies have identified antibiotic use as a risk factor for acquiring CP-CRE. In our study, no class of antibiotic increased the risk of CP-CRE acquisition, probably because only a small number of patients received each class. We were surprised to find that contacts who had taken cephalosporins were less likely to acquire CP-CRE. On further examination, when we compared patients who received only cephalosporins with patients who received no antibiotic, this protective effect disappeared. Nevertheless, compared with other antibiotics, it appears that cephalosporins might pose less of a risk for CP-CRE acquisition. More studies are needed to confirm our findings.

Our findings have practical implications for infection control. Using the risk factors we identified could help us to avoid excessive screening. We calculated that selective screening, based on our three risk factors, would have decreased the number of contacts screened by 30%, but 2 out of 53 positive contacts would have been missed. Institutions need to decide whether that is a trade-off they are willing to make.

Another way to apply our findings could be to add an additional layer of infection control by preemptively implementing contact precautions for patients at highest risk, for example, those with more than one risk factor.
 

1. Weiner LM, Fridkin SK, Aponte-Torres Z, Avery L, Coffin N, Dudeck MA, Edwards JR, Jernigan JA, Konnor R, Soe MM, Peterson K, Clifford McDonald L. Vital signs: preventing antibiotic-resistant infections in hospitals - United States, 2014. Am J Transplant. 2016 Jul;16(7):2224-30.

2. Centers for Disease Control and Prevention. Facility guidance for control of carbapenem-resistant Enterobacteriaceae (CRE): November 2015 update – CRE Toolkit.

3. Schwaber MJ, Carmeli Y. An ongoing national intervention to contain the spread of carbapenem-resistant enterobacteriaceae. Clin Infect Dis. 2014 Mar;58(5):697-703.

Schwartz-Neiderman A, Braun T, Fallach N, Schwartz D, Carmeli Y, Schechner V. Risk factors for carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) acquisition among contacts of newly diagnosed CP-CRE patients. Infect Control Hosp Epidemiol. 2016 Jul 25:1-7.
 

Vered Schechner, MD, MSc, is an infection control physician in the department of epidemiology at Tel Aviv Sourasky Medical Center.

Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.

You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.

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

Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.

You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.

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

Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.

You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.

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

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.