Commentary

The average American consumes about 3400 mg/d of sodium, which is more than double the 1500 mg recommended by the American Heart Association.¹ Excess sodium added to foods during commercial processing and preparation represents the main source of sodium intake in American diets.² Nevertheless, adding salt at the table is still very common, and people who add salt at the table have 1.5 g higher salt intakes than those who do not add salt.³ And as we know, high sodium intake has been associated with elevated blood pressure and an increased rate of cardiovascular disease.⁴

I have designed a self-produced “Salt Awareness—Limit Today” (SALT) label (FIGURE). This label is attached to the cap of a salt shaker in such a way that less salt flows through the openings of the cap. Moreover, the label serves as a reminder to limit salt intake in general. The feedback I have received from my patients has been extremely positive; they report increased awareness and decreased sodium intake. I mention it here so that others may benefit.

Zvi Weizman, MD
Beer-Sheva, Israel

The average American consumes about 3400 mg/d of sodium, which is more than double the 1500 mg recommended by the American Heart Association.¹ Excess sodium added to foods during commercial processing and preparation represents the main source of sodium intake in American diets.² Nevertheless, adding salt at the table is still very common, and people who add salt at the table have 1.5 g higher salt intakes than those who do not add salt.³ And as we know, high sodium intake has been associated with elevated blood pressure and an increased rate of cardiovascular disease.⁴

I have designed a self-produced “Salt Awareness—Limit Today” (SALT) label (FIGURE). This label is attached to the cap of a salt shaker in such a way that less salt flows through the openings of the cap. Moreover, the label serves as a reminder to limit salt intake in general. The feedback I have received from my patients has been extremely positive; they report increased awareness and decreased sodium intake. I mention it here so that others may benefit.

Zvi Weizman, MD
Beer-Sheva, Israel

The average American consumes about 3400 mg/d of sodium, which is more than double the 1500 mg recommended by the American Heart Association.¹ Excess sodium added to foods during commercial processing and preparation represents the main source of sodium intake in American diets.² Nevertheless, adding salt at the table is still very common, and people who add salt at the table have 1.5 g higher salt intakes than those who do not add salt.³ And as we know, high sodium intake has been associated with elevated blood pressure and an increased rate of cardiovascular disease.⁴

I have designed a self-produced “Salt Awareness—Limit Today” (SALT) label (FIGURE). This label is attached to the cap of a salt shaker in such a way that less salt flows through the openings of the cap. Moreover, the label serves as a reminder to limit salt intake in general. The feedback I have received from my patients has been extremely positive; they report increased awareness and decreased sodium intake. I mention it here so that others may benefit.

Zvi Weizman, MD
Beer-Sheva, Israel

In his August editorial, Dr. Hickner noted that an article in the issue prompted him to “wonder whether ultrasound might become the stethoscope of the future” (J Fam Pract. 2016;65:516). To that I say that we need to avoid conflating the stethoscope with point-of-care ultrasound (POCUS).

It is well documented that auscultation skills rapidly deteriorate (specifically in the cardiology realm) in clinical practice.¹ This may occur because many physicians already think ultrasound can replace actually listening to their patients’ hearts. The motto has become, “I’ll just order an echo.”

POCUS is an imaging modality. Period. It can be used to auscultate, but Doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.² The stethoscope remains an outstanding, inexpensive, and convenient screening tool and its use needs to be emphasized.

I strongly believe in training all medical students in POCUS—but as a complementary and adjunctive tool—not as something to replace a perfectly functional piece of equipment used around the world to provide good care.

Todd Fredricks, DO
Athens, Ohio

In his August editorial, Dr. Hickner noted that an article in the issue prompted him to “wonder whether ultrasound might become the stethoscope of the future” (J Fam Pract. 2016;65:516). To that I say that we need to avoid conflating the stethoscope with point-of-care ultrasound (POCUS).

It is well documented that auscultation skills rapidly deteriorate (specifically in the cardiology realm) in clinical practice.¹ This may occur because many physicians already think ultrasound can replace actually listening to their patients’ hearts. The motto has become, “I’ll just order an echo.”

POCUS is an imaging modality. Period. It can be used to auscultate, but Doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.² The stethoscope remains an outstanding, inexpensive, and convenient screening tool and its use needs to be emphasized.

I strongly believe in training all medical students in POCUS—but as a complementary and adjunctive tool—not as something to replace a perfectly functional piece of equipment used around the world to provide good care.

Todd Fredricks, DO
Athens, Ohio

In his August editorial, Dr. Hickner noted that an article in the issue prompted him to “wonder whether ultrasound might become the stethoscope of the future” (J Fam Pract. 2016;65:516). To that I say that we need to avoid conflating the stethoscope with point-of-care ultrasound (POCUS).

It is well documented that auscultation skills rapidly deteriorate (specifically in the cardiology realm) in clinical practice.¹ This may occur because many physicians already think ultrasound can replace actually listening to their patients’ hearts. The motto has become, “I’ll just order an echo.”

POCUS is an imaging modality. Period. It can be used to auscultate, but Doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.² The stethoscope remains an outstanding, inexpensive, and convenient screening tool and its use needs to be emphasized.

I strongly believe in training all medical students in POCUS—but as a complementary and adjunctive tool—not as something to replace a perfectly functional piece of equipment used around the world to provide good care.

Todd Fredricks, DO
Athens, Ohio

The article, “Diabetes update: Your guide to the latest ADA standards,” by Shubrook, et al (J Fam Pract. 2016;65:310-318) is a precise review of current recommendations for diabetes. We would like to draw attention, however, to comorbid diabetes and mental illness.

Diabetes and serious mental illness often coincide, making the treatment of both conditions difficult and leading to higher rates of complications.¹

The American Diabetes Association (ADA)’s “Standards of Medical Care in Diabetes” recognizes that hemoglobin A1C targets for patients should be individualized.² We consider it important to discuss challenges and limitations with each patient.

For example, a more lenient A1C goal may be appropriate when:

• the assessment of the patient shows that he or she is struggling with active symptoms of mental illness
• new medications with undesirable metabolic effects are prescribed or titrated
• social support is poor
• patients have limited confidence in their ability to accomplish tasks and goals
• patients have cognitive limitations
• patients abuse substances.

We suggest that when factors are favorable (eg, younger patient, well-controlled serious mental illness, adequate support, good cognitive skills, no hazardous use of substances, good level of confidence in the ability to control diabetes), the A1C target can be set lower. When the factors are less favorable (eg, older patient, poorly controlled mental illness, abusing substances, cognitive impairment), the target should be set higher and incrementally reduced as care engagement, circumstances, and symptom control improve.

There is a need for further research to investigate the factors that can impact diabetes self-management in patients with comorbid mental illness.

Corinna Falck-Ytter, MD
Stephanie W. Kanuch, MEd
Richard McCormick, PhD
Michael Purdum, PhD
Neal V. Dawson, MD
Shari D. Bolen, MD, MPH
Martha Sajatovic, MD
Cleveland, Ohio

The article, “Diabetes update: Your guide to the latest ADA standards,” by Shubrook, et al (J Fam Pract. 2016;65:310-318) is a precise review of current recommendations for diabetes. We would like to draw attention, however, to comorbid diabetes and mental illness.

Diabetes and serious mental illness often coincide, making the treatment of both conditions difficult and leading to higher rates of complications.¹

The American Diabetes Association (ADA)’s “Standards of Medical Care in Diabetes” recognizes that hemoglobin A1C targets for patients should be individualized.² We consider it important to discuss challenges and limitations with each patient.

For example, a more lenient A1C goal may be appropriate when:

• the assessment of the patient shows that he or she is struggling with active symptoms of mental illness
• new medications with undesirable metabolic effects are prescribed or titrated
• social support is poor
• patients have limited confidence in their ability to accomplish tasks and goals
• patients have cognitive limitations
• patients abuse substances.

We suggest that when factors are favorable (eg, younger patient, well-controlled serious mental illness, adequate support, good cognitive skills, no hazardous use of substances, good level of confidence in the ability to control diabetes), the A1C target can be set lower. When the factors are less favorable (eg, older patient, poorly controlled mental illness, abusing substances, cognitive impairment), the target should be set higher and incrementally reduced as care engagement, circumstances, and symptom control improve.

There is a need for further research to investigate the factors that can impact diabetes self-management in patients with comorbid mental illness.

Corinna Falck-Ytter, MD
Stephanie W. Kanuch, MEd
Richard McCormick, PhD
Michael Purdum, PhD
Neal V. Dawson, MD
Shari D. Bolen, MD, MPH
Martha Sajatovic, MD
Cleveland, Ohio

The article, “Diabetes update: Your guide to the latest ADA standards,” by Shubrook, et al (J Fam Pract. 2016;65:310-318) is a precise review of current recommendations for diabetes. We would like to draw attention, however, to comorbid diabetes and mental illness.

Diabetes and serious mental illness often coincide, making the treatment of both conditions difficult and leading to higher rates of complications.¹

The American Diabetes Association (ADA)’s “Standards of Medical Care in Diabetes” recognizes that hemoglobin A1C targets for patients should be individualized.² We consider it important to discuss challenges and limitations with each patient.

For example, a more lenient A1C goal may be appropriate when:

• the assessment of the patient shows that he or she is struggling with active symptoms of mental illness
• new medications with undesirable metabolic effects are prescribed or titrated
• social support is poor
• patients have limited confidence in their ability to accomplish tasks and goals
• patients have cognitive limitations
• patients abuse substances.

We suggest that when factors are favorable (eg, younger patient, well-controlled serious mental illness, adequate support, good cognitive skills, no hazardous use of substances, good level of confidence in the ability to control diabetes), the A1C target can be set lower. When the factors are less favorable (eg, older patient, poorly controlled mental illness, abusing substances, cognitive impairment), the target should be set higher and incrementally reduced as care engagement, circumstances, and symptom control improve.

There is a need for further research to investigate the factors that can impact diabetes self-management in patients with comorbid mental illness.

Corinna Falck-Ytter, MD
Stephanie W. Kanuch, MEd
Richard McCormick, PhD
Michael Purdum, PhD
Neal V. Dawson, MD
Shari D. Bolen, MD, MPH
Martha Sajatovic, MD
Cleveland, Ohio

Health care has not been at the top of the agenda in this presidential campaign, but it remains a highly contentious political issue. Because the Affordable Care Act (aka Obamacare) was all about expanding health care coverage and not much about cost containment, it is not surprising that health care insurance costs continue to escalate.

The Accountable Care Organization demonstrations around the country have shown that some, but not all, health care organizations are able to bend the steep cost incline downward using incentives, bundled payments, excellent primary care access, and care coordination. But we are once again seeing large increases in insurance premiums, and no one is happy about that.

Take your pick of candidates, but don't expect a difference in your practice "hassle factor"—or paycheck.

Practical solutions are scarce. Good solutions for controlling rising health care costs are difficult to come by in the United States. There are a variety of suggestions and approaches favored by one party or the other that will be decided through political and administrative channels. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-based Incentive Payment System (MIPS), and alternative payment models (APMs) are the federal government’s new programs that have been set out to encourage quality, while controlling costs in outpatient settings.¹ These programs have bipartisan support and are not going away.

In addition, each state is reorganizing Medicaid in an attempt to improve quality and reduce costs. Usually these cost control/quality improvement programs are foisted on us by federal or state governments (which pay for about 64% of health care costs in the United States), by insurers, or both. Fortunately, the American Academy of Family Physicians has been putting the interests of family physicians in front of legislators and policy makers to try to ease the pain as much as possible.

What can YOU do? If you have the time and the stomach for it, join forces with AAFP to become involved in the politics of health care reform and speak up for family medicine and primary care. In your own office or clinic, put the “Choosing Wisely” campaign² (from the American Board of Internal Medicine) into practice: Focus on reducing unnecessary tests and treatments.

In the end, no matter which party occupies the White House for the next 4 years, health care payment reform is inevitable. Both parties agree that the steep rise in health care costs is unsustainable. So take your pick of presidential candidates, but don’t expect that choice to make a lot of difference in your practice “hassle factor”—or paycheck.

Health care has not been at the top of the agenda in this presidential campaign, but it remains a highly contentious political issue. Because the Affordable Care Act (aka Obamacare) was all about expanding health care coverage and not much about cost containment, it is not surprising that health care insurance costs continue to escalate.

The Accountable Care Organization demonstrations around the country have shown that some, but not all, health care organizations are able to bend the steep cost incline downward using incentives, bundled payments, excellent primary care access, and care coordination. But we are once again seeing large increases in insurance premiums, and no one is happy about that.

Take your pick of candidates, but don't expect a difference in your practice "hassle factor"—or paycheck.

Practical solutions are scarce. Good solutions for controlling rising health care costs are difficult to come by in the United States. There are a variety of suggestions and approaches favored by one party or the other that will be decided through political and administrative channels. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-based Incentive Payment System (MIPS), and alternative payment models (APMs) are the federal government’s new programs that have been set out to encourage quality, while controlling costs in outpatient settings.¹ These programs have bipartisan support and are not going away.

In addition, each state is reorganizing Medicaid in an attempt to improve quality and reduce costs. Usually these cost control/quality improvement programs are foisted on us by federal or state governments (which pay for about 64% of health care costs in the United States), by insurers, or both. Fortunately, the American Academy of Family Physicians has been putting the interests of family physicians in front of legislators and policy makers to try to ease the pain as much as possible.

What can YOU do? If you have the time and the stomach for it, join forces with AAFP to become involved in the politics of health care reform and speak up for family medicine and primary care. In your own office or clinic, put the “Choosing Wisely” campaign² (from the American Board of Internal Medicine) into practice: Focus on reducing unnecessary tests and treatments.

In the end, no matter which party occupies the White House for the next 4 years, health care payment reform is inevitable. Both parties agree that the steep rise in health care costs is unsustainable. So take your pick of presidential candidates, but don’t expect that choice to make a lot of difference in your practice “hassle factor”—or paycheck.

Health care has not been at the top of the agenda in this presidential campaign, but it remains a highly contentious political issue. Because the Affordable Care Act (aka Obamacare) was all about expanding health care coverage and not much about cost containment, it is not surprising that health care insurance costs continue to escalate.

The Accountable Care Organization demonstrations around the country have shown that some, but not all, health care organizations are able to bend the steep cost incline downward using incentives, bundled payments, excellent primary care access, and care coordination. But we are once again seeing large increases in insurance premiums, and no one is happy about that.

Take your pick of candidates, but don't expect a difference in your practice "hassle factor"—or paycheck.

Practical solutions are scarce. Good solutions for controlling rising health care costs are difficult to come by in the United States. There are a variety of suggestions and approaches favored by one party or the other that will be decided through political and administrative channels. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Merit-based Incentive Payment System (MIPS), and alternative payment models (APMs) are the federal government’s new programs that have been set out to encourage quality, while controlling costs in outpatient settings.¹ These programs have bipartisan support and are not going away.

In addition, each state is reorganizing Medicaid in an attempt to improve quality and reduce costs. Usually these cost control/quality improvement programs are foisted on us by federal or state governments (which pay for about 64% of health care costs in the United States), by insurers, or both. Fortunately, the American Academy of Family Physicians has been putting the interests of family physicians in front of legislators and policy makers to try to ease the pain as much as possible.

What can YOU do? If you have the time and the stomach for it, join forces with AAFP to become involved in the politics of health care reform and speak up for family medicine and primary care. In your own office or clinic, put the “Choosing Wisely” campaign² (from the American Board of Internal Medicine) into practice: Focus on reducing unnecessary tests and treatments.

In the end, no matter which party occupies the White House for the next 4 years, health care payment reform is inevitable. Both parties agree that the steep rise in health care costs is unsustainable. So take your pick of presidential candidates, but don’t expect that choice to make a lot of difference in your practice “hassle factor”—or paycheck.

A good way to survive an acute myocardial infarction is to go to the best hospital.

Some patients seem to have found out where those are. For those of us who want to know where to go and what to look for, a recent analysis of 800,000 Medicare patients admitted with acute myocardial infarction (AMI) and heart failure in 10,000 hospitals between 2008 and 2009 provides some reassuring news (National Bureau of Economic Research Working Paper 21603). Its findings indicated that in an era when health care choice is seemingly influenced by testimonial TV ads and the creation of hospitals that look like hotels, technical medical quality outranks all the glitz and bricks. Quality was measured by hospital mortality, 30-day readmissions, adherence to well-established guidelines, and patient satisfaction questionnaires. The investigators measured the effect that medical quality and the “comfort quotient” had on the growth of hospital patient volume through the emergency departments and interhospital referrals.

Hospital admissions increased in hospitals with the highest-quality performance. Over the 2-year period, the hospitals with the highest-quality performance had increases in hospital volume. Hospitals with a 1% improvement in the adjusted AMI mortality had a 17% increase in market share and a 1.5 % growth rate.

The authors estimated that patients with an AMI (or their family) were willing to travel an additional 1.8 miles for an ED admission to a hospital with a higher survival rate, and 34 miles further for a transfer to a hospital with a higher survival rate. When patients had the option to choose a hospital to be transferred to for further care, quality of care measures had an even greater impact on choice. Postdischarge evaluation of patient satisfaction had little or no effect on growth.

Patients admitted through the ED have the least chance for hospital choice, but even in these patients knowledge about quality influenced the choice of the hospital and the long-term hospital growth rate. Considering the fact that there is scant information available either to patients or even doctors about quality measures, there appears to be a choice process either by patient family, doctor, or ambulance driver to direct patients to the hospital with the best survival rate.

How they made those decisions is not clear. Comparative hospital survival data are rarely transmitted to staff physicians and are not widely available to the public. I have never seen any data like these in the multitude of hospital TV ads, yet somehow those numbers, real or perceived, affected admission and transfer. Maybe it’s just reputation; we all know about that. If you are really interested, you can find hospital medical quality and patient experience data at Medicare’s Hospital Compare site.

All this is good. Medical quality wins. Other studies, however, suggest that usually the “comfort quotient” and measures of medical quality are more closely linked. It has also been suggested that volume is the driving force for the improvement in both quality measures by providing the resources and logistics for better care. Whatever the mechanism, it seems that high-quality medical care is not a bad way to choose which neighborhood hospital to go to in order to survive an AMI.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

A good way to survive an acute myocardial infarction is to go to the best hospital.

Some patients seem to have found out where those are. For those of us who want to know where to go and what to look for, a recent analysis of 800,000 Medicare patients admitted with acute myocardial infarction (AMI) and heart failure in 10,000 hospitals between 2008 and 2009 provides some reassuring news (National Bureau of Economic Research Working Paper 21603). Its findings indicated that in an era when health care choice is seemingly influenced by testimonial TV ads and the creation of hospitals that look like hotels, technical medical quality outranks all the glitz and bricks. Quality was measured by hospital mortality, 30-day readmissions, adherence to well-established guidelines, and patient satisfaction questionnaires. The investigators measured the effect that medical quality and the “comfort quotient” had on the growth of hospital patient volume through the emergency departments and interhospital referrals.

Hospital admissions increased in hospitals with the highest-quality performance. Over the 2-year period, the hospitals with the highest-quality performance had increases in hospital volume. Hospitals with a 1% improvement in the adjusted AMI mortality had a 17% increase in market share and a 1.5 % growth rate.

The authors estimated that patients with an AMI (or their family) were willing to travel an additional 1.8 miles for an ED admission to a hospital with a higher survival rate, and 34 miles further for a transfer to a hospital with a higher survival rate. When patients had the option to choose a hospital to be transferred to for further care, quality of care measures had an even greater impact on choice. Postdischarge evaluation of patient satisfaction had little or no effect on growth.

Patients admitted through the ED have the least chance for hospital choice, but even in these patients knowledge about quality influenced the choice of the hospital and the long-term hospital growth rate. Considering the fact that there is scant information available either to patients or even doctors about quality measures, there appears to be a choice process either by patient family, doctor, or ambulance driver to direct patients to the hospital with the best survival rate.

How they made those decisions is not clear. Comparative hospital survival data are rarely transmitted to staff physicians and are not widely available to the public. I have never seen any data like these in the multitude of hospital TV ads, yet somehow those numbers, real or perceived, affected admission and transfer. Maybe it’s just reputation; we all know about that. If you are really interested, you can find hospital medical quality and patient experience data at Medicare’s Hospital Compare site.

All this is good. Medical quality wins. Other studies, however, suggest that usually the “comfort quotient” and measures of medical quality are more closely linked. It has also been suggested that volume is the driving force for the improvement in both quality measures by providing the resources and logistics for better care. Whatever the mechanism, it seems that high-quality medical care is not a bad way to choose which neighborhood hospital to go to in order to survive an AMI.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

A good way to survive an acute myocardial infarction is to go to the best hospital.

Some patients seem to have found out where those are. For those of us who want to know where to go and what to look for, a recent analysis of 800,000 Medicare patients admitted with acute myocardial infarction (AMI) and heart failure in 10,000 hospitals between 2008 and 2009 provides some reassuring news (National Bureau of Economic Research Working Paper 21603). Its findings indicated that in an era when health care choice is seemingly influenced by testimonial TV ads and the creation of hospitals that look like hotels, technical medical quality outranks all the glitz and bricks. Quality was measured by hospital mortality, 30-day readmissions, adherence to well-established guidelines, and patient satisfaction questionnaires. The investigators measured the effect that medical quality and the “comfort quotient” had on the growth of hospital patient volume through the emergency departments and interhospital referrals.

Hospital admissions increased in hospitals with the highest-quality performance. Over the 2-year period, the hospitals with the highest-quality performance had increases in hospital volume. Hospitals with a 1% improvement in the adjusted AMI mortality had a 17% increase in market share and a 1.5 % growth rate.

The authors estimated that patients with an AMI (or their family) were willing to travel an additional 1.8 miles for an ED admission to a hospital with a higher survival rate, and 34 miles further for a transfer to a hospital with a higher survival rate. When patients had the option to choose a hospital to be transferred to for further care, quality of care measures had an even greater impact on choice. Postdischarge evaluation of patient satisfaction had little or no effect on growth.

Patients admitted through the ED have the least chance for hospital choice, but even in these patients knowledge about quality influenced the choice of the hospital and the long-term hospital growth rate. Considering the fact that there is scant information available either to patients or even doctors about quality measures, there appears to be a choice process either by patient family, doctor, or ambulance driver to direct patients to the hospital with the best survival rate.

How they made those decisions is not clear. Comparative hospital survival data are rarely transmitted to staff physicians and are not widely available to the public. I have never seen any data like these in the multitude of hospital TV ads, yet somehow those numbers, real or perceived, affected admission and transfer. Maybe it’s just reputation; we all know about that. If you are really interested, you can find hospital medical quality and patient experience data at Medicare’s Hospital Compare site.

All this is good. Medical quality wins. Other studies, however, suggest that usually the “comfort quotient” and measures of medical quality are more closely linked. It has also been suggested that volume is the driving force for the improvement in both quality measures by providing the resources and logistics for better care. Whatever the mechanism, it seems that high-quality medical care is not a bad way to choose which neighborhood hospital to go to in order to survive an AMI.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Editor’s note: For the last five presidential elections, this news organization has offered the Republican and Democrat presidential candidate the opportunity to present their ideas directly to U.S. physicians via side-by-side Guest Editorials. The candidates – or their proxies – have used these pages to reach out to you, our readers, with their views on medicine, health care, and other issues. We have taken pride in the ability to offer you a balanced view in the weeks leading up to the general election. This year, we cannot provide you with that balanced view. Despite repeated efforts via every medium at our disposal – telephone calls, emails, Twitter, LinkedIn, and more – the Donald J. Trump for President organization has not responded to our request for a contribution. Here we present the contribution from Secretary Hillary Clinton’s proxy.

Guest Editorial

As physicians, we have the unique privilege of serving patients, often at their most vulnerable moments. We also bear witness to how our health care system works – and too often, where it falls short – through our patients’ eyes.

That view could change dramatically depending on the outcome of this year’s presidential election. Hillary Clinton has a long track record of expanding affordable health care, and wants to accelerate the march toward universal access to high-quality care. Her opponent, Donald Trump, wants to roll back the progress we’ve made, with a plan that takes health insurance away from more than 20 million Americans.

Secretary Clinton’s career demonstrates her commitment to the ideal of health care as a human right. For example, she was instrumental in the bipartisan effort to pass the Children’s Health Insurance Program. Despite recent gains in health coverage, too many Americans still struggle to access the care they need – where and when they need it. Secretary Clinton’s plan for health care would expand access to care by building on the Affordable Care Act – with more relief for high premiums and out-of-pocket costs, particularly for prescription drugs; by working with states to expand Medicaid and give people the choice of a “public option” health plan. She also worked with Sen. Bernie Sanders (I-Vt.) on a plan to double funding for community health centers and substantially expand our commitment to the National Health Service Corps – so that millions more Americans have access to primary care, especially in rural and medically underserved urban areas, and so that we can offer more loan repayment and scholarships to early-career physicians.

Anyone taking care of patients today knows that improving access to care is only the first step. We must improve the way we deliver care, refocusing around the patient-doctor relationship. Too often there are barriers – regulations, paperwork, or insurance restrictions – to taking care of patients in the way that they deserve. Secretary Clinton wants to ensure an advanced and coordinated health care system that supports patient-doctor relationships instead of getting in the way. She wants to spur delivery system reform to reward value and quality. She was one of the first elected officials to call for modernizing health information technology, reaching across the aisle to work with physician and then-Sen. Bill Frist (R-Tenn.). And she’s offered plans to address major contemporary challenges, such as preventing and better treating Alzheimer’s disease, destigmatizing mental illness, and improving care for substance use disorders.

In addition to improving our health care system, Secretary Clinton believes we must take a number of proactive steps so that all Americans – regardless of location, income, or history – have the opportunity to live full, healthy lives. She believes we must invest in our public health infrastructure to ensure preparedness for emerging threats like Zika at home and abroad; to prevent illness and injury in communities; and to promote health equity. Of course, some of the most important determinants of well-being lie outside the walls of our clinics and hospitals. Secretary Clinton also will move us forward on these fundamental issues, such as women’s rights, criminal justice reform, and climate change.

Meanwhile, Donald Trump offers a very different vision for health care in the United States. His proposals would repeal the Affordable Care Act, instantly stripping millions of people of lifesaving health insurance. He would cut Medicaid through block grants, leaving millions of the poorest Americans without a safety net. And he would once again allow insurers to discriminate, based on preexisting conditions.

The choice in November could not be more important, for our patients and for the practice of medicine. Secretary Clinton’s long track record of fighting for universal, high-quality, affordable health care speaks for itself. With so much more left to do to improve health in our country, she brings the thoughtful leadership and steely determination needed to get the job done.

Dr. Chokshi practices internal medicine at Bellevue Hospital in New York and is a health policy adviser to Hillary for America.

Editor’s note: For the last five presidential elections, this news organization has offered the Republican and Democrat presidential candidate the opportunity to present their ideas directly to U.S. physicians via side-by-side Guest Editorials. The candidates – or their proxies – have used these pages to reach out to you, our readers, with their views on medicine, health care, and other issues. We have taken pride in the ability to offer you a balanced view in the weeks leading up to the general election. This year, we cannot provide you with that balanced view. Despite repeated efforts via every medium at our disposal – telephone calls, emails, Twitter, LinkedIn, and more – the Donald J. Trump for President organization has not responded to our request for a contribution. Here we present the contribution from Secretary Hillary Clinton’s proxy.

Guest Editorial

As physicians, we have the unique privilege of serving patients, often at their most vulnerable moments. We also bear witness to how our health care system works – and too often, where it falls short – through our patients’ eyes.

That view could change dramatically depending on the outcome of this year’s presidential election. Hillary Clinton has a long track record of expanding affordable health care, and wants to accelerate the march toward universal access to high-quality care. Her opponent, Donald Trump, wants to roll back the progress we’ve made, with a plan that takes health insurance away from more than 20 million Americans.

Secretary Clinton’s career demonstrates her commitment to the ideal of health care as a human right. For example, she was instrumental in the bipartisan effort to pass the Children’s Health Insurance Program. Despite recent gains in health coverage, too many Americans still struggle to access the care they need – where and when they need it. Secretary Clinton’s plan for health care would expand access to care by building on the Affordable Care Act – with more relief for high premiums and out-of-pocket costs, particularly for prescription drugs; by working with states to expand Medicaid and give people the choice of a “public option” health plan. She also worked with Sen. Bernie Sanders (I-Vt.) on a plan to double funding for community health centers and substantially expand our commitment to the National Health Service Corps – so that millions more Americans have access to primary care, especially in rural and medically underserved urban areas, and so that we can offer more loan repayment and scholarships to early-career physicians.

Anyone taking care of patients today knows that improving access to care is only the first step. We must improve the way we deliver care, refocusing around the patient-doctor relationship. Too often there are barriers – regulations, paperwork, or insurance restrictions – to taking care of patients in the way that they deserve. Secretary Clinton wants to ensure an advanced and coordinated health care system that supports patient-doctor relationships instead of getting in the way. She wants to spur delivery system reform to reward value and quality. She was one of the first elected officials to call for modernizing health information technology, reaching across the aisle to work with physician and then-Sen. Bill Frist (R-Tenn.). And she’s offered plans to address major contemporary challenges, such as preventing and better treating Alzheimer’s disease, destigmatizing mental illness, and improving care for substance use disorders.

In addition to improving our health care system, Secretary Clinton believes we must take a number of proactive steps so that all Americans – regardless of location, income, or history – have the opportunity to live full, healthy lives. She believes we must invest in our public health infrastructure to ensure preparedness for emerging threats like Zika at home and abroad; to prevent illness and injury in communities; and to promote health equity. Of course, some of the most important determinants of well-being lie outside the walls of our clinics and hospitals. Secretary Clinton also will move us forward on these fundamental issues, such as women’s rights, criminal justice reform, and climate change.

Meanwhile, Donald Trump offers a very different vision for health care in the United States. His proposals would repeal the Affordable Care Act, instantly stripping millions of people of lifesaving health insurance. He would cut Medicaid through block grants, leaving millions of the poorest Americans without a safety net. And he would once again allow insurers to discriminate, based on preexisting conditions.

The choice in November could not be more important, for our patients and for the practice of medicine. Secretary Clinton’s long track record of fighting for universal, high-quality, affordable health care speaks for itself. With so much more left to do to improve health in our country, she brings the thoughtful leadership and steely determination needed to get the job done.

Dr. Chokshi practices internal medicine at Bellevue Hospital in New York and is a health policy adviser to Hillary for America.

Editor’s note: For the last five presidential elections, this news organization has offered the Republican and Democrat presidential candidate the opportunity to present their ideas directly to U.S. physicians via side-by-side Guest Editorials. The candidates – or their proxies – have used these pages to reach out to you, our readers, with their views on medicine, health care, and other issues. We have taken pride in the ability to offer you a balanced view in the weeks leading up to the general election. This year, we cannot provide you with that balanced view. Despite repeated efforts via every medium at our disposal – telephone calls, emails, Twitter, LinkedIn, and more – the Donald J. Trump for President organization has not responded to our request for a contribution. Here we present the contribution from Secretary Hillary Clinton’s proxy.

Guest Editorial

As physicians, we have the unique privilege of serving patients, often at their most vulnerable moments. We also bear witness to how our health care system works – and too often, where it falls short – through our patients’ eyes.

That view could change dramatically depending on the outcome of this year’s presidential election. Hillary Clinton has a long track record of expanding affordable health care, and wants to accelerate the march toward universal access to high-quality care. Her opponent, Donald Trump, wants to roll back the progress we’ve made, with a plan that takes health insurance away from more than 20 million Americans.

Secretary Clinton’s career demonstrates her commitment to the ideal of health care as a human right. For example, she was instrumental in the bipartisan effort to pass the Children’s Health Insurance Program. Despite recent gains in health coverage, too many Americans still struggle to access the care they need – where and when they need it. Secretary Clinton’s plan for health care would expand access to care by building on the Affordable Care Act – with more relief for high premiums and out-of-pocket costs, particularly for prescription drugs; by working with states to expand Medicaid and give people the choice of a “public option” health plan. She also worked with Sen. Bernie Sanders (I-Vt.) on a plan to double funding for community health centers and substantially expand our commitment to the National Health Service Corps – so that millions more Americans have access to primary care, especially in rural and medically underserved urban areas, and so that we can offer more loan repayment and scholarships to early-career physicians.

Anyone taking care of patients today knows that improving access to care is only the first step. We must improve the way we deliver care, refocusing around the patient-doctor relationship. Too often there are barriers – regulations, paperwork, or insurance restrictions – to taking care of patients in the way that they deserve. Secretary Clinton wants to ensure an advanced and coordinated health care system that supports patient-doctor relationships instead of getting in the way. She wants to spur delivery system reform to reward value and quality. She was one of the first elected officials to call for modernizing health information technology, reaching across the aisle to work with physician and then-Sen. Bill Frist (R-Tenn.). And she’s offered plans to address major contemporary challenges, such as preventing and better treating Alzheimer’s disease, destigmatizing mental illness, and improving care for substance use disorders.

In addition to improving our health care system, Secretary Clinton believes we must take a number of proactive steps so that all Americans – regardless of location, income, or history – have the opportunity to live full, healthy lives. She believes we must invest in our public health infrastructure to ensure preparedness for emerging threats like Zika at home and abroad; to prevent illness and injury in communities; and to promote health equity. Of course, some of the most important determinants of well-being lie outside the walls of our clinics and hospitals. Secretary Clinton also will move us forward on these fundamental issues, such as women’s rights, criminal justice reform, and climate change.

Meanwhile, Donald Trump offers a very different vision for health care in the United States. His proposals would repeal the Affordable Care Act, instantly stripping millions of people of lifesaving health insurance. He would cut Medicaid through block grants, leaving millions of the poorest Americans without a safety net. And he would once again allow insurers to discriminate, based on preexisting conditions.

The choice in November could not be more important, for our patients and for the practice of medicine. Secretary Clinton’s long track record of fighting for universal, high-quality, affordable health care speaks for itself. With so much more left to do to improve health in our country, she brings the thoughtful leadership and steely determination needed to get the job done.

Dr. Chokshi practices internal medicine at Bellevue Hospital in New York and is a health policy adviser to Hillary for America.

Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?

And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.

They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.

Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”

Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.

A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?

So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.

It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.

While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.

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.”

Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?

And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.

They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.

Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”

Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.

A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?

So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.

It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.

While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.

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.”

Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?

And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.

They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.

Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”

Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.

A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?

So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.

It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.

While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.

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.”

“2016 UPDATE ON MENOPAUSE”

ANDREW M. KAUNITZ, MD (JULY 2016)

Menopause and hormone therapy

As a long-term believer (proven!) of the value of the old comment, “estrogen forever,” I was pleased to see all the positive comments about estrogen in Dr. Kaunitz’s article. I was disappointed, however, in the comments in the box (page 39), “What this evidence means for practice.”

While my prejudice, statistically supported, is old fashioned, omission of the newer and marvelous way to counteract the only bad effects of estrogen (endometrial stimulation leading to endometrial adenocarcinoma) seems to be a major oversight. The new and least (if any) side-effect method means a levonorgestrel-releasing intrauterine device (LNG-IUD) yielding local progesterone counteraction to this major side effect of estrogen therapy.

Arthur A. Fleisher II, MD
Northridge, California

Dr. Kaunitz responds

I thank Dr. Fleisher for his interest in my 2016 Update on Menopause. I agree that off-label use of the LNG-IUD represents an appropriate alternative to systemic progestin when using estrogen to treat menopausal symptoms in women with an intact uterus.

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

“2016 UPDATE ON MENOPAUSE”

ANDREW M. KAUNITZ, MD (JULY 2016)

Menopause and hormone therapy

As a long-term believer (proven!) of the value of the old comment, “estrogen forever,” I was pleased to see all the positive comments about estrogen in Dr. Kaunitz’s article. I was disappointed, however, in the comments in the box (page 39), “What this evidence means for practice.”

While my prejudice, statistically supported, is old fashioned, omission of the newer and marvelous way to counteract the only bad effects of estrogen (endometrial stimulation leading to endometrial adenocarcinoma) seems to be a major oversight. The new and least (if any) side-effect method means a levonorgestrel-releasing intrauterine device (LNG-IUD) yielding local progesterone counteraction to this major side effect of estrogen therapy.

Arthur A. Fleisher II, MD
Northridge, California

Dr. Kaunitz responds

I thank Dr. Fleisher for his interest in my 2016 Update on Menopause. I agree that off-label use of the LNG-IUD represents an appropriate alternative to systemic progestin when using estrogen to treat menopausal symptoms in women with an intact uterus.

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

“2016 UPDATE ON MENOPAUSE”

ANDREW M. KAUNITZ, MD (JULY 2016)

Menopause and hormone therapy

As a long-term believer (proven!) of the value of the old comment, “estrogen forever,” I was pleased to see all the positive comments about estrogen in Dr. Kaunitz’s article. I was disappointed, however, in the comments in the box (page 39), “What this evidence means for practice.”

While my prejudice, statistically supported, is old fashioned, omission of the newer and marvelous way to counteract the only bad effects of estrogen (endometrial stimulation leading to endometrial adenocarcinoma) seems to be a major oversight. The new and least (if any) side-effect method means a levonorgestrel-releasing intrauterine device (LNG-IUD) yielding local progesterone counteraction to this major side effect of estrogen therapy.

Arthur A. Fleisher II, MD
Northridge, California

Dr. Kaunitz responds

I thank Dr. Fleisher for his interest in my 2016 Update on Menopause. I agree that off-label use of the LNG-IUD represents an appropriate alternative to systemic progestin when using estrogen to treat menopausal symptoms in women with an intact uterus.

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

VIDEO: “LAPAROSCOPIC SALPINGECTOMY AND CORNUAL RESECTION REPURPOSED: A NOVEL APPROACH TO TUBAL OCCLUSION DEVICE REMOVAL”

MICHELLE PACIS, MD, MPH (JULY 2016)

Easier technique for removing tubal occlusion devices?

My patient’s rheumatologist recently asked me to remove the tubal occlusion device (Essure) inserts that I had placed approximately 5 years ago. I think the technique I used was a little easier than the one shown in the video by Dr. Pacis and featured by Dr. Advincula in his video series. I started with a standard salpingectomy from the fimbriated end, as did the technique in the video. Then I made a circumferential incision of the tubal serosa at the junction of the tube as it enters the cornua, taking care to not cut the device insert, which could be visualized and felt with cold shears. The proximal end of the device insert, including the post and coil, then easily pulled out with some elongation of the coil. Since I did not need to resect the cornua, I was able to easily seal off the small defect without need to suture.

Alexander Lin, MD
Chicago, Illinois

Dr. Pacis responds

Thank you for sharing your method for tubal occlusion device removal. Your technique would certainly work for devices that reside predominantly in the tube. We have found that many of the devices become quite anchored and adherent to the tubal mucosa. While there are many surgical approaches to device removal, our preference is to perform salpingectomy with cornual resection, so as to avoid traction on the microinsert, and remove the device intact. We are then able to give the specimen, which contains the insert, to pathology so they can comment on the status of the device.

VIDEO: “LAPAROSCOPIC SALPINGECTOMY AND CORNUAL RESECTION REPURPOSED: A NOVEL APPROACH TO TUBAL OCCLUSION DEVICE REMOVAL”

MICHELLE PACIS, MD, MPH (JULY 2016)

Easier technique for removing tubal occlusion devices?

My patient’s rheumatologist recently asked me to remove the tubal occlusion device (Essure) inserts that I had placed approximately 5 years ago. I think the technique I used was a little easier than the one shown in the video by Dr. Pacis and featured by Dr. Advincula in his video series. I started with a standard salpingectomy from the fimbriated end, as did the technique in the video. Then I made a circumferential incision of the tubal serosa at the junction of the tube as it enters the cornua, taking care to not cut the device insert, which could be visualized and felt with cold shears. The proximal end of the device insert, including the post and coil, then easily pulled out with some elongation of the coil. Since I did not need to resect the cornua, I was able to easily seal off the small defect without need to suture.

Alexander Lin, MD
Chicago, Illinois

Dr. Pacis responds

Thank you for sharing your method for tubal occlusion device removal. Your technique would certainly work for devices that reside predominantly in the tube. We have found that many of the devices become quite anchored and adherent to the tubal mucosa. While there are many surgical approaches to device removal, our preference is to perform salpingectomy with cornual resection, so as to avoid traction on the microinsert, and remove the device intact. We are then able to give the specimen, which contains the insert, to pathology so they can comment on the status of the device.

VIDEO: “LAPAROSCOPIC SALPINGECTOMY AND CORNUAL RESECTION REPURPOSED: A NOVEL APPROACH TO TUBAL OCCLUSION DEVICE REMOVAL”

MICHELLE PACIS, MD, MPH (JULY 2016)

Easier technique for removing tubal occlusion devices?

My patient’s rheumatologist recently asked me to remove the tubal occlusion device (Essure) inserts that I had placed approximately 5 years ago. I think the technique I used was a little easier than the one shown in the video by Dr. Pacis and featured by Dr. Advincula in his video series. I started with a standard salpingectomy from the fimbriated end, as did the technique in the video. Then I made a circumferential incision of the tubal serosa at the junction of the tube as it enters the cornua, taking care to not cut the device insert, which could be visualized and felt with cold shears. The proximal end of the device insert, including the post and coil, then easily pulled out with some elongation of the coil. Since I did not need to resect the cornua, I was able to easily seal off the small defect without need to suture.

Alexander Lin, MD
Chicago, Illinois

Dr. Pacis responds

Thank you for sharing your method for tubal occlusion device removal. Your technique would certainly work for devices that reside predominantly in the tube. We have found that many of the devices become quite anchored and adherent to the tubal mucosa. While there are many surgical approaches to device removal, our preference is to perform salpingectomy with cornual resection, so as to avoid traction on the microinsert, and remove the device intact. We are then able to give the specimen, which contains the insert, to pathology so they can comment on the status of the device.