Commentary

Keeping up on medical literature is never easy. Time is limited between work and family. It’s often hard to know what to read. Most journals are a combination of research and practical information.

I’m not an academic and never will be. I have nothing against my colleagues who are, but it’s just not my personality type. I’m a happy-to-see-patients-all-day type of doctor.

I try to stick with reading things that have an immediate impact on how I practice: review articles, information about new diagnostic procedures and treatments, and news about the economics of medicine. That’s about it. If I can’t use it now or in the immediate future, it’s not relevant to my practice. My patients want to know what I can do for them today, not in 5-10 years. There’s enough to keep up on that’s relevant to current practice as it is.

Research in medicine is obviously crucial, since what we do is based on it. There is a lot of interesting and potentially game-changing research out there. But medical literature is full of small studies that show promise for something only to be shot down when larger investigations are done. It’s not practical or even good medicine to make treatment decisions based on small-scale preliminary data and anecdotal reports.

Even the oft-cited “green journal” – Neurology – isn’t on my reading list. I admit that it has its share of practical knowledge, but the last time I read it, the majority of pages were devoted to research that was promising, though not imminently applicable to patient care. That’s not for me.

Time is always at a premium in modern life. There’s no shortage of journals and interesting research to peruse, and so I try to stay with what’s practical for both me and my patients. I’ll leave the research to those who are good at it, and do my best to support the people who come to my office every day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Keeping up on medical literature is never easy. Time is limited between work and family. It’s often hard to know what to read. Most journals are a combination of research and practical information.

I’m not an academic and never will be. I have nothing against my colleagues who are, but it’s just not my personality type. I’m a happy-to-see-patients-all-day type of doctor.

I try to stick with reading things that have an immediate impact on how I practice: review articles, information about new diagnostic procedures and treatments, and news about the economics of medicine. That’s about it. If I can’t use it now or in the immediate future, it’s not relevant to my practice. My patients want to know what I can do for them today, not in 5-10 years. There’s enough to keep up on that’s relevant to current practice as it is.

Research in medicine is obviously crucial, since what we do is based on it. There is a lot of interesting and potentially game-changing research out there. But medical literature is full of small studies that show promise for something only to be shot down when larger investigations are done. It’s not practical or even good medicine to make treatment decisions based on small-scale preliminary data and anecdotal reports.

Even the oft-cited “green journal” – Neurology – isn’t on my reading list. I admit that it has its share of practical knowledge, but the last time I read it, the majority of pages were devoted to research that was promising, though not imminently applicable to patient care. That’s not for me.

Time is always at a premium in modern life. There’s no shortage of journals and interesting research to peruse, and so I try to stay with what’s practical for both me and my patients. I’ll leave the research to those who are good at it, and do my best to support the people who come to my office every day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Keeping up on medical literature is never easy. Time is limited between work and family. It’s often hard to know what to read. Most journals are a combination of research and practical information.

I’m not an academic and never will be. I have nothing against my colleagues who are, but it’s just not my personality type. I’m a happy-to-see-patients-all-day type of doctor.

I try to stick with reading things that have an immediate impact on how I practice: review articles, information about new diagnostic procedures and treatments, and news about the economics of medicine. That’s about it. If I can’t use it now or in the immediate future, it’s not relevant to my practice. My patients want to know what I can do for them today, not in 5-10 years. There’s enough to keep up on that’s relevant to current practice as it is.

Research in medicine is obviously crucial, since what we do is based on it. There is a lot of interesting and potentially game-changing research out there. But medical literature is full of small studies that show promise for something only to be shot down when larger investigations are done. It’s not practical or even good medicine to make treatment decisions based on small-scale preliminary data and anecdotal reports.

Even the oft-cited “green journal” – Neurology – isn’t on my reading list. I admit that it has its share of practical knowledge, but the last time I read it, the majority of pages were devoted to research that was promising, though not imminently applicable to patient care. That’s not for me.

Time is always at a premium in modern life. There’s no shortage of journals and interesting research to peruse, and so I try to stay with what’s practical for both me and my patients. I’ll leave the research to those who are good at it, and do my best to support the people who come to my office every day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Due to advancements in surgical treatment, chemotherapy, and radiation therapy, gynecologic cancer survival rates are continuing to improve and quality of life is evolving into an even more significant focus in cancer care.

Roughly 30%-40% of all women with a gynecologic malignancy will experience climacteric symptoms and menopause prior to the anticipated time of natural menopause (J Clin Oncol. 2009 Mar 10;27[8]:1214-9). Cessation of ovarian estrogen and progesterone production can result in short-term as well as long-term sequelae, including vasomotor symptoms, vaginal dryness, osteoporosis, and mood disturbances. Iatrogenic menopause after cancer treatment can be more sudden and severe when compared with the natural course of physiologic menopause. As a result, determination of safe, effective modalities for treating these symptoms is of particular importance for survivor quality of life.

Both combination and estrogen-only hormone replacement therapy (HT) provide greater improvement in these specific symptoms and overall quality of life than placebo as demonstrated in several observational and randomized control trials (Cochrane Database Syst Rev. 2009 Apr 15;[2]:CD004143).

Endometrial cancer

Endometrial cancer is the most common gynecologic malignancy, with approximately 54,000 new cases anticipated in the United States in 2015. Twenty-five percent of these new cases will be in premenopausal women, and with an ever-increasing obesity rate, this number may continue to climb.

Women with early-stage Type 1 endometrial cancer who have vasomotor symptoms after surgery may be offered a short course of estrogen-based HT at the lowest effective dose following hysterectomy/bilateral salpingo-oophorectomy and staging procedure (J Clin Oncol. 2006 Feb 1;24[4]:587-92). For women with genitourinary symptoms, vaginal moisturizers and/or low-dose vaginal estrogen are reasonable options. Unfortunately, there are no data to guide the use of estrogen replacement therapy in women with Type 2 endometrial cancers (Gynecol Oncol. 2011 Aug;122[2]:447-54).

Ovarian cancer

There is minimal data implicating a hormonal causation to ovarian carcinogenesis. Most women with epithelial ovarian cancer do not express tumor estrogen or progesterone receptors. Treatment will result in abrupt, iatrogenic menopause, raising the question of whether it is safe to use HT in patients with epithelial ovarian cancer.

Multiple studies have failed to demonstrate a difference in 5-year survival rates in women with epithelial cancer using HT for 2 years or less (JAMA. 2009 Jul 15;302[3]:298-305, Eur J Gynaecol Oncol. 2000;21[2]:192-6, Cancer. 1999 Sep 15;86[6]:1013-8). As such, symptomatic patients could be offered a course of HT; however, caution should be exercised in women with estrogen/progesterone–expressing tumors or nonepithelial tumors. As with endometrial cancer patients, the lowest effective doses should be prescribed.

Cervical cancer

Most cervical squamous and adenocarcinomas are not hormone dependent. For women with early-stage squamous cell carcinoma, ovarian conservation may be possible or oophoropexy may be offered. However, for many patients, bilateral salpingo-oophorectomy at the time of hysterectomy is more common, and the local effect of radiation therapy can result in vaginal atrophy with subsequent dyspareunia or ovarian failure from radiation scatter. Even for patients who undergo oophoropexy, radiation scatter may still result in ovarian failure. In a few observational studies, there are no data to infer that cervical cancer is hormonally related or that survival rates are decreased.

Currently, HT use in cervical cancer survivors is considered safe. Of note, for women with more advanced-stage cervical cancer and who received chemoradiation for primary treatment, combination therapy with estrogen and progesterone may be more appropriate if the uterus remains in situ. However, for women who have undergone hysterectomy, combination therapy with progesterone may not be warranted and estrogen alone (orally or vaginally) is acceptable (Gynecol Oncol. 2011 Aug;122[2]:447-54)

Nonhormonal therapies

Women presenting with menopausal symptoms in whom estrogen therapy is contraindicated or not desired can also consider using nonhormonal therapies as an alternative. These include selective serotonin reuptake inhibitors (SSRIs) and alpha-2 adrenergic agonists, such as clonidine. Albeit not as effective as HT, these alternative therapies are reasonable options, particularly for management of vasomotor symptoms.

From a limited number of observational studies and a few randomized trials, short-term hormone replacement therapy does not present increased risk to survivors of gynecologic cancers. Additionally, patients have the added option of using nonhormonal therapies, which may provide some benefit. The decision to institute HT should occur after a thorough discussion of the potential to optimize symptom control and the theoretical risk of stimulating quiescent malignant disease.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures.

Due to advancements in surgical treatment, chemotherapy, and radiation therapy, gynecologic cancer survival rates are continuing to improve and quality of life is evolving into an even more significant focus in cancer care.

Roughly 30%-40% of all women with a gynecologic malignancy will experience climacteric symptoms and menopause prior to the anticipated time of natural menopause (J Clin Oncol. 2009 Mar 10;27[8]:1214-9). Cessation of ovarian estrogen and progesterone production can result in short-term as well as long-term sequelae, including vasomotor symptoms, vaginal dryness, osteoporosis, and mood disturbances. Iatrogenic menopause after cancer treatment can be more sudden and severe when compared with the natural course of physiologic menopause. As a result, determination of safe, effective modalities for treating these symptoms is of particular importance for survivor quality of life.

Both combination and estrogen-only hormone replacement therapy (HT) provide greater improvement in these specific symptoms and overall quality of life than placebo as demonstrated in several observational and randomized control trials (Cochrane Database Syst Rev. 2009 Apr 15;[2]:CD004143).

Endometrial cancer

Endometrial cancer is the most common gynecologic malignancy, with approximately 54,000 new cases anticipated in the United States in 2015. Twenty-five percent of these new cases will be in premenopausal women, and with an ever-increasing obesity rate, this number may continue to climb.

Women with early-stage Type 1 endometrial cancer who have vasomotor symptoms after surgery may be offered a short course of estrogen-based HT at the lowest effective dose following hysterectomy/bilateral salpingo-oophorectomy and staging procedure (J Clin Oncol. 2006 Feb 1;24[4]:587-92). For women with genitourinary symptoms, vaginal moisturizers and/or low-dose vaginal estrogen are reasonable options. Unfortunately, there are no data to guide the use of estrogen replacement therapy in women with Type 2 endometrial cancers (Gynecol Oncol. 2011 Aug;122[2]:447-54).

Ovarian cancer

There is minimal data implicating a hormonal causation to ovarian carcinogenesis. Most women with epithelial ovarian cancer do not express tumor estrogen or progesterone receptors. Treatment will result in abrupt, iatrogenic menopause, raising the question of whether it is safe to use HT in patients with epithelial ovarian cancer.

Multiple studies have failed to demonstrate a difference in 5-year survival rates in women with epithelial cancer using HT for 2 years or less (JAMA. 2009 Jul 15;302[3]:298-305, Eur J Gynaecol Oncol. 2000;21[2]:192-6, Cancer. 1999 Sep 15;86[6]:1013-8). As such, symptomatic patients could be offered a course of HT; however, caution should be exercised in women with estrogen/progesterone–expressing tumors or nonepithelial tumors. As with endometrial cancer patients, the lowest effective doses should be prescribed.

Cervical cancer

Most cervical squamous and adenocarcinomas are not hormone dependent. For women with early-stage squamous cell carcinoma, ovarian conservation may be possible or oophoropexy may be offered. However, for many patients, bilateral salpingo-oophorectomy at the time of hysterectomy is more common, and the local effect of radiation therapy can result in vaginal atrophy with subsequent dyspareunia or ovarian failure from radiation scatter. Even for patients who undergo oophoropexy, radiation scatter may still result in ovarian failure. In a few observational studies, there are no data to infer that cervical cancer is hormonally related or that survival rates are decreased.

Currently, HT use in cervical cancer survivors is considered safe. Of note, for women with more advanced-stage cervical cancer and who received chemoradiation for primary treatment, combination therapy with estrogen and progesterone may be more appropriate if the uterus remains in situ. However, for women who have undergone hysterectomy, combination therapy with progesterone may not be warranted and estrogen alone (orally or vaginally) is acceptable (Gynecol Oncol. 2011 Aug;122[2]:447-54)

Nonhormonal therapies

Women presenting with menopausal symptoms in whom estrogen therapy is contraindicated or not desired can also consider using nonhormonal therapies as an alternative. These include selective serotonin reuptake inhibitors (SSRIs) and alpha-2 adrenergic agonists, such as clonidine. Albeit not as effective as HT, these alternative therapies are reasonable options, particularly for management of vasomotor symptoms.

From a limited number of observational studies and a few randomized trials, short-term hormone replacement therapy does not present increased risk to survivors of gynecologic cancers. Additionally, patients have the added option of using nonhormonal therapies, which may provide some benefit. The decision to institute HT should occur after a thorough discussion of the potential to optimize symptom control and the theoretical risk of stimulating quiescent malignant disease.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures.

Due to advancements in surgical treatment, chemotherapy, and radiation therapy, gynecologic cancer survival rates are continuing to improve and quality of life is evolving into an even more significant focus in cancer care.

Roughly 30%-40% of all women with a gynecologic malignancy will experience climacteric symptoms and menopause prior to the anticipated time of natural menopause (J Clin Oncol. 2009 Mar 10;27[8]:1214-9). Cessation of ovarian estrogen and progesterone production can result in short-term as well as long-term sequelae, including vasomotor symptoms, vaginal dryness, osteoporosis, and mood disturbances. Iatrogenic menopause after cancer treatment can be more sudden and severe when compared with the natural course of physiologic menopause. As a result, determination of safe, effective modalities for treating these symptoms is of particular importance for survivor quality of life.

Both combination and estrogen-only hormone replacement therapy (HT) provide greater improvement in these specific symptoms and overall quality of life than placebo as demonstrated in several observational and randomized control trials (Cochrane Database Syst Rev. 2009 Apr 15;[2]:CD004143).

Endometrial cancer

Endometrial cancer is the most common gynecologic malignancy, with approximately 54,000 new cases anticipated in the United States in 2015. Twenty-five percent of these new cases will be in premenopausal women, and with an ever-increasing obesity rate, this number may continue to climb.

Women with early-stage Type 1 endometrial cancer who have vasomotor symptoms after surgery may be offered a short course of estrogen-based HT at the lowest effective dose following hysterectomy/bilateral salpingo-oophorectomy and staging procedure (J Clin Oncol. 2006 Feb 1;24[4]:587-92). For women with genitourinary symptoms, vaginal moisturizers and/or low-dose vaginal estrogen are reasonable options. Unfortunately, there are no data to guide the use of estrogen replacement therapy in women with Type 2 endometrial cancers (Gynecol Oncol. 2011 Aug;122[2]:447-54).

Ovarian cancer

There is minimal data implicating a hormonal causation to ovarian carcinogenesis. Most women with epithelial ovarian cancer do not express tumor estrogen or progesterone receptors. Treatment will result in abrupt, iatrogenic menopause, raising the question of whether it is safe to use HT in patients with epithelial ovarian cancer.

Multiple studies have failed to demonstrate a difference in 5-year survival rates in women with epithelial cancer using HT for 2 years or less (JAMA. 2009 Jul 15;302[3]:298-305, Eur J Gynaecol Oncol. 2000;21[2]:192-6, Cancer. 1999 Sep 15;86[6]:1013-8). As such, symptomatic patients could be offered a course of HT; however, caution should be exercised in women with estrogen/progesterone–expressing tumors or nonepithelial tumors. As with endometrial cancer patients, the lowest effective doses should be prescribed.

Cervical cancer

Most cervical squamous and adenocarcinomas are not hormone dependent. For women with early-stage squamous cell carcinoma, ovarian conservation may be possible or oophoropexy may be offered. However, for many patients, bilateral salpingo-oophorectomy at the time of hysterectomy is more common, and the local effect of radiation therapy can result in vaginal atrophy with subsequent dyspareunia or ovarian failure from radiation scatter. Even for patients who undergo oophoropexy, radiation scatter may still result in ovarian failure. In a few observational studies, there are no data to infer that cervical cancer is hormonally related or that survival rates are decreased.

Currently, HT use in cervical cancer survivors is considered safe. Of note, for women with more advanced-stage cervical cancer and who received chemoradiation for primary treatment, combination therapy with estrogen and progesterone may be more appropriate if the uterus remains in situ. However, for women who have undergone hysterectomy, combination therapy with progesterone may not be warranted and estrogen alone (orally or vaginally) is acceptable (Gynecol Oncol. 2011 Aug;122[2]:447-54)

Nonhormonal therapies

Women presenting with menopausal symptoms in whom estrogen therapy is contraindicated or not desired can also consider using nonhormonal therapies as an alternative. These include selective serotonin reuptake inhibitors (SSRIs) and alpha-2 adrenergic agonists, such as clonidine. Albeit not as effective as HT, these alternative therapies are reasonable options, particularly for management of vasomotor symptoms.

From a limited number of observational studies and a few randomized trials, short-term hormone replacement therapy does not present increased risk to survivors of gynecologic cancers. Additionally, patients have the added option of using nonhormonal therapies, which may provide some benefit. The decision to institute HT should occur after a thorough discussion of the potential to optimize symptom control and the theoretical risk of stimulating quiescent malignant disease.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures.

We are in the midst of an epidemic of heroin and prescription opioid abuse. While the two do not completely explain each other, they are tragically and irrevocably linked.

From 2001 to 2013, we have observed a threefold increase in the total number of overdose deaths from opioid pain relievers (about 16,000 in 2013) and a fivefold increase in the total number of overdose deaths from heroin (about 8,000 in 2013).

Heroin initiation is almost 20 times higher among individuals reporting nonmedical prescription pain reliever use. Among opioid-treatment seekers, the majority of individuals who initiated opioid use in the 1960s were first exposed to heroin. This is in contrast to those who initiated in the 2000s, among whom the majority were exposed to prescription opioids. For young adults, the main sources of opioids are family, friends … and clinicians.

Opioids are powerfully addictive and can be snorted, swallowed, smoked, or shot. Data from the START (Starting Treatment with Agonist Replacement Therapies) trial suggest that individuals who inject opioids are less likely to remain in treatment than noninjectors. This necessarily increases the risk for injectors to inject again and be at risk for overdose.

Opioid overdose can be reversed with the use of naloxone. But naloxone has to be immediately or quickly available for it to be effective. Take-home naloxone programs are located in 30 U.S. states and the District of Columbia. Since 1996, home naloxone programs have reported more than 26,000 drug overdose reversals with naloxone.

On Nov. 18, the Food and Drug Administration announced the approval of a naloxone nasal spray. Prior to this approval, naloxone was only available in the injectable form (syringe or auto-injector), and needle management likely posed a barrier to first responders. The nasal spray can be administered easily without medical training. Naloxone nasal spray administered in one nostril delivered approximately the same levels or higher of naloxone as a single dose of an FDA-approved naloxone intramuscular injection in approximately the same time frame.

It is one thing to save a heroin addict who has just overdosed with nasal naloxone followed by appropriate medical attention. It is entirely another to engage them in an effective drug treatment program.

If naloxone revives them, it is treatment that can save them.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

We are in the midst of an epidemic of heroin and prescription opioid abuse. While the two do not completely explain each other, they are tragically and irrevocably linked.

From 2001 to 2013, we have observed a threefold increase in the total number of overdose deaths from opioid pain relievers (about 16,000 in 2013) and a fivefold increase in the total number of overdose deaths from heroin (about 8,000 in 2013).

Heroin initiation is almost 20 times higher among individuals reporting nonmedical prescription pain reliever use. Among opioid-treatment seekers, the majority of individuals who initiated opioid use in the 1960s were first exposed to heroin. This is in contrast to those who initiated in the 2000s, among whom the majority were exposed to prescription opioids. For young adults, the main sources of opioids are family, friends … and clinicians.

Opioids are powerfully addictive and can be snorted, swallowed, smoked, or shot. Data from the START (Starting Treatment with Agonist Replacement Therapies) trial suggest that individuals who inject opioids are less likely to remain in treatment than noninjectors. This necessarily increases the risk for injectors to inject again and be at risk for overdose.

Opioid overdose can be reversed with the use of naloxone. But naloxone has to be immediately or quickly available for it to be effective. Take-home naloxone programs are located in 30 U.S. states and the District of Columbia. Since 1996, home naloxone programs have reported more than 26,000 drug overdose reversals with naloxone.

On Nov. 18, the Food and Drug Administration announced the approval of a naloxone nasal spray. Prior to this approval, naloxone was only available in the injectable form (syringe or auto-injector), and needle management likely posed a barrier to first responders. The nasal spray can be administered easily without medical training. Naloxone nasal spray administered in one nostril delivered approximately the same levels or higher of naloxone as a single dose of an FDA-approved naloxone intramuscular injection in approximately the same time frame.

It is one thing to save a heroin addict who has just overdosed with nasal naloxone followed by appropriate medical attention. It is entirely another to engage them in an effective drug treatment program.

If naloxone revives them, it is treatment that can save them.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

We are in the midst of an epidemic of heroin and prescription opioid abuse. While the two do not completely explain each other, they are tragically and irrevocably linked.

From 2001 to 2013, we have observed a threefold increase in the total number of overdose deaths from opioid pain relievers (about 16,000 in 2013) and a fivefold increase in the total number of overdose deaths from heroin (about 8,000 in 2013).

Heroin initiation is almost 20 times higher among individuals reporting nonmedical prescription pain reliever use. Among opioid-treatment seekers, the majority of individuals who initiated opioid use in the 1960s were first exposed to heroin. This is in contrast to those who initiated in the 2000s, among whom the majority were exposed to prescription opioids. For young adults, the main sources of opioids are family, friends … and clinicians.

Opioids are powerfully addictive and can be snorted, swallowed, smoked, or shot. Data from the START (Starting Treatment with Agonist Replacement Therapies) trial suggest that individuals who inject opioids are less likely to remain in treatment than noninjectors. This necessarily increases the risk for injectors to inject again and be at risk for overdose.

Opioid overdose can be reversed with the use of naloxone. But naloxone has to be immediately or quickly available for it to be effective. Take-home naloxone programs are located in 30 U.S. states and the District of Columbia. Since 1996, home naloxone programs have reported more than 26,000 drug overdose reversals with naloxone.

On Nov. 18, the Food and Drug Administration announced the approval of a naloxone nasal spray. Prior to this approval, naloxone was only available in the injectable form (syringe or auto-injector), and needle management likely posed a barrier to first responders. The nasal spray can be administered easily without medical training. Naloxone nasal spray administered in one nostril delivered approximately the same levels or higher of naloxone as a single dose of an FDA-approved naloxone intramuscular injection in approximately the same time frame.

It is one thing to save a heroin addict who has just overdosed with nasal naloxone followed by appropriate medical attention. It is entirely another to engage them in an effective drug treatment program.

If naloxone revives them, it is treatment that can save them.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

When I think of the word “relationship,” I imagine gazing into the loving eyes of my husband, playing hide and seek with my children, or texting my best friend for no good reason other than to just say hello.

There is a special comfort zone we expect from people who are close to us; a feeling of love and acceptance that we can’t find elsewhere.

But in a much broader sense, our important relationships extend far beyond our inner circle to include every single person who is involved with our health care team. Our team includes the hospital executives who create new safety initiatives, develop budgets, and oversee a host of other patient care and fiscal functions. The physical therapists who evaluate our patients and make recommendations on how to safely transition them out of the hospital are on our team. The housekeepers who scrub the toilets and wash the linens to prevent nosocomial infections are on our team. They, along with many others, play a pivotal role in our patients’ care, although many important players make their impact behind the scenes.

Yet, of course, our most important professional relationships are not with the CEO, the pharmacist, or even the nursing staff. Our most important relationships are with our patients and their families. I recently attended an all-day conference on a little-known gem called Relationship-Based Care (RBC), a culture transformation and operational model that is gaining steam globally. The RBC model focuses not only on well-known metrics, such as patient safety, quality care, and patient satisfaction; it also emphasizes staff satisfaction by improving each and every relationship. Specifically, it creates therapeutic relationships between caregivers and the patients and families they serve, strengthens relationships between members of the health care team, and last, but certainly not least, it nurtures each caregiver’s relationship with himself or herself. What a novel, and much needed concept!

Numerous hospitals that have implemented this training model have achieved impressive outcomes, including significant improvement in HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, and staff satisfaction survey scores so high that one hospital gained national recognition as one of the best places to work in America.

I look forward to future training on RBC and am glad to see that addressing the needs of caregivers, not just care receivers, is starting to take center stage, as it rightfully should. After all, how can we give our all to our patients when we are not whole?

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

When I think of the word “relationship,” I imagine gazing into the loving eyes of my husband, playing hide and seek with my children, or texting my best friend for no good reason other than to just say hello.

There is a special comfort zone we expect from people who are close to us; a feeling of love and acceptance that we can’t find elsewhere.

But in a much broader sense, our important relationships extend far beyond our inner circle to include every single person who is involved with our health care team. Our team includes the hospital executives who create new safety initiatives, develop budgets, and oversee a host of other patient care and fiscal functions. The physical therapists who evaluate our patients and make recommendations on how to safely transition them out of the hospital are on our team. The housekeepers who scrub the toilets and wash the linens to prevent nosocomial infections are on our team. They, along with many others, play a pivotal role in our patients’ care, although many important players make their impact behind the scenes.

Yet, of course, our most important professional relationships are not with the CEO, the pharmacist, or even the nursing staff. Our most important relationships are with our patients and their families. I recently attended an all-day conference on a little-known gem called Relationship-Based Care (RBC), a culture transformation and operational model that is gaining steam globally. The RBC model focuses not only on well-known metrics, such as patient safety, quality care, and patient satisfaction; it also emphasizes staff satisfaction by improving each and every relationship. Specifically, it creates therapeutic relationships between caregivers and the patients and families they serve, strengthens relationships between members of the health care team, and last, but certainly not least, it nurtures each caregiver’s relationship with himself or herself. What a novel, and much needed concept!

Numerous hospitals that have implemented this training model have achieved impressive outcomes, including significant improvement in HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, and staff satisfaction survey scores so high that one hospital gained national recognition as one of the best places to work in America.

I look forward to future training on RBC and am glad to see that addressing the needs of caregivers, not just care receivers, is starting to take center stage, as it rightfully should. After all, how can we give our all to our patients when we are not whole?

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

When I think of the word “relationship,” I imagine gazing into the loving eyes of my husband, playing hide and seek with my children, or texting my best friend for no good reason other than to just say hello.

There is a special comfort zone we expect from people who are close to us; a feeling of love and acceptance that we can’t find elsewhere.

But in a much broader sense, our important relationships extend far beyond our inner circle to include every single person who is involved with our health care team. Our team includes the hospital executives who create new safety initiatives, develop budgets, and oversee a host of other patient care and fiscal functions. The physical therapists who evaluate our patients and make recommendations on how to safely transition them out of the hospital are on our team. The housekeepers who scrub the toilets and wash the linens to prevent nosocomial infections are on our team. They, along with many others, play a pivotal role in our patients’ care, although many important players make their impact behind the scenes.

Yet, of course, our most important professional relationships are not with the CEO, the pharmacist, or even the nursing staff. Our most important relationships are with our patients and their families. I recently attended an all-day conference on a little-known gem called Relationship-Based Care (RBC), a culture transformation and operational model that is gaining steam globally. The RBC model focuses not only on well-known metrics, such as patient safety, quality care, and patient satisfaction; it also emphasizes staff satisfaction by improving each and every relationship. Specifically, it creates therapeutic relationships between caregivers and the patients and families they serve, strengthens relationships between members of the health care team, and last, but certainly not least, it nurtures each caregiver’s relationship with himself or herself. What a novel, and much needed concept!

Numerous hospitals that have implemented this training model have achieved impressive outcomes, including significant improvement in HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, and staff satisfaction survey scores so high that one hospital gained national recognition as one of the best places to work in America.

I look forward to future training on RBC and am glad to see that addressing the needs of caregivers, not just care receivers, is starting to take center stage, as it rightfully should. After all, how can we give our all to our patients when we are not whole?

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

Orthopedic surgery is going through a time of remarkable change. Health care reform, heightened public scrutiny, shifting population demographics, increased reliance on the Internet for information, ongoing metamorphosis of our profession into a business, and lack of consistent high-quality clinical evidence have created a new frontier of challenges and opportunities. At heart are the needs to deliver high-quality education that is in line with new technological media, to reclaim our ability to guide musculoskeletal care at the policymaking level, to fortify our long-held tradition of ethical responsibility, to invest in research and the training of physician-scientists, to maintain unity among the different subspecialties, and to increase female and minority representation. Never before has understanding and applying the key tenets of our philosophy as orthopedic surgeons been more crucial.

The changing landscape of orthopedic practice has been an unsettling topic in many of the American Academy of Orthopaedic Surgeons (AAOS) presidential addresses in recent years.^1-11 What are the challenges and what can we learn moving forward? In this article, we seek to answer these questions by drawing insights from the combined experience and wisdom of past AAOS presidents since the turn of the 21st century.

Education

Education is the cornerstone of providing quality musculoskeletal care¹² and staying up to date with technological advances.¹³ The modes of education delivery, however, have changed. No longer is orthopedic education confined to tangible textbooks and journal articles, nor is it limited to those of us in the profession. Instead, orthopedic education has shifted toward online learning¹⁴ and is available to patients and nonorthopedic providers.¹² With more patients gaining access to rapidly growing online resources, a unique challenge has arisen: an abundance of data with variable quality of evidence influencing the decision-making process. This has created what Richard Kyle¹⁵ described as the “trap of the new technology war,” where patient misinformation and direct-to-consumer marketing can lead to dangerous musculoskeletal care delivery, including unrealistic patient expectations.³ To compound the problem, our ability to provide orthopedic education in formats compatible with the new learning mediums has not been up to the demand, with issues of cost, accessibility, and efficacy plaguing the current process.^3,5 Also, we have yet to unlock the benefits of surgical simulation, which has the potential to provide more effective training at no risk to the patient.^4,13 By adapting to the new learning formats, we can provide numerous new opportunities for keeping up to date on evolving practice management principles, which, with added accessibility, will be used more often by orthopedic surgeons and the public.¹³ 

Research

Research is vital for quality improvement and the continuation of excellence.⁵ It is only with research that we can provide groundbreaking advances and measure the outcomes of our interventions.² Unfortunately, orthopedic research funding continues to be disproportionately low, especially given that musculoskeletal ailments are the leading cause of both physician visits and chronic impairment in the United States.² For example, the National Institute of Arthritis and Musculoskeletal and Skin Diseases receives only 10% of what our country spends on cancer research and 15% of what is spent on heart- and lung-disease research.² To compound the problem of limited funding, the number of physician-scientists has been dropping at an alarming rate.² As a result, we must not only refocus our research efforts so that they are efficient and effective, but we must also invest in the training of orthopedic physician-scientists to ensure a continuous stream of groundbreaking discoveries. We owe it to our patients to provide them with proven, effective, and high-quality care.

Industry Relationships

Local and national attention will continue to focus on our relationships with industry. The challenge is twofold: mitigating the negative portrayal of industry relationships and navigating the changes applied to industry funding for research and education.⁹ Our collaboration with industry is important for the development and advancement of orthopedics,¹⁵ but it must be guided by the professional and ethical guidelines established by the AAOS, ensuring that the best interest of patients remains a top priority.^8,15 We must maintain the public’s trust by using every opportunity to convey our lone goal in collaborating with industry, ie, improving patient care.⁹ According to James Beaty,⁷ any relationship with industry should be “so ethical that it could be printed on the front page of the newspaper and we could face our neighbors with our heads held high.”

Gender and Minority Representation

The racial and ethnic makeup of the United States is undergoing a rapid change. Over the next 4 decades, the white population is projected to become the minority, while women will continue to outnumber men.¹⁶ Despite the rapidly changing demographics of the United States, health care disparities persist. As of 2011, minorities and women made up only 22.55% and 14.52%, respectively, of all orthopedic surgery residents.¹⁷ This limited diversity in orthopedic training programs is alarming and may lead to suboptimal physician–patient relationships, because patients tend to be more comfortable with and respond better to the care provided by physicians of similar background.³ In addition, if we do not integrate women into orthopedics, the number of female medical students applying to orthopedic residency programs might decline.³

Equating excellent medical care with diversity and cultural competence requires that we bridge the gap that has prevented patients from obtaining high-quality care.⁸ To achieve this goal, we need to continue recruiting orthopedic surgeons from all segments of our population. Ultimately, health care disparities can be effectively reduced through the delivery of culturally competent care.⁸

Physician–Patient Relationship

Medical liability has resulted in the development of damaging attitudes among physicians, with many viewing patients as potential adversaries and even avoiding high-risk procedures altogether.⁶ This deterioration of the physician–patient relationship has been another troubling consequence of managed care that emphasizes quantity and speed.¹ As a result, we are perceived by the public as impersonal, poor listeners, and difficult to see on short notice.¹

The poor perception of orthopedic surgeons by the general public is not acceptable for a field that places such a high value on excellence. Patient-centered care is at the core of quality improvement, and improving patient relationships starts and ends with us and with each patient we treat.⁶ In a health care environment in which the average orthopedic surgeon cares for thousands of patients each year, we must make certain to use each opportunity to engage our patients and enhance our relationships with them.⁶ The basic necessities of patient-centered care include empowerment of the patient through education, better communication, and transparency; providing accurate and evidence-based information; and cooperation among physicians.^3,6 The benefits of improving personal relationships with patients are multifold and could have lasting positive effects: increased physician and patient satisfaction, better patient compliance, greater practice efficiency, and fewer malpractice lawsuits.¹ We can also benefit from mobilizing a greater constituency to advocate alongside us.⁶

Unity

Despite accounting for less than 3% of all physicians, orthopedic surgeons have assumed an influential voice in the field of medicine.¹³ This is attributed not only to the success of our interventions but, more importantly, to the fact that we have “stuck together.”¹³ The concept of “sticking together” may seem a cliché and facile but will certainly be a pressing need as we move ahead. We draw strength from the breadth and diversity of our subspecialties, but this strength may become a weakness if we do not join in promoting the betterment of our profession as a whole.¹⁴ To avoid duplications and bring synergy to all our efforts, we should continue to develop new partnerships in our specialty societies⁶ and speak with one voice to our patients and to the public.¹⁵ Joshua Jacobs¹¹ reminds us of the warning Benjamin Franklin imparted to the signers of the Declaration of Independence, “We must hang together, or most assuredly, we will all hang separately.” To ensure the continued strength of the house of orthopedics, we must live by this tenet.

Advocacy

The federal government has become increasingly involved in regulating the practice of medicine.⁹ Orthopedic surgery has been hit especially hard, because the cost of implants and continued innovation has fueled the belief that our profession is a major contributor to unsustainable health care costs.¹¹ We now face multiple legislative regulations related to physician reimbursement, ownership, self-referral, medical liability, and mandates of the Affordable Care Act.⁹ As a result, there has been a decreasing role for orthopedic surgeons as independent practitioners, with more orthopedists forgoing physician-owned practices for large hospital corporations. We are also in increasing competition for limited resources.¹⁰ This is compounded by the fact that those regulating health care, paying for health care, and allocating research funding fail to comprehend the high societal needs for treatment of musculoskeletal diseases and injuries,⁶ which will only increase in the coming decades.¹⁴

The aforementioned challenges make our involvement at all levels of the political process more necessary than ever before.^5,9 E. Anthony Rankin⁸ reminds us, “As physicians, we cannot in good conscience allow our patients’ access to quality orthopedic care to be determined solely by the government, the insurance companies, the trial lawyers, or others…. Either we will have a voice in defining the future of health care, or it will be defined by others for us.” Our advocacy approach, however, should be very careful. Joshua Jacobs¹¹ cautions that “we will be most effective if our advocacy message is presented as a potential solution to the current health care crisis, not just as a demand for fair reimbursement.” Instead, we can achieve this goal with what Richard Gelberman² summarized as “doing what we do best: accumulating knowledge, positioning ourselves as the authorities that we are, and using what we learn to advocate for better patient care and research.”

Value Medicine

Orthopedic surgeons are now expected to provide not just high-quality care but low-cost care. In line with the emerging emphasis on value, sharp focus has been placed on the assessment of physician performance and treatment outcomes as quality-of-care measures.⁶ But how have we measured the quality of the care we provide? We have not, or, at least, we have not had valid or reliable means of doing so.⁶ Gone are the days of telling the world of the excellence of our profession in the treatment of musculoskeletal disease. We now must prove to our patients, the government, and payers that what we do works.^12,13 If we fail to communicate the cost effectiveness of our interventions, our new knowledge and technologies will not be accepted or funded.¹⁰ We should, however, not be discouraged by the new “value equation,” but use it as an incentive to provide evidence-based care and to improve the efficiency of resource utilization.¹⁴ Today, we are urged to be leaders in quality improvement, both in our individual orthopedic practices and as a profession.^10,12,13

Conclusion

Meeting increasingly higher demands for musculoskeletal care in an evolving medical landscape will bring a new set of challenges that will be more frequent and more intense than those in the past.¹⁴ Today, we are tasked with providing fiscally efficient, culturally competent, high-quality, evidence-based, and compassionate care. We are also tasked with reclaiming our ability to shape the future of our profession at the policymaking level. In doing so, the need for unity, advocacy, commitment to education and research, women and minority representation, and open communication with the public has never been more relevant. As we continue to advance as a profession, we must resist the temptation to look back in defiance of change but move forward, confident in our ability to evolve. ◾

Orthopedic surgery is going through a time of remarkable change. Health care reform, heightened public scrutiny, shifting population demographics, increased reliance on the Internet for information, ongoing metamorphosis of our profession into a business, and lack of consistent high-quality clinical evidence have created a new frontier of challenges and opportunities. At heart are the needs to deliver high-quality education that is in line with new technological media, to reclaim our ability to guide musculoskeletal care at the policymaking level, to fortify our long-held tradition of ethical responsibility, to invest in research and the training of physician-scientists, to maintain unity among the different subspecialties, and to increase female and minority representation. Never before has understanding and applying the key tenets of our philosophy as orthopedic surgeons been more crucial.

The changing landscape of orthopedic practice has been an unsettling topic in many of the American Academy of Orthopaedic Surgeons (AAOS) presidential addresses in recent years.^1-11 What are the challenges and what can we learn moving forward? In this article, we seek to answer these questions by drawing insights from the combined experience and wisdom of past AAOS presidents since the turn of the 21st century.

Education

Education is the cornerstone of providing quality musculoskeletal care¹² and staying up to date with technological advances.¹³ The modes of education delivery, however, have changed. No longer is orthopedic education confined to tangible textbooks and journal articles, nor is it limited to those of us in the profession. Instead, orthopedic education has shifted toward online learning¹⁴ and is available to patients and nonorthopedic providers.¹² With more patients gaining access to rapidly growing online resources, a unique challenge has arisen: an abundance of data with variable quality of evidence influencing the decision-making process. This has created what Richard Kyle¹⁵ described as the “trap of the new technology war,” where patient misinformation and direct-to-consumer marketing can lead to dangerous musculoskeletal care delivery, including unrealistic patient expectations.³ To compound the problem, our ability to provide orthopedic education in formats compatible with the new learning mediums has not been up to the demand, with issues of cost, accessibility, and efficacy plaguing the current process.^3,5 Also, we have yet to unlock the benefits of surgical simulation, which has the potential to provide more effective training at no risk to the patient.^4,13 By adapting to the new learning formats, we can provide numerous new opportunities for keeping up to date on evolving practice management principles, which, with added accessibility, will be used more often by orthopedic surgeons and the public.¹³ 

Research

Research is vital for quality improvement and the continuation of excellence.⁵ It is only with research that we can provide groundbreaking advances and measure the outcomes of our interventions.² Unfortunately, orthopedic research funding continues to be disproportionately low, especially given that musculoskeletal ailments are the leading cause of both physician visits and chronic impairment in the United States.² For example, the National Institute of Arthritis and Musculoskeletal and Skin Diseases receives only 10% of what our country spends on cancer research and 15% of what is spent on heart- and lung-disease research.² To compound the problem of limited funding, the number of physician-scientists has been dropping at an alarming rate.² As a result, we must not only refocus our research efforts so that they are efficient and effective, but we must also invest in the training of orthopedic physician-scientists to ensure a continuous stream of groundbreaking discoveries. We owe it to our patients to provide them with proven, effective, and high-quality care.

Industry Relationships

Local and national attention will continue to focus on our relationships with industry. The challenge is twofold: mitigating the negative portrayal of industry relationships and navigating the changes applied to industry funding for research and education.⁹ Our collaboration with industry is important for the development and advancement of orthopedics,¹⁵ but it must be guided by the professional and ethical guidelines established by the AAOS, ensuring that the best interest of patients remains a top priority.^8,15 We must maintain the public’s trust by using every opportunity to convey our lone goal in collaborating with industry, ie, improving patient care.⁹ According to James Beaty,⁷ any relationship with industry should be “so ethical that it could be printed on the front page of the newspaper and we could face our neighbors with our heads held high.”

Gender and Minority Representation

The racial and ethnic makeup of the United States is undergoing a rapid change. Over the next 4 decades, the white population is projected to become the minority, while women will continue to outnumber men.¹⁶ Despite the rapidly changing demographics of the United States, health care disparities persist. As of 2011, minorities and women made up only 22.55% and 14.52%, respectively, of all orthopedic surgery residents.¹⁷ This limited diversity in orthopedic training programs is alarming and may lead to suboptimal physician–patient relationships, because patients tend to be more comfortable with and respond better to the care provided by physicians of similar background.³ In addition, if we do not integrate women into orthopedics, the number of female medical students applying to orthopedic residency programs might decline.³

Equating excellent medical care with diversity and cultural competence requires that we bridge the gap that has prevented patients from obtaining high-quality care.⁸ To achieve this goal, we need to continue recruiting orthopedic surgeons from all segments of our population. Ultimately, health care disparities can be effectively reduced through the delivery of culturally competent care.⁸

Physician–Patient Relationship

Medical liability has resulted in the development of damaging attitudes among physicians, with many viewing patients as potential adversaries and even avoiding high-risk procedures altogether.⁶ This deterioration of the physician–patient relationship has been another troubling consequence of managed care that emphasizes quantity and speed.¹ As a result, we are perceived by the public as impersonal, poor listeners, and difficult to see on short notice.¹

The poor perception of orthopedic surgeons by the general public is not acceptable for a field that places such a high value on excellence. Patient-centered care is at the core of quality improvement, and improving patient relationships starts and ends with us and with each patient we treat.⁶ In a health care environment in which the average orthopedic surgeon cares for thousands of patients each year, we must make certain to use each opportunity to engage our patients and enhance our relationships with them.⁶ The basic necessities of patient-centered care include empowerment of the patient through education, better communication, and transparency; providing accurate and evidence-based information; and cooperation among physicians.^3,6 The benefits of improving personal relationships with patients are multifold and could have lasting positive effects: increased physician and patient satisfaction, better patient compliance, greater practice efficiency, and fewer malpractice lawsuits.¹ We can also benefit from mobilizing a greater constituency to advocate alongside us.⁶

Unity

Despite accounting for less than 3% of all physicians, orthopedic surgeons have assumed an influential voice in the field of medicine.¹³ This is attributed not only to the success of our interventions but, more importantly, to the fact that we have “stuck together.”¹³ The concept of “sticking together” may seem a cliché and facile but will certainly be a pressing need as we move ahead. We draw strength from the breadth and diversity of our subspecialties, but this strength may become a weakness if we do not join in promoting the betterment of our profession as a whole.¹⁴ To avoid duplications and bring synergy to all our efforts, we should continue to develop new partnerships in our specialty societies⁶ and speak with one voice to our patients and to the public.¹⁵ Joshua Jacobs¹¹ reminds us of the warning Benjamin Franklin imparted to the signers of the Declaration of Independence, “We must hang together, or most assuredly, we will all hang separately.” To ensure the continued strength of the house of orthopedics, we must live by this tenet.

Advocacy

The federal government has become increasingly involved in regulating the practice of medicine.⁹ Orthopedic surgery has been hit especially hard, because the cost of implants and continued innovation has fueled the belief that our profession is a major contributor to unsustainable health care costs.¹¹ We now face multiple legislative regulations related to physician reimbursement, ownership, self-referral, medical liability, and mandates of the Affordable Care Act.⁹ As a result, there has been a decreasing role for orthopedic surgeons as independent practitioners, with more orthopedists forgoing physician-owned practices for large hospital corporations. We are also in increasing competition for limited resources.¹⁰ This is compounded by the fact that those regulating health care, paying for health care, and allocating research funding fail to comprehend the high societal needs for treatment of musculoskeletal diseases and injuries,⁶ which will only increase in the coming decades.¹⁴

The aforementioned challenges make our involvement at all levels of the political process more necessary than ever before.^5,9 E. Anthony Rankin⁸ reminds us, “As physicians, we cannot in good conscience allow our patients’ access to quality orthopedic care to be determined solely by the government, the insurance companies, the trial lawyers, or others…. Either we will have a voice in defining the future of health care, or it will be defined by others for us.” Our advocacy approach, however, should be very careful. Joshua Jacobs¹¹ cautions that “we will be most effective if our advocacy message is presented as a potential solution to the current health care crisis, not just as a demand for fair reimbursement.” Instead, we can achieve this goal with what Richard Gelberman² summarized as “doing what we do best: accumulating knowledge, positioning ourselves as the authorities that we are, and using what we learn to advocate for better patient care and research.”

Value Medicine

Orthopedic surgeons are now expected to provide not just high-quality care but low-cost care. In line with the emerging emphasis on value, sharp focus has been placed on the assessment of physician performance and treatment outcomes as quality-of-care measures.⁶ But how have we measured the quality of the care we provide? We have not, or, at least, we have not had valid or reliable means of doing so.⁶ Gone are the days of telling the world of the excellence of our profession in the treatment of musculoskeletal disease. We now must prove to our patients, the government, and payers that what we do works.^12,13 If we fail to communicate the cost effectiveness of our interventions, our new knowledge and technologies will not be accepted or funded.¹⁰ We should, however, not be discouraged by the new “value equation,” but use it as an incentive to provide evidence-based care and to improve the efficiency of resource utilization.¹⁴ Today, we are urged to be leaders in quality improvement, both in our individual orthopedic practices and as a profession.^10,12,13

Conclusion

Meeting increasingly higher demands for musculoskeletal care in an evolving medical landscape will bring a new set of challenges that will be more frequent and more intense than those in the past.¹⁴ Today, we are tasked with providing fiscally efficient, culturally competent, high-quality, evidence-based, and compassionate care. We are also tasked with reclaiming our ability to shape the future of our profession at the policymaking level. In doing so, the need for unity, advocacy, commitment to education and research, women and minority representation, and open communication with the public has never been more relevant. As we continue to advance as a profession, we must resist the temptation to look back in defiance of change but move forward, confident in our ability to evolve. ◾

Orthopedic surgery is going through a time of remarkable change. Health care reform, heightened public scrutiny, shifting population demographics, increased reliance on the Internet for information, ongoing metamorphosis of our profession into a business, and lack of consistent high-quality clinical evidence have created a new frontier of challenges and opportunities. At heart are the needs to deliver high-quality education that is in line with new technological media, to reclaim our ability to guide musculoskeletal care at the policymaking level, to fortify our long-held tradition of ethical responsibility, to invest in research and the training of physician-scientists, to maintain unity among the different subspecialties, and to increase female and minority representation. Never before has understanding and applying the key tenets of our philosophy as orthopedic surgeons been more crucial.

The changing landscape of orthopedic practice has been an unsettling topic in many of the American Academy of Orthopaedic Surgeons (AAOS) presidential addresses in recent years.^1-11 What are the challenges and what can we learn moving forward? In this article, we seek to answer these questions by drawing insights from the combined experience and wisdom of past AAOS presidents since the turn of the 21st century.

Education

Education is the cornerstone of providing quality musculoskeletal care¹² and staying up to date with technological advances.¹³ The modes of education delivery, however, have changed. No longer is orthopedic education confined to tangible textbooks and journal articles, nor is it limited to those of us in the profession. Instead, orthopedic education has shifted toward online learning¹⁴ and is available to patients and nonorthopedic providers.¹² With more patients gaining access to rapidly growing online resources, a unique challenge has arisen: an abundance of data with variable quality of evidence influencing the decision-making process. This has created what Richard Kyle¹⁵ described as the “trap of the new technology war,” where patient misinformation and direct-to-consumer marketing can lead to dangerous musculoskeletal care delivery, including unrealistic patient expectations.³ To compound the problem, our ability to provide orthopedic education in formats compatible with the new learning mediums has not been up to the demand, with issues of cost, accessibility, and efficacy plaguing the current process.^3,5 Also, we have yet to unlock the benefits of surgical simulation, which has the potential to provide more effective training at no risk to the patient.^4,13 By adapting to the new learning formats, we can provide numerous new opportunities for keeping up to date on evolving practice management principles, which, with added accessibility, will be used more often by orthopedic surgeons and the public.¹³ 

Research

Research is vital for quality improvement and the continuation of excellence.⁵ It is only with research that we can provide groundbreaking advances and measure the outcomes of our interventions.² Unfortunately, orthopedic research funding continues to be disproportionately low, especially given that musculoskeletal ailments are the leading cause of both physician visits and chronic impairment in the United States.² For example, the National Institute of Arthritis and Musculoskeletal and Skin Diseases receives only 10% of what our country spends on cancer research and 15% of what is spent on heart- and lung-disease research.² To compound the problem of limited funding, the number of physician-scientists has been dropping at an alarming rate.² As a result, we must not only refocus our research efforts so that they are efficient and effective, but we must also invest in the training of orthopedic physician-scientists to ensure a continuous stream of groundbreaking discoveries. We owe it to our patients to provide them with proven, effective, and high-quality care.

Industry Relationships

Local and national attention will continue to focus on our relationships with industry. The challenge is twofold: mitigating the negative portrayal of industry relationships and navigating the changes applied to industry funding for research and education.⁹ Our collaboration with industry is important for the development and advancement of orthopedics,¹⁵ but it must be guided by the professional and ethical guidelines established by the AAOS, ensuring that the best interest of patients remains a top priority.^8,15 We must maintain the public’s trust by using every opportunity to convey our lone goal in collaborating with industry, ie, improving patient care.⁹ According to James Beaty,⁷ any relationship with industry should be “so ethical that it could be printed on the front page of the newspaper and we could face our neighbors with our heads held high.”

Gender and Minority Representation

The racial and ethnic makeup of the United States is undergoing a rapid change. Over the next 4 decades, the white population is projected to become the minority, while women will continue to outnumber men.¹⁶ Despite the rapidly changing demographics of the United States, health care disparities persist. As of 2011, minorities and women made up only 22.55% and 14.52%, respectively, of all orthopedic surgery residents.¹⁷ This limited diversity in orthopedic training programs is alarming and may lead to suboptimal physician–patient relationships, because patients tend to be more comfortable with and respond better to the care provided by physicians of similar background.³ In addition, if we do not integrate women into orthopedics, the number of female medical students applying to orthopedic residency programs might decline.³

Equating excellent medical care with diversity and cultural competence requires that we bridge the gap that has prevented patients from obtaining high-quality care.⁸ To achieve this goal, we need to continue recruiting orthopedic surgeons from all segments of our population. Ultimately, health care disparities can be effectively reduced through the delivery of culturally competent care.⁸

Physician–Patient Relationship

Medical liability has resulted in the development of damaging attitudes among physicians, with many viewing patients as potential adversaries and even avoiding high-risk procedures altogether.⁶ This deterioration of the physician–patient relationship has been another troubling consequence of managed care that emphasizes quantity and speed.¹ As a result, we are perceived by the public as impersonal, poor listeners, and difficult to see on short notice.¹

The poor perception of orthopedic surgeons by the general public is not acceptable for a field that places such a high value on excellence. Patient-centered care is at the core of quality improvement, and improving patient relationships starts and ends with us and with each patient we treat.⁶ In a health care environment in which the average orthopedic surgeon cares for thousands of patients each year, we must make certain to use each opportunity to engage our patients and enhance our relationships with them.⁶ The basic necessities of patient-centered care include empowerment of the patient through education, better communication, and transparency; providing accurate and evidence-based information; and cooperation among physicians.^3,6 The benefits of improving personal relationships with patients are multifold and could have lasting positive effects: increased physician and patient satisfaction, better patient compliance, greater practice efficiency, and fewer malpractice lawsuits.¹ We can also benefit from mobilizing a greater constituency to advocate alongside us.⁶

Unity

Despite accounting for less than 3% of all physicians, orthopedic surgeons have assumed an influential voice in the field of medicine.¹³ This is attributed not only to the success of our interventions but, more importantly, to the fact that we have “stuck together.”¹³ The concept of “sticking together” may seem a cliché and facile but will certainly be a pressing need as we move ahead. We draw strength from the breadth and diversity of our subspecialties, but this strength may become a weakness if we do not join in promoting the betterment of our profession as a whole.¹⁴ To avoid duplications and bring synergy to all our efforts, we should continue to develop new partnerships in our specialty societies⁶ and speak with one voice to our patients and to the public.¹⁵ Joshua Jacobs¹¹ reminds us of the warning Benjamin Franklin imparted to the signers of the Declaration of Independence, “We must hang together, or most assuredly, we will all hang separately.” To ensure the continued strength of the house of orthopedics, we must live by this tenet.

Advocacy

The federal government has become increasingly involved in regulating the practice of medicine.⁹ Orthopedic surgery has been hit especially hard, because the cost of implants and continued innovation has fueled the belief that our profession is a major contributor to unsustainable health care costs.¹¹ We now face multiple legislative regulations related to physician reimbursement, ownership, self-referral, medical liability, and mandates of the Affordable Care Act.⁹ As a result, there has been a decreasing role for orthopedic surgeons as independent practitioners, with more orthopedists forgoing physician-owned practices for large hospital corporations. We are also in increasing competition for limited resources.¹⁰ This is compounded by the fact that those regulating health care, paying for health care, and allocating research funding fail to comprehend the high societal needs for treatment of musculoskeletal diseases and injuries,⁶ which will only increase in the coming decades.¹⁴

The aforementioned challenges make our involvement at all levels of the political process more necessary than ever before.^5,9 E. Anthony Rankin⁸ reminds us, “As physicians, we cannot in good conscience allow our patients’ access to quality orthopedic care to be determined solely by the government, the insurance companies, the trial lawyers, or others…. Either we will have a voice in defining the future of health care, or it will be defined by others for us.” Our advocacy approach, however, should be very careful. Joshua Jacobs¹¹ cautions that “we will be most effective if our advocacy message is presented as a potential solution to the current health care crisis, not just as a demand for fair reimbursement.” Instead, we can achieve this goal with what Richard Gelberman² summarized as “doing what we do best: accumulating knowledge, positioning ourselves as the authorities that we are, and using what we learn to advocate for better patient care and research.”

Value Medicine

Orthopedic surgeons are now expected to provide not just high-quality care but low-cost care. In line with the emerging emphasis on value, sharp focus has been placed on the assessment of physician performance and treatment outcomes as quality-of-care measures.⁶ But how have we measured the quality of the care we provide? We have not, or, at least, we have not had valid or reliable means of doing so.⁶ Gone are the days of telling the world of the excellence of our profession in the treatment of musculoskeletal disease. We now must prove to our patients, the government, and payers that what we do works.^12,13 If we fail to communicate the cost effectiveness of our interventions, our new knowledge and technologies will not be accepted or funded.¹⁰ We should, however, not be discouraged by the new “value equation,” but use it as an incentive to provide evidence-based care and to improve the efficiency of resource utilization.¹⁴ Today, we are urged to be leaders in quality improvement, both in our individual orthopedic practices and as a profession.^10,12,13

Conclusion

Meeting increasingly higher demands for musculoskeletal care in an evolving medical landscape will bring a new set of challenges that will be more frequent and more intense than those in the past.¹⁴ Today, we are tasked with providing fiscally efficient, culturally competent, high-quality, evidence-based, and compassionate care. We are also tasked with reclaiming our ability to shape the future of our profession at the policymaking level. In doing so, the need for unity, advocacy, commitment to education and research, women and minority representation, and open communication with the public has never been more relevant. As we continue to advance as a profession, we must resist the temptation to look back in defiance of change but move forward, confident in our ability to evolve. ◾

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

It’s 7:30 Monday evening and the good news is that you were able to leave the office a little after 7:00 and are now at home. The bad news is that you are on call tonight and you are scheduled to work a usual 10-hour day tomorrow.

Should you:

A) Tuck the kids in, warm up a bowl of chili, and lie down on the couch in the den and hope to get a few hours of prophylactic sleep?

B) Go to bed at your usual bedtime of 10:30?

C) Stay up until midnight when experience tells you that the likelihood of getting a call drops significantly ... but unfortunately never approaches zero?

D) Say “To hell with it” and stay up all night binge-watching a whole season of “Justified?”

E) Or, stay up all night surfing the Internet looking for job opportunities that don’t include night call?

Of course, there is no correct answer because stuff happens whenever it chooses to and no strategy will ever guarantee you an uninterrupted 8 hours of sleep when you are on call. However, I learned from a recent article in the Wall Street Journal (A Good Night’s Sleep Is Tied to Interruptions, Not Just Hours – Sumathi Reddy – Nov. 30, 2015) that there is some evidence that “C” clearly is the best choice.

A study from John Hopkins University, Baltimore, published in the journal Sleep found that subjects who were awakened multiple times during the night exhibited a greater decline in positive mood than did those subjects who were sleep deprived by being made to stay up past their usual bedtime (2015 Nov 1;38[11]:1735-42).

Another study from the University of Pittsburgh discovered that elderly subjects’ cognitive performance was impaired when their sleep was interrupted but not when they were allowed to sleep uninterrupted for a shorter period of time (J Gerontol B Psychol Sci Soc Sci. 2009 Mar;64B[2]:180-7).

And, investigators at the University of Tel Aviv have found that subjects who endured 8 hours of fragmented sleep demonstrated declines in their positive mood and ability to attend that were similar to subjects who were allowed only 4 hours of uninterrupted sleep (Sleep Med. 2011 Mar;12[3]:257-61).

Where were these sleep researchers 45 years ago, when I was experimenting with my own strategies for navigating a night on call with a minimum of emotional and cognitive damage? It took me several years to discover that it was fruitless to try grabbing an hour or two of prophylactic sleep early in the evening when the risk of being awakened by a call was still relatively high. The rare occasion when I slept without interruption was of little comfort on the other nights when I could feel every wakening erode my feeble attempts at projecting a pleasant bedside (my bed that is) manner.

It took another few years of trial and error to improve my skill at determining the optimal time to turn in on a given night. It was never perfect, but eventually, I developed an instinct – based on the level of disease in the community, the pulse of the office during the day, and the weather – that kept the interruptions to a minimum. Despite what you may have heard, I never found the phase of moon to be terribly helpful in predicting when I could more safely go to bed.

There is no avoiding the unpleasant truth that being on call puts you at risk for sleep deprivation. One way or another, you are going to be sleep deprived when you show up at the office the next day. But, your best chance of continuing to appear to be a sensitive and intelligent physician is staying up late until the likelihood you will be awakened by a call has reached its traditional nadir.

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

If you have ever waited anxiously for the results of a blood test or biopsy, you may be surprised to learn that some psychologists at the University of California, Riverside, believe that there can be a bright side to those dark days you spent worrying (“Two Definitions of Waiting Well.” Emotion 2015 Oct 12 [epub ahead of print]).

Surveying more than 200 recent law school graduates every 2 weeks during their 4-month wait for the results of the California bar exam, the researchers discovered that those who rode it out anxiously and pessimistically handled the bad news of failure “more productively.” And they welcomed the good news “more joyously” than did their peers who had “suffered little during the wait.”

While these psychologists’ findings may be of some help to aspiring lawyers or freshly minted physicians waiting to hear if they have passed their boards, I don’t think we should take them to heart when ordering lab work or imaging studies on our patients. After all, flunking the bar exam may be a life-altering event, but it isn’t a life-ending one such as learning that the biopsy you waited a week for has detected a cancer that has metastasized beyond the reaches of radiation and chemotherapy.

The bottom line is that waiting for potentially bad news is anxiety provoking regardless of whether it is for the results of a qualifying exam or a simple CBC. And, as physicians, it is our responsibility to do whatever we can to minimize that anxiety by following some simple commonsense rules of courtesy and decency.

First, we must understand that even low-risk preop screening lab work that we may view as innocuous may trigger significant anxiety in many patients. For example, a patient who knew someone whose leukemia was discovered as the result of a preop screening CBC may worry that a similar fate will be revealed by his blood test.

Second, we should ask ourselves every time we order some lab work or imaging study if it is really necessary. Are we just trying to cover our behinds and protect ourselves from a malpractice suit? Do we know what we are going to do with an equivocal borderline result? An unnecessary blood test isn’t just a waste of someone’s money and a symptom of sloppy medicine. It can be the cause of an anxiety-provoking wait for the patient.

Finally, if we are going to order a lab test, even if it is just for preop screening, it is our obligation to inform the patient of the result in a timely fashion. In my universe, that means the same day that the physician receives the result. In today’s world with its panoply of communication platforms, informing the patient can be as simple as leaving a message on a system previously approved by the patient. Obviously, bad or complicated news should be delivered directly by the physician with a phone call. Of course, informing the patient of even normal lab work results takes time, but it is the courteous and decent thing to do and signals to the patient that she has a physician who cares. If it seems like too much work, it may be that the physician is ordering too much lab work.

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.”

Native to China, India, and Iran, Melia azedarach – also known as Chinaberry (Ku-lian), Pride of China, Indian lilac, Persian lilac, and white cedar – is a large nondeciduous tree now cultivated throughout the world.^1-3 The leaves and fruits of this member of the Meliaceae family have been found to exhibit anthelmintic and antifeedant activity toward insects.⁴ The root bark or dried stem bark of the plant is used in traditional Chinese medicine to treat dermatoses and to expel and repel worms.^5,6M. azedarach has also been used in Ayurveda³; it is known as Bakayn in India and Pakistan, where it has been used in traditional medicine to treat leprosy, scrofula, nausea, vomiting, thirst, and eruptive skin conditions.^3,7

Traditional indications

Cropley and Hasegawa noted in 2007 that M. azedarach was used in the 19th century in the United States primarily as an anthelmintic, but also to treat tinea capitis and to eliminate lice.Further, they noted that the plant, which was widely cultivated in the South, was used, according to the literature of the 1800s, as a diuretic, as well as to promote hair growth, and treat scalp eruptions, fever, and malaria.⁸

A 2006 ethnopharmacologic study by Saikia et al. of medicinal plants used in Assam (Northeast India) to treat skin disorders and for cosmetic purposes revealed that M. azedarach was one of the primary plants used for medicinal purposes, including 18 skin conditions such as acne, burns, carbuncles, abscesses, measles, pediculosis, cellulitis, and prickly heat.⁹

Four years later, in an ethnopharmacologic study of medicinal plants used to treat cutaneous disorders and in folk cosmetics, Abbasi et al. interviewed residents in 30 remote tribal communities in the Northwest Frontier Province of Pakistan, finding that M. azedarach was one of 15 plant species identified as curative for numerous skin diseases, including boils, acne, and scabies.¹⁰

Biologic activity

Various constituents of M. azedarach have been associated with a wide range of biologic activity. The antifungal activity of the plant has been attributed to its hydroxycoumarin content; anti-inflammatory activity to its monoterpenes; bacteriostatic properties to its beta-carboline alkaloids; antiviral effects to its meliacin and meliacarpin; and insecticidal and antifeedant activity to its limonoids, which belong to the tetranortriterpenoid class of compounds.^7,11 Limonoids also are reputed to confer antibacterial, antiviral, and antifungal activities.¹² Recent research suggests the potential of M. azedarach to offer a correspondingly broad impact on various conditions.

Forest & Kim Starr

Anticancer potential

Zhou et al. isolated new ring C-seco limonoids from Brazilian M. azedarach in 2004 and evaluated their cytotoxic activity, finding that two limonoids significantly inhibited HeLa S3 cancer cells.^4,11

In 2009, He et al. extracted water-soluble polysaccharides from the fruit of M. azedarach and assessed their cytotoxic activity against four human cell lines in vitro. They found that the major polysaccharide component exhibited potent cytotoxic activity in the BGC-823 cell line.³ Also that year, Wu et al. isolated three new and multiple known steroids from the leaves of Chinese M. azedarach, finding that two of the newly identified steroids – (20S)-5,24(28)-ergostadiene-3-beta,7-alpha,16-beta,20-tetrol and (20S)-5-ergostene-3-beta,7-alpha,16-beta,20-tetrol – and one of the known ones exerted significant cytotoxic impact in three human cancer cell lines (A-549, H460, U251).¹

Two years later, Wu et al. isolated two new triterpenoids (21,24-cycloeupha-7-ene-3-beta,16beta,21-alpha,25-tetrol and 3-beta-acetoxy-12-beta-hydroxy-eupha-7,24-dien-21,16-beta-olide) and two new steroids (29-hydroperoxy-stigmasta-7,24(28) xi-dien-3-beta-ol and 24-xi-hydroperoxy-24-vinyl-lathosterol) along with several known related substances from M. azedarach bark. Five of the known compounds demonstrated cytotoxic activity against three human cancer cell lines (A-549, H460, HGC27).⁶

More recently, Yuan et al. isolated two limonoids, one triterpenoid, one steroid, and one sesquiterpenoid, as well as nine known limonoids from the bark of M. azedarach. In addition, the investigators observed that seven of the limonoids exhibited significant inhibitory properties against five human tumor cell lines (HL-60, SMM-C7721, A-549, MCF-7, and SW480).⁵

Efficacy against head lice

In 2007, Carpinella et al. investigated in vitro the pediculicidal and ovicidal activity of an M. azedarach extract against Pediculus humanus capitis, noting the increasing resistance of head lice to synthetic drugs. A combination of 20% ripe fruit extract with 10% ripe fruit oil was found to be the most effective in eradicating adult lice (96.5%). The investigators also prepared a formulation of extract and oil at 10% combined with an emulsifier and preservatives that yielded 92.3% mortality of adult lice and complete inhibition of nymph emergence. They concluded that the use of M. azedarach formulations may be a viable and natural way to control head lice.²M. azedarach also has been the key active ingredient in an antimicrobial cream and a preparation to treat tinea pedis.⁷

Topical cream

Saleem et al. reported in 2008 on an herbal cream preparation using a standardized extract of M. azedarach flowers that displayed strong antibacterial activity against cellulitis, pustules, and pyogenic infections, and other conditions in clinical trials in children under the age of 10 years in four different villages in Pakistan. Subjects with bacterial infections anywhere on the body were divided into three groups, one treated with M. azedarach cream, one with placebo (negative control), and one with neomycin (positive control). Each treatment was applied twice daily for 15 days. The investigators observed that the healing effects of M. azedarach were similar to those rendered by neomycin.⁷

Conclusion

Not only has M. azedarach been used in several traditional medical systems, but its uses have consistently included cutaneous indications. Its most convincing modern application may be for head lice, but recent evidence and traditional uses suggest that this versatile plant may indeed warrant a more prominent role in the current dermatologic armamentarium. Future research is needed, and should provide some interesting answers.

References

1. Steroids. 2009 Sep;74(9):761-5.

2. J Am Acad Dermatol. 2007 Feb;56(2):250-6.

3. Fitoterapia. 2009 Oct;80(7):399-403.

4. Chem Pharm Bull (Tokyo). 2005 Oct;53(10):1362-5.

5. Planta Med. 2013 Jan;79(2):163-8.

6. Planta Med. 2011 Jun;77(9):922-8.

7. Phytomedicine. 2008 Apr;15(4):231-6.

8. J Am Acad Dermatol. 2007 Aug;57(2):366-7.

9. J Ethnopharmacol. 2006 Jun 30;106(2):149-57.

10. J Ethnopharmacol. 2010 Mar 24;128(2):322-35.

11. J Nat Prod. 2004 Sep;67(9):1544-7.

12. Chem Biodivers. 2010 Apr;7(4):839-59.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Native to China, India, and Iran, Melia azedarach – also known as Chinaberry (Ku-lian), Pride of China, Indian lilac, Persian lilac, and white cedar – is a large nondeciduous tree now cultivated throughout the world.^1-3 The leaves and fruits of this member of the Meliaceae family have been found to exhibit anthelmintic and antifeedant activity toward insects.⁴ The root bark or dried stem bark of the plant is used in traditional Chinese medicine to treat dermatoses and to expel and repel worms.^5,6M. azedarach has also been used in Ayurveda³; it is known as Bakayn in India and Pakistan, where it has been used in traditional medicine to treat leprosy, scrofula, nausea, vomiting, thirst, and eruptive skin conditions.^3,7

Traditional indications

Cropley and Hasegawa noted in 2007 that M. azedarach was used in the 19th century in the United States primarily as an anthelmintic, but also to treat tinea capitis and to eliminate lice.Further, they noted that the plant, which was widely cultivated in the South, was used, according to the literature of the 1800s, as a diuretic, as well as to promote hair growth, and treat scalp eruptions, fever, and malaria.⁸

A 2006 ethnopharmacologic study by Saikia et al. of medicinal plants used in Assam (Northeast India) to treat skin disorders and for cosmetic purposes revealed that M. azedarach was one of the primary plants used for medicinal purposes, including 18 skin conditions such as acne, burns, carbuncles, abscesses, measles, pediculosis, cellulitis, and prickly heat.⁹

Four years later, in an ethnopharmacologic study of medicinal plants used to treat cutaneous disorders and in folk cosmetics, Abbasi et al. interviewed residents in 30 remote tribal communities in the Northwest Frontier Province of Pakistan, finding that M. azedarach was one of 15 plant species identified as curative for numerous skin diseases, including boils, acne, and scabies.¹⁰

Biologic activity

Various constituents of M. azedarach have been associated with a wide range of biologic activity. The antifungal activity of the plant has been attributed to its hydroxycoumarin content; anti-inflammatory activity to its monoterpenes; bacteriostatic properties to its beta-carboline alkaloids; antiviral effects to its meliacin and meliacarpin; and insecticidal and antifeedant activity to its limonoids, which belong to the tetranortriterpenoid class of compounds.^7,11 Limonoids also are reputed to confer antibacterial, antiviral, and antifungal activities.¹² Recent research suggests the potential of M. azedarach to offer a correspondingly broad impact on various conditions.

Forest & Kim Starr

Anticancer potential

Zhou et al. isolated new ring C-seco limonoids from Brazilian M. azedarach in 2004 and evaluated their cytotoxic activity, finding that two limonoids significantly inhibited HeLa S3 cancer cells.^4,11

In 2009, He et al. extracted water-soluble polysaccharides from the fruit of M. azedarach and assessed their cytotoxic activity against four human cell lines in vitro. They found that the major polysaccharide component exhibited potent cytotoxic activity in the BGC-823 cell line.³ Also that year, Wu et al. isolated three new and multiple known steroids from the leaves of Chinese M. azedarach, finding that two of the newly identified steroids – (20S)-5,24(28)-ergostadiene-3-beta,7-alpha,16-beta,20-tetrol and (20S)-5-ergostene-3-beta,7-alpha,16-beta,20-tetrol – and one of the known ones exerted significant cytotoxic impact in three human cancer cell lines (A-549, H460, U251).¹

Two years later, Wu et al. isolated two new triterpenoids (21,24-cycloeupha-7-ene-3-beta,16beta,21-alpha,25-tetrol and 3-beta-acetoxy-12-beta-hydroxy-eupha-7,24-dien-21,16-beta-olide) and two new steroids (29-hydroperoxy-stigmasta-7,24(28) xi-dien-3-beta-ol and 24-xi-hydroperoxy-24-vinyl-lathosterol) along with several known related substances from M. azedarach bark. Five of the known compounds demonstrated cytotoxic activity against three human cancer cell lines (A-549, H460, HGC27).⁶

More recently, Yuan et al. isolated two limonoids, one triterpenoid, one steroid, and one sesquiterpenoid, as well as nine known limonoids from the bark of M. azedarach. In addition, the investigators observed that seven of the limonoids exhibited significant inhibitory properties against five human tumor cell lines (HL-60, SMM-C7721, A-549, MCF-7, and SW480).⁵

Efficacy against head lice

In 2007, Carpinella et al. investigated in vitro the pediculicidal and ovicidal activity of an M. azedarach extract against Pediculus humanus capitis, noting the increasing resistance of head lice to synthetic drugs. A combination of 20% ripe fruit extract with 10% ripe fruit oil was found to be the most effective in eradicating adult lice (96.5%). The investigators also prepared a formulation of extract and oil at 10% combined with an emulsifier and preservatives that yielded 92.3% mortality of adult lice and complete inhibition of nymph emergence. They concluded that the use of M. azedarach formulations may be a viable and natural way to control head lice.²M. azedarach also has been the key active ingredient in an antimicrobial cream and a preparation to treat tinea pedis.⁷

Topical cream

Saleem et al. reported in 2008 on an herbal cream preparation using a standardized extract of M. azedarach flowers that displayed strong antibacterial activity against cellulitis, pustules, and pyogenic infections, and other conditions in clinical trials in children under the age of 10 years in four different villages in Pakistan. Subjects with bacterial infections anywhere on the body were divided into three groups, one treated with M. azedarach cream, one with placebo (negative control), and one with neomycin (positive control). Each treatment was applied twice daily for 15 days. The investigators observed that the healing effects of M. azedarach were similar to those rendered by neomycin.⁷

Conclusion

Not only has M. azedarach been used in several traditional medical systems, but its uses have consistently included cutaneous indications. Its most convincing modern application may be for head lice, but recent evidence and traditional uses suggest that this versatile plant may indeed warrant a more prominent role in the current dermatologic armamentarium. Future research is needed, and should provide some interesting answers.

References

1. Steroids. 2009 Sep;74(9):761-5.

2. J Am Acad Dermatol. 2007 Feb;56(2):250-6.

3. Fitoterapia. 2009 Oct;80(7):399-403.

4. Chem Pharm Bull (Tokyo). 2005 Oct;53(10):1362-5.

5. Planta Med. 2013 Jan;79(2):163-8.

6. Planta Med. 2011 Jun;77(9):922-8.

7. Phytomedicine. 2008 Apr;15(4):231-6.

8. J Am Acad Dermatol. 2007 Aug;57(2):366-7.

9. J Ethnopharmacol. 2006 Jun 30;106(2):149-57.

10. J Ethnopharmacol. 2010 Mar 24;128(2):322-35.

11. J Nat Prod. 2004 Sep;67(9):1544-7.

12. Chem Biodivers. 2010 Apr;7(4):839-59.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Native to China, India, and Iran, Melia azedarach – also known as Chinaberry (Ku-lian), Pride of China, Indian lilac, Persian lilac, and white cedar – is a large nondeciduous tree now cultivated throughout the world.^1-3 The leaves and fruits of this member of the Meliaceae family have been found to exhibit anthelmintic and antifeedant activity toward insects.⁴ The root bark or dried stem bark of the plant is used in traditional Chinese medicine to treat dermatoses and to expel and repel worms.^5,6M. azedarach has also been used in Ayurveda³; it is known as Bakayn in India and Pakistan, where it has been used in traditional medicine to treat leprosy, scrofula, nausea, vomiting, thirst, and eruptive skin conditions.^3,7

Traditional indications

Cropley and Hasegawa noted in 2007 that M. azedarach was used in the 19th century in the United States primarily as an anthelmintic, but also to treat tinea capitis and to eliminate lice.Further, they noted that the plant, which was widely cultivated in the South, was used, according to the literature of the 1800s, as a diuretic, as well as to promote hair growth, and treat scalp eruptions, fever, and malaria.⁸

A 2006 ethnopharmacologic study by Saikia et al. of medicinal plants used in Assam (Northeast India) to treat skin disorders and for cosmetic purposes revealed that M. azedarach was one of the primary plants used for medicinal purposes, including 18 skin conditions such as acne, burns, carbuncles, abscesses, measles, pediculosis, cellulitis, and prickly heat.⁹

Four years later, in an ethnopharmacologic study of medicinal plants used to treat cutaneous disorders and in folk cosmetics, Abbasi et al. interviewed residents in 30 remote tribal communities in the Northwest Frontier Province of Pakistan, finding that M. azedarach was one of 15 plant species identified as curative for numerous skin diseases, including boils, acne, and scabies.¹⁰

Biologic activity

Various constituents of M. azedarach have been associated with a wide range of biologic activity. The antifungal activity of the plant has been attributed to its hydroxycoumarin content; anti-inflammatory activity to its monoterpenes; bacteriostatic properties to its beta-carboline alkaloids; antiviral effects to its meliacin and meliacarpin; and insecticidal and antifeedant activity to its limonoids, which belong to the tetranortriterpenoid class of compounds.^7,11 Limonoids also are reputed to confer antibacterial, antiviral, and antifungal activities.¹² Recent research suggests the potential of M. azedarach to offer a correspondingly broad impact on various conditions.

Forest & Kim Starr

Anticancer potential

Zhou et al. isolated new ring C-seco limonoids from Brazilian M. azedarach in 2004 and evaluated their cytotoxic activity, finding that two limonoids significantly inhibited HeLa S3 cancer cells.^4,11

In 2009, He et al. extracted water-soluble polysaccharides from the fruit of M. azedarach and assessed their cytotoxic activity against four human cell lines in vitro. They found that the major polysaccharide component exhibited potent cytotoxic activity in the BGC-823 cell line.³ Also that year, Wu et al. isolated three new and multiple known steroids from the leaves of Chinese M. azedarach, finding that two of the newly identified steroids – (20S)-5,24(28)-ergostadiene-3-beta,7-alpha,16-beta,20-tetrol and (20S)-5-ergostene-3-beta,7-alpha,16-beta,20-tetrol – and one of the known ones exerted significant cytotoxic impact in three human cancer cell lines (A-549, H460, U251).¹

Two years later, Wu et al. isolated two new triterpenoids (21,24-cycloeupha-7-ene-3-beta,16beta,21-alpha,25-tetrol and 3-beta-acetoxy-12-beta-hydroxy-eupha-7,24-dien-21,16-beta-olide) and two new steroids (29-hydroperoxy-stigmasta-7,24(28) xi-dien-3-beta-ol and 24-xi-hydroperoxy-24-vinyl-lathosterol) along with several known related substances from M. azedarach bark. Five of the known compounds demonstrated cytotoxic activity against three human cancer cell lines (A-549, H460, HGC27).⁶

More recently, Yuan et al. isolated two limonoids, one triterpenoid, one steroid, and one sesquiterpenoid, as well as nine known limonoids from the bark of M. azedarach. In addition, the investigators observed that seven of the limonoids exhibited significant inhibitory properties against five human tumor cell lines (HL-60, SMM-C7721, A-549, MCF-7, and SW480).⁵

Efficacy against head lice

In 2007, Carpinella et al. investigated in vitro the pediculicidal and ovicidal activity of an M. azedarach extract against Pediculus humanus capitis, noting the increasing resistance of head lice to synthetic drugs. A combination of 20% ripe fruit extract with 10% ripe fruit oil was found to be the most effective in eradicating adult lice (96.5%). The investigators also prepared a formulation of extract and oil at 10% combined with an emulsifier and preservatives that yielded 92.3% mortality of adult lice and complete inhibition of nymph emergence. They concluded that the use of M. azedarach formulations may be a viable and natural way to control head lice.²M. azedarach also has been the key active ingredient in an antimicrobial cream and a preparation to treat tinea pedis.⁷

Topical cream

Saleem et al. reported in 2008 on an herbal cream preparation using a standardized extract of M. azedarach flowers that displayed strong antibacterial activity against cellulitis, pustules, and pyogenic infections, and other conditions in clinical trials in children under the age of 10 years in four different villages in Pakistan. Subjects with bacterial infections anywhere on the body were divided into three groups, one treated with M. azedarach cream, one with placebo (negative control), and one with neomycin (positive control). Each treatment was applied twice daily for 15 days. The investigators observed that the healing effects of M. azedarach were similar to those rendered by neomycin.⁷

Conclusion

Not only has M. azedarach been used in several traditional medical systems, but its uses have consistently included cutaneous indications. Its most convincing modern application may be for head lice, but recent evidence and traditional uses suggest that this versatile plant may indeed warrant a more prominent role in the current dermatologic armamentarium. Future research is needed, and should provide some interesting answers.

References

1. Steroids. 2009 Sep;74(9):761-5.

2. J Am Acad Dermatol. 2007 Feb;56(2):250-6.

3. Fitoterapia. 2009 Oct;80(7):399-403.

4. Chem Pharm Bull (Tokyo). 2005 Oct;53(10):1362-5.

5. Planta Med. 2013 Jan;79(2):163-8.

6. Planta Med. 2011 Jun;77(9):922-8.

7. Phytomedicine. 2008 Apr;15(4):231-6.

8. J Am Acad Dermatol. 2007 Aug;57(2):366-7.

9. J Ethnopharmacol. 2006 Jun 30;106(2):149-57.

10. J Ethnopharmacol. 2010 Mar 24;128(2):322-35.

11. J Nat Prod. 2004 Sep;67(9):1544-7.

12. Chem Biodivers. 2010 Apr;7(4):839-59.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.