Commentary

A 70-year-old patient with no psychiatric history presents to your office complaining of memory problems. The patient frequently misplaces items, forgets appointments, and has difficulty completing tasks. You observe that the patient interrupts you frequently and misinterprets your instructions during cognitive screening. The patient is concerned about having dementia. That’s on your differential, but could it be attention-deficit/hyperactivity disorder? Even in an older patient, it’s worth considering.

Until recently, attention-deficit/hyperactivity disorder (ADHD) was considered primarily a disorder of childhood and adolescence. The modern conceptualization of ADHD originated in the mid-19th century, largely because of political and societal changes that made formal, classroom-based schooling accessible to many more children (Atten Defic Hyperact Disord. 2014;6[3]:125-51). Although symptoms must cause dysfunction in two or more settings to meet DSM-5 criteria for the disorder, ADHD remains best understood as a classroom problem.

A growing body of evidence, however, reveals that ADHD symptoms persist into adulthood in two-thirds of cases (J Atten Disord. 2015 Sep 22. pil: 1087054715604360); (Psychol Med. 2015 Jan 23;1-12). Older adults might be especially prone to misdiagnosis given that they and their clinicians might be more concerned about the possibility of a neurodegenerative disorder.

The DSM-5 clearly defines ADHD as a neurodevelopmental disorder that begins in childhood. Nonetheless, the manual says that ADHD can be diagnosed retrospectively in adults who have at least five inattentive or hyperactive symptoms (compared with six or more for children) and who recall having “several” inattentive or hyperactive symptoms prior to age 12. ADHD symptoms attenuate in adulthood. Remission rates vary considerably across studies, but even among adults who no longer meet criteria for the diagnosis, residual symptoms are common and continue to interfere with functioning (Psychol Med. 2006;36:159-65); (Psychol Med. 2015;23:1-12); (J Atten Disord. 2015 Sep 22). Inattentive symptoms are more likely to persist than hyperactive-impulsive symptoms (Atten Def Hyperact Disord. 2015 Jun 12).

To date, little research has focused on ADHD symptoms in the geriatric population. Investigators of a recent cohort study of noninstitutionalized Dutch adults over 60 years old estimate that the prevalence of ADHD in this population is 2.8% with an additional 1.4% reporting functional impairment because of subsyndromal disease (Br J Psychiatry. 2012 Oct;201[4]:298-305).

Since attention is requisite to virtually all cognitive tasks, inattention can negatively affect functioning in a variety of ways. Patients and clinicians could easily misinterpret inattentive symptoms as deficits in other cognitive domains, such as memory. A thorough developmental history should clarify the diagnosis by identifying whether or not cognitive symptoms were present in childhood. Standardized scales, such as the Wender Utah Rating Scale and the Barkley Childhood Symptoms Scale, can help clinicians elicit a history of childhood ADHD symptoms and assess the validity of retrospective self-reports. Since inattention is a nonspecific symptom, the differential diagnosis also should include depression, anxiety, and delirium, among others.

Neuropsychological testing can clarify the diagnosis by quantifying patient performance across cognitive domains, comparing patient performance to normative data, and controlling for motivational factors. The pattern of cognitive deficits is well established and unique for most forms of dementia in their early stages. For example, rapid forgetting is the “first and worst” symptom of Alzheimer’s disease, the most common form of dementia. Attention typically is the next cognitive domain affected in Alzheimer’s disease, preceding visuospatial and language involvement (Brain. 1999 Mar;122[Pt. 3]:383-404). As dementias progress and more cognitive domains are affected, neuropsychological testing might be less helpful in differentiating dementias from each other and teasing out comorbidities such as ADHD, depression, anxiety, and substance use disorders. From another perspective, preexisting ADHD exacerbates cognitive deficits, impairing function and mimicking more advanced neurodegenerative disease. Therefore, identifying and treating comorbid ADHD may improve functioning in patients with dementia.

ADHD and Alzheimer’s disease might share some pathophysiologic mechanisms. Dysregulated cholinergic and noradrenergic activity have been observed in both conditions (Science. 2000 Dec 22;290[5500]:2315-9; (J Neuropathol Exp Neurol. 2011 Nov;70[11]:960-9). Research also suggests that cholinesterase inhibitors might disproportionately slow the decline of attention in Alzheimer’s disease, relative to their effects on disease progression in other cognitive domains (J Alzheimers Dis. 2014;40[3]:737-42). However, small case-control studies have not shown an association between ADHD and Alzheimer’s disease, and cohort studies in the elderly are lacking (Eur J Neurol. Jan;18[1]:78-84); (J Aging Res. 2011;2011. doi:10.4061/2011/729801).

Though ADHD affects a relatively small proportion of the elderly population, it presents a unique challenge when evaluating patients for suspected neurodegenerative disorders. Clinician awareness, detailed history-taking, and neuropsychological testing are essential to diagnosing ADHD in the geriatric population. Appropriate treatment of ADHD might improve functional outcomes for patients, including those with comorbid dementia. Although ADHD and Alzheimer’s disease have some neurobiologic similarities, further research is needed to clarify how these disorders interact, both biologically and clinically.

Dr. Vardi completed her General Psychiatry residency at Brown University, Providence, R.I., and obtained her medical degree from Vanderbilt University, Nashville, Tenn. Dr. Lee completed her General Psychiatry residency training at the University of Maryland/Sheppard Pratt program, Baltimore, and obtained her medical degree at Case Western Reserve University, Cleveland. Currently, they are both geropsychiatry fellows at the University of California, San Diego.

A 70-year-old patient with no psychiatric history presents to your office complaining of memory problems. The patient frequently misplaces items, forgets appointments, and has difficulty completing tasks. You observe that the patient interrupts you frequently and misinterprets your instructions during cognitive screening. The patient is concerned about having dementia. That’s on your differential, but could it be attention-deficit/hyperactivity disorder? Even in an older patient, it’s worth considering.

Until recently, attention-deficit/hyperactivity disorder (ADHD) was considered primarily a disorder of childhood and adolescence. The modern conceptualization of ADHD originated in the mid-19th century, largely because of political and societal changes that made formal, classroom-based schooling accessible to many more children (Atten Defic Hyperact Disord. 2014;6[3]:125-51). Although symptoms must cause dysfunction in two or more settings to meet DSM-5 criteria for the disorder, ADHD remains best understood as a classroom problem.

A growing body of evidence, however, reveals that ADHD symptoms persist into adulthood in two-thirds of cases (J Atten Disord. 2015 Sep 22. pil: 1087054715604360); (Psychol Med. 2015 Jan 23;1-12). Older adults might be especially prone to misdiagnosis given that they and their clinicians might be more concerned about the possibility of a neurodegenerative disorder.

The DSM-5 clearly defines ADHD as a neurodevelopmental disorder that begins in childhood. Nonetheless, the manual says that ADHD can be diagnosed retrospectively in adults who have at least five inattentive or hyperactive symptoms (compared with six or more for children) and who recall having “several” inattentive or hyperactive symptoms prior to age 12. ADHD symptoms attenuate in adulthood. Remission rates vary considerably across studies, but even among adults who no longer meet criteria for the diagnosis, residual symptoms are common and continue to interfere with functioning (Psychol Med. 2006;36:159-65); (Psychol Med. 2015;23:1-12); (J Atten Disord. 2015 Sep 22). Inattentive symptoms are more likely to persist than hyperactive-impulsive symptoms (Atten Def Hyperact Disord. 2015 Jun 12).

To date, little research has focused on ADHD symptoms in the geriatric population. Investigators of a recent cohort study of noninstitutionalized Dutch adults over 60 years old estimate that the prevalence of ADHD in this population is 2.8% with an additional 1.4% reporting functional impairment because of subsyndromal disease (Br J Psychiatry. 2012 Oct;201[4]:298-305).

Since attention is requisite to virtually all cognitive tasks, inattention can negatively affect functioning in a variety of ways. Patients and clinicians could easily misinterpret inattentive symptoms as deficits in other cognitive domains, such as memory. A thorough developmental history should clarify the diagnosis by identifying whether or not cognitive symptoms were present in childhood. Standardized scales, such as the Wender Utah Rating Scale and the Barkley Childhood Symptoms Scale, can help clinicians elicit a history of childhood ADHD symptoms and assess the validity of retrospective self-reports. Since inattention is a nonspecific symptom, the differential diagnosis also should include depression, anxiety, and delirium, among others.

Neuropsychological testing can clarify the diagnosis by quantifying patient performance across cognitive domains, comparing patient performance to normative data, and controlling for motivational factors. The pattern of cognitive deficits is well established and unique for most forms of dementia in their early stages. For example, rapid forgetting is the “first and worst” symptom of Alzheimer’s disease, the most common form of dementia. Attention typically is the next cognitive domain affected in Alzheimer’s disease, preceding visuospatial and language involvement (Brain. 1999 Mar;122[Pt. 3]:383-404). As dementias progress and more cognitive domains are affected, neuropsychological testing might be less helpful in differentiating dementias from each other and teasing out comorbidities such as ADHD, depression, anxiety, and substance use disorders. From another perspective, preexisting ADHD exacerbates cognitive deficits, impairing function and mimicking more advanced neurodegenerative disease. Therefore, identifying and treating comorbid ADHD may improve functioning in patients with dementia.

ADHD and Alzheimer’s disease might share some pathophysiologic mechanisms. Dysregulated cholinergic and noradrenergic activity have been observed in both conditions (Science. 2000 Dec 22;290[5500]:2315-9; (J Neuropathol Exp Neurol. 2011 Nov;70[11]:960-9). Research also suggests that cholinesterase inhibitors might disproportionately slow the decline of attention in Alzheimer’s disease, relative to their effects on disease progression in other cognitive domains (J Alzheimers Dis. 2014;40[3]:737-42). However, small case-control studies have not shown an association between ADHD and Alzheimer’s disease, and cohort studies in the elderly are lacking (Eur J Neurol. Jan;18[1]:78-84); (J Aging Res. 2011;2011. doi:10.4061/2011/729801).

Though ADHD affects a relatively small proportion of the elderly population, it presents a unique challenge when evaluating patients for suspected neurodegenerative disorders. Clinician awareness, detailed history-taking, and neuropsychological testing are essential to diagnosing ADHD in the geriatric population. Appropriate treatment of ADHD might improve functional outcomes for patients, including those with comorbid dementia. Although ADHD and Alzheimer’s disease have some neurobiologic similarities, further research is needed to clarify how these disorders interact, both biologically and clinically.

Dr. Vardi completed her General Psychiatry residency at Brown University, Providence, R.I., and obtained her medical degree from Vanderbilt University, Nashville, Tenn. Dr. Lee completed her General Psychiatry residency training at the University of Maryland/Sheppard Pratt program, Baltimore, and obtained her medical degree at Case Western Reserve University, Cleveland. Currently, they are both geropsychiatry fellows at the University of California, San Diego.

A 70-year-old patient with no psychiatric history presents to your office complaining of memory problems. The patient frequently misplaces items, forgets appointments, and has difficulty completing tasks. You observe that the patient interrupts you frequently and misinterprets your instructions during cognitive screening. The patient is concerned about having dementia. That’s on your differential, but could it be attention-deficit/hyperactivity disorder? Even in an older patient, it’s worth considering.

Until recently, attention-deficit/hyperactivity disorder (ADHD) was considered primarily a disorder of childhood and adolescence. The modern conceptualization of ADHD originated in the mid-19th century, largely because of political and societal changes that made formal, classroom-based schooling accessible to many more children (Atten Defic Hyperact Disord. 2014;6[3]:125-51). Although symptoms must cause dysfunction in two or more settings to meet DSM-5 criteria for the disorder, ADHD remains best understood as a classroom problem.

A growing body of evidence, however, reveals that ADHD symptoms persist into adulthood in two-thirds of cases (J Atten Disord. 2015 Sep 22. pil: 1087054715604360); (Psychol Med. 2015 Jan 23;1-12). Older adults might be especially prone to misdiagnosis given that they and their clinicians might be more concerned about the possibility of a neurodegenerative disorder.

The DSM-5 clearly defines ADHD as a neurodevelopmental disorder that begins in childhood. Nonetheless, the manual says that ADHD can be diagnosed retrospectively in adults who have at least five inattentive or hyperactive symptoms (compared with six or more for children) and who recall having “several” inattentive or hyperactive symptoms prior to age 12. ADHD symptoms attenuate in adulthood. Remission rates vary considerably across studies, but even among adults who no longer meet criteria for the diagnosis, residual symptoms are common and continue to interfere with functioning (Psychol Med. 2006;36:159-65); (Psychol Med. 2015;23:1-12); (J Atten Disord. 2015 Sep 22). Inattentive symptoms are more likely to persist than hyperactive-impulsive symptoms (Atten Def Hyperact Disord. 2015 Jun 12).

To date, little research has focused on ADHD symptoms in the geriatric population. Investigators of a recent cohort study of noninstitutionalized Dutch adults over 60 years old estimate that the prevalence of ADHD in this population is 2.8% with an additional 1.4% reporting functional impairment because of subsyndromal disease (Br J Psychiatry. 2012 Oct;201[4]:298-305).

Since attention is requisite to virtually all cognitive tasks, inattention can negatively affect functioning in a variety of ways. Patients and clinicians could easily misinterpret inattentive symptoms as deficits in other cognitive domains, such as memory. A thorough developmental history should clarify the diagnosis by identifying whether or not cognitive symptoms were present in childhood. Standardized scales, such as the Wender Utah Rating Scale and the Barkley Childhood Symptoms Scale, can help clinicians elicit a history of childhood ADHD symptoms and assess the validity of retrospective self-reports. Since inattention is a nonspecific symptom, the differential diagnosis also should include depression, anxiety, and delirium, among others.

Neuropsychological testing can clarify the diagnosis by quantifying patient performance across cognitive domains, comparing patient performance to normative data, and controlling for motivational factors. The pattern of cognitive deficits is well established and unique for most forms of dementia in their early stages. For example, rapid forgetting is the “first and worst” symptom of Alzheimer’s disease, the most common form of dementia. Attention typically is the next cognitive domain affected in Alzheimer’s disease, preceding visuospatial and language involvement (Brain. 1999 Mar;122[Pt. 3]:383-404). As dementias progress and more cognitive domains are affected, neuropsychological testing might be less helpful in differentiating dementias from each other and teasing out comorbidities such as ADHD, depression, anxiety, and substance use disorders. From another perspective, preexisting ADHD exacerbates cognitive deficits, impairing function and mimicking more advanced neurodegenerative disease. Therefore, identifying and treating comorbid ADHD may improve functioning in patients with dementia.

ADHD and Alzheimer’s disease might share some pathophysiologic mechanisms. Dysregulated cholinergic and noradrenergic activity have been observed in both conditions (Science. 2000 Dec 22;290[5500]:2315-9; (J Neuropathol Exp Neurol. 2011 Nov;70[11]:960-9). Research also suggests that cholinesterase inhibitors might disproportionately slow the decline of attention in Alzheimer’s disease, relative to their effects on disease progression in other cognitive domains (J Alzheimers Dis. 2014;40[3]:737-42). However, small case-control studies have not shown an association between ADHD and Alzheimer’s disease, and cohort studies in the elderly are lacking (Eur J Neurol. Jan;18[1]:78-84); (J Aging Res. 2011;2011. doi:10.4061/2011/729801).

Though ADHD affects a relatively small proportion of the elderly population, it presents a unique challenge when evaluating patients for suspected neurodegenerative disorders. Clinician awareness, detailed history-taking, and neuropsychological testing are essential to diagnosing ADHD in the geriatric population. Appropriate treatment of ADHD might improve functional outcomes for patients, including those with comorbid dementia. Although ADHD and Alzheimer’s disease have some neurobiologic similarities, further research is needed to clarify how these disorders interact, both biologically and clinically.

Dr. Vardi completed her General Psychiatry residency at Brown University, Providence, R.I., and obtained her medical degree from Vanderbilt University, Nashville, Tenn. Dr. Lee completed her General Psychiatry residency training at the University of Maryland/Sheppard Pratt program, Baltimore, and obtained her medical degree at Case Western Reserve University, Cleveland. Currently, they are both geropsychiatry fellows at the University of California, San Diego.

Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.

I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.

Physicians, Especially Orthopedists, Are Not Happy

Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,¹ 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.

What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives²; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.³ Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.

Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 2014⁴ places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.⁵

What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.

DeBotton⁶ wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report⁴ is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?

Humanism

Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”⁷ In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.⁸ A century after Osler, Stellato⁹ echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”

Humanism, then, is the trait underlying professionalism.^10,11 Communication skills are essential to humanism.¹² However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”¹³ In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.¹⁴ Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.

Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?

Residency and the Academic Medical Center

The education of the orthopedic surgeon starts with the selection process. Simon¹⁵ noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.¹⁶ Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.

The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.¹⁷ However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.¹⁸ “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”¹⁹ Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).

How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.²⁰ As Gofton and Regehr²¹ noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.²² Trainees absorb what they hear and see.

In 2003, Inui²³ published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”²³ In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”²³ In effect, the academic medical center is part of the hidden curriculum.

Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.²⁴ A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.²⁵ At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.²⁶

Of the factors affecting physician dissatisfaction, workplace stress is predominant.²⁷ In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,²⁸ “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues²⁹ extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,³⁰ they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.³⁰

What Can We Do?

The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”¹⁵ This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”

Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.

As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.³¹

Chervenak and colleagues³² forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.³³

Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.³⁴ This will be difficult, but it is necessary for improving professional satisfaction.

For practicing physicians, Wynia³⁵ made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.

But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues³⁶ concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt³⁷ uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.

Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.

Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.

I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.

Physicians, Especially Orthopedists, Are Not Happy

Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,¹ 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.

What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives²; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.³ Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.

Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 2014⁴ places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.⁵

What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.

DeBotton⁶ wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report⁴ is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?

Humanism

Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”⁷ In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.⁸ A century after Osler, Stellato⁹ echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”

Humanism, then, is the trait underlying professionalism.^10,11 Communication skills are essential to humanism.¹² However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”¹³ In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.¹⁴ Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.

Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?

Residency and the Academic Medical Center

The education of the orthopedic surgeon starts with the selection process. Simon¹⁵ noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.¹⁶ Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.

The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.¹⁷ However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.¹⁸ “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”¹⁹ Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).

How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.²⁰ As Gofton and Regehr²¹ noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.²² Trainees absorb what they hear and see.

In 2003, Inui²³ published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”²³ In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”²³ In effect, the academic medical center is part of the hidden curriculum.

Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.²⁴ A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.²⁵ At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.²⁶

Of the factors affecting physician dissatisfaction, workplace stress is predominant.²⁷ In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,²⁸ “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues²⁹ extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,³⁰ they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.³⁰

What Can We Do?

The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”¹⁵ This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”

Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.

As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.³¹

Chervenak and colleagues³² forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.³³

Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.³⁴ This will be difficult, but it is necessary for improving professional satisfaction.

For practicing physicians, Wynia³⁵ made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.

But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues³⁶ concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt³⁷ uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.

Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.

Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.

I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.

Physicians, Especially Orthopedists, Are Not Happy

Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,¹ 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.

What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives²; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.³ Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.

Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 2014⁴ places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.⁵

What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.

DeBotton⁶ wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report⁴ is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?

Humanism

Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”⁷ In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.⁸ A century after Osler, Stellato⁹ echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”

Humanism, then, is the trait underlying professionalism.^10,11 Communication skills are essential to humanism.¹² However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”¹³ In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.¹⁴ Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.

Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?

Residency and the Academic Medical Center

The education of the orthopedic surgeon starts with the selection process. Simon¹⁵ noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.¹⁶ Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.

The residency process has been substantially altered by work-hour restrictions. The 20th-century residency, which emphasizes taking responsibility for the patient throughout a hospital stay, has now been dismissed as “nostalgic professionalism.” Residents are now advised to avoid such activities as checking laboratory results from home and coming to work when they are not feeling well.¹⁷ However, there has been considerable pushback against diminishing nostalgic professionalism, primarily from surgeons.¹⁸ “Teaching residents that they should go home to rest at the end of their shift without regard for the circumstances of their cases in progress is not an acceptable example for training.”¹⁹ Current promulgated restrictions on duty hours move concern for the “circumstances of their cases” to the back burner—the shift ends, the physician leaves. Residents are pulled one way by forces telling them to leave (Accreditation Council for Graduate Medical Education) and the other way by forces telling them to stay (their conscience).

How do residents develop their surgical identities and concepts of humanism and professionalism? There is a substantial body of evidence that the so-called hidden curriculum is the dominant factor: trainees emulate what their faculty say and do.²⁰ As Gofton and Regehr²¹ noted, “It is vital for members of the surgical academic community to recognize [that] the attitudes, beliefs, and values implicit in every action, every word, every inaction, and every silence are not only shaping the attitudes, beliefs, and values of one’s protégés, but also are shaping the decisions of students who are considering the possibility of becoming one’s protégés.” It is not easy being a surgical role model given the conflicts affecting academic surgeons. For example, should a surgeon allot extra time so a trainee can do a case properly, or should the case be finished expeditiously in order to avoid canceling the next case, or to get to a committee meeting or a kid’s ballgame on time? Monetary pressures, along with the possibility of losing operative time because the schedule was not full, can influence the decision to operate or not.²² Trainees absorb what they hear and see.

In 2003, Inui²³ published A Flag in the Wind: Educating for Professionalism in Medicine, in which he stated, “There can be little doubt that physicians in general as well as the leadership of the organization of medicine have been preoccupied with finances and the economics of medical care. … The topics and the language of academic leadership [have] shifted in the last twenty years. … Core functions of the academic medical center became ‘enterprises.’” He also noted, “The most difficult challenge of all may be the need to understand—and to be explicitly mindful of, and articulate about—medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities.”²³ In addition, the “institutional environment we create … [is] a reflection of the values we hold as a professional community.”²³ In effect, the academic medical center is part of the hidden curriculum.

Curiously, academic institutions tend not to reward clinical excellence—a self-defeating measure for any institution that recognizes the importance of the hidden curriculum.²⁴ A peer evaluation of hospitalists revealed that the most highly regarded were highly associated with humanism and a passion for clinical medicine.²⁵ At a prominent institution, however, it was found that clinical educators were less likely than research faculty to hold a higher rank.²⁶

Of the factors affecting physician dissatisfaction, workplace stress is predominant.²⁷ In this age of organizational physicians, job satisfaction correlates with how a physician feels about his or her ability to function as a physician. In a study by Wai and colleagues,²⁸ “surgical faculty reported low satisfaction with a number of questions about communication in their medical schools and their clinical practice locations.” The authors indicated that “medical school and department governance are critical determinants of faculty satisfaction within academic surgical centers.” Pololi and colleagues²⁹ extensively studied the culture of academic medicine and summarized the sources of discontent: “competitive individualism, undervaluing of humanistic qualities, deprecation, and the erosion of trust.” In another study,³⁰ they studied the incidence (~25%) of, and reasons for, considering to leave academic medicine. Reasons included feeling isolated in the department, lack of institutional support, poor communication with administrators, and a perceived difference between the stated culture of the institution and what was observed on a daily basis.³⁰

What Can We Do?

The obvious starting point is the selection process—focusing more on finding the “best,” not necessarily the “brightest.”¹⁵ This is not easy. Recommendation letters are often based on limited contact and may or may not reflect applicants’ true character. Numerous websites advise resident applicants on what questions to expect and how to prepare and practice for them. I have found questions of current events very illuminating, as they can probe how applicants view the world. Given the high income of orthopedic surgeons, some applicants likely are attracted to that aspect of the specialty. These applicants are not the “best.”

Residents who exhibit questionable ethical reasoning or behavior must be identified and not be allowed to finish their program. It is the responsibility of the program, not the board, to ensure that those entering practice exhibit a high degree of professionalism. Faculty must seriously recognize, every day, that everything they do is part of the hidden curriculum.

As noted, the academic medical environment can be inimical. Faculty who experience dissonance must be able to effectively confront administrative leadership to express their concerns, and they need to feel their concerns are recognized. Leaders of academic medical centers must guide their institutions in such a way that the day-to-day functions are compatible with the stated mission and values.³¹

Chervenak and colleagues³² forcefully stated that “appropriate ethical values” are the core component that academic leadership needs in order to respond to the opposing forces of increasing pressures of patient satisfaction, compliance, liability, and other administrative demands on one hand and diminishing resources on the other hand. They listed 4 “professional virtues” that characterize responsible professional leadership: self-effacement, which obligates physician leaders to be unbiased; self-sacrifice, the willingness to risk individual and organizational self-interest, especially in the economic domain; compassion, or “What can I do to help?”; and integrity. The principles of effective leadership are not that complicated, but implementing them requires conviction and courage.³³

Physicians increasingly are practicing in the organization setting. They need to increase their involvement in the organization in order to promulgate the needs of physicians. Organizational executive leadership is primarily driven by budgetary and capital planning processes; physician input is essential to ensure resources are directed toward better patient care. A feeling of loss of control over one’s practice is a primary cause of physician dissatisfaction. The schism between physicians and administrators traditionally has been characterized by a lack of trust; a more trusting relationship, reinforced by frequent constructive dialogue, will result in more physician control of the practice.³⁴ This will be difficult, but it is necessary for improving professional satisfaction.

For practicing physicians, Wynia³⁵ made the compelling case that professionalism demands self-regulation, which involves identifying and reporting impaired or incompetent physicians—another task that requires conviction and courage.

But the core issue is how an orthopedist regards the day-to-day aspects of his or her practice. Shanafelt and colleagues³⁶ concluded that surgeons are not very good at assessing their own well-being and stress levels. Certainly high stress can affect well-being, which in turn can affect professionalism. West and Shanafelt³⁷ uniquely described this relationship: “The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency. Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.” This description sounds completely synchronized with the current career dissatisfaction of orthopedic surgeons.

Improving orthopedists’ status requires ethical and involved leadership, both in academia and in our professional organizations, which too often seem mired in the (not so effective) status quo. Recognizing that the resident selection process is fallible is the first step in taking action—engaging in scrupulous role modeling and insisting that residents demonstrate professionalism and communication skills in their daily work. Becoming involved in organizational management is preferable to becoming angry and dissatisfied. Getting to know one’s patients is its own reward in terms of career satisfaction. Orthopedic surgeons have a well-earned macho image—that image can be enhanced with a dose of humanism. The result would be a true professional who enjoys his or her practice and has a satisfying career.

"Report to the Administrator’s Office for a discussion 7:00 am sharp,” reads the email on your phone. The phone log sheet from your administrator is handed to you as you are running to the operating room and reads, “Call back Mr. Smith’s health insurance company because your patient stayed overnight unexpectedly in the hospital, and if the return phone call is not received by 8:40 am the complete hospital stay will be disallowed.” The text message reads, “The head nurse from the emergency department wants to have a discussion with you tomorrow about what transpired in room 23 last night at 1:33 am.” Your physician assistant calls you because a recent history and physical examination from the out-of-state internist has not been cosigned by you, and, therefore, the patient is still in the admitting office; the admitting officer is waiting to go home and won’t accept the physician assistant’s signature.

This simple illustration of a surgeon’s typical morning is hardly hyperbole. Demands and finger-pointing are routine aspects of care, with a concurrent need to attribute blame and create a hostile work environment whether in the office, operating room, or floor of the hospital by anyone who can proudly say to the physician, “Gotcha!” The environment that produces this ethos is toxic and needs to be changed. While all members of a patient care team must be accountable, no member should be antagonistic toward another, and each member must feel a part of a working whole that is led by a competent, caring, and identifiable physician. Yes, the doctor must be the team captain; he or she must take back the reins of care immediately in order to provide the patient with the best possible outcome.

The loss of leadership can be traced back to the rise of regulatory controls put in place by government entities or local hospital administration to contain costs and limit liability. While the target goals of such measures are laudable, the negative impact on the doctor–patient relationship has been palpable and problematic and requires reassessment. The profession itself will be preserved by refocusing on the doctor–patient relationship and returning the physician to the role of team leader. Our patients deserve to feel as though their health care resides in the hands of the physician as the leader of a team that is pursuing a common goal: patient care with minimal distractions.

What, though, makes a great captain or leader? Sociologists have said that in a stable environment a “participatory model” of leadership is appropriate, while in a high-growth or changing environment, like the one in which we presently live, an “authoritative model” can be used to right the ship.^1,2 Many types of leaders exist within both models. Leaders who are “innovators” will design and bring new ideas and original thought but may generate too many ideas that can’t be implemented practically in the hospital setting. Leaders who are “developers” will build and move forward to achieve challenging goals but may be impatient when ideas do not work and may be perceived in many interdisciplinary meetings as unruly. “Bureaucratic” leaders, presently seen in many leadership positions, can be classified as stabilizers and, while they may maintain equilibrium and keep things running smoothly, they often insist on a policy for every situation, resulting in stasis and sometimes even paralysis of the surgical center or hospital system.

I believe that health management and patient care require the simultaneous use of the authoritative and participatory models to encourage innovation, set attainable short- and long-term goals, and maintain the physician as the team leader. To lead effectively under this hybrid model, the physician must be accessible and fair, a teacher and a student, and a risk-taker, but, ultimately, at the end of every day, the physician must be accountable.

The time has come for physician leaders to assemble the troops: administrators, clinical providers, and nonclinical support staff. To paraphrase John Quincy Adams, in your actions inspire others to dream more and become more; then, and only then, are you an excellent leader. A secret to effective leadership is in finding one’s voice and acknowledging strengths and weaknesses. The leader must recruit other leaders who are very different from himself or herself and must listen to them deeply and trust them completely. One of our former first ladies said wisely, “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” To truly find this leadership model, we as busy surgeons must spend some concentrated time away from our patients and exciting research to sit in the room with our nurses, administrators, and all other members of the health care community and listen to their thoughts and understand their concerns. We must understand policy to assess if it is reasonable and, if it is not, to reject it and propose more effective and appropriate rules for good care. We must remove from leadership positions those that do not have the interest of the patient as their primary concern. We must challenge any policy that does not have the patient’s interest and health as its raison d’etre. We must be proactive and not reactive. We must be ready to stand tall and politely question when dictated to unless evidence-based medical reasons can be presented.

You may ask, therefore, where should we lead? The answer is obvious! We need to be involved in every aspect of this great profession. We need to be the leaders of hospital systems, we need to be in charge of research institutions, and, as always, we need to be the chief of the operating room and the chief within each room as the team leader for the nurse, anesthesiologist, and nonclinical staff in order to safely guide our patients through the stress of a medical crisis or routine intervention. We need to find those of us with other degrees, whether MPH, MBA, MHA, or JD, and place those physicians in positions of business and political leadership as well as in leadership positions in hospitals and private practitioner offices. We need to encourage our medical students, residents, and fellows to continue their rigorous training to include an understanding of health care policy and economics so as to help manage and resolve the crisis at hand.

We must now navigate the sea of change to allow for continuity of care and not throw up our arms in despair. The role of physician as private practitioner or as full-time faculty member has its origins deeply imbedded in the roots of our profession, and this traditional role as caretaker and scientist must continue. But in this century, we need to be leaders in the political and business communities as well. This vision requires a new and fresh momentum. We cannot sit idly by as patient care becomes increasingly managed by nonphysicians. The time has come to use our unique position as doctors to frame the debate, participate in the discussion, and lead our profession and the management of health care toward calmer waters with compassion, science, and responsibility. To do this, we must demand transparency, proceed with respect, and require excellence from everyone around us and make sure it is demanded from all of us.◾

"Report to the Administrator’s Office for a discussion 7:00 am sharp,” reads the email on your phone. The phone log sheet from your administrator is handed to you as you are running to the operating room and reads, “Call back Mr. Smith’s health insurance company because your patient stayed overnight unexpectedly in the hospital, and if the return phone call is not received by 8:40 am the complete hospital stay will be disallowed.” The text message reads, “The head nurse from the emergency department wants to have a discussion with you tomorrow about what transpired in room 23 last night at 1:33 am.” Your physician assistant calls you because a recent history and physical examination from the out-of-state internist has not been cosigned by you, and, therefore, the patient is still in the admitting office; the admitting officer is waiting to go home and won’t accept the physician assistant’s signature.

This simple illustration of a surgeon’s typical morning is hardly hyperbole. Demands and finger-pointing are routine aspects of care, with a concurrent need to attribute blame and create a hostile work environment whether in the office, operating room, or floor of the hospital by anyone who can proudly say to the physician, “Gotcha!” The environment that produces this ethos is toxic and needs to be changed. While all members of a patient care team must be accountable, no member should be antagonistic toward another, and each member must feel a part of a working whole that is led by a competent, caring, and identifiable physician. Yes, the doctor must be the team captain; he or she must take back the reins of care immediately in order to provide the patient with the best possible outcome.

The loss of leadership can be traced back to the rise of regulatory controls put in place by government entities or local hospital administration to contain costs and limit liability. While the target goals of such measures are laudable, the negative impact on the doctor–patient relationship has been palpable and problematic and requires reassessment. The profession itself will be preserved by refocusing on the doctor–patient relationship and returning the physician to the role of team leader. Our patients deserve to feel as though their health care resides in the hands of the physician as the leader of a team that is pursuing a common goal: patient care with minimal distractions.

What, though, makes a great captain or leader? Sociologists have said that in a stable environment a “participatory model” of leadership is appropriate, while in a high-growth or changing environment, like the one in which we presently live, an “authoritative model” can be used to right the ship.^1,2 Many types of leaders exist within both models. Leaders who are “innovators” will design and bring new ideas and original thought but may generate too many ideas that can’t be implemented practically in the hospital setting. Leaders who are “developers” will build and move forward to achieve challenging goals but may be impatient when ideas do not work and may be perceived in many interdisciplinary meetings as unruly. “Bureaucratic” leaders, presently seen in many leadership positions, can be classified as stabilizers and, while they may maintain equilibrium and keep things running smoothly, they often insist on a policy for every situation, resulting in stasis and sometimes even paralysis of the surgical center or hospital system.

I believe that health management and patient care require the simultaneous use of the authoritative and participatory models to encourage innovation, set attainable short- and long-term goals, and maintain the physician as the team leader. To lead effectively under this hybrid model, the physician must be accessible and fair, a teacher and a student, and a risk-taker, but, ultimately, at the end of every day, the physician must be accountable.

The time has come for physician leaders to assemble the troops: administrators, clinical providers, and nonclinical support staff. To paraphrase John Quincy Adams, in your actions inspire others to dream more and become more; then, and only then, are you an excellent leader. A secret to effective leadership is in finding one’s voice and acknowledging strengths and weaknesses. The leader must recruit other leaders who are very different from himself or herself and must listen to them deeply and trust them completely. One of our former first ladies said wisely, “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” To truly find this leadership model, we as busy surgeons must spend some concentrated time away from our patients and exciting research to sit in the room with our nurses, administrators, and all other members of the health care community and listen to their thoughts and understand their concerns. We must understand policy to assess if it is reasonable and, if it is not, to reject it and propose more effective and appropriate rules for good care. We must remove from leadership positions those that do not have the interest of the patient as their primary concern. We must challenge any policy that does not have the patient’s interest and health as its raison d’etre. We must be proactive and not reactive. We must be ready to stand tall and politely question when dictated to unless evidence-based medical reasons can be presented.

You may ask, therefore, where should we lead? The answer is obvious! We need to be involved in every aspect of this great profession. We need to be the leaders of hospital systems, we need to be in charge of research institutions, and, as always, we need to be the chief of the operating room and the chief within each room as the team leader for the nurse, anesthesiologist, and nonclinical staff in order to safely guide our patients through the stress of a medical crisis or routine intervention. We need to find those of us with other degrees, whether MPH, MBA, MHA, or JD, and place those physicians in positions of business and political leadership as well as in leadership positions in hospitals and private practitioner offices. We need to encourage our medical students, residents, and fellows to continue their rigorous training to include an understanding of health care policy and economics so as to help manage and resolve the crisis at hand.

We must now navigate the sea of change to allow for continuity of care and not throw up our arms in despair. The role of physician as private practitioner or as full-time faculty member has its origins deeply imbedded in the roots of our profession, and this traditional role as caretaker and scientist must continue. But in this century, we need to be leaders in the political and business communities as well. This vision requires a new and fresh momentum. We cannot sit idly by as patient care becomes increasingly managed by nonphysicians. The time has come to use our unique position as doctors to frame the debate, participate in the discussion, and lead our profession and the management of health care toward calmer waters with compassion, science, and responsibility. To do this, we must demand transparency, proceed with respect, and require excellence from everyone around us and make sure it is demanded from all of us.◾

"Report to the Administrator’s Office for a discussion 7:00 am sharp,” reads the email on your phone. The phone log sheet from your administrator is handed to you as you are running to the operating room and reads, “Call back Mr. Smith’s health insurance company because your patient stayed overnight unexpectedly in the hospital, and if the return phone call is not received by 8:40 am the complete hospital stay will be disallowed.” The text message reads, “The head nurse from the emergency department wants to have a discussion with you tomorrow about what transpired in room 23 last night at 1:33 am.” Your physician assistant calls you because a recent history and physical examination from the out-of-state internist has not been cosigned by you, and, therefore, the patient is still in the admitting office; the admitting officer is waiting to go home and won’t accept the physician assistant’s signature.

This simple illustration of a surgeon’s typical morning is hardly hyperbole. Demands and finger-pointing are routine aspects of care, with a concurrent need to attribute blame and create a hostile work environment whether in the office, operating room, or floor of the hospital by anyone who can proudly say to the physician, “Gotcha!” The environment that produces this ethos is toxic and needs to be changed. While all members of a patient care team must be accountable, no member should be antagonistic toward another, and each member must feel a part of a working whole that is led by a competent, caring, and identifiable physician. Yes, the doctor must be the team captain; he or she must take back the reins of care immediately in order to provide the patient with the best possible outcome.

The loss of leadership can be traced back to the rise of regulatory controls put in place by government entities or local hospital administration to contain costs and limit liability. While the target goals of such measures are laudable, the negative impact on the doctor–patient relationship has been palpable and problematic and requires reassessment. The profession itself will be preserved by refocusing on the doctor–patient relationship and returning the physician to the role of team leader. Our patients deserve to feel as though their health care resides in the hands of the physician as the leader of a team that is pursuing a common goal: patient care with minimal distractions.

What, though, makes a great captain or leader? Sociologists have said that in a stable environment a “participatory model” of leadership is appropriate, while in a high-growth or changing environment, like the one in which we presently live, an “authoritative model” can be used to right the ship.^1,2 Many types of leaders exist within both models. Leaders who are “innovators” will design and bring new ideas and original thought but may generate too many ideas that can’t be implemented practically in the hospital setting. Leaders who are “developers” will build and move forward to achieve challenging goals but may be impatient when ideas do not work and may be perceived in many interdisciplinary meetings as unruly. “Bureaucratic” leaders, presently seen in many leadership positions, can be classified as stabilizers and, while they may maintain equilibrium and keep things running smoothly, they often insist on a policy for every situation, resulting in stasis and sometimes even paralysis of the surgical center or hospital system.

I believe that health management and patient care require the simultaneous use of the authoritative and participatory models to encourage innovation, set attainable short- and long-term goals, and maintain the physician as the team leader. To lead effectively under this hybrid model, the physician must be accessible and fair, a teacher and a student, and a risk-taker, but, ultimately, at the end of every day, the physician must be accountable.

The time has come for physician leaders to assemble the troops: administrators, clinical providers, and nonclinical support staff. To paraphrase John Quincy Adams, in your actions inspire others to dream more and become more; then, and only then, are you an excellent leader. A secret to effective leadership is in finding one’s voice and acknowledging strengths and weaknesses. The leader must recruit other leaders who are very different from himself or herself and must listen to them deeply and trust them completely. One of our former first ladies said wisely, “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” To truly find this leadership model, we as busy surgeons must spend some concentrated time away from our patients and exciting research to sit in the room with our nurses, administrators, and all other members of the health care community and listen to their thoughts and understand their concerns. We must understand policy to assess if it is reasonable and, if it is not, to reject it and propose more effective and appropriate rules for good care. We must remove from leadership positions those that do not have the interest of the patient as their primary concern. We must challenge any policy that does not have the patient’s interest and health as its raison d’etre. We must be proactive and not reactive. We must be ready to stand tall and politely question when dictated to unless evidence-based medical reasons can be presented.

You may ask, therefore, where should we lead? The answer is obvious! We need to be involved in every aspect of this great profession. We need to be the leaders of hospital systems, we need to be in charge of research institutions, and, as always, we need to be the chief of the operating room and the chief within each room as the team leader for the nurse, anesthesiologist, and nonclinical staff in order to safely guide our patients through the stress of a medical crisis or routine intervention. We need to find those of us with other degrees, whether MPH, MBA, MHA, or JD, and place those physicians in positions of business and political leadership as well as in leadership positions in hospitals and private practitioner offices. We need to encourage our medical students, residents, and fellows to continue their rigorous training to include an understanding of health care policy and economics so as to help manage and resolve the crisis at hand.

We must now navigate the sea of change to allow for continuity of care and not throw up our arms in despair. The role of physician as private practitioner or as full-time faculty member has its origins deeply imbedded in the roots of our profession, and this traditional role as caretaker and scientist must continue. But in this century, we need to be leaders in the political and business communities as well. This vision requires a new and fresh momentum. We cannot sit idly by as patient care becomes increasingly managed by nonphysicians. The time has come to use our unique position as doctors to frame the debate, participate in the discussion, and lead our profession and the management of health care toward calmer waters with compassion, science, and responsibility. To do this, we must demand transparency, proceed with respect, and require excellence from everyone around us and make sure it is demanded from all of us.◾

The setting is a medical office with a newly pregnant couple and their doctor. There is a lot of discussion and counseling planned at this visit. Some patients are anxious, some are not, but always they have questions. This scene plays itself out in my office multiple times a day.

The order will vary with the practitioner, but is likely to include a review of medical symptoms of the pregnancy, such as nausea and fatigue, or abnormal bleeding. Additionally, we will explore medical questions including family history, medical history, medications, and any hereditary genetic risk. The couples’ list of questions will sometimes be short, sometimes extensive, and inevitably includes several of the following: Can I color my hair? Can I use self-tanner or teeth whitener? Can I get a bikini wax? Can I get a massage? Can I travel? Some come in with a bag of varying herbal or vitamin supplements that they want to know are safe during pregnancy.

While these questions are important, they often supersede questions about nutrition, exercise, and pregnancy weight gain, and we do need to address those before the visit is over.

Recommendations

With that in mind, here are the key messages related to exercise and nutrition that I proactively weave into my patients’ early pregnancy visits.

Continuing exercise in pregnancy is important to maintain cardiovascular health, muscle tone, and well-being. Just as when we are not pregnant, a sedentary lifestyle affects our overall health in a negative manner, unless avoiding exercise is recommended for a medical indication. Neither overdoing nor under exercising are a good way to achieve the body’s goals. Exercising to a conversational pace is a good measurement to achieve. For those who do not have a regular exercise routine, a good-paced walk several times a week or a prenatal fitness class can be a reasonable option.

The old adage of “eating for two” is one that we need to dispense with early in the process. In actuality, eating for “1.2” should be adequate for most patients. When starting a singleton pregnancy with a normal body mass index, only about 300 more calories a day should meet the new nutritional demands. Patients who are overweight or underweight need those guidelines adjusted and sometimes, in those situations, a nutritionist’s input can be a helpful addition.

Although the nutritional demands during pregnancy increase only a little bit, what we choose to eat while pregnant is important. While cravings influence our appetite, it continues to be important to pay attention to the variety of foods on our plate.

There is no specific pregnancy diet. Simply following the normal recommendations for healthy eating is the correct idea. Making sure to get adequate folic acid – at least 800 mcg daily – beginning preconceptionally to prevent neural tube defects, and then enough calcium to encourage healthy bone development – 1,000 mg per day either through supplements or food sources – is a good place to start.

Focusing on nutrient-dense foods such as lean proteins, low-fat dairy products, fruits, vegetables, and whole grains and incorporating a variety of these foods into the diet is ideal. That looks like this: Two to three servings of vegetables of different colors, two servings of fruit, three servings of whole grains, and two to three servings of lean protein sources on a daily basis.

Protein-rich foods should be varied to include seafood, lean meats, eggs, beans, nuts, and seed sources. Ideally, all women – especially those who are pregnant or breastfeeding – should incorporate two to three servings of a variety of seafood a week into this rotation to optimize the natural benefits of omega-3 fatty acids. The data suggest that this has not been the case, and it is important to emphasize these benefits to fetal and maternal well-being both for the short and long term.

Quite frankly, avoiding seafood is likely to pose more harm than otherwise. And there are only four types of fish that should be avoided during pregnancy: shark, swordfish, tilefish, and king mackerel. That leaves us with a long list of choices to fit varying tastes and budgets; everything from salmon and canned tuna to tilapia or cod and more can be safely enjoyed during pregnancy.

Managing the visit

This new pregnancy visit does take a long time. Our office has put together a folder that includes information and handouts on recommended genetic testing; good health and nutrition in pregnancy; a schedule of visits; information on nausea and vomiting symptoms; and testing done in routine prenatal care. This serves to help the physician remember the points to discuss, streamlines the visit, and allows the patient to take material home to review without having to commit the entire visit to memory.

We also have information on our website about medications that can be used in pregnancy and other common questions that patients and their spouses can use as a reference later.

There are many topics to discuss and multiple questions to be addressed, both medical and not. Getting the couple off to a good start and with a healthy plan will impact their pregnancy and baby’s development and outcome over the next 9 months, and hopefully, encourage these healthy habits to continue. Ultimately, I remind my patients that our goals are the same, and that these 40 weeks are just practice for the parenting ahead.

Dr. Siegel is an ob.gyn. at Atlanta Women’s Obstetrics & Gynecology in Georgia. She also consults with the National Fisheries Institute.

The setting is a medical office with a newly pregnant couple and their doctor. There is a lot of discussion and counseling planned at this visit. Some patients are anxious, some are not, but always they have questions. This scene plays itself out in my office multiple times a day.

The order will vary with the practitioner, but is likely to include a review of medical symptoms of the pregnancy, such as nausea and fatigue, or abnormal bleeding. Additionally, we will explore medical questions including family history, medical history, medications, and any hereditary genetic risk. The couples’ list of questions will sometimes be short, sometimes extensive, and inevitably includes several of the following: Can I color my hair? Can I use self-tanner or teeth whitener? Can I get a bikini wax? Can I get a massage? Can I travel? Some come in with a bag of varying herbal or vitamin supplements that they want to know are safe during pregnancy.

While these questions are important, they often supersede questions about nutrition, exercise, and pregnancy weight gain, and we do need to address those before the visit is over.

Recommendations

With that in mind, here are the key messages related to exercise and nutrition that I proactively weave into my patients’ early pregnancy visits.

Continuing exercise in pregnancy is important to maintain cardiovascular health, muscle tone, and well-being. Just as when we are not pregnant, a sedentary lifestyle affects our overall health in a negative manner, unless avoiding exercise is recommended for a medical indication. Neither overdoing nor under exercising are a good way to achieve the body’s goals. Exercising to a conversational pace is a good measurement to achieve. For those who do not have a regular exercise routine, a good-paced walk several times a week or a prenatal fitness class can be a reasonable option.

The old adage of “eating for two” is one that we need to dispense with early in the process. In actuality, eating for “1.2” should be adequate for most patients. When starting a singleton pregnancy with a normal body mass index, only about 300 more calories a day should meet the new nutritional demands. Patients who are overweight or underweight need those guidelines adjusted and sometimes, in those situations, a nutritionist’s input can be a helpful addition.

Although the nutritional demands during pregnancy increase only a little bit, what we choose to eat while pregnant is important. While cravings influence our appetite, it continues to be important to pay attention to the variety of foods on our plate.

There is no specific pregnancy diet. Simply following the normal recommendations for healthy eating is the correct idea. Making sure to get adequate folic acid – at least 800 mcg daily – beginning preconceptionally to prevent neural tube defects, and then enough calcium to encourage healthy bone development – 1,000 mg per day either through supplements or food sources – is a good place to start.

Focusing on nutrient-dense foods such as lean proteins, low-fat dairy products, fruits, vegetables, and whole grains and incorporating a variety of these foods into the diet is ideal. That looks like this: Two to three servings of vegetables of different colors, two servings of fruit, three servings of whole grains, and two to three servings of lean protein sources on a daily basis.

Protein-rich foods should be varied to include seafood, lean meats, eggs, beans, nuts, and seed sources. Ideally, all women – especially those who are pregnant or breastfeeding – should incorporate two to three servings of a variety of seafood a week into this rotation to optimize the natural benefits of omega-3 fatty acids. The data suggest that this has not been the case, and it is important to emphasize these benefits to fetal and maternal well-being both for the short and long term.

Quite frankly, avoiding seafood is likely to pose more harm than otherwise. And there are only four types of fish that should be avoided during pregnancy: shark, swordfish, tilefish, and king mackerel. That leaves us with a long list of choices to fit varying tastes and budgets; everything from salmon and canned tuna to tilapia or cod and more can be safely enjoyed during pregnancy.

Managing the visit

This new pregnancy visit does take a long time. Our office has put together a folder that includes information and handouts on recommended genetic testing; good health and nutrition in pregnancy; a schedule of visits; information on nausea and vomiting symptoms; and testing done in routine prenatal care. This serves to help the physician remember the points to discuss, streamlines the visit, and allows the patient to take material home to review without having to commit the entire visit to memory.

We also have information on our website about medications that can be used in pregnancy and other common questions that patients and their spouses can use as a reference later.

There are many topics to discuss and multiple questions to be addressed, both medical and not. Getting the couple off to a good start and with a healthy plan will impact their pregnancy and baby’s development and outcome over the next 9 months, and hopefully, encourage these healthy habits to continue. Ultimately, I remind my patients that our goals are the same, and that these 40 weeks are just practice for the parenting ahead.

Dr. Siegel is an ob.gyn. at Atlanta Women’s Obstetrics & Gynecology in Georgia. She also consults with the National Fisheries Institute.

The setting is a medical office with a newly pregnant couple and their doctor. There is a lot of discussion and counseling planned at this visit. Some patients are anxious, some are not, but always they have questions. This scene plays itself out in my office multiple times a day.

The order will vary with the practitioner, but is likely to include a review of medical symptoms of the pregnancy, such as nausea and fatigue, or abnormal bleeding. Additionally, we will explore medical questions including family history, medical history, medications, and any hereditary genetic risk. The couples’ list of questions will sometimes be short, sometimes extensive, and inevitably includes several of the following: Can I color my hair? Can I use self-tanner or teeth whitener? Can I get a bikini wax? Can I get a massage? Can I travel? Some come in with a bag of varying herbal or vitamin supplements that they want to know are safe during pregnancy.

While these questions are important, they often supersede questions about nutrition, exercise, and pregnancy weight gain, and we do need to address those before the visit is over.

Recommendations

With that in mind, here are the key messages related to exercise and nutrition that I proactively weave into my patients’ early pregnancy visits.

Continuing exercise in pregnancy is important to maintain cardiovascular health, muscle tone, and well-being. Just as when we are not pregnant, a sedentary lifestyle affects our overall health in a negative manner, unless avoiding exercise is recommended for a medical indication. Neither overdoing nor under exercising are a good way to achieve the body’s goals. Exercising to a conversational pace is a good measurement to achieve. For those who do not have a regular exercise routine, a good-paced walk several times a week or a prenatal fitness class can be a reasonable option.

The old adage of “eating for two” is one that we need to dispense with early in the process. In actuality, eating for “1.2” should be adequate for most patients. When starting a singleton pregnancy with a normal body mass index, only about 300 more calories a day should meet the new nutritional demands. Patients who are overweight or underweight need those guidelines adjusted and sometimes, in those situations, a nutritionist’s input can be a helpful addition.

Although the nutritional demands during pregnancy increase only a little bit, what we choose to eat while pregnant is important. While cravings influence our appetite, it continues to be important to pay attention to the variety of foods on our plate.

There is no specific pregnancy diet. Simply following the normal recommendations for healthy eating is the correct idea. Making sure to get adequate folic acid – at least 800 mcg daily – beginning preconceptionally to prevent neural tube defects, and then enough calcium to encourage healthy bone development – 1,000 mg per day either through supplements or food sources – is a good place to start.

Focusing on nutrient-dense foods such as lean proteins, low-fat dairy products, fruits, vegetables, and whole grains and incorporating a variety of these foods into the diet is ideal. That looks like this: Two to three servings of vegetables of different colors, two servings of fruit, three servings of whole grains, and two to three servings of lean protein sources on a daily basis.

Protein-rich foods should be varied to include seafood, lean meats, eggs, beans, nuts, and seed sources. Ideally, all women – especially those who are pregnant or breastfeeding – should incorporate two to three servings of a variety of seafood a week into this rotation to optimize the natural benefits of omega-3 fatty acids. The data suggest that this has not been the case, and it is important to emphasize these benefits to fetal and maternal well-being both for the short and long term.

Quite frankly, avoiding seafood is likely to pose more harm than otherwise. And there are only four types of fish that should be avoided during pregnancy: shark, swordfish, tilefish, and king mackerel. That leaves us with a long list of choices to fit varying tastes and budgets; everything from salmon and canned tuna to tilapia or cod and more can be safely enjoyed during pregnancy.

Managing the visit

This new pregnancy visit does take a long time. Our office has put together a folder that includes information and handouts on recommended genetic testing; good health and nutrition in pregnancy; a schedule of visits; information on nausea and vomiting symptoms; and testing done in routine prenatal care. This serves to help the physician remember the points to discuss, streamlines the visit, and allows the patient to take material home to review without having to commit the entire visit to memory.

We also have information on our website about medications that can be used in pregnancy and other common questions that patients and their spouses can use as a reference later.

There are many topics to discuss and multiple questions to be addressed, both medical and not. Getting the couple off to a good start and with a healthy plan will impact their pregnancy and baby’s development and outcome over the next 9 months, and hopefully, encourage these healthy habits to continue. Ultimately, I remind my patients that our goals are the same, and that these 40 weeks are just practice for the parenting ahead.

Dr. Siegel is an ob.gyn. at Atlanta Women’s Obstetrics & Gynecology in Georgia. She also consults with the National Fisheries Institute.

Results reported earlier this month at the Transcatheter Cardiovascular Therapeutics annual meeting for the Absorb bioresorbable vascular scaffold made by Abbott Vascular showed the device was statistically noninferior for treating selected coronary stenoses, compared with Xience, a standard of care drug-eluting metallic stent, in the ABSORB III trial, designed as the study to get Absorb onto the U.S. market.

Given the way such trials develop now, after consultation with the Food and Drug Administration, it seems very likely that proving noninferiority against the best metallic-stent competitor will mean that, sometime in 2016, the Absorb bioresorbable scaffold will become the first U.S. routinely available coronary device built to dissolve away after a period of time, about 3 years in this case.

Mitchel L. Zoler/Frontline Medical News

That means that sometime in the next year, U.S. interventional cardiologists, patients, other collaborating physicians, and payers will have to start deciding whether the potential advantages of using a stentlike device that eventually disappears is worth a probable uptick in price as well as certain other limitations. One of the key variables is that for the moment the advantages remain mostly hypothetical.

Dr. Gregg W. Stone, chairman of the ABSORB III trial and one of the leading advocates for U.S. development of bioresorbable vascular scaffolds (BVS) told me about some of the hoped-for benefits that BVS could provide by leaving the coronaries. Imaging data have already suggested that it improves vasomotion, and other possible benefits include restored vascular adaptability, stimulated plaque regression, and reduced late polymer reactions and neoatherosclerosis. “This is all hypothetical, and we won’t know whether the promise is a reality until we have the 5-year results from ABSORB IV, which won’t be until 6-7 years from now,” Dr. Stone said.

Of course, he added, other, more modest benefits are already real: It’s been proven that the BVS really goes away after about 3 years, which makes noninvasive imaging of coronaries where a BVS was placed easier; and it also frees side-branch arteries, as well as the treated segment itself, from the metal jacket of a stent. And some patients like the idea of a disappearing stent for “personal, religious, or cultural reasons,” he said.

Balancing this are the device’s very real limitations. Because a BVS is stiffer and less maneuverable than is a metallic stent, it isn’t appropriate for heavily calcified lesions, tortuous arteries, chronic total occlusions, true bifurcations, or bypass grafts. Also, the width of the struts on the Absorb BVS make it unsuitable for use in coronary arteries less than 2.5 mm in diameter, a limitation borne out by the ABSORB III results, which showed a much higher rate of target-lesion failure and stent thrombosis, compared with the Xience stent in the 19% of lesions that sneaked into the study in coronaries narrower than 2.5 mm. Also, for the time being, BVS is targeted only for patients with stable coronary disease or patients who have stabilized following an acute coronary syndrome event and not for patients with an acute MI or unstable acute coronary syndrome.

Dr. Stone estimated that, collectively, these clinical and anatomic limitations exclude roughly half the patients who undergo percutaneous interventions today. “The sweet spot may be young patients with relatively noncomplex lesions.”

There are more restrictions, based on what using a BVS means for the operator. Not only is the device harder to deliver to a specific coronary site, but it requires “more lesion preparation, more accurate sizing, and more frequent postdilitation.” Operators “need to realize that if they use a BVS, they can’t get away with as much as they can with state-of-the-art metallic stents,” Dr. Stone said. In fact, he felt that the ABSORB III results showed “we could do better with more training and more attention to detail.” In the future, operators “will need to work harder and pay attention to procedural factors.”

The increased technical demands posed by a BVS and the possibility that not all of the devices were placed optimally in the trial may have led to another source of doubt about Absorb: its performance relative to Xience.

At the meeting, Dr. Stone reported results from a meta-analysis of the four randomized controlled trials that have now reported 1-year outcomes data for the Absorb BVS compared with Xience: ABSORB III (with 2,008 patients), ABSORB II (502 patients), ABSORB Japan (400 patients), and ABSORB China (480 patients).

Mitchel L. Zoler/Frontline Medical News

The meta-analysis confirmed two concerning trends also seen in the results from ABSORB III by itself: a strong trend toward an increased risk of 1-year stent thrombosis with Absorb, at 1.3%, compared with a 0.6% risk with Xience (P = .08); and a statistically significant excess of target-vessel MI with Absorb, at 5.1%, compared with 3.3% with Xience (P = .04). Results from both the meta-analysis and from ABSORB III by itself also showed numerically higher rates of target-lesion failure – the primary efficacy endpoint – with Absorb, although not enough of a difference to undermine fulfilling the prespecified definition of noninferiority in ABSORB III.

“I think we can do better if people pay better attention to their technique.” Dr. Stone said. But it remains to be seen whether the inferior performance of Absorb relative to a metallic stent can be overcome with better training and technique, and if so, whether operators will be willing to take the extra steps required to overcome the challenges of the device. Some physicians “will focus on the fact that target-lesion failure was higher with Absorb, and they will want to wait to see whether Absorb actually improves hard outcomes,” he acknowledged. “Some will focus on the promise; other will say ‘show me the data.’ ”

One of his collaborators on ABSORB III, Dr. Dean J. Kereiakes, said that opting for Absorb will require a “leap of faith.”

“Absorb has limitations,” Dr. Stone concluded. “Physician and patient opinions will vary, and the device is not for every patient and every lesion.”

Physicians will soon need to start deciding exactly which patients in their practice, if any, are good candidates for a BVS.

[email protected]

On Twitter @mitchelzoler

Results reported earlier this month at the Transcatheter Cardiovascular Therapeutics annual meeting for the Absorb bioresorbable vascular scaffold made by Abbott Vascular showed the device was statistically noninferior for treating selected coronary stenoses, compared with Xience, a standard of care drug-eluting metallic stent, in the ABSORB III trial, designed as the study to get Absorb onto the U.S. market.

Given the way such trials develop now, after consultation with the Food and Drug Administration, it seems very likely that proving noninferiority against the best metallic-stent competitor will mean that, sometime in 2016, the Absorb bioresorbable scaffold will become the first U.S. routinely available coronary device built to dissolve away after a period of time, about 3 years in this case.

Mitchel L. Zoler/Frontline Medical News

That means that sometime in the next year, U.S. interventional cardiologists, patients, other collaborating physicians, and payers will have to start deciding whether the potential advantages of using a stentlike device that eventually disappears is worth a probable uptick in price as well as certain other limitations. One of the key variables is that for the moment the advantages remain mostly hypothetical.

Dr. Gregg W. Stone, chairman of the ABSORB III trial and one of the leading advocates for U.S. development of bioresorbable vascular scaffolds (BVS) told me about some of the hoped-for benefits that BVS could provide by leaving the coronaries. Imaging data have already suggested that it improves vasomotion, and other possible benefits include restored vascular adaptability, stimulated plaque regression, and reduced late polymer reactions and neoatherosclerosis. “This is all hypothetical, and we won’t know whether the promise is a reality until we have the 5-year results from ABSORB IV, which won’t be until 6-7 years from now,” Dr. Stone said.

Of course, he added, other, more modest benefits are already real: It’s been proven that the BVS really goes away after about 3 years, which makes noninvasive imaging of coronaries where a BVS was placed easier; and it also frees side-branch arteries, as well as the treated segment itself, from the metal jacket of a stent. And some patients like the idea of a disappearing stent for “personal, religious, or cultural reasons,” he said.

Balancing this are the device’s very real limitations. Because a BVS is stiffer and less maneuverable than is a metallic stent, it isn’t appropriate for heavily calcified lesions, tortuous arteries, chronic total occlusions, true bifurcations, or bypass grafts. Also, the width of the struts on the Absorb BVS make it unsuitable for use in coronary arteries less than 2.5 mm in diameter, a limitation borne out by the ABSORB III results, which showed a much higher rate of target-lesion failure and stent thrombosis, compared with the Xience stent in the 19% of lesions that sneaked into the study in coronaries narrower than 2.5 mm. Also, for the time being, BVS is targeted only for patients with stable coronary disease or patients who have stabilized following an acute coronary syndrome event and not for patients with an acute MI or unstable acute coronary syndrome.

Dr. Stone estimated that, collectively, these clinical and anatomic limitations exclude roughly half the patients who undergo percutaneous interventions today. “The sweet spot may be young patients with relatively noncomplex lesions.”

There are more restrictions, based on what using a BVS means for the operator. Not only is the device harder to deliver to a specific coronary site, but it requires “more lesion preparation, more accurate sizing, and more frequent postdilitation.” Operators “need to realize that if they use a BVS, they can’t get away with as much as they can with state-of-the-art metallic stents,” Dr. Stone said. In fact, he felt that the ABSORB III results showed “we could do better with more training and more attention to detail.” In the future, operators “will need to work harder and pay attention to procedural factors.”

The increased technical demands posed by a BVS and the possibility that not all of the devices were placed optimally in the trial may have led to another source of doubt about Absorb: its performance relative to Xience.

At the meeting, Dr. Stone reported results from a meta-analysis of the four randomized controlled trials that have now reported 1-year outcomes data for the Absorb BVS compared with Xience: ABSORB III (with 2,008 patients), ABSORB II (502 patients), ABSORB Japan (400 patients), and ABSORB China (480 patients).

Mitchel L. Zoler/Frontline Medical News

The meta-analysis confirmed two concerning trends also seen in the results from ABSORB III by itself: a strong trend toward an increased risk of 1-year stent thrombosis with Absorb, at 1.3%, compared with a 0.6% risk with Xience (P = .08); and a statistically significant excess of target-vessel MI with Absorb, at 5.1%, compared with 3.3% with Xience (P = .04). Results from both the meta-analysis and from ABSORB III by itself also showed numerically higher rates of target-lesion failure – the primary efficacy endpoint – with Absorb, although not enough of a difference to undermine fulfilling the prespecified definition of noninferiority in ABSORB III.

“I think we can do better if people pay better attention to their technique.” Dr. Stone said. But it remains to be seen whether the inferior performance of Absorb relative to a metallic stent can be overcome with better training and technique, and if so, whether operators will be willing to take the extra steps required to overcome the challenges of the device. Some physicians “will focus on the fact that target-lesion failure was higher with Absorb, and they will want to wait to see whether Absorb actually improves hard outcomes,” he acknowledged. “Some will focus on the promise; other will say ‘show me the data.’ ”

One of his collaborators on ABSORB III, Dr. Dean J. Kereiakes, said that opting for Absorb will require a “leap of faith.”

“Absorb has limitations,” Dr. Stone concluded. “Physician and patient opinions will vary, and the device is not for every patient and every lesion.”

Physicians will soon need to start deciding exactly which patients in their practice, if any, are good candidates for a BVS.

[email protected]

On Twitter @mitchelzoler

Results reported earlier this month at the Transcatheter Cardiovascular Therapeutics annual meeting for the Absorb bioresorbable vascular scaffold made by Abbott Vascular showed the device was statistically noninferior for treating selected coronary stenoses, compared with Xience, a standard of care drug-eluting metallic stent, in the ABSORB III trial, designed as the study to get Absorb onto the U.S. market.

Given the way such trials develop now, after consultation with the Food and Drug Administration, it seems very likely that proving noninferiority against the best metallic-stent competitor will mean that, sometime in 2016, the Absorb bioresorbable scaffold will become the first U.S. routinely available coronary device built to dissolve away after a period of time, about 3 years in this case.

Mitchel L. Zoler/Frontline Medical News

That means that sometime in the next year, U.S. interventional cardiologists, patients, other collaborating physicians, and payers will have to start deciding whether the potential advantages of using a stentlike device that eventually disappears is worth a probable uptick in price as well as certain other limitations. One of the key variables is that for the moment the advantages remain mostly hypothetical.

Dr. Gregg W. Stone, chairman of the ABSORB III trial and one of the leading advocates for U.S. development of bioresorbable vascular scaffolds (BVS) told me about some of the hoped-for benefits that BVS could provide by leaving the coronaries. Imaging data have already suggested that it improves vasomotion, and other possible benefits include restored vascular adaptability, stimulated plaque regression, and reduced late polymer reactions and neoatherosclerosis. “This is all hypothetical, and we won’t know whether the promise is a reality until we have the 5-year results from ABSORB IV, which won’t be until 6-7 years from now,” Dr. Stone said.

Of course, he added, other, more modest benefits are already real: It’s been proven that the BVS really goes away after about 3 years, which makes noninvasive imaging of coronaries where a BVS was placed easier; and it also frees side-branch arteries, as well as the treated segment itself, from the metal jacket of a stent. And some patients like the idea of a disappearing stent for “personal, religious, or cultural reasons,” he said.

Balancing this are the device’s very real limitations. Because a BVS is stiffer and less maneuverable than is a metallic stent, it isn’t appropriate for heavily calcified lesions, tortuous arteries, chronic total occlusions, true bifurcations, or bypass grafts. Also, the width of the struts on the Absorb BVS make it unsuitable for use in coronary arteries less than 2.5 mm in diameter, a limitation borne out by the ABSORB III results, which showed a much higher rate of target-lesion failure and stent thrombosis, compared with the Xience stent in the 19% of lesions that sneaked into the study in coronaries narrower than 2.5 mm. Also, for the time being, BVS is targeted only for patients with stable coronary disease or patients who have stabilized following an acute coronary syndrome event and not for patients with an acute MI or unstable acute coronary syndrome.

Dr. Stone estimated that, collectively, these clinical and anatomic limitations exclude roughly half the patients who undergo percutaneous interventions today. “The sweet spot may be young patients with relatively noncomplex lesions.”

There are more restrictions, based on what using a BVS means for the operator. Not only is the device harder to deliver to a specific coronary site, but it requires “more lesion preparation, more accurate sizing, and more frequent postdilitation.” Operators “need to realize that if they use a BVS, they can’t get away with as much as they can with state-of-the-art metallic stents,” Dr. Stone said. In fact, he felt that the ABSORB III results showed “we could do better with more training and more attention to detail.” In the future, operators “will need to work harder and pay attention to procedural factors.”

The increased technical demands posed by a BVS and the possibility that not all of the devices were placed optimally in the trial may have led to another source of doubt about Absorb: its performance relative to Xience.

At the meeting, Dr. Stone reported results from a meta-analysis of the four randomized controlled trials that have now reported 1-year outcomes data for the Absorb BVS compared with Xience: ABSORB III (with 2,008 patients), ABSORB II (502 patients), ABSORB Japan (400 patients), and ABSORB China (480 patients).

Mitchel L. Zoler/Frontline Medical News

The meta-analysis confirmed two concerning trends also seen in the results from ABSORB III by itself: a strong trend toward an increased risk of 1-year stent thrombosis with Absorb, at 1.3%, compared with a 0.6% risk with Xience (P = .08); and a statistically significant excess of target-vessel MI with Absorb, at 5.1%, compared with 3.3% with Xience (P = .04). Results from both the meta-analysis and from ABSORB III by itself also showed numerically higher rates of target-lesion failure – the primary efficacy endpoint – with Absorb, although not enough of a difference to undermine fulfilling the prespecified definition of noninferiority in ABSORB III.

“I think we can do better if people pay better attention to their technique.” Dr. Stone said. But it remains to be seen whether the inferior performance of Absorb relative to a metallic stent can be overcome with better training and technique, and if so, whether operators will be willing to take the extra steps required to overcome the challenges of the device. Some physicians “will focus on the fact that target-lesion failure was higher with Absorb, and they will want to wait to see whether Absorb actually improves hard outcomes,” he acknowledged. “Some will focus on the promise; other will say ‘show me the data.’ ”

One of his collaborators on ABSORB III, Dr. Dean J. Kereiakes, said that opting for Absorb will require a “leap of faith.”

“Absorb has limitations,” Dr. Stone concluded. “Physician and patient opinions will vary, and the device is not for every patient and every lesion.”

Physicians will soon need to start deciding exactly which patients in their practice, if any, are good candidates for a BVS.

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On Twitter @mitchelzoler