Commentary

I’m rich. Aren’t you?

In reality, you’re probably not (depending on what your definition of rich is), and I’m not either.

The problem, unfortunately, is the public perception that all doctors are rich. They see raw numbers, hear about well-publicized cases of criminal medical fraud, read about some world-famous brain surgeon and his 5-million-square-foot house, and immediately figure we’re all rolling in dough.

For most of us, though, that’s far from the norm. We struggle with declining reimbursements and increasing overheads: rent, staff salaries, office supplies, etc. By the time you take the myriad expenses out, there often isn’t much left for us. And, like everyone else, we have mortgages, families to take care of, student loans, and grocery bills. While most of us can still support families and a moderate lifestyle, we sure aren’t rich. When you take time into account (60-70 hours per week), my hourly salary isn’t that high.

Yet, the majority of people don’t see it that way. Granted, we may be in a better financial position than some of our patients, but it still amazes me when they ask me to waive copays or other visit costs. I always say no, and some argue, “But you’re a doctor! You can afford it.” Whether I can or can’t is immaterial. I pay my family’s medical bills in full and on time and would never dream of asking for a discount or freebie for any reason. You let one person skip, then another, then another ... and it starts to add up quickly.

I have several patients who are quite wealthy. I wouldn’t ask them to pay an extra copay “because you can afford it,” but that’s no different from others asking me to waive theirs for the same reason.

I just wish patients would see, or the lay press would show, the reality of finances for a modern-day average doctor. I, personally, am sick of people who still affiliate us with Porsches, two homes, and Wednesday-afternoon golfing. A few of those docs may still be around, but they are a rare exception, not the rule. And I don’t see that changing any time soon.

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

I’m rich. Aren’t you?

In reality, you’re probably not (depending on what your definition of rich is), and I’m not either.

The problem, unfortunately, is the public perception that all doctors are rich. They see raw numbers, hear about well-publicized cases of criminal medical fraud, read about some world-famous brain surgeon and his 5-million-square-foot house, and immediately figure we’re all rolling in dough.

For most of us, though, that’s far from the norm. We struggle with declining reimbursements and increasing overheads: rent, staff salaries, office supplies, etc. By the time you take the myriad expenses out, there often isn’t much left for us. And, like everyone else, we have mortgages, families to take care of, student loans, and grocery bills. While most of us can still support families and a moderate lifestyle, we sure aren’t rich. When you take time into account (60-70 hours per week), my hourly salary isn’t that high.

Yet, the majority of people don’t see it that way. Granted, we may be in a better financial position than some of our patients, but it still amazes me when they ask me to waive copays or other visit costs. I always say no, and some argue, “But you’re a doctor! You can afford it.” Whether I can or can’t is immaterial. I pay my family’s medical bills in full and on time and would never dream of asking for a discount or freebie for any reason. You let one person skip, then another, then another ... and it starts to add up quickly.

I have several patients who are quite wealthy. I wouldn’t ask them to pay an extra copay “because you can afford it,” but that’s no different from others asking me to waive theirs for the same reason.

I just wish patients would see, or the lay press would show, the reality of finances for a modern-day average doctor. I, personally, am sick of people who still affiliate us with Porsches, two homes, and Wednesday-afternoon golfing. A few of those docs may still be around, but they are a rare exception, not the rule. And I don’t see that changing any time soon.

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

I’m rich. Aren’t you?

In reality, you’re probably not (depending on what your definition of rich is), and I’m not either.

The problem, unfortunately, is the public perception that all doctors are rich. They see raw numbers, hear about well-publicized cases of criminal medical fraud, read about some world-famous brain surgeon and his 5-million-square-foot house, and immediately figure we’re all rolling in dough.

For most of us, though, that’s far from the norm. We struggle with declining reimbursements and increasing overheads: rent, staff salaries, office supplies, etc. By the time you take the myriad expenses out, there often isn’t much left for us. And, like everyone else, we have mortgages, families to take care of, student loans, and grocery bills. While most of us can still support families and a moderate lifestyle, we sure aren’t rich. When you take time into account (60-70 hours per week), my hourly salary isn’t that high.

Yet, the majority of people don’t see it that way. Granted, we may be in a better financial position than some of our patients, but it still amazes me when they ask me to waive copays or other visit costs. I always say no, and some argue, “But you’re a doctor! You can afford it.” Whether I can or can’t is immaterial. I pay my family’s medical bills in full and on time and would never dream of asking for a discount or freebie for any reason. You let one person skip, then another, then another ... and it starts to add up quickly.

I have several patients who are quite wealthy. I wouldn’t ask them to pay an extra copay “because you can afford it,” but that’s no different from others asking me to waive theirs for the same reason.

I just wish patients would see, or the lay press would show, the reality of finances for a modern-day average doctor. I, personally, am sick of people who still affiliate us with Porsches, two homes, and Wednesday-afternoon golfing. A few of those docs may still be around, but they are a rare exception, not the rule. And I don’t see that changing any time soon.

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

Social media platforms are by far the most common form of communication among our teens. A 2015 study by the Pew Research Center stated that 71% of teens between the ages of 12 and 18 years use more than one form of social media. But little education and awareness of the legal implications of the information exchanged is provided to these teens, which has landed some of them in significant legal trouble.

Gone are the days when rivals could just pass mean comments to each other in the hallway or leave obnoxious comments on a bathroom wall. Today, within minutes malicious comments are quickly posted on social media to be shared by all. This makes the impact of the impulsive, mindless, and usually immature sentiments much more damaging, and unfortunately can result in severe, sometimes unforeseen consequences.

Cyberbullying is bullying or intimidating through electronic technology. This has become all too commonplace among teenagers because it takes so little to post unflattering pictures, or quotes, or threating messages from the privacy of your home. Much of what would never be spoken face to face is posted without regard. Two teen girls in Florida were charged with a felony for the suicide of a classmate they unrelentingly bullied. This was just one of many stories of a child being brought to despair by immature and cowardly teens misusing social media. Surely they never realized that their immature act would land them in jail. It is a crime to threaten to kill or seriously harm, menace, or harass a person for any reason, regardless of one’s age.

Defamation is a social tort that protects the reputation of a person from untrue comments or innuendos. In the past this was considered to be gossip or rumor-mongering, but now, given the advent of new technology, publishing these same comments makes one the author and, therefore, may be liable for defamation of character. This may not mean jail time for a person, but can certainly land that person in court, requiring his or her parents to incur significant legal fees.

Probably the most important legal issue that teens – as well as adults – should know about are the laws regarding sexual texting or “sexting.” For those of us born in the era before social media, sexting is the distribution of nude pictures of themselves or anyone else. When the image is that of a person under the age of 18 years, it is considered child pornography and subject to punishment by law. Because child pornography is taken very seriously, dosomething.org is a website for young people that promotes social awareness in hopes of changing behavior. This site presents the alarming percentages of teens who send and or receive nude or sexually explicit photos. Many have no idea they are committing a felony.

The unfortunate reality is that many photos or videos that were exchanged between trusted friends end up in the hands of ill-intended teens and get widely disseminated on social media. Anyone caught having or disseminating child pornography, regardless of who started it, is at risk of criminal repercussions. There have been several so-called “THOT” pages (That Ho Over There) started at high schools where students published nude pictures of classmates. These pages go viral within minutes, and although they are taken down quickly, the damage usually is already done. These actions can result in expulsion and suspension of students and significant emotional distress to the victim.

Another legal concern is the issue of privacy. Many users don’t realize that personal information displayed on social media can be easily obtained and misused. Identity theft is on the rise, not just because criminals are more savvy, but because so many people are careless with their information. Disclosure of email, birth date, and cell phone number are all desirable pieces of information that drive marketing, but more importantly, allows information to be used and misconstrued by anyone to create a phony identity, gain access to accounts, stalk, harass, or even resort to blackmail. The unauthorized use of personal information is illegal and punishable by law.

Another legal issue associated with social media are copyright laws. Many teens, as well as adults, have no idea of the laws that protect the music, videos, pictures, and images thoughtlessly placed on social media. Most don’t realize that just because it is commonly done doesn’t mean that it’s legal. Once a picture is posted, it can be shared, altered, and downloaded all over the world by anyone.

There have been reports of lawsuits brought by parents who found pictures of their children were used in advertisements by major companies without their knowledge or permission. Companies, likewise, have brought suit against individuals who have unknowingly misused their product in a post to entertain their friends. In fact, many of the apps that people download have a check box to acknowledge that the owners are free to use material posted at their discretion, which most folks check without reading the fine print. Because the laws on the books lag behind the changing times, there is often a lot of room for interpretation that puts everyone at risk. So teenagers must understand that just because material is published doesn’t mean it is free to be used for personal distribution.

Primary care physicians play a critical role in educating families. Dosomething.org and stopbullying.gov are two great resources for parents and children alike. Educating teens to the legal and social repercussions is key in protecting them. Schools and parents have to be aware themselves and continually stress the importance of Internet safety and appropriate use of social media.

Dr. Pearce is a pediatrician in Frankfort, Ill. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Email her at [email protected]

Social media platforms are by far the most common form of communication among our teens. A 2015 study by the Pew Research Center stated that 71% of teens between the ages of 12 and 18 years use more than one form of social media. But little education and awareness of the legal implications of the information exchanged is provided to these teens, which has landed some of them in significant legal trouble.

Gone are the days when rivals could just pass mean comments to each other in the hallway or leave obnoxious comments on a bathroom wall. Today, within minutes malicious comments are quickly posted on social media to be shared by all. This makes the impact of the impulsive, mindless, and usually immature sentiments much more damaging, and unfortunately can result in severe, sometimes unforeseen consequences.

Cyberbullying is bullying or intimidating through electronic technology. This has become all too commonplace among teenagers because it takes so little to post unflattering pictures, or quotes, or threating messages from the privacy of your home. Much of what would never be spoken face to face is posted without regard. Two teen girls in Florida were charged with a felony for the suicide of a classmate they unrelentingly bullied. This was just one of many stories of a child being brought to despair by immature and cowardly teens misusing social media. Surely they never realized that their immature act would land them in jail. It is a crime to threaten to kill or seriously harm, menace, or harass a person for any reason, regardless of one’s age.

Defamation is a social tort that protects the reputation of a person from untrue comments or innuendos. In the past this was considered to be gossip or rumor-mongering, but now, given the advent of new technology, publishing these same comments makes one the author and, therefore, may be liable for defamation of character. This may not mean jail time for a person, but can certainly land that person in court, requiring his or her parents to incur significant legal fees.

Probably the most important legal issue that teens – as well as adults – should know about are the laws regarding sexual texting or “sexting.” For those of us born in the era before social media, sexting is the distribution of nude pictures of themselves or anyone else. When the image is that of a person under the age of 18 years, it is considered child pornography and subject to punishment by law. Because child pornography is taken very seriously, dosomething.org is a website for young people that promotes social awareness in hopes of changing behavior. This site presents the alarming percentages of teens who send and or receive nude or sexually explicit photos. Many have no idea they are committing a felony.

The unfortunate reality is that many photos or videos that were exchanged between trusted friends end up in the hands of ill-intended teens and get widely disseminated on social media. Anyone caught having or disseminating child pornography, regardless of who started it, is at risk of criminal repercussions. There have been several so-called “THOT” pages (That Ho Over There) started at high schools where students published nude pictures of classmates. These pages go viral within minutes, and although they are taken down quickly, the damage usually is already done. These actions can result in expulsion and suspension of students and significant emotional distress to the victim.

Another legal concern is the issue of privacy. Many users don’t realize that personal information displayed on social media can be easily obtained and misused. Identity theft is on the rise, not just because criminals are more savvy, but because so many people are careless with their information. Disclosure of email, birth date, and cell phone number are all desirable pieces of information that drive marketing, but more importantly, allows information to be used and misconstrued by anyone to create a phony identity, gain access to accounts, stalk, harass, or even resort to blackmail. The unauthorized use of personal information is illegal and punishable by law.

Another legal issue associated with social media are copyright laws. Many teens, as well as adults, have no idea of the laws that protect the music, videos, pictures, and images thoughtlessly placed on social media. Most don’t realize that just because it is commonly done doesn’t mean that it’s legal. Once a picture is posted, it can be shared, altered, and downloaded all over the world by anyone.

There have been reports of lawsuits brought by parents who found pictures of their children were used in advertisements by major companies without their knowledge or permission. Companies, likewise, have brought suit against individuals who have unknowingly misused their product in a post to entertain their friends. In fact, many of the apps that people download have a check box to acknowledge that the owners are free to use material posted at their discretion, which most folks check without reading the fine print. Because the laws on the books lag behind the changing times, there is often a lot of room for interpretation that puts everyone at risk. So teenagers must understand that just because material is published doesn’t mean it is free to be used for personal distribution.

Primary care physicians play a critical role in educating families. Dosomething.org and stopbullying.gov are two great resources for parents and children alike. Educating teens to the legal and social repercussions is key in protecting them. Schools and parents have to be aware themselves and continually stress the importance of Internet safety and appropriate use of social media.

Dr. Pearce is a pediatrician in Frankfort, Ill. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Email her at [email protected]

Social media platforms are by far the most common form of communication among our teens. A 2015 study by the Pew Research Center stated that 71% of teens between the ages of 12 and 18 years use more than one form of social media. But little education and awareness of the legal implications of the information exchanged is provided to these teens, which has landed some of them in significant legal trouble.

Gone are the days when rivals could just pass mean comments to each other in the hallway or leave obnoxious comments on a bathroom wall. Today, within minutes malicious comments are quickly posted on social media to be shared by all. This makes the impact of the impulsive, mindless, and usually immature sentiments much more damaging, and unfortunately can result in severe, sometimes unforeseen consequences.

Cyberbullying is bullying or intimidating through electronic technology. This has become all too commonplace among teenagers because it takes so little to post unflattering pictures, or quotes, or threating messages from the privacy of your home. Much of what would never be spoken face to face is posted without regard. Two teen girls in Florida were charged with a felony for the suicide of a classmate they unrelentingly bullied. This was just one of many stories of a child being brought to despair by immature and cowardly teens misusing social media. Surely they never realized that their immature act would land them in jail. It is a crime to threaten to kill or seriously harm, menace, or harass a person for any reason, regardless of one’s age.

Defamation is a social tort that protects the reputation of a person from untrue comments or innuendos. In the past this was considered to be gossip or rumor-mongering, but now, given the advent of new technology, publishing these same comments makes one the author and, therefore, may be liable for defamation of character. This may not mean jail time for a person, but can certainly land that person in court, requiring his or her parents to incur significant legal fees.

Probably the most important legal issue that teens – as well as adults – should know about are the laws regarding sexual texting or “sexting.” For those of us born in the era before social media, sexting is the distribution of nude pictures of themselves or anyone else. When the image is that of a person under the age of 18 years, it is considered child pornography and subject to punishment by law. Because child pornography is taken very seriously, dosomething.org is a website for young people that promotes social awareness in hopes of changing behavior. This site presents the alarming percentages of teens who send and or receive nude or sexually explicit photos. Many have no idea they are committing a felony.

The unfortunate reality is that many photos or videos that were exchanged between trusted friends end up in the hands of ill-intended teens and get widely disseminated on social media. Anyone caught having or disseminating child pornography, regardless of who started it, is at risk of criminal repercussions. There have been several so-called “THOT” pages (That Ho Over There) started at high schools where students published nude pictures of classmates. These pages go viral within minutes, and although they are taken down quickly, the damage usually is already done. These actions can result in expulsion and suspension of students and significant emotional distress to the victim.

Another legal concern is the issue of privacy. Many users don’t realize that personal information displayed on social media can be easily obtained and misused. Identity theft is on the rise, not just because criminals are more savvy, but because so many people are careless with their information. Disclosure of email, birth date, and cell phone number are all desirable pieces of information that drive marketing, but more importantly, allows information to be used and misconstrued by anyone to create a phony identity, gain access to accounts, stalk, harass, or even resort to blackmail. The unauthorized use of personal information is illegal and punishable by law.

Another legal issue associated with social media are copyright laws. Many teens, as well as adults, have no idea of the laws that protect the music, videos, pictures, and images thoughtlessly placed on social media. Most don’t realize that just because it is commonly done doesn’t mean that it’s legal. Once a picture is posted, it can be shared, altered, and downloaded all over the world by anyone.

There have been reports of lawsuits brought by parents who found pictures of their children were used in advertisements by major companies without their knowledge or permission. Companies, likewise, have brought suit against individuals who have unknowingly misused their product in a post to entertain their friends. In fact, many of the apps that people download have a check box to acknowledge that the owners are free to use material posted at their discretion, which most folks check without reading the fine print. Because the laws on the books lag behind the changing times, there is often a lot of room for interpretation that puts everyone at risk. So teenagers must understand that just because material is published doesn’t mean it is free to be used for personal distribution.

Primary care physicians play a critical role in educating families. Dosomething.org and stopbullying.gov are two great resources for parents and children alike. Educating teens to the legal and social repercussions is key in protecting them. Schools and parents have to be aware themselves and continually stress the importance of Internet safety and appropriate use of social media.

Dr. Pearce is a pediatrician in Frankfort, Ill. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Email her at [email protected]

“Teach residents…really? You want to add yet another time-consuming responsibility to my already hectic schedule?” Residency. The mere mention of the word conjures up chilling memories of 3 am codes, 20-30 hour zombie shifts, and anxiety and stress levels that we never knew before and, fortunately, have not known since. That was a time in life many of us want to put in the deepest recesses of our minds, never to emerge again.

But, on the other hand, there were a lot of good things about our residency training that we should probably never forget, such as the humility with which we approached patient care. At that time in our lives we gladly acknowledged we did not know everything and we were eager to research each and every condition to get a firm handle on what we could and should do to help our patients get better.

Fast forward a decade or two. Now many of us have spouses, children, aging parents, mortgages, and retirement accounts we are feverishly trying to fund. There never seems to be enough time to finish even the most fundamental responsibilities. Not to mention now there are national initiatives, mandatory rules, and sometimes frightening regulations in place that dramatically impact how we practice medicine and sometimes make us feel more like automatons than the physicians we dreamed of becoming when we first applied to medical school years ago.

With all of our current and future responsibilities, how can the average hospitalist embrace young physicians and pour himself into their lives? Or, perhaps the question is better asked, how can we not? None of us morphed from a green medical school graduate to a knowledgeable, well-respected physician without a great deal of hand holding (and sometimes hand wringing), encouragement and investment of time from our teaching attendings. But even if you are hesitant to invest the time and energy to teach resident physicians should you have the opportunity. Keep in mind, in 2015 we are not only teaching them, they are teaching us too!

Young physicians are overflowing with technological knowledge that many of us have never been exposed to, knowledge that can help escalate our own skill sets. They bring fresh ideas, novel approaches to patient care, and frequently, cutting edge medical innovations from the universities from which come.

So, if you are ever asked to teach our future colleagues, remember: you may very well find that the time you invest benefits you as much, if not more, than it does them.

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

“Teach residents…really? You want to add yet another time-consuming responsibility to my already hectic schedule?” Residency. The mere mention of the word conjures up chilling memories of 3 am codes, 20-30 hour zombie shifts, and anxiety and stress levels that we never knew before and, fortunately, have not known since. That was a time in life many of us want to put in the deepest recesses of our minds, never to emerge again.

But, on the other hand, there were a lot of good things about our residency training that we should probably never forget, such as the humility with which we approached patient care. At that time in our lives we gladly acknowledged we did not know everything and we were eager to research each and every condition to get a firm handle on what we could and should do to help our patients get better.

Fast forward a decade or two. Now many of us have spouses, children, aging parents, mortgages, and retirement accounts we are feverishly trying to fund. There never seems to be enough time to finish even the most fundamental responsibilities. Not to mention now there are national initiatives, mandatory rules, and sometimes frightening regulations in place that dramatically impact how we practice medicine and sometimes make us feel more like automatons than the physicians we dreamed of becoming when we first applied to medical school years ago.

With all of our current and future responsibilities, how can the average hospitalist embrace young physicians and pour himself into their lives? Or, perhaps the question is better asked, how can we not? None of us morphed from a green medical school graduate to a knowledgeable, well-respected physician without a great deal of hand holding (and sometimes hand wringing), encouragement and investment of time from our teaching attendings. But even if you are hesitant to invest the time and energy to teach resident physicians should you have the opportunity. Keep in mind, in 2015 we are not only teaching them, they are teaching us too!

Young physicians are overflowing with technological knowledge that many of us have never been exposed to, knowledge that can help escalate our own skill sets. They bring fresh ideas, novel approaches to patient care, and frequently, cutting edge medical innovations from the universities from which come.

So, if you are ever asked to teach our future colleagues, remember: you may very well find that the time you invest benefits you as much, if not more, than it does them.

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

“Teach residents…really? You want to add yet another time-consuming responsibility to my already hectic schedule?” Residency. The mere mention of the word conjures up chilling memories of 3 am codes, 20-30 hour zombie shifts, and anxiety and stress levels that we never knew before and, fortunately, have not known since. That was a time in life many of us want to put in the deepest recesses of our minds, never to emerge again.

But, on the other hand, there were a lot of good things about our residency training that we should probably never forget, such as the humility with which we approached patient care. At that time in our lives we gladly acknowledged we did not know everything and we were eager to research each and every condition to get a firm handle on what we could and should do to help our patients get better.

Fast forward a decade or two. Now many of us have spouses, children, aging parents, mortgages, and retirement accounts we are feverishly trying to fund. There never seems to be enough time to finish even the most fundamental responsibilities. Not to mention now there are national initiatives, mandatory rules, and sometimes frightening regulations in place that dramatically impact how we practice medicine and sometimes make us feel more like automatons than the physicians we dreamed of becoming when we first applied to medical school years ago.

With all of our current and future responsibilities, how can the average hospitalist embrace young physicians and pour himself into their lives? Or, perhaps the question is better asked, how can we not? None of us morphed from a green medical school graduate to a knowledgeable, well-respected physician without a great deal of hand holding (and sometimes hand wringing), encouragement and investment of time from our teaching attendings. But even if you are hesitant to invest the time and energy to teach resident physicians should you have the opportunity. Keep in mind, in 2015 we are not only teaching them, they are teaching us too!

Young physicians are overflowing with technological knowledge that many of us have never been exposed to, knowledge that can help escalate our own skill sets. They bring fresh ideas, novel approaches to patient care, and frequently, cutting edge medical innovations from the universities from which come.

So, if you are ever asked to teach our future colleagues, remember: you may very well find that the time you invest benefits you as much, if not more, than it does them.

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

As I was writing my introduction to this current edition of the Master Class in Gynecologic Surgery, focusing on minimally invasive surgery for the obese female patient, I was listening to Chuck Todd, host of “Meet the Press.” Instantaneously, television and my thoughts became one; in the last segment of the program, Mr. Todd discussed what he was able to consume for $50 at the Iowa State Fair. I learned that his diet that day consisted of a pork chop on a stick, mac and cheese, a bacon-wrapped corn dog, cheese on a stick with jalapeños, a deep-fried Twinkie, and even fried apple pie with bacon. While Mr. Todd is thin and healthy, the array of foods at the fair reflects our nation’s penchant toward fast food that is fat laden and fried. Though our county is not alone in the world, obesity has reached epidemic proportion in the United States.

According to a May 2015 Department of Health & Human Services report on the health status of the nation, 69% of adults in the United States are overweight and 35% are obese. As a result, the minimally invasive gynecologic surgeon is dealing with an increasing population of women with comorbidities related to their obesity that can confound surgery outcomes. Moreover, anatomic landmarks that the young medical student learns in his or her first anatomy classes are modified due to the size of panniculus and the migration of the umbilicus relative to the bifurcation of the aorta.

I asked Dr. Amina Ahmed to join me in discussing the management of the obese patient undergoing minimally invasive gynecologic surgery. After completing her fellowship in gynecologic oncology, Dr. Ahmed has been on staff at both the University of Iowa Hospitals and Clinics, Iowa City, and Advocate Lutheran General Hospital, Park Ridge, Ill. She will soon join the gynecologic oncology faculty at Rush University Medical Center, Chicago. Given the increased rate of obesity in both Chicago and Iowa, Dr. Ahmed has become an expert in this area in a short period of time.

Dr. Miller is a clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column, Master Class. Dr. Miller disclosed that he is a consultant and on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien.

As I was writing my introduction to this current edition of the Master Class in Gynecologic Surgery, focusing on minimally invasive surgery for the obese female patient, I was listening to Chuck Todd, host of “Meet the Press.” Instantaneously, television and my thoughts became one; in the last segment of the program, Mr. Todd discussed what he was able to consume for $50 at the Iowa State Fair. I learned that his diet that day consisted of a pork chop on a stick, mac and cheese, a bacon-wrapped corn dog, cheese on a stick with jalapeños, a deep-fried Twinkie, and even fried apple pie with bacon. While Mr. Todd is thin and healthy, the array of foods at the fair reflects our nation’s penchant toward fast food that is fat laden and fried. Though our county is not alone in the world, obesity has reached epidemic proportion in the United States.

According to a May 2015 Department of Health & Human Services report on the health status of the nation, 69% of adults in the United States are overweight and 35% are obese. As a result, the minimally invasive gynecologic surgeon is dealing with an increasing population of women with comorbidities related to their obesity that can confound surgery outcomes. Moreover, anatomic landmarks that the young medical student learns in his or her first anatomy classes are modified due to the size of panniculus and the migration of the umbilicus relative to the bifurcation of the aorta.

I asked Dr. Amina Ahmed to join me in discussing the management of the obese patient undergoing minimally invasive gynecologic surgery. After completing her fellowship in gynecologic oncology, Dr. Ahmed has been on staff at both the University of Iowa Hospitals and Clinics, Iowa City, and Advocate Lutheran General Hospital, Park Ridge, Ill. She will soon join the gynecologic oncology faculty at Rush University Medical Center, Chicago. Given the increased rate of obesity in both Chicago and Iowa, Dr. Ahmed has become an expert in this area in a short period of time.

Dr. Miller is a clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column, Master Class. Dr. Miller disclosed that he is a consultant and on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien.

As I was writing my introduction to this current edition of the Master Class in Gynecologic Surgery, focusing on minimally invasive surgery for the obese female patient, I was listening to Chuck Todd, host of “Meet the Press.” Instantaneously, television and my thoughts became one; in the last segment of the program, Mr. Todd discussed what he was able to consume for $50 at the Iowa State Fair. I learned that his diet that day consisted of a pork chop on a stick, mac and cheese, a bacon-wrapped corn dog, cheese on a stick with jalapeños, a deep-fried Twinkie, and even fried apple pie with bacon. While Mr. Todd is thin and healthy, the array of foods at the fair reflects our nation’s penchant toward fast food that is fat laden and fried. Though our county is not alone in the world, obesity has reached epidemic proportion in the United States.

According to a May 2015 Department of Health & Human Services report on the health status of the nation, 69% of adults in the United States are overweight and 35% are obese. As a result, the minimally invasive gynecologic surgeon is dealing with an increasing population of women with comorbidities related to their obesity that can confound surgery outcomes. Moreover, anatomic landmarks that the young medical student learns in his or her first anatomy classes are modified due to the size of panniculus and the migration of the umbilicus relative to the bifurcation of the aorta.

I asked Dr. Amina Ahmed to join me in discussing the management of the obese patient undergoing minimally invasive gynecologic surgery. After completing her fellowship in gynecologic oncology, Dr. Ahmed has been on staff at both the University of Iowa Hospitals and Clinics, Iowa City, and Advocate Lutheran General Hospital, Park Ridge, Ill. She will soon join the gynecologic oncology faculty at Rush University Medical Center, Chicago. Given the increased rate of obesity in both Chicago and Iowa, Dr. Ahmed has become an expert in this area in a short period of time.

Dr. Miller is a clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column, Master Class. Dr. Miller disclosed that he is a consultant and on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien.

The current epidemic of obesity presents gynecologic surgeons with the challenge of safely and successfully performing minimally invasive surgery in women who are morbidly or superobese.

In 2004, the prevalence of a body mass index greater than 40 kg/m² was almost 7.0% in females in the United States (JAMA. 2006 Apr 5;295[13]:1549-55.). Most recently, 8.3% of women were reported to have a BMI greater than 40 (JAMA. 2014 Feb 26;311[8]:806-14.). This is a value that the World Health Organization defines as Class III obesity and that, according to further stratification reported in the surgical literature, includes the categories of morbid obesity (40-44.9), superobesity (greater than 45), and super-superobesity (greater than 60).

As a gynecologic oncologist, I see firsthand the impact of obesity on the risk of multiple gynecologic conditions and female cancers, including endometrial cancer, as well as the benefits of a minimally invasive approach. I frequently perform hysterectomies via the minimally invasive approach to treat precancer and cancer of the uterus in morbidly and superobese women who have significant central adiposity.

MIGS benefits in the obese

In the past 15 years, and particularly in the past decade, evidence that obese patients benefit from laparoscopic surgery compared with traditional laparotomy has increased. I consider minimally invasive surgery the standard of care for women with endometrial cancer, regardless of the BMI.

As Dr. Stacey A. Scheib and her colleagues wrote in a recent review on laparoscopy in the morbidly obese, most of the gynecologic literature comparing laparoscopic surgery with laparotomy in this population is focused on gynecologic oncology because obesity is so strongly associated with endometrial and other cancers in women (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:182-95.). In one prospective study of women with clinical stage I endometrial cancer and BMIs between 28 and 60, those who underwent laparoscopic surgery – 40 of 42 women over 2 years – had significantly longer operative times but less operative morbidity, shorter hospital stays, faster recovery and better postsurgical quality of life, compared with women who had undergone laparotomy in the previous 2 years. The control patients also had clinical stage I endometrial cancer and similar BMIs (Gynecol Oncol. 2000 Sep;78[3 Pt 1]:329-35.).

Research comparing robotics and conventional laparoscopy in obese gynecologic surgery patients is limited, and findings are inconsistent. It will remain difficult to compare the two approaches because few surgeons are equally skilled in both approaches and because the learning curve for conventional laparoscopy is so much steeper than for robotics.

I favor the robotic approach for morbidly and superobese patients for its superior visualization and ergonomics.

Patient positioning

It is important to use an operative bed that will accommodate the weight and width of obese patients and enable Trendelenburg positioning of up to 45 degrees. We use a bariatric bed with a 1,000-pound weight limit.

Obese patients are at greater risk for neuromuscular injuries and pressure sores, so careful patient positioning and padding of pressure points is critically important. We have found a surgical bean bag to be much more effective in preventing slippage for the morbidly or superobese patient than is egg-crate foam. The bean bag conforms nicely to the shape of the patient’s back, neck, and arms when it is appropriately desufflated. After desufflation, the bean bag must be well taped onto the operative bed.

I sometimes use shoulder blocks for extra assurance. When used, these braces must be attached to the bean bag and not to the patient.

We typically pad the arms completely with gel pads or foam before the bean bag is desufflated. We also often pad the knees and calves before the legs are placed and secured in stirrups made for the morbidly obese, with the buttocks slightly off the table.

In a review of literature on obesity and laparoscopy outcomes, Dr. Georgine Lamvu and her associates recommended that the arms be tucked in the “military” position, along the length of the body (Am J Obstet Gynecol. 2004 Aug;191[2]:669-74.). To ensure that both arms are properly tucked against the length of the body, we use bed extenders or sleds to widen the bed as necessary.

Abdominal access

I use the open Hasson technique in my obese patients and enter the peritoneum under direct visualization. In patients with high levels of morbid obesity, I have found it helpful to retract the adipose tissue using thin Breisky vaginal retractors. These retractors can hold the adipose tissue away from the fascia to facilitate entry into the abdominal cavity via the open technique.

Utilizing the umbilicus as the initial entry point – often desirable in minimally invasive surgery – is frequently not possible in morbidly obese patients because as BMI increases, the umbilicus migrates toward the pubic bone and away from the aortic bifurcation. In patients who were overweight (BMI greater than 25), Dr. W.W. Hurd and his associates noted a repositioning of the umbilicus below the aortic bifurcation of 2 cm or greater (Obstet Gynecol. 1992 Jul;80[1]:48-51.).

Instead, a supraumbilical or left upper quadrant site for initial entry enables optimal triangulation of trocars and visualization of disease. The trocars must then be placed more lateral and cephalad than in thinner women. In doing so, risk to the inferior epigastric is mitigated. Moreover, longer trocar lengths (150 mm) may be required.

To utilize an umbilical entry, it is imperative that the panniculus be placed cephalad to a position between the two anterior iliac spines (Obstet Gynecol. 1998 Nov;92[5]:869-72.). By doing this, the umbilicus is now repositioned relative to the bifurcation of the aorta similar to the thinner patient. This can either be accomplished using assistants to move the panniculus cephalad or taping the panniculus.

Alternatively, if the Hasson technique is not utilized, a Veress needle (50 mm in length) may be used. Based on MRI and CT visualization, Dr. Hurd has long recommended using a 90-degree angle in the obese population, compared with a 45-degree angle in nonobese women (J Reprod Med. 1991;36[7]:473-6.).

I usually place the patient into a moderate Trendelenburg position before docking the robot and observe the patient’s cardiac and respiratory responses to the induction of anesthesia. Adjustments in the degree of Trendelenburg positioning, the insufflation pressure level, and the ventilation settings can then be made if necessary. Occasionally I will decrease the insufflation pressure from 15 to 12 mm Hg, for instance, to accommodate ventilation needs.

A note from Dr. Charles E. Miller, Master Class Medical Editor

It must be recognized that not all physicians agree with the use of shoulder braces. In a review of literature on brachial plexus injuries in gynecologic surgery during 1980-2012, Dr. Nigel Pereira and his associates identified eight case reports, all of which involved Trendelenburg positioning and seven of which utilized shoulder braces. In their evaluation of the literature, the authors concluded that “the force of the shoulder braces on the clavicle and scapula opposes the force of gravity on the humerus, thereby stretching the brachial plexus and leading to nerve injury. This is particularly exaggerated when the arm is hyperabducted (less than 90 degrees), the head is laterally flexed to the opposite side, or the abducted arm is sagging.”

The authors also point out that longer times spent under general anesthesia (commensurate with increased operating times) increase the risk of brachial plexus injury “by increasing joint mobility (particularly when muscle relaxants are used) because the neighboring bony structure is more likely to compress or impinge on the brachial plexus” (CRSLS e2014.00077. [doi:10.4293/CRSLS.2014.00077]).

More pearls from Dr. Miller

Preoperative care. Prior to surgery it is important to examine a patient’s panniculus closely for evidence of infection. As the area underneath the panniculus receives little oxygen, it is at greater risk for both bacterial and fungal infections. If infection is noted, treatment prior to surgery is strongly recommended. Moreover, as the skin under the panniculus is often times “broken down,” which can compromise healing, lateral incisions should not be made in this area.

Since obese women have more severe comorbidities (such as metabolic syndrome, obstructed sleep apnea, coronary artery disease, poorly controlled hypertension, and a difficult airway) and a greater risk of perioperative complications than women who are not obese, they generally require a more-extensive preoperative work-up and additional perioperative considerations. If the minimally invasive gynecologic surgeon is uncomfortable with evaluation of cardiac and pulmonary status, medical clearance and perioperative consultation with an anesthesiologist prior to surgery is strongly recommended.

Perioperative care. There are no studies in the literature supporting the use of antibiotic prophylaxis prior to surgery despite the increased risk of postoperative wound infection in morbidly obese patients. Increased risk of surgical site infection post abdominal hysterectomy has been noted in women with a BMI greater than 35. Therefore, consideration should be given to the use of prophylactic antibiotics. For patients weighing more than 80 kg, I advise using 2 gm prophylactic cefazolin; increase this to 3 gm in patients that weigh more than 120 kg.

The morbidly obese patient is also at greater risk of deep venous thrombosis, especially when the procedure is lengthy. Sequential compression devices are essential. Moreover, use of such antithrombotic agents as Lovenox [enoxaparin] and heparin should be considered until the patient is ambulating.

Postoperative care. It is imperative to stress the need for extensive pulmonary toilet or hygiene (i.e., coughing and breathing deeply to clear mucus and secretions from the airways) as well as early ambulation. The patient should also be counseled to use pain medication judiciously. And until the patient is mobile, the use of antithrombotic agents, such as Lovenox and heparin, should be continued.

Dr. Ahmed reports that she has no disclosures related to this Master Class. Dr. Miller disclosed that he is a consultant and is on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien. Email Dr. Ahmed and Dr. Miller at [email protected].

The current epidemic of obesity presents gynecologic surgeons with the challenge of safely and successfully performing minimally invasive surgery in women who are morbidly or superobese.

In 2004, the prevalence of a body mass index greater than 40 kg/m² was almost 7.0% in females in the United States (JAMA. 2006 Apr 5;295[13]:1549-55.). Most recently, 8.3% of women were reported to have a BMI greater than 40 (JAMA. 2014 Feb 26;311[8]:806-14.). This is a value that the World Health Organization defines as Class III obesity and that, according to further stratification reported in the surgical literature, includes the categories of morbid obesity (40-44.9), superobesity (greater than 45), and super-superobesity (greater than 60).

As a gynecologic oncologist, I see firsthand the impact of obesity on the risk of multiple gynecologic conditions and female cancers, including endometrial cancer, as well as the benefits of a minimally invasive approach. I frequently perform hysterectomies via the minimally invasive approach to treat precancer and cancer of the uterus in morbidly and superobese women who have significant central adiposity.

MIGS benefits in the obese

In the past 15 years, and particularly in the past decade, evidence that obese patients benefit from laparoscopic surgery compared with traditional laparotomy has increased. I consider minimally invasive surgery the standard of care for women with endometrial cancer, regardless of the BMI.

As Dr. Stacey A. Scheib and her colleagues wrote in a recent review on laparoscopy in the morbidly obese, most of the gynecologic literature comparing laparoscopic surgery with laparotomy in this population is focused on gynecologic oncology because obesity is so strongly associated with endometrial and other cancers in women (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:182-95.). In one prospective study of women with clinical stage I endometrial cancer and BMIs between 28 and 60, those who underwent laparoscopic surgery – 40 of 42 women over 2 years – had significantly longer operative times but less operative morbidity, shorter hospital stays, faster recovery and better postsurgical quality of life, compared with women who had undergone laparotomy in the previous 2 years. The control patients also had clinical stage I endometrial cancer and similar BMIs (Gynecol Oncol. 2000 Sep;78[3 Pt 1]:329-35.).

Research comparing robotics and conventional laparoscopy in obese gynecologic surgery patients is limited, and findings are inconsistent. It will remain difficult to compare the two approaches because few surgeons are equally skilled in both approaches and because the learning curve for conventional laparoscopy is so much steeper than for robotics.

I favor the robotic approach for morbidly and superobese patients for its superior visualization and ergonomics.

Patient positioning

It is important to use an operative bed that will accommodate the weight and width of obese patients and enable Trendelenburg positioning of up to 45 degrees. We use a bariatric bed with a 1,000-pound weight limit.

Obese patients are at greater risk for neuromuscular injuries and pressure sores, so careful patient positioning and padding of pressure points is critically important. We have found a surgical bean bag to be much more effective in preventing slippage for the morbidly or superobese patient than is egg-crate foam. The bean bag conforms nicely to the shape of the patient’s back, neck, and arms when it is appropriately desufflated. After desufflation, the bean bag must be well taped onto the operative bed.

I sometimes use shoulder blocks for extra assurance. When used, these braces must be attached to the bean bag and not to the patient.

We typically pad the arms completely with gel pads or foam before the bean bag is desufflated. We also often pad the knees and calves before the legs are placed and secured in stirrups made for the morbidly obese, with the buttocks slightly off the table.

In a review of literature on obesity and laparoscopy outcomes, Dr. Georgine Lamvu and her associates recommended that the arms be tucked in the “military” position, along the length of the body (Am J Obstet Gynecol. 2004 Aug;191[2]:669-74.). To ensure that both arms are properly tucked against the length of the body, we use bed extenders or sleds to widen the bed as necessary.

Abdominal access

I use the open Hasson technique in my obese patients and enter the peritoneum under direct visualization. In patients with high levels of morbid obesity, I have found it helpful to retract the adipose tissue using thin Breisky vaginal retractors. These retractors can hold the adipose tissue away from the fascia to facilitate entry into the abdominal cavity via the open technique.

Utilizing the umbilicus as the initial entry point – often desirable in minimally invasive surgery – is frequently not possible in morbidly obese patients because as BMI increases, the umbilicus migrates toward the pubic bone and away from the aortic bifurcation. In patients who were overweight (BMI greater than 25), Dr. W.W. Hurd and his associates noted a repositioning of the umbilicus below the aortic bifurcation of 2 cm or greater (Obstet Gynecol. 1992 Jul;80[1]:48-51.).

Instead, a supraumbilical or left upper quadrant site for initial entry enables optimal triangulation of trocars and visualization of disease. The trocars must then be placed more lateral and cephalad than in thinner women. In doing so, risk to the inferior epigastric is mitigated. Moreover, longer trocar lengths (150 mm) may be required.

To utilize an umbilical entry, it is imperative that the panniculus be placed cephalad to a position between the two anterior iliac spines (Obstet Gynecol. 1998 Nov;92[5]:869-72.). By doing this, the umbilicus is now repositioned relative to the bifurcation of the aorta similar to the thinner patient. This can either be accomplished using assistants to move the panniculus cephalad or taping the panniculus.

Alternatively, if the Hasson technique is not utilized, a Veress needle (50 mm in length) may be used. Based on MRI and CT visualization, Dr. Hurd has long recommended using a 90-degree angle in the obese population, compared with a 45-degree angle in nonobese women (J Reprod Med. 1991;36[7]:473-6.).

I usually place the patient into a moderate Trendelenburg position before docking the robot and observe the patient’s cardiac and respiratory responses to the induction of anesthesia. Adjustments in the degree of Trendelenburg positioning, the insufflation pressure level, and the ventilation settings can then be made if necessary. Occasionally I will decrease the insufflation pressure from 15 to 12 mm Hg, for instance, to accommodate ventilation needs.

A note from Dr. Charles E. Miller, Master Class Medical Editor

It must be recognized that not all physicians agree with the use of shoulder braces. In a review of literature on brachial plexus injuries in gynecologic surgery during 1980-2012, Dr. Nigel Pereira and his associates identified eight case reports, all of which involved Trendelenburg positioning and seven of which utilized shoulder braces. In their evaluation of the literature, the authors concluded that “the force of the shoulder braces on the clavicle and scapula opposes the force of gravity on the humerus, thereby stretching the brachial plexus and leading to nerve injury. This is particularly exaggerated when the arm is hyperabducted (less than 90 degrees), the head is laterally flexed to the opposite side, or the abducted arm is sagging.”

The authors also point out that longer times spent under general anesthesia (commensurate with increased operating times) increase the risk of brachial plexus injury “by increasing joint mobility (particularly when muscle relaxants are used) because the neighboring bony structure is more likely to compress or impinge on the brachial plexus” (CRSLS e2014.00077. [doi:10.4293/CRSLS.2014.00077]).

More pearls from Dr. Miller

Preoperative care. Prior to surgery it is important to examine a patient’s panniculus closely for evidence of infection. As the area underneath the panniculus receives little oxygen, it is at greater risk for both bacterial and fungal infections. If infection is noted, treatment prior to surgery is strongly recommended. Moreover, as the skin under the panniculus is often times “broken down,” which can compromise healing, lateral incisions should not be made in this area.

Since obese women have more severe comorbidities (such as metabolic syndrome, obstructed sleep apnea, coronary artery disease, poorly controlled hypertension, and a difficult airway) and a greater risk of perioperative complications than women who are not obese, they generally require a more-extensive preoperative work-up and additional perioperative considerations. If the minimally invasive gynecologic surgeon is uncomfortable with evaluation of cardiac and pulmonary status, medical clearance and perioperative consultation with an anesthesiologist prior to surgery is strongly recommended.

Perioperative care. There are no studies in the literature supporting the use of antibiotic prophylaxis prior to surgery despite the increased risk of postoperative wound infection in morbidly obese patients. Increased risk of surgical site infection post abdominal hysterectomy has been noted in women with a BMI greater than 35. Therefore, consideration should be given to the use of prophylactic antibiotics. For patients weighing more than 80 kg, I advise using 2 gm prophylactic cefazolin; increase this to 3 gm in patients that weigh more than 120 kg.

The morbidly obese patient is also at greater risk of deep venous thrombosis, especially when the procedure is lengthy. Sequential compression devices are essential. Moreover, use of such antithrombotic agents as Lovenox [enoxaparin] and heparin should be considered until the patient is ambulating.

Postoperative care. It is imperative to stress the need for extensive pulmonary toilet or hygiene (i.e., coughing and breathing deeply to clear mucus and secretions from the airways) as well as early ambulation. The patient should also be counseled to use pain medication judiciously. And until the patient is mobile, the use of antithrombotic agents, such as Lovenox and heparin, should be continued.

Dr. Ahmed reports that she has no disclosures related to this Master Class. Dr. Miller disclosed that he is a consultant and is on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien. Email Dr. Ahmed and Dr. Miller at [email protected].

The current epidemic of obesity presents gynecologic surgeons with the challenge of safely and successfully performing minimally invasive surgery in women who are morbidly or superobese.

In 2004, the prevalence of a body mass index greater than 40 kg/m² was almost 7.0% in females in the United States (JAMA. 2006 Apr 5;295[13]:1549-55.). Most recently, 8.3% of women were reported to have a BMI greater than 40 (JAMA. 2014 Feb 26;311[8]:806-14.). This is a value that the World Health Organization defines as Class III obesity and that, according to further stratification reported in the surgical literature, includes the categories of morbid obesity (40-44.9), superobesity (greater than 45), and super-superobesity (greater than 60).

As a gynecologic oncologist, I see firsthand the impact of obesity on the risk of multiple gynecologic conditions and female cancers, including endometrial cancer, as well as the benefits of a minimally invasive approach. I frequently perform hysterectomies via the minimally invasive approach to treat precancer and cancer of the uterus in morbidly and superobese women who have significant central adiposity.

MIGS benefits in the obese

In the past 15 years, and particularly in the past decade, evidence that obese patients benefit from laparoscopic surgery compared with traditional laparotomy has increased. I consider minimally invasive surgery the standard of care for women with endometrial cancer, regardless of the BMI.

As Dr. Stacey A. Scheib and her colleagues wrote in a recent review on laparoscopy in the morbidly obese, most of the gynecologic literature comparing laparoscopic surgery with laparotomy in this population is focused on gynecologic oncology because obesity is so strongly associated with endometrial and other cancers in women (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:182-95.). In one prospective study of women with clinical stage I endometrial cancer and BMIs between 28 and 60, those who underwent laparoscopic surgery – 40 of 42 women over 2 years – had significantly longer operative times but less operative morbidity, shorter hospital stays, faster recovery and better postsurgical quality of life, compared with women who had undergone laparotomy in the previous 2 years. The control patients also had clinical stage I endometrial cancer and similar BMIs (Gynecol Oncol. 2000 Sep;78[3 Pt 1]:329-35.).

Research comparing robotics and conventional laparoscopy in obese gynecologic surgery patients is limited, and findings are inconsistent. It will remain difficult to compare the two approaches because few surgeons are equally skilled in both approaches and because the learning curve for conventional laparoscopy is so much steeper than for robotics.

I favor the robotic approach for morbidly and superobese patients for its superior visualization and ergonomics.

Patient positioning

It is important to use an operative bed that will accommodate the weight and width of obese patients and enable Trendelenburg positioning of up to 45 degrees. We use a bariatric bed with a 1,000-pound weight limit.

Obese patients are at greater risk for neuromuscular injuries and pressure sores, so careful patient positioning and padding of pressure points is critically important. We have found a surgical bean bag to be much more effective in preventing slippage for the morbidly or superobese patient than is egg-crate foam. The bean bag conforms nicely to the shape of the patient’s back, neck, and arms when it is appropriately desufflated. After desufflation, the bean bag must be well taped onto the operative bed.

I sometimes use shoulder blocks for extra assurance. When used, these braces must be attached to the bean bag and not to the patient.

We typically pad the arms completely with gel pads or foam before the bean bag is desufflated. We also often pad the knees and calves before the legs are placed and secured in stirrups made for the morbidly obese, with the buttocks slightly off the table.

In a review of literature on obesity and laparoscopy outcomes, Dr. Georgine Lamvu and her associates recommended that the arms be tucked in the “military” position, along the length of the body (Am J Obstet Gynecol. 2004 Aug;191[2]:669-74.). To ensure that both arms are properly tucked against the length of the body, we use bed extenders or sleds to widen the bed as necessary.

Abdominal access

I use the open Hasson technique in my obese patients and enter the peritoneum under direct visualization. In patients with high levels of morbid obesity, I have found it helpful to retract the adipose tissue using thin Breisky vaginal retractors. These retractors can hold the adipose tissue away from the fascia to facilitate entry into the abdominal cavity via the open technique.

Utilizing the umbilicus as the initial entry point – often desirable in minimally invasive surgery – is frequently not possible in morbidly obese patients because as BMI increases, the umbilicus migrates toward the pubic bone and away from the aortic bifurcation. In patients who were overweight (BMI greater than 25), Dr. W.W. Hurd and his associates noted a repositioning of the umbilicus below the aortic bifurcation of 2 cm or greater (Obstet Gynecol. 1992 Jul;80[1]:48-51.).

Instead, a supraumbilical or left upper quadrant site for initial entry enables optimal triangulation of trocars and visualization of disease. The trocars must then be placed more lateral and cephalad than in thinner women. In doing so, risk to the inferior epigastric is mitigated. Moreover, longer trocar lengths (150 mm) may be required.

To utilize an umbilical entry, it is imperative that the panniculus be placed cephalad to a position between the two anterior iliac spines (Obstet Gynecol. 1998 Nov;92[5]:869-72.). By doing this, the umbilicus is now repositioned relative to the bifurcation of the aorta similar to the thinner patient. This can either be accomplished using assistants to move the panniculus cephalad or taping the panniculus.

Alternatively, if the Hasson technique is not utilized, a Veress needle (50 mm in length) may be used. Based on MRI and CT visualization, Dr. Hurd has long recommended using a 90-degree angle in the obese population, compared with a 45-degree angle in nonobese women (J Reprod Med. 1991;36[7]:473-6.).

I usually place the patient into a moderate Trendelenburg position before docking the robot and observe the patient’s cardiac and respiratory responses to the induction of anesthesia. Adjustments in the degree of Trendelenburg positioning, the insufflation pressure level, and the ventilation settings can then be made if necessary. Occasionally I will decrease the insufflation pressure from 15 to 12 mm Hg, for instance, to accommodate ventilation needs.

A note from Dr. Charles E. Miller, Master Class Medical Editor

It must be recognized that not all physicians agree with the use of shoulder braces. In a review of literature on brachial plexus injuries in gynecologic surgery during 1980-2012, Dr. Nigel Pereira and his associates identified eight case reports, all of which involved Trendelenburg positioning and seven of which utilized shoulder braces. In their evaluation of the literature, the authors concluded that “the force of the shoulder braces on the clavicle and scapula opposes the force of gravity on the humerus, thereby stretching the brachial plexus and leading to nerve injury. This is particularly exaggerated when the arm is hyperabducted (less than 90 degrees), the head is laterally flexed to the opposite side, or the abducted arm is sagging.”

The authors also point out that longer times spent under general anesthesia (commensurate with increased operating times) increase the risk of brachial plexus injury “by increasing joint mobility (particularly when muscle relaxants are used) because the neighboring bony structure is more likely to compress or impinge on the brachial plexus” (CRSLS e2014.00077. [doi:10.4293/CRSLS.2014.00077]).

More pearls from Dr. Miller

Preoperative care. Prior to surgery it is important to examine a patient’s panniculus closely for evidence of infection. As the area underneath the panniculus receives little oxygen, it is at greater risk for both bacterial and fungal infections. If infection is noted, treatment prior to surgery is strongly recommended. Moreover, as the skin under the panniculus is often times “broken down,” which can compromise healing, lateral incisions should not be made in this area.

Since obese women have more severe comorbidities (such as metabolic syndrome, obstructed sleep apnea, coronary artery disease, poorly controlled hypertension, and a difficult airway) and a greater risk of perioperative complications than women who are not obese, they generally require a more-extensive preoperative work-up and additional perioperative considerations. If the minimally invasive gynecologic surgeon is uncomfortable with evaluation of cardiac and pulmonary status, medical clearance and perioperative consultation with an anesthesiologist prior to surgery is strongly recommended.

Perioperative care. There are no studies in the literature supporting the use of antibiotic prophylaxis prior to surgery despite the increased risk of postoperative wound infection in morbidly obese patients. Increased risk of surgical site infection post abdominal hysterectomy has been noted in women with a BMI greater than 35. Therefore, consideration should be given to the use of prophylactic antibiotics. For patients weighing more than 80 kg, I advise using 2 gm prophylactic cefazolin; increase this to 3 gm in patients that weigh more than 120 kg.

The morbidly obese patient is also at greater risk of deep venous thrombosis, especially when the procedure is lengthy. Sequential compression devices are essential. Moreover, use of such antithrombotic agents as Lovenox [enoxaparin] and heparin should be considered until the patient is ambulating.

Postoperative care. It is imperative to stress the need for extensive pulmonary toilet or hygiene (i.e., coughing and breathing deeply to clear mucus and secretions from the airways) as well as early ambulation. The patient should also be counseled to use pain medication judiciously. And until the patient is mobile, the use of antithrombotic agents, such as Lovenox and heparin, should be continued.

Dr. Ahmed reports that she has no disclosures related to this Master Class. Dr. Miller disclosed that he is a consultant and is on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien. Email Dr. Ahmed and Dr. Miller at [email protected].

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.

Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.

Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).

Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.

This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.

Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]. Dr. Powell said he had no relevant financial disclosures.

Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.

Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.

Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).

Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.

This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.

Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]. Dr. Powell said he had no relevant financial disclosures.

Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.

Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.

Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).

Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.

This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.

Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]. Dr. Powell said he had no relevant financial disclosures.