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Put ‘The Digital Doctor’ on your summer reading list
The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.
I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.
At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.
Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.
Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?
To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?
Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.
The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.
This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.
As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?
What about technologies like OpenNotes that empower patients? How will this affect the doctor-patient relationship? What are we to do about patients who make bad choices, opt for high copays to save money up front, or choose Minute Clinics for all their health care needs? Will patients be harmed by such openness? The jury is still out.
For those who like clear black-and-white answers, Dr. Wachter’s book will seem maddeningly gray. Yet as a practicing clinician, I found it enlightening and thought provoking, and hope you will, too. I also hope it prompts you to step away from the computer, walk next door to your colleague’s office, and start a real-life conversation.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.
I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.
At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.
Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.
Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?
To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?
Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.
The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.
This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.
As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?
What about technologies like OpenNotes that empower patients? How will this affect the doctor-patient relationship? What are we to do about patients who make bad choices, opt for high copays to save money up front, or choose Minute Clinics for all their health care needs? Will patients be harmed by such openness? The jury is still out.
For those who like clear black-and-white answers, Dr. Wachter’s book will seem maddeningly gray. Yet as a practicing clinician, I found it enlightening and thought provoking, and hope you will, too. I also hope it prompts you to step away from the computer, walk next door to your colleague’s office, and start a real-life conversation.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
The last time I spoke with my 70-year-old mother in Rhode Island, I asked her how she made out at her latest dermatology appointment. She burst forth: “Don’t get me started! The doctor spent the whole time with his face in the computer screen. He hardly examined me!” It went downhill from there.
I feel both her pain and his. As a Gen-X physician, I’m in a unique position. I trained in the pre-EHR age with the Dr. Marcus Welby–type physicians my parents knew and admired. I have also embraced the digitization of medicine and the advances this affords. At Kaiser Permanente, I help run one of the country’s most robust telemedicine programs, and I answer dozens of patient e-mails each week. Yet I too experience the frustration of having to split my attention between my screens and my patients.
At conferences and in articles, it seems the chasm between physicians who eagerly embrace the new digital world of medicine and those who long for the way things used to be is expanding rather than shrinking. Too often, there is insufficient dialogue between these two groups. Dr. Robert Wachter hopes to change that.
Professor and associate chair of the department of medicine at the University of California, San Francisco, Dr. Wachter has authored six books, has developed the concept of the “hospitalist,” and has been a leader in patient safety. His latest book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (McGraw-Hill, 2015) has been hailed as a “must read” for physicians and other health care practitioners. I agree.
Medicine is in the midst of profound change that is as frightening as it is exciting. Dr. Wachter captures this tension through memorable patient stories and interviews. He argues that technology has made medicine both better and worse. It has enabled clinicians to improve diagnostics and health care delivery. Consider the explosive growth of “big data” in health care and of patient empowerment (e-mailing, texting, Skyping, OpenNotes). Yet, an astute observer acknowledges technology’s shortfalls. For example, what happens when information is incorrectly entered in an EHR? What are physicians to do with the massive patient data we receive?
To illustrate his theme, Dr. Wachter examines EHRs in depth. He argues that the most brilliant engineers can create the most complex computer systems, but if they’re not implemented and funded systemically, how will they be successful? Why would private practice physicians want to relinquish their “tried-and-true paper prescription and record system for an expensive and complex EHR?” And what happens when EHRs don’t talk to one another?
Despite their obvious advantages, EHRs have several drawbacks, including poor usability, time-consuming data entry (that adversely affects the doctor-patient relationship), the high cost of implementation, and decreased satisfaction among physicians with their jobs, Dr. Wachter notes. Who has the solution to these problems? Is it Silicon Valley? Or did they create the problem? (Dr. Wachter spends a great deal of time interviewing key players from that region.) Ultimately, he determines that the EHR, despite its brilliant advantages, wasn’t designed to give both physicians and patients what they really want.
The most compelling patient story that Dr. Wachter shares concerns a teenage boy who nearly died from an overdose of an antibiotic. He shows with devastating clarity how one wrong click of the keypad can lead to tragedy. No one – physicians, nurses, nor pharmacists – caught the error (the patient was administered 38.5 tablets instead of 1 tablet). Why? Dr. Wachter blames our “blind trust” in computers, which causes us to not question when something seems wrong. Moreover, multiple warnings went unheeded by nurses, who probably suffered from “alert fatigue,” desensitization to warning alarms (think of the ubiquitous car alarms sounding and how no one reacts to them), he says.
This leads to Dr. Wachter’s dive into the “complex interface between technology and people.” At what point do computers stop assisting physicians and begin replacing them? While he clearly believes that the human component of the doctor-patient relationship is irreplaceable, he does acknowledge through interviews with people such as Vinod Khosla, cofounder of Sun Microsystems, that computers will continue to “displace” much of the physician’s diagnostic and prescription work.
As Dr. Wachter seesaws through both sides of this argument, he finds himself “stick[ing] up for my teams: humans and the subset of humans called doctors.” After all, isn’t diagnostic skill at the core of an astute clinician’s arsenal? How do we relinquish it to computers?
What about technologies like OpenNotes that empower patients? How will this affect the doctor-patient relationship? What are we to do about patients who make bad choices, opt for high copays to save money up front, or choose Minute Clinics for all their health care needs? Will patients be harmed by such openness? The jury is still out.
For those who like clear black-and-white answers, Dr. Wachter’s book will seem maddeningly gray. Yet as a practicing clinician, I found it enlightening and thought provoking, and hope you will, too. I also hope it prompts you to step away from the computer, walk next door to your colleague’s office, and start a real-life conversation.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
Veterans’ Health and Opioid Safety–Contexts, Risks, and Outreach Implications
America has been facing an epidemic of drug overdoses. Prescription opioid (PO) misuse has been a major driver of this phenomenon. According to the CDC, from 1999 to 2013 the drug poisoning death rate more than doubled from 6.1 to 13.8 people per 100,000, and the rate for drug poisoning deaths involving opioid analgesics nearly quadrupled from 1.4 to 5.1 people per 100,000.1
This epidemic has greatly impacted active-duty military personnel and veterans who face especially elevated risks of opioid misuse and overdose.2-4 The army has reported that among active-duty personnel, drug toxicity deaths more than doubled between 2006 and 2011, and overdose rates are greatly elevated among VA patients compared with the civilian population.3,5 A May 2014 VHA report indicated that 440,000 current patients were prescribed opioids, placing them at potential risk, and 55,000 veteran patients were diagnosed as having a current opioid use disorder, placing them at even greater risk.3,6
Military personnel and veterans who experience combat- or service-related injuries are frequently prescribed POs to manage pain.7,8 However, POs can be misused, and routine pain management can easily lead to risky behavior through common practices such as unmonitored dose escalation and the use of POs in combination with other drugs or alcohol. Some service members and veterans engage in unsupervised, nonmedical use of POs for a range of reasons, including self-management of physical pain, anxiety, or sleep disorders.
Veterans’ PO use can take place within the broader context of readjustment to civilian life and its numerous challenges, including unemployment, homelessness, social isolation, cognitive impairment (eg, traumatic brain injury [TBI]), and mental health concerns (eg, depression, posttraumatic stress disorder [PTSD]).2,3,8,9 All of these factors can intensify the negative health consequences associated with PO misuse and can greatly increase the chance for overdose and accidental injury. Accordingly, veterans represent a vulnerable population at disproportionate risk of PO misuse and overdose. As current research is demonstrating, these risks are potentially even higher for women, minority, homeless, and otherwise socially isolated veterans, as well as those with mental health concerns.10,11
Preventing Overdose Death
Overdose events are both preventable and reversible.12 One policy response has been to provide outreach education programs that distribute naloxone (commonly referred to by its trade name, Narcan), an opioid antagonist that can reverse opioid- involved overdose, and train PO users, their family, and friends in its use. In response to the rise of PO misuse and PO-related overdose, VA, DoD, public health departments, drug treatment programs, and community groups have implemented opioid safety and overdose prevention programs targeting prescription drug users, their families, and their peers. Typical programs provide information about preventing opioid misuse, identifying and preventing an overdose, understanding overdose risks (eg, tolerance, mixing drugs, using alone), and responding to an overdose (eg, calling 911, rescue breathing, naloxone administration). The effectiveness of these programs is well established.13-17
The army has been highly responsive to this problem. Following contact with a Wilkes County, North Carolina-based overdose prevention program, army medical personnel at Fort Bragg implemented Operation Opioid SAFE in 2011, which provided overdose prevention training and naloxone to active-duty soldiers at risk for opioid overdose in the course of routine pain management.18 This program represents a forward-looking intervention in keeping with the CDC’s recent call to public agencies to educate laypersons to administer naloxone to those in need.12 This initiative has great potential to reach active-duty soldiers. However, additional outreach programs are needed to reach the veteran population who face similar overdose risks but may not be served by the VA, which is now providing risk reduction information and naloxone through its Overdose Education and Naloxone Distribution Program.6,19
Another approach to preventing opioid overdose has been to restrict access to POs, including a reduction in prescribing POs and the use of prescription drug monitoring programs to combat diversion. These programs are raising awareness and reducing misuse (especially casual misuse) among many populations. However, patients dealing with chronic pain still need medications, and POs work for many of them. Unfortunately, with restricted access to POs, some veterans self-treat pain with diverted POs or even switch to illicit substances, such as heroin.20 Without medical oversight for their opioid use (and the standardized dosage and contraindication information that it involves), these veterans experience an even greater risk of opioid- related overdose.
Assessing the Problem
Despite findings about the clustering of opioid-related risks among particular veteran subpopulations, very little is currently known about how these risks emerge over time and what conditions and events precipitate them. The Institute for Special Populations Research (ISPR) of the National Development and Research Institutes, Inc. (NDRI), is conducting a project to address the emergence of opioid-related risk behaviors over time and to track the changing dimensions of veterans’ reintegration experiences that impact PO and other substance use patterns. This project examines opioid-using veterans’ substance use patterns alongside other physiologic, social, and psychological dimensions of their lives, ranging from PTSD symptoms, depression, and pain severity to social relationships and employment status. The goal is to provide critical biopsychosocial insights into the stressors, turning points, and substance use patterns that precede emergence of overdose risk behaviors and the protective factors that keep some opioid-using veterans safe, despite their struggles with pain and the psychosocial challenges of reintegration.
With this work, ISPR hopes to greatly inform the development of effective programs for preventing opioid misuse and opioid-related overdose among veterans by helping to identify the salient contexts for risky opioid use and gaining a better understanding of how even routine, adherent pain management behaviors sometimes lead to risky situations. This task is suited to both qualitative inquiry and survey research, and to that end, ISPR has conducted in-depth interviews with veterans who have experienced a PO-related overdose to gain a better understanding of proximal and distal antecedents of overdose. These interviews have helped ISPR to develop an Overdose Risk Behavior Scale, which is being administered to 250 veterans to monitor risk trajectories over a period of 2 years.
Preliminary results suggest that veterans are engaging in a variety of risky practices, such as off-label use of POs, mixing prescription opioids with other drugs and/or alcohol, and excessive opioid misuse without other people present. The research is also finding that these risky behaviors are deeply rooted in social factors (eg, unemployment, homelessness, and relationships) and mental health issues. Consistent with other research, we are finding that a large portion of veterans do not utilize or engage VA hospitals for a variety of reasons, including discharge status, confusion about eligibility, and a dissociation from military status, often due to experiences of trauma and/or moral injury.21
The ISPR has also convened focus groups involving homeless and female veterans to better understand the gendered dimensions of substance abuse challenges.4 In collaboration with the New York City Department of Health and Mental Hygiene (NYCDOHMH), ISPR is convening additional focus groups with male and female veterans currently using opioids to gain insights into ways to promote opioid safety and prevent overdose among the veteran population.
Policy and Outreach
Ongoing work indicates that there is a need for additional community-based approaches to reach this high-risk population. In this community and through this work, ISPR is finding that community-based, low-threshold approaches are paramount. For veterans who do not utilize the VA, the foundational principles of risk mitigation, which urge individuals to “come as you are” and service providers to meet clientele “where they are” in low-threshold settings, are essential guidelines for conducting effective outreach.22
In New York City, for example, where the ISPR study is being conducted, the veteran community is served by a diverse network of veterans’ organizations, many of which serve specific veteran subpopulations, including the homeless (eg, Jericho Project), black/African American (eg, Black Vets for Social Justice), female (eg, Service Women’s Action Network), and substance-dependent veterans (eg, Reality House). The study has been working with these groups to develop strategies for overdose reduction. We are fortunate that the NYCDOHMH has been promoting overdose prevention and reversal within the community. They have collaborated with ISPR to support efforts to reach within the veteran population.
Although robust, collaborative community-based projects involving veteran populations have been slow to emerge, the ISPR findings indicate that by collaborating with veterans and supporting them with overdose prevention knowledge and skills, they can be better prepared to participate in peer outreach efforts and in some cases, even become community health providers to other veterans in need. As many veterans have suggested, the “battle-buddy” military model of support could be adapted and widely implemented for veterans. With these veterans and the organizations that support them, ISPR aims to further the overdose prevention and opioid safety prevention efforts and pioneer new prevention and information resources for PO-using veterans, their friends, and family members. This effort is also helping to construct valuable ties with veterans service organizations (VSOs) that will empower them in future outreach to localized veteran subpopulations.
This joint effort will provide the means to develop more creative and time-sensitive interventions that prevent or mitigate risky behaviors before they lead to negative health consequences, including overdose and even untimely death. Helping to understand how veterans conceptualize risk and draw on social and institutional supports will allow for greater refinement in future efforts to educate veterans and assist them in establishing meaningful institutional affiliations and social relationships that may serve as protective factors against opioid-related health risks.
The ongoing dialogue with many veterans and the organizations that serve them has yielded recommendations to help improve their transitions to civilian life. Many veterans suggested the need for a continuum of services and more frequent/robust outreach, such as support and referral programs at every stage of the military/veteran career through VSOs. Many veterans also suggested the need for increased access to a range of treatment options on demand, including traditional 12-step and faith-based programs, medically assisted maintenance and therapy programs (eg, methadone and buprenorphine), as well as complementary and alternative medical approaches (eg, acupuncture).
Veterans have also advocated for the provision of different technological and philosophical approaches to assist them as civilians. For example, some veterans suggested that it is critical to address the stigma associated with seeking treatment and to provide treatment in nonjudgmental settings. Further, many advocated for expansion of short- and long-term maintenance therapies and increasing the availability of risk reduction services, such as the provision of naloxone and other low threshold interventions.
For those veterans who have difficulty giving up POs or other drugs completely due to comorbid conditions (eg, serious chronic pain, depression, PTSD, TBI, and dependence), the need to help reduce the stigma of treatment and the harms associated with drug misuse is great. A further insight we have developed while working with the veteran population is that community-based interagency collaboration can help veterans connect with other veterans and the services they need and to realize the potential for their voices to impact policies designed to assist them. Whether within the VA or elsewhere, primary care and mental health practitioners should urge their patients to take up broader networks of health-positive relationships. Indeed, strengthening partnerships between the VA, local health departments, and community-based groups may greatly benefit the larger veteran population.
Acknowledgements
This research was funded by grants from the National Institute on Drug Abuse (NIDA, R01 DA036754) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA, R01 AA020178).
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, any of its agencies, NIDA, NIAAA, or NDRI. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Chen L-H, Hedegaard H, Warner M. QuickStats: rates of deaths from drug poisoning and drug poisoning involving opioid analgesics—United States, 1999-2013. MMWR Morb Mortal Wkly Rep. 2015;64(1):32.
2. Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307(9):940-947.
3. Headquarters, Department of the U.S. Army. Army 2020: Generating Health & Discipline in the Force Ahead of the Strategic Reset. Report 2012. U.S. Army Website. http://usarmy.vo.llnwd.net/e2/c /downloads/235822.pdf. Published January 2012. Accessed May 11, 2015.
4. Bennett AS, Elliott L, Golub A. Opioid and other substance misuse, overdose risk, and the potential for prevention among a sample of OEF/OIF veterans in New York City. Subst Use Misuse. 2013;48(10):894-907.
5. Bohnert AS, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poisoning mortality among patients in the Department of Veterans Affairs Health System. Med Care. 2011;49(4):393-396.
6. Oliva EM. Opioid overdose education and naloxone distribution (OEND): preventing and responding to an opioid overdose. Department of Veterans Affairs Website. http://www.hsrd.research.va.gov/for _researchers/cyber_seminars/archives/video _archive.cfm?SessionID=868. Published September 2, 2014. Accessed May 11, 2015.
7. Toblin RL, Quartana PJ, Riviere LA, Walper KC, Hoge CW. Chronic pain and opioid use in US soldiers after combat deployment. JAMA Intern Med. 2014;174(8):1400-1401.
8. Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces; Board on the Health of Select Populations; Institute of Medicine. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press; 2013.
9. Bray RM, Olmsted KR, Williams J. Misuse of prescription pain medications in US active duty service members. In: Wiederhold BK, ed. Pain Syndromes—From Recruitment to Returning Troops: Wounds of War IV. Amsterdam, Netherlands: IOS Press; 2012:3-16.
10. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care. Am J Public Health. 2010;100(12):2450-2456.
11. Galea S, Ahern J, Tardiff K, et al. Racial/ethnic disparities in overdose mortality trends in New York City, 1990-1998. J Urban Health. 2003;80(2):201-211.
12. Centers for Disease Control and Prevention. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(6):101-105.
13. Tracy M, Piper TM, Ompad D, et al. Circumstances of witnessed drug overdose in New York City: implications for intervention. Drug Alcohol Depend. 2005;79(2):181-190.
14. Strang J, Best D, Man L, Noble A, Gossop M. Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation. Int J Drug Policy. 2000;11(6):437-445.
15. Piper TM, Rudenstine S, Stancliff S, et al. Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City. Harm Reduct J. 2007;4:3.
16. Behar E, Santos GM, Wheeler E, Rowe C, Coffin PO. Brief overdose education is sufficient for naloxone distribution to opioid users. Drug Alcohol Depend. 2015;148:209-212.
17. Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH. Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. J Urban Health. 2011;88(6):1020-1030.
18. Operation OpioidSAFE rescues wounded soldiers from prescription drug addiction [news release]. Fort Bragg, NC: U.S. Army; November 13, 2012.
19. VA Pharmacy Benefits Management Services, Medical Advisory Panel, VISN Pharmacist Executives; VA OEND National Support and Development Work Group. Naloxone kits and naloxone autoinjectors: recommendations for issuing naloxone kits and naloxone autoinjectors for the VA Overdose Education and Naloxone Distribution (OEND) program. http://www .pbm.va.gov/clinicalguidance/clinicalrecommendations/Naloxone_Kits_and_Autoinjector_Recommendations_for_Use_May _2015.pdf. Published May 2015. Accessed May 15, 2015.
20. Goebel JR, Compton P, Zubkoff L, et al. Prescription sharing, alcohol use, and street drug use to manage pain among veterans. J Pain Symptom Manage. 2011;41(5):848-858.
21. Shiner B. Health services use in the Department of Veterans Affairs among returning Iraq War and Afghan War veterans with PTSD. PTSD Res Q. 2011;22(2):1-3.
22. Marlatt GA. Harm reduction: come as you are. Addict Behav. 1996;21(6):779-788.
America has been facing an epidemic of drug overdoses. Prescription opioid (PO) misuse has been a major driver of this phenomenon. According to the CDC, from 1999 to 2013 the drug poisoning death rate more than doubled from 6.1 to 13.8 people per 100,000, and the rate for drug poisoning deaths involving opioid analgesics nearly quadrupled from 1.4 to 5.1 people per 100,000.1
This epidemic has greatly impacted active-duty military personnel and veterans who face especially elevated risks of opioid misuse and overdose.2-4 The army has reported that among active-duty personnel, drug toxicity deaths more than doubled between 2006 and 2011, and overdose rates are greatly elevated among VA patients compared with the civilian population.3,5 A May 2014 VHA report indicated that 440,000 current patients were prescribed opioids, placing them at potential risk, and 55,000 veteran patients were diagnosed as having a current opioid use disorder, placing them at even greater risk.3,6
Military personnel and veterans who experience combat- or service-related injuries are frequently prescribed POs to manage pain.7,8 However, POs can be misused, and routine pain management can easily lead to risky behavior through common practices such as unmonitored dose escalation and the use of POs in combination with other drugs or alcohol. Some service members and veterans engage in unsupervised, nonmedical use of POs for a range of reasons, including self-management of physical pain, anxiety, or sleep disorders.
Veterans’ PO use can take place within the broader context of readjustment to civilian life and its numerous challenges, including unemployment, homelessness, social isolation, cognitive impairment (eg, traumatic brain injury [TBI]), and mental health concerns (eg, depression, posttraumatic stress disorder [PTSD]).2,3,8,9 All of these factors can intensify the negative health consequences associated with PO misuse and can greatly increase the chance for overdose and accidental injury. Accordingly, veterans represent a vulnerable population at disproportionate risk of PO misuse and overdose. As current research is demonstrating, these risks are potentially even higher for women, minority, homeless, and otherwise socially isolated veterans, as well as those with mental health concerns.10,11
Preventing Overdose Death
Overdose events are both preventable and reversible.12 One policy response has been to provide outreach education programs that distribute naloxone (commonly referred to by its trade name, Narcan), an opioid antagonist that can reverse opioid- involved overdose, and train PO users, their family, and friends in its use. In response to the rise of PO misuse and PO-related overdose, VA, DoD, public health departments, drug treatment programs, and community groups have implemented opioid safety and overdose prevention programs targeting prescription drug users, their families, and their peers. Typical programs provide information about preventing opioid misuse, identifying and preventing an overdose, understanding overdose risks (eg, tolerance, mixing drugs, using alone), and responding to an overdose (eg, calling 911, rescue breathing, naloxone administration). The effectiveness of these programs is well established.13-17
The army has been highly responsive to this problem. Following contact with a Wilkes County, North Carolina-based overdose prevention program, army medical personnel at Fort Bragg implemented Operation Opioid SAFE in 2011, which provided overdose prevention training and naloxone to active-duty soldiers at risk for opioid overdose in the course of routine pain management.18 This program represents a forward-looking intervention in keeping with the CDC’s recent call to public agencies to educate laypersons to administer naloxone to those in need.12 This initiative has great potential to reach active-duty soldiers. However, additional outreach programs are needed to reach the veteran population who face similar overdose risks but may not be served by the VA, which is now providing risk reduction information and naloxone through its Overdose Education and Naloxone Distribution Program.6,19
Another approach to preventing opioid overdose has been to restrict access to POs, including a reduction in prescribing POs and the use of prescription drug monitoring programs to combat diversion. These programs are raising awareness and reducing misuse (especially casual misuse) among many populations. However, patients dealing with chronic pain still need medications, and POs work for many of them. Unfortunately, with restricted access to POs, some veterans self-treat pain with diverted POs or even switch to illicit substances, such as heroin.20 Without medical oversight for their opioid use (and the standardized dosage and contraindication information that it involves), these veterans experience an even greater risk of opioid- related overdose.
Assessing the Problem
Despite findings about the clustering of opioid-related risks among particular veteran subpopulations, very little is currently known about how these risks emerge over time and what conditions and events precipitate them. The Institute for Special Populations Research (ISPR) of the National Development and Research Institutes, Inc. (NDRI), is conducting a project to address the emergence of opioid-related risk behaviors over time and to track the changing dimensions of veterans’ reintegration experiences that impact PO and other substance use patterns. This project examines opioid-using veterans’ substance use patterns alongside other physiologic, social, and psychological dimensions of their lives, ranging from PTSD symptoms, depression, and pain severity to social relationships and employment status. The goal is to provide critical biopsychosocial insights into the stressors, turning points, and substance use patterns that precede emergence of overdose risk behaviors and the protective factors that keep some opioid-using veterans safe, despite their struggles with pain and the psychosocial challenges of reintegration.
With this work, ISPR hopes to greatly inform the development of effective programs for preventing opioid misuse and opioid-related overdose among veterans by helping to identify the salient contexts for risky opioid use and gaining a better understanding of how even routine, adherent pain management behaviors sometimes lead to risky situations. This task is suited to both qualitative inquiry and survey research, and to that end, ISPR has conducted in-depth interviews with veterans who have experienced a PO-related overdose to gain a better understanding of proximal and distal antecedents of overdose. These interviews have helped ISPR to develop an Overdose Risk Behavior Scale, which is being administered to 250 veterans to monitor risk trajectories over a period of 2 years.
Preliminary results suggest that veterans are engaging in a variety of risky practices, such as off-label use of POs, mixing prescription opioids with other drugs and/or alcohol, and excessive opioid misuse without other people present. The research is also finding that these risky behaviors are deeply rooted in social factors (eg, unemployment, homelessness, and relationships) and mental health issues. Consistent with other research, we are finding that a large portion of veterans do not utilize or engage VA hospitals for a variety of reasons, including discharge status, confusion about eligibility, and a dissociation from military status, often due to experiences of trauma and/or moral injury.21
The ISPR has also convened focus groups involving homeless and female veterans to better understand the gendered dimensions of substance abuse challenges.4 In collaboration with the New York City Department of Health and Mental Hygiene (NYCDOHMH), ISPR is convening additional focus groups with male and female veterans currently using opioids to gain insights into ways to promote opioid safety and prevent overdose among the veteran population.
Policy and Outreach
Ongoing work indicates that there is a need for additional community-based approaches to reach this high-risk population. In this community and through this work, ISPR is finding that community-based, low-threshold approaches are paramount. For veterans who do not utilize the VA, the foundational principles of risk mitigation, which urge individuals to “come as you are” and service providers to meet clientele “where they are” in low-threshold settings, are essential guidelines for conducting effective outreach.22
In New York City, for example, where the ISPR study is being conducted, the veteran community is served by a diverse network of veterans’ organizations, many of which serve specific veteran subpopulations, including the homeless (eg, Jericho Project), black/African American (eg, Black Vets for Social Justice), female (eg, Service Women’s Action Network), and substance-dependent veterans (eg, Reality House). The study has been working with these groups to develop strategies for overdose reduction. We are fortunate that the NYCDOHMH has been promoting overdose prevention and reversal within the community. They have collaborated with ISPR to support efforts to reach within the veteran population.
Although robust, collaborative community-based projects involving veteran populations have been slow to emerge, the ISPR findings indicate that by collaborating with veterans and supporting them with overdose prevention knowledge and skills, they can be better prepared to participate in peer outreach efforts and in some cases, even become community health providers to other veterans in need. As many veterans have suggested, the “battle-buddy” military model of support could be adapted and widely implemented for veterans. With these veterans and the organizations that support them, ISPR aims to further the overdose prevention and opioid safety prevention efforts and pioneer new prevention and information resources for PO-using veterans, their friends, and family members. This effort is also helping to construct valuable ties with veterans service organizations (VSOs) that will empower them in future outreach to localized veteran subpopulations.
This joint effort will provide the means to develop more creative and time-sensitive interventions that prevent or mitigate risky behaviors before they lead to negative health consequences, including overdose and even untimely death. Helping to understand how veterans conceptualize risk and draw on social and institutional supports will allow for greater refinement in future efforts to educate veterans and assist them in establishing meaningful institutional affiliations and social relationships that may serve as protective factors against opioid-related health risks.
The ongoing dialogue with many veterans and the organizations that serve them has yielded recommendations to help improve their transitions to civilian life. Many veterans suggested the need for a continuum of services and more frequent/robust outreach, such as support and referral programs at every stage of the military/veteran career through VSOs. Many veterans also suggested the need for increased access to a range of treatment options on demand, including traditional 12-step and faith-based programs, medically assisted maintenance and therapy programs (eg, methadone and buprenorphine), as well as complementary and alternative medical approaches (eg, acupuncture).
Veterans have also advocated for the provision of different technological and philosophical approaches to assist them as civilians. For example, some veterans suggested that it is critical to address the stigma associated with seeking treatment and to provide treatment in nonjudgmental settings. Further, many advocated for expansion of short- and long-term maintenance therapies and increasing the availability of risk reduction services, such as the provision of naloxone and other low threshold interventions.
For those veterans who have difficulty giving up POs or other drugs completely due to comorbid conditions (eg, serious chronic pain, depression, PTSD, TBI, and dependence), the need to help reduce the stigma of treatment and the harms associated with drug misuse is great. A further insight we have developed while working with the veteran population is that community-based interagency collaboration can help veterans connect with other veterans and the services they need and to realize the potential for their voices to impact policies designed to assist them. Whether within the VA or elsewhere, primary care and mental health practitioners should urge their patients to take up broader networks of health-positive relationships. Indeed, strengthening partnerships between the VA, local health departments, and community-based groups may greatly benefit the larger veteran population.
Acknowledgements
This research was funded by grants from the National Institute on Drug Abuse (NIDA, R01 DA036754) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA, R01 AA020178).
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, any of its agencies, NIDA, NIAAA, or NDRI. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
America has been facing an epidemic of drug overdoses. Prescription opioid (PO) misuse has been a major driver of this phenomenon. According to the CDC, from 1999 to 2013 the drug poisoning death rate more than doubled from 6.1 to 13.8 people per 100,000, and the rate for drug poisoning deaths involving opioid analgesics nearly quadrupled from 1.4 to 5.1 people per 100,000.1
This epidemic has greatly impacted active-duty military personnel and veterans who face especially elevated risks of opioid misuse and overdose.2-4 The army has reported that among active-duty personnel, drug toxicity deaths more than doubled between 2006 and 2011, and overdose rates are greatly elevated among VA patients compared with the civilian population.3,5 A May 2014 VHA report indicated that 440,000 current patients were prescribed opioids, placing them at potential risk, and 55,000 veteran patients were diagnosed as having a current opioid use disorder, placing them at even greater risk.3,6
Military personnel and veterans who experience combat- or service-related injuries are frequently prescribed POs to manage pain.7,8 However, POs can be misused, and routine pain management can easily lead to risky behavior through common practices such as unmonitored dose escalation and the use of POs in combination with other drugs or alcohol. Some service members and veterans engage in unsupervised, nonmedical use of POs for a range of reasons, including self-management of physical pain, anxiety, or sleep disorders.
Veterans’ PO use can take place within the broader context of readjustment to civilian life and its numerous challenges, including unemployment, homelessness, social isolation, cognitive impairment (eg, traumatic brain injury [TBI]), and mental health concerns (eg, depression, posttraumatic stress disorder [PTSD]).2,3,8,9 All of these factors can intensify the negative health consequences associated with PO misuse and can greatly increase the chance for overdose and accidental injury. Accordingly, veterans represent a vulnerable population at disproportionate risk of PO misuse and overdose. As current research is demonstrating, these risks are potentially even higher for women, minority, homeless, and otherwise socially isolated veterans, as well as those with mental health concerns.10,11
Preventing Overdose Death
Overdose events are both preventable and reversible.12 One policy response has been to provide outreach education programs that distribute naloxone (commonly referred to by its trade name, Narcan), an opioid antagonist that can reverse opioid- involved overdose, and train PO users, their family, and friends in its use. In response to the rise of PO misuse and PO-related overdose, VA, DoD, public health departments, drug treatment programs, and community groups have implemented opioid safety and overdose prevention programs targeting prescription drug users, their families, and their peers. Typical programs provide information about preventing opioid misuse, identifying and preventing an overdose, understanding overdose risks (eg, tolerance, mixing drugs, using alone), and responding to an overdose (eg, calling 911, rescue breathing, naloxone administration). The effectiveness of these programs is well established.13-17
The army has been highly responsive to this problem. Following contact with a Wilkes County, North Carolina-based overdose prevention program, army medical personnel at Fort Bragg implemented Operation Opioid SAFE in 2011, which provided overdose prevention training and naloxone to active-duty soldiers at risk for opioid overdose in the course of routine pain management.18 This program represents a forward-looking intervention in keeping with the CDC’s recent call to public agencies to educate laypersons to administer naloxone to those in need.12 This initiative has great potential to reach active-duty soldiers. However, additional outreach programs are needed to reach the veteran population who face similar overdose risks but may not be served by the VA, which is now providing risk reduction information and naloxone through its Overdose Education and Naloxone Distribution Program.6,19
Another approach to preventing opioid overdose has been to restrict access to POs, including a reduction in prescribing POs and the use of prescription drug monitoring programs to combat diversion. These programs are raising awareness and reducing misuse (especially casual misuse) among many populations. However, patients dealing with chronic pain still need medications, and POs work for many of them. Unfortunately, with restricted access to POs, some veterans self-treat pain with diverted POs or even switch to illicit substances, such as heroin.20 Without medical oversight for their opioid use (and the standardized dosage and contraindication information that it involves), these veterans experience an even greater risk of opioid- related overdose.
Assessing the Problem
Despite findings about the clustering of opioid-related risks among particular veteran subpopulations, very little is currently known about how these risks emerge over time and what conditions and events precipitate them. The Institute for Special Populations Research (ISPR) of the National Development and Research Institutes, Inc. (NDRI), is conducting a project to address the emergence of opioid-related risk behaviors over time and to track the changing dimensions of veterans’ reintegration experiences that impact PO and other substance use patterns. This project examines opioid-using veterans’ substance use patterns alongside other physiologic, social, and psychological dimensions of their lives, ranging from PTSD symptoms, depression, and pain severity to social relationships and employment status. The goal is to provide critical biopsychosocial insights into the stressors, turning points, and substance use patterns that precede emergence of overdose risk behaviors and the protective factors that keep some opioid-using veterans safe, despite their struggles with pain and the psychosocial challenges of reintegration.
With this work, ISPR hopes to greatly inform the development of effective programs for preventing opioid misuse and opioid-related overdose among veterans by helping to identify the salient contexts for risky opioid use and gaining a better understanding of how even routine, adherent pain management behaviors sometimes lead to risky situations. This task is suited to both qualitative inquiry and survey research, and to that end, ISPR has conducted in-depth interviews with veterans who have experienced a PO-related overdose to gain a better understanding of proximal and distal antecedents of overdose. These interviews have helped ISPR to develop an Overdose Risk Behavior Scale, which is being administered to 250 veterans to monitor risk trajectories over a period of 2 years.
Preliminary results suggest that veterans are engaging in a variety of risky practices, such as off-label use of POs, mixing prescription opioids with other drugs and/or alcohol, and excessive opioid misuse without other people present. The research is also finding that these risky behaviors are deeply rooted in social factors (eg, unemployment, homelessness, and relationships) and mental health issues. Consistent with other research, we are finding that a large portion of veterans do not utilize or engage VA hospitals for a variety of reasons, including discharge status, confusion about eligibility, and a dissociation from military status, often due to experiences of trauma and/or moral injury.21
The ISPR has also convened focus groups involving homeless and female veterans to better understand the gendered dimensions of substance abuse challenges.4 In collaboration with the New York City Department of Health and Mental Hygiene (NYCDOHMH), ISPR is convening additional focus groups with male and female veterans currently using opioids to gain insights into ways to promote opioid safety and prevent overdose among the veteran population.
Policy and Outreach
Ongoing work indicates that there is a need for additional community-based approaches to reach this high-risk population. In this community and through this work, ISPR is finding that community-based, low-threshold approaches are paramount. For veterans who do not utilize the VA, the foundational principles of risk mitigation, which urge individuals to “come as you are” and service providers to meet clientele “where they are” in low-threshold settings, are essential guidelines for conducting effective outreach.22
In New York City, for example, where the ISPR study is being conducted, the veteran community is served by a diverse network of veterans’ organizations, many of which serve specific veteran subpopulations, including the homeless (eg, Jericho Project), black/African American (eg, Black Vets for Social Justice), female (eg, Service Women’s Action Network), and substance-dependent veterans (eg, Reality House). The study has been working with these groups to develop strategies for overdose reduction. We are fortunate that the NYCDOHMH has been promoting overdose prevention and reversal within the community. They have collaborated with ISPR to support efforts to reach within the veteran population.
Although robust, collaborative community-based projects involving veteran populations have been slow to emerge, the ISPR findings indicate that by collaborating with veterans and supporting them with overdose prevention knowledge and skills, they can be better prepared to participate in peer outreach efforts and in some cases, even become community health providers to other veterans in need. As many veterans have suggested, the “battle-buddy” military model of support could be adapted and widely implemented for veterans. With these veterans and the organizations that support them, ISPR aims to further the overdose prevention and opioid safety prevention efforts and pioneer new prevention and information resources for PO-using veterans, their friends, and family members. This effort is also helping to construct valuable ties with veterans service organizations (VSOs) that will empower them in future outreach to localized veteran subpopulations.
This joint effort will provide the means to develop more creative and time-sensitive interventions that prevent or mitigate risky behaviors before they lead to negative health consequences, including overdose and even untimely death. Helping to understand how veterans conceptualize risk and draw on social and institutional supports will allow for greater refinement in future efforts to educate veterans and assist them in establishing meaningful institutional affiliations and social relationships that may serve as protective factors against opioid-related health risks.
The ongoing dialogue with many veterans and the organizations that serve them has yielded recommendations to help improve their transitions to civilian life. Many veterans suggested the need for a continuum of services and more frequent/robust outreach, such as support and referral programs at every stage of the military/veteran career through VSOs. Many veterans also suggested the need for increased access to a range of treatment options on demand, including traditional 12-step and faith-based programs, medically assisted maintenance and therapy programs (eg, methadone and buprenorphine), as well as complementary and alternative medical approaches (eg, acupuncture).
Veterans have also advocated for the provision of different technological and philosophical approaches to assist them as civilians. For example, some veterans suggested that it is critical to address the stigma associated with seeking treatment and to provide treatment in nonjudgmental settings. Further, many advocated for expansion of short- and long-term maintenance therapies and increasing the availability of risk reduction services, such as the provision of naloxone and other low threshold interventions.
For those veterans who have difficulty giving up POs or other drugs completely due to comorbid conditions (eg, serious chronic pain, depression, PTSD, TBI, and dependence), the need to help reduce the stigma of treatment and the harms associated with drug misuse is great. A further insight we have developed while working with the veteran population is that community-based interagency collaboration can help veterans connect with other veterans and the services they need and to realize the potential for their voices to impact policies designed to assist them. Whether within the VA or elsewhere, primary care and mental health practitioners should urge their patients to take up broader networks of health-positive relationships. Indeed, strengthening partnerships between the VA, local health departments, and community-based groups may greatly benefit the larger veteran population.
Acknowledgements
This research was funded by grants from the National Institute on Drug Abuse (NIDA, R01 DA036754) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA, R01 AA020178).
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, any of its agencies, NIDA, NIAAA, or NDRI. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Chen L-H, Hedegaard H, Warner M. QuickStats: rates of deaths from drug poisoning and drug poisoning involving opioid analgesics—United States, 1999-2013. MMWR Morb Mortal Wkly Rep. 2015;64(1):32.
2. Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307(9):940-947.
3. Headquarters, Department of the U.S. Army. Army 2020: Generating Health & Discipline in the Force Ahead of the Strategic Reset. Report 2012. U.S. Army Website. http://usarmy.vo.llnwd.net/e2/c /downloads/235822.pdf. Published January 2012. Accessed May 11, 2015.
4. Bennett AS, Elliott L, Golub A. Opioid and other substance misuse, overdose risk, and the potential for prevention among a sample of OEF/OIF veterans in New York City. Subst Use Misuse. 2013;48(10):894-907.
5. Bohnert AS, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poisoning mortality among patients in the Department of Veterans Affairs Health System. Med Care. 2011;49(4):393-396.
6. Oliva EM. Opioid overdose education and naloxone distribution (OEND): preventing and responding to an opioid overdose. Department of Veterans Affairs Website. http://www.hsrd.research.va.gov/for _researchers/cyber_seminars/archives/video _archive.cfm?SessionID=868. Published September 2, 2014. Accessed May 11, 2015.
7. Toblin RL, Quartana PJ, Riviere LA, Walper KC, Hoge CW. Chronic pain and opioid use in US soldiers after combat deployment. JAMA Intern Med. 2014;174(8):1400-1401.
8. Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces; Board on the Health of Select Populations; Institute of Medicine. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press; 2013.
9. Bray RM, Olmsted KR, Williams J. Misuse of prescription pain medications in US active duty service members. In: Wiederhold BK, ed. Pain Syndromes—From Recruitment to Returning Troops: Wounds of War IV. Amsterdam, Netherlands: IOS Press; 2012:3-16.
10. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care. Am J Public Health. 2010;100(12):2450-2456.
11. Galea S, Ahern J, Tardiff K, et al. Racial/ethnic disparities in overdose mortality trends in New York City, 1990-1998. J Urban Health. 2003;80(2):201-211.
12. Centers for Disease Control and Prevention. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(6):101-105.
13. Tracy M, Piper TM, Ompad D, et al. Circumstances of witnessed drug overdose in New York City: implications for intervention. Drug Alcohol Depend. 2005;79(2):181-190.
14. Strang J, Best D, Man L, Noble A, Gossop M. Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation. Int J Drug Policy. 2000;11(6):437-445.
15. Piper TM, Rudenstine S, Stancliff S, et al. Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City. Harm Reduct J. 2007;4:3.
16. Behar E, Santos GM, Wheeler E, Rowe C, Coffin PO. Brief overdose education is sufficient for naloxone distribution to opioid users. Drug Alcohol Depend. 2015;148:209-212.
17. Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH. Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. J Urban Health. 2011;88(6):1020-1030.
18. Operation OpioidSAFE rescues wounded soldiers from prescription drug addiction [news release]. Fort Bragg, NC: U.S. Army; November 13, 2012.
19. VA Pharmacy Benefits Management Services, Medical Advisory Panel, VISN Pharmacist Executives; VA OEND National Support and Development Work Group. Naloxone kits and naloxone autoinjectors: recommendations for issuing naloxone kits and naloxone autoinjectors for the VA Overdose Education and Naloxone Distribution (OEND) program. http://www .pbm.va.gov/clinicalguidance/clinicalrecommendations/Naloxone_Kits_and_Autoinjector_Recommendations_for_Use_May _2015.pdf. Published May 2015. Accessed May 15, 2015.
20. Goebel JR, Compton P, Zubkoff L, et al. Prescription sharing, alcohol use, and street drug use to manage pain among veterans. J Pain Symptom Manage. 2011;41(5):848-858.
21. Shiner B. Health services use in the Department of Veterans Affairs among returning Iraq War and Afghan War veterans with PTSD. PTSD Res Q. 2011;22(2):1-3.
22. Marlatt GA. Harm reduction: come as you are. Addict Behav. 1996;21(6):779-788.
1. Chen L-H, Hedegaard H, Warner M. QuickStats: rates of deaths from drug poisoning and drug poisoning involving opioid analgesics—United States, 1999-2013. MMWR Morb Mortal Wkly Rep. 2015;64(1):32.
2. Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307(9):940-947.
3. Headquarters, Department of the U.S. Army. Army 2020: Generating Health & Discipline in the Force Ahead of the Strategic Reset. Report 2012. U.S. Army Website. http://usarmy.vo.llnwd.net/e2/c /downloads/235822.pdf. Published January 2012. Accessed May 11, 2015.
4. Bennett AS, Elliott L, Golub A. Opioid and other substance misuse, overdose risk, and the potential for prevention among a sample of OEF/OIF veterans in New York City. Subst Use Misuse. 2013;48(10):894-907.
5. Bohnert AS, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poisoning mortality among patients in the Department of Veterans Affairs Health System. Med Care. 2011;49(4):393-396.
6. Oliva EM. Opioid overdose education and naloxone distribution (OEND): preventing and responding to an opioid overdose. Department of Veterans Affairs Website. http://www.hsrd.research.va.gov/for _researchers/cyber_seminars/archives/video _archive.cfm?SessionID=868. Published September 2, 2014. Accessed May 11, 2015.
7. Toblin RL, Quartana PJ, Riviere LA, Walper KC, Hoge CW. Chronic pain and opioid use in US soldiers after combat deployment. JAMA Intern Med. 2014;174(8):1400-1401.
8. Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces; Board on the Health of Select Populations; Institute of Medicine. Substance Use Disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press; 2013.
9. Bray RM, Olmsted KR, Williams J. Misuse of prescription pain medications in US active duty service members. In: Wiederhold BK, ed. Pain Syndromes—From Recruitment to Returning Troops: Wounds of War IV. Amsterdam, Netherlands: IOS Press; 2012:3-16.
10. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care. Am J Public Health. 2010;100(12):2450-2456.
11. Galea S, Ahern J, Tardiff K, et al. Racial/ethnic disparities in overdose mortality trends in New York City, 1990-1998. J Urban Health. 2003;80(2):201-211.
12. Centers for Disease Control and Prevention. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(6):101-105.
13. Tracy M, Piper TM, Ompad D, et al. Circumstances of witnessed drug overdose in New York City: implications for intervention. Drug Alcohol Depend. 2005;79(2):181-190.
14. Strang J, Best D, Man L, Noble A, Gossop M. Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation. Int J Drug Policy. 2000;11(6):437-445.
15. Piper TM, Rudenstine S, Stancliff S, et al. Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City. Harm Reduct J. 2007;4:3.
16. Behar E, Santos GM, Wheeler E, Rowe C, Coffin PO. Brief overdose education is sufficient for naloxone distribution to opioid users. Drug Alcohol Depend. 2015;148:209-212.
17. Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH. Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. J Urban Health. 2011;88(6):1020-1030.
18. Operation OpioidSAFE rescues wounded soldiers from prescription drug addiction [news release]. Fort Bragg, NC: U.S. Army; November 13, 2012.
19. VA Pharmacy Benefits Management Services, Medical Advisory Panel, VISN Pharmacist Executives; VA OEND National Support and Development Work Group. Naloxone kits and naloxone autoinjectors: recommendations for issuing naloxone kits and naloxone autoinjectors for the VA Overdose Education and Naloxone Distribution (OEND) program. http://www .pbm.va.gov/clinicalguidance/clinicalrecommendations/Naloxone_Kits_and_Autoinjector_Recommendations_for_Use_May _2015.pdf. Published May 2015. Accessed May 15, 2015.
20. Goebel JR, Compton P, Zubkoff L, et al. Prescription sharing, alcohol use, and street drug use to manage pain among veterans. J Pain Symptom Manage. 2011;41(5):848-858.
21. Shiner B. Health services use in the Department of Veterans Affairs among returning Iraq War and Afghan War veterans with PTSD. PTSD Res Q. 2011;22(2):1-3.
22. Marlatt GA. Harm reduction: come as you are. Addict Behav. 1996;21(6):779-788.
Antimicrobial Dosing for Empiric and Documented Pseudomonas
Pseudomonas is a genus of aerobic, Gram-negative bacilli consisting of about 200 species. Pseudomonas aeruginosa (P aeruginosa) is the species most commonly associated with serious hospital-acquired infections and is commonly found in moist environments in hospitals, such as sinks, showers, and machinery/equipment. The symptoms of an infection by this bacterium are variable based on the site of infection and can manifest in various sites, such as the respiratory tract, urinary tract, ears, eyes, heart, skin, and soft tissue.1 General risk factors for infection with P aeruginosa include immunosuppression, history of lung disease, hospitalization lasting at least 5 days, history of repeated antibiotic use within 90 days, and a history of pseudomonal colonization/infection.
Related: Antibiotic Therapy and Bacterial Resistance in Patients With Spinal Cord Injury
Pseudomonas aeruginosa is a challenging organism to manage, as it is inherently resistant to many antibiotics. Furthermore, antibiotics effective against infections caused by P aeruginosa often require specific regimens as a result of the high minimum inhibitory concentration (MIC) of the organism. Two specific strategies that have been analyzed for proper coverage of P aeruginosa include the use of higher than usual doses and extended infusions. Due to significant challenges associated with obtaining patient outcomes data in human clinical trials, researchers often use Monte Carlo simulations, which are computational algorithms that simulate the variables of a study (ie, patient demographics) to be as real as possible to accurately predict therapeutic responses in patients.
Analyzing pharmacokinetic (PK) and pharmacodynamic (PD) indexes is valuable for determining therapeutic efficacy, as these indexes consider both the antibiotic dose/concentration and its effect over time in relation to response to therapy. The free-drug area under the concentration time curve (fAUC/MIC) ratio is a PK/PD value commonly used to describe the free-drug concentration over 24 hours that is above the MIC.2 The fAUC is dependent on creatinine clearance (CrCl) and, therefore, is specific to each patient. A threshold value for the fAUC/MIC is determined for an antibiotic, and a therapeutic regimen is dosed accordingly to assure fAUC/MIC attainment above the minimum threshold. The probability of target attainment (PTA), which is the probability that the threshold value of a PD index is achieved at a certain MIC, and the probability of cure (POC) for a given antibiotic regimen are used to determine the efficacy of an antibiotic in Monte Carlo simulations.2
Related: Bacteremia From an Unlikely Source
A study by Zelenitsky and colleagues evaluated the efficacy of 3 ciprofloxacin dosing regimens using Monte Carlo simulations (400 mg IV every 12 hours [standard dose], 400 mg IV every 8 hours [high dose], and a PD-targeted regimen dosed to attain an fAUC/MIC value > 86).3 An fAUC/MIC value of 86 was previously determined to predict cure rates of at least 90%.4 The Clinical and Laboratory Standards Institute defines a P aeruginosa MIC of ≤ 1 μg/mL to be susceptible and an MIC of ≥ 4 μg/mL to be resistant to ciprofloxacin.5
The researchers determined PTA and POC values for each regimen based on various MICs. The in vitro laboratory simulations revealed the PTA and POC values approached 100% for all 3 regimens when the MIC was 0.125 μg/mL. However, when the MIC was 1 μg/mL, the PTA for the standard and high dose was 0%, and the PD-targeted regimen was 40%. The POC was 27%, 40%, and 72% for the standard dose, high dose, and the PD-targeted regimen, respectively. Although the PD-targeted regimen was the most efficacious, it took doses exceeding 1,300 mg and 1,800 mg daily to achieve similar results. In addition, PD-targeted regimens are not practical for dosing due to patient variability in CrCl. From these simulations, it was concluded that the high dose of ciprofloxacin 400 mg IV every 8 hours should be recommended for treating Pseudomonas infections in patients with normal renal function.
Related: Antimicrobial Stewardship in an Outpatient Parenteral Antibiotic Therapy Program
In another study by Lodise and colleagues, researchers examined the clinical implications of an extended-infusion dosing strategy for piperacillin-tazobactam in the critically ill.6 The 2 piperacillin- tazobactam regimens evaluated were 3.375 g IV over 30 minutes given every 4 or 6 hours and 3.375 g IV over 4 hours given every 8 hours. The 14-day mortality rate in critically ill patients who received the extended- and intermittent-infusion regimens was 12.2% and 31.6%, respectively (P = .04). Additionally, patients receiving the extended-infusion regimen had a decreased in-house length of stay compared with the intermittent-infusion group (21 vs 38 days, P = .02). Despite having a lower drug concentration peak, the extended-infusion regimen maintains steady drug concentrations above the MIC for a greater period, resulting in prolonged therapeutic efficacy. Other antibiotics (cefepime7 and ceftazidime8) have been studied by using the same methodology of comparing intermittent and extended infusions and have had similar results.
Given the management challenges associated with P aeruginosa infections, it is important for clinicians to recognize patients who may have or be at risk of infection with P aeruginosa and use appropriate dosing regimens to effectively manage infections and improve patient outcomes.
Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Murray PR, Pfaller MA, Rosenthal KS. Medical Microbiology. 7th ed. Philadelphia, PA: Elsevier; 2012.
2. Mouton JW, Dudley MN, Cars O, Derendorf H, Drusano GL. Standardization of pharmacokinetic/pharmacodynamic (PK/PD) terminology for anti-infective drugs: an update. J Antimicrob Chemother. 2005;55(5):601-607.
3. Zelenitsky S, Ariano R, Harding G, Forrest A. Evaluating ciprofloxacin dosing for Pseudomonas aeruginosa infection by using clinical outcome-based Monte Carlo simulations. Antimicrob Agents Chemother. 2005;49(10):4009-4014.
4. Zelenitsky SA, Harding GK, Sun S, Ubhi K, Ariano RE. Treatment and outcome of Pseudomonas aeruginosa bacteraemia: an antibiotic pharmacodynamic analysis. J Antimicrob Chemother. 2003;52(4):668-674.
5. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Third Informational Supplement. CLSI document M100-S23. Wayne, PA: Clinical and Laboratory Standards Institute; 2013:63.
6. Lodise TP Jr, Lomaestro B, Drusano GL. Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy. Clin Infect Dis. 2007;44(3):357-363.
7. Mouton JW, Den Hollander JG. Killing of Pseudomonas aeruginosa during continuous and intermittent infusion of ceftazidime in an in vitro pharmacokinetic model. Antimicrob Agents Chemother. 1994;38(5):931-936
8. Bauer KA, West JE, O’Brien JM, Goff DA. Extended-infusion cefepime reduces mortality in patients with Pseudomonas aeruginosa infections. Antimicrob Agents Chemother. 2013;57(7):2907-2912.
Pseudomonas is a genus of aerobic, Gram-negative bacilli consisting of about 200 species. Pseudomonas aeruginosa (P aeruginosa) is the species most commonly associated with serious hospital-acquired infections and is commonly found in moist environments in hospitals, such as sinks, showers, and machinery/equipment. The symptoms of an infection by this bacterium are variable based on the site of infection and can manifest in various sites, such as the respiratory tract, urinary tract, ears, eyes, heart, skin, and soft tissue.1 General risk factors for infection with P aeruginosa include immunosuppression, history of lung disease, hospitalization lasting at least 5 days, history of repeated antibiotic use within 90 days, and a history of pseudomonal colonization/infection.
Related: Antibiotic Therapy and Bacterial Resistance in Patients With Spinal Cord Injury
Pseudomonas aeruginosa is a challenging organism to manage, as it is inherently resistant to many antibiotics. Furthermore, antibiotics effective against infections caused by P aeruginosa often require specific regimens as a result of the high minimum inhibitory concentration (MIC) of the organism. Two specific strategies that have been analyzed for proper coverage of P aeruginosa include the use of higher than usual doses and extended infusions. Due to significant challenges associated with obtaining patient outcomes data in human clinical trials, researchers often use Monte Carlo simulations, which are computational algorithms that simulate the variables of a study (ie, patient demographics) to be as real as possible to accurately predict therapeutic responses in patients.
Analyzing pharmacokinetic (PK) and pharmacodynamic (PD) indexes is valuable for determining therapeutic efficacy, as these indexes consider both the antibiotic dose/concentration and its effect over time in relation to response to therapy. The free-drug area under the concentration time curve (fAUC/MIC) ratio is a PK/PD value commonly used to describe the free-drug concentration over 24 hours that is above the MIC.2 The fAUC is dependent on creatinine clearance (CrCl) and, therefore, is specific to each patient. A threshold value for the fAUC/MIC is determined for an antibiotic, and a therapeutic regimen is dosed accordingly to assure fAUC/MIC attainment above the minimum threshold. The probability of target attainment (PTA), which is the probability that the threshold value of a PD index is achieved at a certain MIC, and the probability of cure (POC) for a given antibiotic regimen are used to determine the efficacy of an antibiotic in Monte Carlo simulations.2
Related: Bacteremia From an Unlikely Source
A study by Zelenitsky and colleagues evaluated the efficacy of 3 ciprofloxacin dosing regimens using Monte Carlo simulations (400 mg IV every 12 hours [standard dose], 400 mg IV every 8 hours [high dose], and a PD-targeted regimen dosed to attain an fAUC/MIC value > 86).3 An fAUC/MIC value of 86 was previously determined to predict cure rates of at least 90%.4 The Clinical and Laboratory Standards Institute defines a P aeruginosa MIC of ≤ 1 μg/mL to be susceptible and an MIC of ≥ 4 μg/mL to be resistant to ciprofloxacin.5
The researchers determined PTA and POC values for each regimen based on various MICs. The in vitro laboratory simulations revealed the PTA and POC values approached 100% for all 3 regimens when the MIC was 0.125 μg/mL. However, when the MIC was 1 μg/mL, the PTA for the standard and high dose was 0%, and the PD-targeted regimen was 40%. The POC was 27%, 40%, and 72% for the standard dose, high dose, and the PD-targeted regimen, respectively. Although the PD-targeted regimen was the most efficacious, it took doses exceeding 1,300 mg and 1,800 mg daily to achieve similar results. In addition, PD-targeted regimens are not practical for dosing due to patient variability in CrCl. From these simulations, it was concluded that the high dose of ciprofloxacin 400 mg IV every 8 hours should be recommended for treating Pseudomonas infections in patients with normal renal function.
Related: Antimicrobial Stewardship in an Outpatient Parenteral Antibiotic Therapy Program
In another study by Lodise and colleagues, researchers examined the clinical implications of an extended-infusion dosing strategy for piperacillin-tazobactam in the critically ill.6 The 2 piperacillin- tazobactam regimens evaluated were 3.375 g IV over 30 minutes given every 4 or 6 hours and 3.375 g IV over 4 hours given every 8 hours. The 14-day mortality rate in critically ill patients who received the extended- and intermittent-infusion regimens was 12.2% and 31.6%, respectively (P = .04). Additionally, patients receiving the extended-infusion regimen had a decreased in-house length of stay compared with the intermittent-infusion group (21 vs 38 days, P = .02). Despite having a lower drug concentration peak, the extended-infusion regimen maintains steady drug concentrations above the MIC for a greater period, resulting in prolonged therapeutic efficacy. Other antibiotics (cefepime7 and ceftazidime8) have been studied by using the same methodology of comparing intermittent and extended infusions and have had similar results.
Given the management challenges associated with P aeruginosa infections, it is important for clinicians to recognize patients who may have or be at risk of infection with P aeruginosa and use appropriate dosing regimens to effectively manage infections and improve patient outcomes.
Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Pseudomonas is a genus of aerobic, Gram-negative bacilli consisting of about 200 species. Pseudomonas aeruginosa (P aeruginosa) is the species most commonly associated with serious hospital-acquired infections and is commonly found in moist environments in hospitals, such as sinks, showers, and machinery/equipment. The symptoms of an infection by this bacterium are variable based on the site of infection and can manifest in various sites, such as the respiratory tract, urinary tract, ears, eyes, heart, skin, and soft tissue.1 General risk factors for infection with P aeruginosa include immunosuppression, history of lung disease, hospitalization lasting at least 5 days, history of repeated antibiotic use within 90 days, and a history of pseudomonal colonization/infection.
Related: Antibiotic Therapy and Bacterial Resistance in Patients With Spinal Cord Injury
Pseudomonas aeruginosa is a challenging organism to manage, as it is inherently resistant to many antibiotics. Furthermore, antibiotics effective against infections caused by P aeruginosa often require specific regimens as a result of the high minimum inhibitory concentration (MIC) of the organism. Two specific strategies that have been analyzed for proper coverage of P aeruginosa include the use of higher than usual doses and extended infusions. Due to significant challenges associated with obtaining patient outcomes data in human clinical trials, researchers often use Monte Carlo simulations, which are computational algorithms that simulate the variables of a study (ie, patient demographics) to be as real as possible to accurately predict therapeutic responses in patients.
Analyzing pharmacokinetic (PK) and pharmacodynamic (PD) indexes is valuable for determining therapeutic efficacy, as these indexes consider both the antibiotic dose/concentration and its effect over time in relation to response to therapy. The free-drug area under the concentration time curve (fAUC/MIC) ratio is a PK/PD value commonly used to describe the free-drug concentration over 24 hours that is above the MIC.2 The fAUC is dependent on creatinine clearance (CrCl) and, therefore, is specific to each patient. A threshold value for the fAUC/MIC is determined for an antibiotic, and a therapeutic regimen is dosed accordingly to assure fAUC/MIC attainment above the minimum threshold. The probability of target attainment (PTA), which is the probability that the threshold value of a PD index is achieved at a certain MIC, and the probability of cure (POC) for a given antibiotic regimen are used to determine the efficacy of an antibiotic in Monte Carlo simulations.2
Related: Bacteremia From an Unlikely Source
A study by Zelenitsky and colleagues evaluated the efficacy of 3 ciprofloxacin dosing regimens using Monte Carlo simulations (400 mg IV every 12 hours [standard dose], 400 mg IV every 8 hours [high dose], and a PD-targeted regimen dosed to attain an fAUC/MIC value > 86).3 An fAUC/MIC value of 86 was previously determined to predict cure rates of at least 90%.4 The Clinical and Laboratory Standards Institute defines a P aeruginosa MIC of ≤ 1 μg/mL to be susceptible and an MIC of ≥ 4 μg/mL to be resistant to ciprofloxacin.5
The researchers determined PTA and POC values for each regimen based on various MICs. The in vitro laboratory simulations revealed the PTA and POC values approached 100% for all 3 regimens when the MIC was 0.125 μg/mL. However, when the MIC was 1 μg/mL, the PTA for the standard and high dose was 0%, and the PD-targeted regimen was 40%. The POC was 27%, 40%, and 72% for the standard dose, high dose, and the PD-targeted regimen, respectively. Although the PD-targeted regimen was the most efficacious, it took doses exceeding 1,300 mg and 1,800 mg daily to achieve similar results. In addition, PD-targeted regimens are not practical for dosing due to patient variability in CrCl. From these simulations, it was concluded that the high dose of ciprofloxacin 400 mg IV every 8 hours should be recommended for treating Pseudomonas infections in patients with normal renal function.
Related: Antimicrobial Stewardship in an Outpatient Parenteral Antibiotic Therapy Program
In another study by Lodise and colleagues, researchers examined the clinical implications of an extended-infusion dosing strategy for piperacillin-tazobactam in the critically ill.6 The 2 piperacillin- tazobactam regimens evaluated were 3.375 g IV over 30 minutes given every 4 or 6 hours and 3.375 g IV over 4 hours given every 8 hours. The 14-day mortality rate in critically ill patients who received the extended- and intermittent-infusion regimens was 12.2% and 31.6%, respectively (P = .04). Additionally, patients receiving the extended-infusion regimen had a decreased in-house length of stay compared with the intermittent-infusion group (21 vs 38 days, P = .02). Despite having a lower drug concentration peak, the extended-infusion regimen maintains steady drug concentrations above the MIC for a greater period, resulting in prolonged therapeutic efficacy. Other antibiotics (cefepime7 and ceftazidime8) have been studied by using the same methodology of comparing intermittent and extended infusions and have had similar results.
Given the management challenges associated with P aeruginosa infections, it is important for clinicians to recognize patients who may have or be at risk of infection with P aeruginosa and use appropriate dosing regimens to effectively manage infections and improve patient outcomes.
Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Murray PR, Pfaller MA, Rosenthal KS. Medical Microbiology. 7th ed. Philadelphia, PA: Elsevier; 2012.
2. Mouton JW, Dudley MN, Cars O, Derendorf H, Drusano GL. Standardization of pharmacokinetic/pharmacodynamic (PK/PD) terminology for anti-infective drugs: an update. J Antimicrob Chemother. 2005;55(5):601-607.
3. Zelenitsky S, Ariano R, Harding G, Forrest A. Evaluating ciprofloxacin dosing for Pseudomonas aeruginosa infection by using clinical outcome-based Monte Carlo simulations. Antimicrob Agents Chemother. 2005;49(10):4009-4014.
4. Zelenitsky SA, Harding GK, Sun S, Ubhi K, Ariano RE. Treatment and outcome of Pseudomonas aeruginosa bacteraemia: an antibiotic pharmacodynamic analysis. J Antimicrob Chemother. 2003;52(4):668-674.
5. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Third Informational Supplement. CLSI document M100-S23. Wayne, PA: Clinical and Laboratory Standards Institute; 2013:63.
6. Lodise TP Jr, Lomaestro B, Drusano GL. Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy. Clin Infect Dis. 2007;44(3):357-363.
7. Mouton JW, Den Hollander JG. Killing of Pseudomonas aeruginosa during continuous and intermittent infusion of ceftazidime in an in vitro pharmacokinetic model. Antimicrob Agents Chemother. 1994;38(5):931-936
8. Bauer KA, West JE, O’Brien JM, Goff DA. Extended-infusion cefepime reduces mortality in patients with Pseudomonas aeruginosa infections. Antimicrob Agents Chemother. 2013;57(7):2907-2912.
1. Murray PR, Pfaller MA, Rosenthal KS. Medical Microbiology. 7th ed. Philadelphia, PA: Elsevier; 2012.
2. Mouton JW, Dudley MN, Cars O, Derendorf H, Drusano GL. Standardization of pharmacokinetic/pharmacodynamic (PK/PD) terminology for anti-infective drugs: an update. J Antimicrob Chemother. 2005;55(5):601-607.
3. Zelenitsky S, Ariano R, Harding G, Forrest A. Evaluating ciprofloxacin dosing for Pseudomonas aeruginosa infection by using clinical outcome-based Monte Carlo simulations. Antimicrob Agents Chemother. 2005;49(10):4009-4014.
4. Zelenitsky SA, Harding GK, Sun S, Ubhi K, Ariano RE. Treatment and outcome of Pseudomonas aeruginosa bacteraemia: an antibiotic pharmacodynamic analysis. J Antimicrob Chemother. 2003;52(4):668-674.
5. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Third Informational Supplement. CLSI document M100-S23. Wayne, PA: Clinical and Laboratory Standards Institute; 2013:63.
6. Lodise TP Jr, Lomaestro B, Drusano GL. Piperacillin-tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended-infusion dosing strategy. Clin Infect Dis. 2007;44(3):357-363.
7. Mouton JW, Den Hollander JG. Killing of Pseudomonas aeruginosa during continuous and intermittent infusion of ceftazidime in an in vitro pharmacokinetic model. Antimicrob Agents Chemother. 1994;38(5):931-936
8. Bauer KA, West JE, O’Brien JM, Goff DA. Extended-infusion cefepime reduces mortality in patients with Pseudomonas aeruginosa infections. Antimicrob Agents Chemother. 2013;57(7):2907-2912.
Opportunities and limits in universal screening for perinatal depression
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice recently published a revised opinion on screening for perinatal depression, recommending that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” The statement adds that “women with current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders warrant particularly close monitoring, evaluation, and assessment.” A list of validated depression screening tools is included (Obstet. Gynecol. 2015;125:1268-71). In previous iterations, the committee had not recommended formal screening for perinatal depression (referred to as major or minor depressive episodes occurring during pregnancy or during the first 12 months after delivery) and left the utility of screening as an open question to the field.
Noting that screening alone cannot improve clinical outcomes, the ACOG opinion says that it “must be coupled with appropriate follow-up and treatment when indicated,” and – most critically – adds that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” The latter recommendation is followed by the statement that “systems should be in place to ensure follow-up for diagnosis and treatment.”
Many states have initiated programs for screening for perinatal depression, which is intuitive given the prevalence of mood and anxiety disorders in women of reproductive age. Unfortunately, to date, there are no data indicating whether screening results in improved outcomes, or what type of treatment women receive as a result of screening; the ACOG opinion notes that definitive evidence on the benefit of screening is “limited.”
In prevalence studies, maternal morbidity associated with untreated perinatal mood and anxiety disorders clearly exceeds the morbidity associated with hemorrhage and pregnancy-induced hypertension, with significant effects on families and children as well. Therefore, even in the absence of an evidence base, there is support for routine screening and for ob.gyns. to initiate treatment and to facilitate referrals to appropriate settings.
In Massachusetts, where I practice, screening is not mandatory but is becoming increasingly popular, and resources to manage those with positive screening results are being developed.
The MCPAP (Massachusetts Child Psychiatry Access Project) for Moms was established to enhance screening for perinatal depression and to provide screening and educational tools, as well as free telephone backup, consultation, and referral service for ob.gyn. practices. MCPAP for Moms is coupled with an extensive community-based perinatal mood and anxiety service network: mental health providers, including social workers; specialized nurses with expertise in perinatal mental health; and support groups for women suffering from perinatal mood and anxiety disorders. The program is new and has promise, although evidence supporting its effectiveness is not yet available.
Some argue that screening and treatment of perinatal depression by nonpsychiatric providers opens up a “Pandora’s box.” But should the box be opened nonetheless?
Obvious problems might include many women with positive screening results not being referred for appropriate treatment or, if referred, receiving incomplete treatment – all very valid concerns. But one could also argue that with a highly prevalent illness that presents during a discrete period of time, the opportunity to screen in the obstetric setting (or in the pediatric setting, a separate topic) is an opportunity to at least help mitigate some of the suffering associated with perinatal depression.
The clinician in the community who will screen these women will need to manage the substantial responsibility of initiating treatment for patients with perinatal depression or referring them for management. The main question following diagnosis of perinatal depression is really not necessarily how “best” to treat a patient with perinatal depression. An evidence base exists supporting efficacy for treatments, including medication and certain psychotherapies. Perhaps the greatest pitfall inherent in an opinion like the one from ACOG relates to the incomplete infrastructure and associated resources in many parts of the country – and in our health care system – needed to accommodate and effectively manage the increasing number of women who will be diagnosed with perinatal mood and anxiety disorders as a consequence of more widespread screening.
Whether community-based ob.gyns. will be comfortable with direct treatment of perinatal psychiatric illness or the extent to which they view this as part of their clinical responsibility remains to be seen. It is possible that they will follow suit, just as primary care physicians became increasingly comfortable prescribing antidepressants in the early 1990s as easy and safe antidepressant treatments became available, particularly for patients with relatively straightforward major depression.
This committee opinion is an incremental advance, compared with previous opinions, and most critically, puts the conversation back on the national scene at an important time, as population health management is becoming an increasingly proximate reality.
The opinion leaves many unanswered questions regarding implementation on a national level, which may be beyond the scope of the committee’s task. But the recommendations, if carried out, will increase the likelihood of mitigating at least some of the substantial suffering associated with a highly prevalent illness.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, e-mail him at [email protected].
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice recently published a revised opinion on screening for perinatal depression, recommending that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” The statement adds that “women with current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders warrant particularly close monitoring, evaluation, and assessment.” A list of validated depression screening tools is included (Obstet. Gynecol. 2015;125:1268-71). In previous iterations, the committee had not recommended formal screening for perinatal depression (referred to as major or minor depressive episodes occurring during pregnancy or during the first 12 months after delivery) and left the utility of screening as an open question to the field.
Noting that screening alone cannot improve clinical outcomes, the ACOG opinion says that it “must be coupled with appropriate follow-up and treatment when indicated,” and – most critically – adds that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” The latter recommendation is followed by the statement that “systems should be in place to ensure follow-up for diagnosis and treatment.”
Many states have initiated programs for screening for perinatal depression, which is intuitive given the prevalence of mood and anxiety disorders in women of reproductive age. Unfortunately, to date, there are no data indicating whether screening results in improved outcomes, or what type of treatment women receive as a result of screening; the ACOG opinion notes that definitive evidence on the benefit of screening is “limited.”
In prevalence studies, maternal morbidity associated with untreated perinatal mood and anxiety disorders clearly exceeds the morbidity associated with hemorrhage and pregnancy-induced hypertension, with significant effects on families and children as well. Therefore, even in the absence of an evidence base, there is support for routine screening and for ob.gyns. to initiate treatment and to facilitate referrals to appropriate settings.
In Massachusetts, where I practice, screening is not mandatory but is becoming increasingly popular, and resources to manage those with positive screening results are being developed.
The MCPAP (Massachusetts Child Psychiatry Access Project) for Moms was established to enhance screening for perinatal depression and to provide screening and educational tools, as well as free telephone backup, consultation, and referral service for ob.gyn. practices. MCPAP for Moms is coupled with an extensive community-based perinatal mood and anxiety service network: mental health providers, including social workers; specialized nurses with expertise in perinatal mental health; and support groups for women suffering from perinatal mood and anxiety disorders. The program is new and has promise, although evidence supporting its effectiveness is not yet available.
Some argue that screening and treatment of perinatal depression by nonpsychiatric providers opens up a “Pandora’s box.” But should the box be opened nonetheless?
Obvious problems might include many women with positive screening results not being referred for appropriate treatment or, if referred, receiving incomplete treatment – all very valid concerns. But one could also argue that with a highly prevalent illness that presents during a discrete period of time, the opportunity to screen in the obstetric setting (or in the pediatric setting, a separate topic) is an opportunity to at least help mitigate some of the suffering associated with perinatal depression.
The clinician in the community who will screen these women will need to manage the substantial responsibility of initiating treatment for patients with perinatal depression or referring them for management. The main question following diagnosis of perinatal depression is really not necessarily how “best” to treat a patient with perinatal depression. An evidence base exists supporting efficacy for treatments, including medication and certain psychotherapies. Perhaps the greatest pitfall inherent in an opinion like the one from ACOG relates to the incomplete infrastructure and associated resources in many parts of the country – and in our health care system – needed to accommodate and effectively manage the increasing number of women who will be diagnosed with perinatal mood and anxiety disorders as a consequence of more widespread screening.
Whether community-based ob.gyns. will be comfortable with direct treatment of perinatal psychiatric illness or the extent to which they view this as part of their clinical responsibility remains to be seen. It is possible that they will follow suit, just as primary care physicians became increasingly comfortable prescribing antidepressants in the early 1990s as easy and safe antidepressant treatments became available, particularly for patients with relatively straightforward major depression.
This committee opinion is an incremental advance, compared with previous opinions, and most critically, puts the conversation back on the national scene at an important time, as population health management is becoming an increasingly proximate reality.
The opinion leaves many unanswered questions regarding implementation on a national level, which may be beyond the scope of the committee’s task. But the recommendations, if carried out, will increase the likelihood of mitigating at least some of the substantial suffering associated with a highly prevalent illness.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, e-mail him at [email protected].
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice recently published a revised opinion on screening for perinatal depression, recommending that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” The statement adds that “women with current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders warrant particularly close monitoring, evaluation, and assessment.” A list of validated depression screening tools is included (Obstet. Gynecol. 2015;125:1268-71). In previous iterations, the committee had not recommended formal screening for perinatal depression (referred to as major or minor depressive episodes occurring during pregnancy or during the first 12 months after delivery) and left the utility of screening as an open question to the field.
Noting that screening alone cannot improve clinical outcomes, the ACOG opinion says that it “must be coupled with appropriate follow-up and treatment when indicated,” and – most critically – adds that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” The latter recommendation is followed by the statement that “systems should be in place to ensure follow-up for diagnosis and treatment.”
Many states have initiated programs for screening for perinatal depression, which is intuitive given the prevalence of mood and anxiety disorders in women of reproductive age. Unfortunately, to date, there are no data indicating whether screening results in improved outcomes, or what type of treatment women receive as a result of screening; the ACOG opinion notes that definitive evidence on the benefit of screening is “limited.”
In prevalence studies, maternal morbidity associated with untreated perinatal mood and anxiety disorders clearly exceeds the morbidity associated with hemorrhage and pregnancy-induced hypertension, with significant effects on families and children as well. Therefore, even in the absence of an evidence base, there is support for routine screening and for ob.gyns. to initiate treatment and to facilitate referrals to appropriate settings.
In Massachusetts, where I practice, screening is not mandatory but is becoming increasingly popular, and resources to manage those with positive screening results are being developed.
The MCPAP (Massachusetts Child Psychiatry Access Project) for Moms was established to enhance screening for perinatal depression and to provide screening and educational tools, as well as free telephone backup, consultation, and referral service for ob.gyn. practices. MCPAP for Moms is coupled with an extensive community-based perinatal mood and anxiety service network: mental health providers, including social workers; specialized nurses with expertise in perinatal mental health; and support groups for women suffering from perinatal mood and anxiety disorders. The program is new and has promise, although evidence supporting its effectiveness is not yet available.
Some argue that screening and treatment of perinatal depression by nonpsychiatric providers opens up a “Pandora’s box.” But should the box be opened nonetheless?
Obvious problems might include many women with positive screening results not being referred for appropriate treatment or, if referred, receiving incomplete treatment – all very valid concerns. But one could also argue that with a highly prevalent illness that presents during a discrete period of time, the opportunity to screen in the obstetric setting (or in the pediatric setting, a separate topic) is an opportunity to at least help mitigate some of the suffering associated with perinatal depression.
The clinician in the community who will screen these women will need to manage the substantial responsibility of initiating treatment for patients with perinatal depression or referring them for management. The main question following diagnosis of perinatal depression is really not necessarily how “best” to treat a patient with perinatal depression. An evidence base exists supporting efficacy for treatments, including medication and certain psychotherapies. Perhaps the greatest pitfall inherent in an opinion like the one from ACOG relates to the incomplete infrastructure and associated resources in many parts of the country – and in our health care system – needed to accommodate and effectively manage the increasing number of women who will be diagnosed with perinatal mood and anxiety disorders as a consequence of more widespread screening.
Whether community-based ob.gyns. will be comfortable with direct treatment of perinatal psychiatric illness or the extent to which they view this as part of their clinical responsibility remains to be seen. It is possible that they will follow suit, just as primary care physicians became increasingly comfortable prescribing antidepressants in the early 1990s as easy and safe antidepressant treatments became available, particularly for patients with relatively straightforward major depression.
This committee opinion is an incremental advance, compared with previous opinions, and most critically, puts the conversation back on the national scene at an important time, as population health management is becoming an increasingly proximate reality.
The opinion leaves many unanswered questions regarding implementation on a national level, which may be beyond the scope of the committee’s task. But the recommendations, if carried out, will increase the likelihood of mitigating at least some of the substantial suffering associated with a highly prevalent illness.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, e-mail him at [email protected].
Addressing unmet contraception needs in patients with cancer
Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.
Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).
In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).
Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).
Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.
Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.
Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.
As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.
Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.
Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.
Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).
In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).
Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).
Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.
Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.
Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.
As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.
Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.
Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.
Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).
In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).
Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).
Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.
Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.
Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.
As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.
Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.
Steroids for sciatica
The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.
I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.
In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.
Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.
So, how well do they work?
Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.
The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.
Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.
The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.
Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no disclosures about this article.
The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.
I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.
In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.
Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.
So, how well do they work?
Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.
The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.
Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.
The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.
Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no disclosures about this article.
The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.
I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.
In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.
Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.
So, how well do they work?
Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.
The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.
Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.
The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.
Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no disclosures about this article.
Identifying melasma triggers
Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.
Ask about exposure to:
1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.
2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).
3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.
4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).
5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.
• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.
• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.
• Triggers of melanocyte-stimulating hormone.
The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.
Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.
Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.
Ask about exposure to:
1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.
2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).
3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.
4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).
5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.
• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.
• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.
• Triggers of melanocyte-stimulating hormone.
The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.
Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.
Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.
Ask about exposure to:
1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.
2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).
3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.
4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).
5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.
• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.
• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.
• Triggers of melanocyte-stimulating hormone.
The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.
Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.
Editorial: Relevance of the ABS MOC Program
The American Board of Surgery (ABS) was founded in 1937 by the leading surgical organizations of the time in recognition of the need to differentiate formally trained surgeons from other doctors who were performing operations without formal training.
At its onset, the ABS acknowledged that it had a dual purpose: to protect the public and improve the specialty of surgery. Eligibility criteria for certification were defined – graduation from an approved medical school, the requisite duration of surgical training, a list of operations performed, high ethical standards – and passing an examination became a differentiating requirement.
Over the nearly eight decades since its founding, the ABS has retained its position as the premier certifying body for surgeons in the United States. Its mission statement, “to serve the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice,” embodies the elements of the Maintenance of Certification (MOC) Program. Setting standards for board certification is a privilege of self-regulation that has been granted to our profession by the American public. In return, we must demonstrate our commitment to serve the best interests of the public through our processes and requirements.
ABS certification is based upon education, evaluation, and assessment. Appropriate undergraduate medical education, accredited surgical training, broad operative experience, and high ethical standing continue as essential requirements of ABS certification. For the first four decades of its existence, once ABS certification was achieved, it was valid for a surgeon’s entire professional career. This changed as the ABS Directors recognized the rapid evolution of surgical practice and believed it was necessary for diplomates to demonstrate that they were up to date with advances in medical knowledge and patient care. In 1976, the ABS adopted time-limited certification and required its diplomates to “recertify” by passing an examination every 10 years. In 2000, a requirement for its diplomates to complete 100 hours of continuing medical education (CME) credits in the 2 years prior to applying for the recertification exam (60 in Category I and 40 in Category II) was implemented. This requirement has been modified since; however, the basic rationale for its adoption remains relevant.
In 2005, the American Board of Medical Specialties (ABMS), which establishes standards for its 24 member boards, introduced MOC and proposed standards based on the six competencies jointly developed by the Accreditation Council on Graduate Medical Education and the ABMS. These competencies – patient care, medical knowledge, professionalism, interpersonal communication skills, practice-based learning and improvement, and systems-based practice – were the basis for the four parts of MOC: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. The development of MOC was further recognition that board certification needed to become a more continuous process as the pace of change in medicine had accelerated beyond any seen previously.
Boards and their diplomates have the responsibility to demonstrate to the public and their peers an enduring commitment to maintain standards for the profession, participate in lifelong education, possess medical knowledge relevant to the specialty, and improve their performance in practice. All surgeons certified or recertified beginning July 2005 have been enrolled in ABS MOC. A decade later, 95% of ABS diplomates with time-limited certificates are enrolled in the ABS MOC program and more than 90% are actively participating.
Although the ABMS established general requirements for MOC that its member boards must meet, each board is allowed to develop its own requirements. The foundations of the ABS MOC program were established before the term “maintenance of certification” was used. Professional standards have been a requirement for ABS certification since its beginning and exam requirements have been in place for more than a generation. All diplomates must fulfill the professional standing requirements to have a valid unrestricted state medical license, have hospital or ambulatory surgery center privileges if clinically active, and have references from the chief of surgery and the chair of the credentials committee where they practice.
The ABS MOC program is meant to be practice relevant. This allows surgeons to satisfy the requirements by completing CME that they choose and by participating in performance assessment activities in a way that best applies to their practices. The requirement that two-thirds of the CME hours earned be self-assessment demonstrates a greater level of engagement of the learner and shows that knowledge acquisition is achieved at the conclusion of the activity. The addition of a practice performance improvement activity requirement has generated the most controversy and misunderstanding. To meet this requirement, diplomates are asked to assess some aspect of their practice and seek to improve that. This can be done in conjunction with a hospital through participation in a national, regional, or state registry that tracks patient outcomes, or by participating in a hospital-based quality improvement activity. Some diplomates have developed performance improvement activities within their offices by focusing on a specific area for evaluation, defining measures and goals for improvement, analyzing results and making changes when appropriate, and then reassessing to develop an action plan for improvement.
Regardless of what you choose, the ABS asks only that you attest to your participation and does not collect, review, or otherwise scrutinize your results.
The ABS MOC program extends over a 10-year period. Requirements for the first 9 years are organized in identical 3-year reporting cycles running from Jan. 1 to Dec. 31. By the end of each 3-year cycle, diplomates are required to submit information on how they are meeting MOC requirements through an individualized secure login on the ABS website (www.absurgery.org). Successful completion of an MOC exam continues to be required every 10 years; however the exam may be taken in years 8 and 9 of the 10-year cycle.
ABS MOC is a surgeon-defined, national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC program demonstrates your commitment to remain current in your area of practice and to strive to improve what you do.
Since its beginning, the ABS has exercised its duty to develop, promote, and refine standards for certification in surgery. Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The ABS Board of Directors is focused on how ABS MOC can be an even more meaningful process for surgeons without increasing the already substantial administrative burden everyone faces. We are following the progress of innovative programs being piloted by other boards and organizations involved in quality improvement. The ABS recognizes that MOC requirements established or changed will affect roughly 30,000 surgeons who practice in a wide variety of environments. We encourage our diplomates to provide ideas to improve the program as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public.
For more information, please see the MOC Requirements page on the ABS website.
Dr. Malangoni is Associate Executive Director, American Board of Surgery, Philadelphia. Dr. Lewis is Executive Director, American Board of Surgery, Philadelphia.
The American Board of Surgery (ABS) was founded in 1937 by the leading surgical organizations of the time in recognition of the need to differentiate formally trained surgeons from other doctors who were performing operations without formal training.
At its onset, the ABS acknowledged that it had a dual purpose: to protect the public and improve the specialty of surgery. Eligibility criteria for certification were defined – graduation from an approved medical school, the requisite duration of surgical training, a list of operations performed, high ethical standards – and passing an examination became a differentiating requirement.
Over the nearly eight decades since its founding, the ABS has retained its position as the premier certifying body for surgeons in the United States. Its mission statement, “to serve the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice,” embodies the elements of the Maintenance of Certification (MOC) Program. Setting standards for board certification is a privilege of self-regulation that has been granted to our profession by the American public. In return, we must demonstrate our commitment to serve the best interests of the public through our processes and requirements.
ABS certification is based upon education, evaluation, and assessment. Appropriate undergraduate medical education, accredited surgical training, broad operative experience, and high ethical standing continue as essential requirements of ABS certification. For the first four decades of its existence, once ABS certification was achieved, it was valid for a surgeon’s entire professional career. This changed as the ABS Directors recognized the rapid evolution of surgical practice and believed it was necessary for diplomates to demonstrate that they were up to date with advances in medical knowledge and patient care. In 1976, the ABS adopted time-limited certification and required its diplomates to “recertify” by passing an examination every 10 years. In 2000, a requirement for its diplomates to complete 100 hours of continuing medical education (CME) credits in the 2 years prior to applying for the recertification exam (60 in Category I and 40 in Category II) was implemented. This requirement has been modified since; however, the basic rationale for its adoption remains relevant.
In 2005, the American Board of Medical Specialties (ABMS), which establishes standards for its 24 member boards, introduced MOC and proposed standards based on the six competencies jointly developed by the Accreditation Council on Graduate Medical Education and the ABMS. These competencies – patient care, medical knowledge, professionalism, interpersonal communication skills, practice-based learning and improvement, and systems-based practice – were the basis for the four parts of MOC: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. The development of MOC was further recognition that board certification needed to become a more continuous process as the pace of change in medicine had accelerated beyond any seen previously.
Boards and their diplomates have the responsibility to demonstrate to the public and their peers an enduring commitment to maintain standards for the profession, participate in lifelong education, possess medical knowledge relevant to the specialty, and improve their performance in practice. All surgeons certified or recertified beginning July 2005 have been enrolled in ABS MOC. A decade later, 95% of ABS diplomates with time-limited certificates are enrolled in the ABS MOC program and more than 90% are actively participating.
Although the ABMS established general requirements for MOC that its member boards must meet, each board is allowed to develop its own requirements. The foundations of the ABS MOC program were established before the term “maintenance of certification” was used. Professional standards have been a requirement for ABS certification since its beginning and exam requirements have been in place for more than a generation. All diplomates must fulfill the professional standing requirements to have a valid unrestricted state medical license, have hospital or ambulatory surgery center privileges if clinically active, and have references from the chief of surgery and the chair of the credentials committee where they practice.
The ABS MOC program is meant to be practice relevant. This allows surgeons to satisfy the requirements by completing CME that they choose and by participating in performance assessment activities in a way that best applies to their practices. The requirement that two-thirds of the CME hours earned be self-assessment demonstrates a greater level of engagement of the learner and shows that knowledge acquisition is achieved at the conclusion of the activity. The addition of a practice performance improvement activity requirement has generated the most controversy and misunderstanding. To meet this requirement, diplomates are asked to assess some aspect of their practice and seek to improve that. This can be done in conjunction with a hospital through participation in a national, regional, or state registry that tracks patient outcomes, or by participating in a hospital-based quality improvement activity. Some diplomates have developed performance improvement activities within their offices by focusing on a specific area for evaluation, defining measures and goals for improvement, analyzing results and making changes when appropriate, and then reassessing to develop an action plan for improvement.
Regardless of what you choose, the ABS asks only that you attest to your participation and does not collect, review, or otherwise scrutinize your results.
The ABS MOC program extends over a 10-year period. Requirements for the first 9 years are organized in identical 3-year reporting cycles running from Jan. 1 to Dec. 31. By the end of each 3-year cycle, diplomates are required to submit information on how they are meeting MOC requirements through an individualized secure login on the ABS website (www.absurgery.org). Successful completion of an MOC exam continues to be required every 10 years; however the exam may be taken in years 8 and 9 of the 10-year cycle.
ABS MOC is a surgeon-defined, national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC program demonstrates your commitment to remain current in your area of practice and to strive to improve what you do.
Since its beginning, the ABS has exercised its duty to develop, promote, and refine standards for certification in surgery. Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The ABS Board of Directors is focused on how ABS MOC can be an even more meaningful process for surgeons without increasing the already substantial administrative burden everyone faces. We are following the progress of innovative programs being piloted by other boards and organizations involved in quality improvement. The ABS recognizes that MOC requirements established or changed will affect roughly 30,000 surgeons who practice in a wide variety of environments. We encourage our diplomates to provide ideas to improve the program as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public.
For more information, please see the MOC Requirements page on the ABS website.
Dr. Malangoni is Associate Executive Director, American Board of Surgery, Philadelphia. Dr. Lewis is Executive Director, American Board of Surgery, Philadelphia.
The American Board of Surgery (ABS) was founded in 1937 by the leading surgical organizations of the time in recognition of the need to differentiate formally trained surgeons from other doctors who were performing operations without formal training.
At its onset, the ABS acknowledged that it had a dual purpose: to protect the public and improve the specialty of surgery. Eligibility criteria for certification were defined – graduation from an approved medical school, the requisite duration of surgical training, a list of operations performed, high ethical standards – and passing an examination became a differentiating requirement.
Over the nearly eight decades since its founding, the ABS has retained its position as the premier certifying body for surgeons in the United States. Its mission statement, “to serve the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice,” embodies the elements of the Maintenance of Certification (MOC) Program. Setting standards for board certification is a privilege of self-regulation that has been granted to our profession by the American public. In return, we must demonstrate our commitment to serve the best interests of the public through our processes and requirements.
ABS certification is based upon education, evaluation, and assessment. Appropriate undergraduate medical education, accredited surgical training, broad operative experience, and high ethical standing continue as essential requirements of ABS certification. For the first four decades of its existence, once ABS certification was achieved, it was valid for a surgeon’s entire professional career. This changed as the ABS Directors recognized the rapid evolution of surgical practice and believed it was necessary for diplomates to demonstrate that they were up to date with advances in medical knowledge and patient care. In 1976, the ABS adopted time-limited certification and required its diplomates to “recertify” by passing an examination every 10 years. In 2000, a requirement for its diplomates to complete 100 hours of continuing medical education (CME) credits in the 2 years prior to applying for the recertification exam (60 in Category I and 40 in Category II) was implemented. This requirement has been modified since; however, the basic rationale for its adoption remains relevant.
In 2005, the American Board of Medical Specialties (ABMS), which establishes standards for its 24 member boards, introduced MOC and proposed standards based on the six competencies jointly developed by the Accreditation Council on Graduate Medical Education and the ABMS. These competencies – patient care, medical knowledge, professionalism, interpersonal communication skills, practice-based learning and improvement, and systems-based practice – were the basis for the four parts of MOC: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. The development of MOC was further recognition that board certification needed to become a more continuous process as the pace of change in medicine had accelerated beyond any seen previously.
Boards and their diplomates have the responsibility to demonstrate to the public and their peers an enduring commitment to maintain standards for the profession, participate in lifelong education, possess medical knowledge relevant to the specialty, and improve their performance in practice. All surgeons certified or recertified beginning July 2005 have been enrolled in ABS MOC. A decade later, 95% of ABS diplomates with time-limited certificates are enrolled in the ABS MOC program and more than 90% are actively participating.
Although the ABMS established general requirements for MOC that its member boards must meet, each board is allowed to develop its own requirements. The foundations of the ABS MOC program were established before the term “maintenance of certification” was used. Professional standards have been a requirement for ABS certification since its beginning and exam requirements have been in place for more than a generation. All diplomates must fulfill the professional standing requirements to have a valid unrestricted state medical license, have hospital or ambulatory surgery center privileges if clinically active, and have references from the chief of surgery and the chair of the credentials committee where they practice.
The ABS MOC program is meant to be practice relevant. This allows surgeons to satisfy the requirements by completing CME that they choose and by participating in performance assessment activities in a way that best applies to their practices. The requirement that two-thirds of the CME hours earned be self-assessment demonstrates a greater level of engagement of the learner and shows that knowledge acquisition is achieved at the conclusion of the activity. The addition of a practice performance improvement activity requirement has generated the most controversy and misunderstanding. To meet this requirement, diplomates are asked to assess some aspect of their practice and seek to improve that. This can be done in conjunction with a hospital through participation in a national, regional, or state registry that tracks patient outcomes, or by participating in a hospital-based quality improvement activity. Some diplomates have developed performance improvement activities within their offices by focusing on a specific area for evaluation, defining measures and goals for improvement, analyzing results and making changes when appropriate, and then reassessing to develop an action plan for improvement.
Regardless of what you choose, the ABS asks only that you attest to your participation and does not collect, review, or otherwise scrutinize your results.
The ABS MOC program extends over a 10-year period. Requirements for the first 9 years are organized in identical 3-year reporting cycles running from Jan. 1 to Dec. 31. By the end of each 3-year cycle, diplomates are required to submit information on how they are meeting MOC requirements through an individualized secure login on the ABS website (www.absurgery.org). Successful completion of an MOC exam continues to be required every 10 years; however the exam may be taken in years 8 and 9 of the 10-year cycle.
ABS MOC is a surgeon-defined, national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC program demonstrates your commitment to remain current in your area of practice and to strive to improve what you do.
Since its beginning, the ABS has exercised its duty to develop, promote, and refine standards for certification in surgery. Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The ABS Board of Directors is focused on how ABS MOC can be an even more meaningful process for surgeons without increasing the already substantial administrative burden everyone faces. We are following the progress of innovative programs being piloted by other boards and organizations involved in quality improvement. The ABS recognizes that MOC requirements established or changed will affect roughly 30,000 surgeons who practice in a wide variety of environments. We encourage our diplomates to provide ideas to improve the program as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public.
For more information, please see the MOC Requirements page on the ABS website.
Dr. Malangoni is Associate Executive Director, American Board of Surgery, Philadelphia. Dr. Lewis is Executive Director, American Board of Surgery, Philadelphia.
The Rural Surgeon: Surgical practice in the Indian Health Service
Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).
Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.
While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.
I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.
I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.
I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.
What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.
Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.
Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.
Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.
There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.
There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.
We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.
One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).
Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.
Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.
Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.
I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.
There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities.
Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.
Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).
Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.
While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.
I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.
I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.
I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.
What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.
Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.
Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.
Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.
There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.
There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.
We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.
One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).
Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.
Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.
Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.
I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.
There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities.
Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.
Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).
Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.
While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.
I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.
I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.
I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.
What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.
Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.
Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.
Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.
There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.
There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.
We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.
One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).
Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.
Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.
Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.
I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.
There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities.
Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.
An Update on Acute Care Surgery
Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].
At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.
Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.
References
1. A growing crisis in patient access to emergency surgical care.
Bull. Am. Coll. Surg. 2006;91:8-19
2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at
http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.
4. Kellermann A. Crisis in the emergency department.
N. Engl. J. Med. 2006; 355:1300-3
5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.
6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266
8. Rotondo MF. At the center of the “perfect storm”: the patient.
9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.
11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.
12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.
J Am. Coll. Surg. 2008;206:782-8
Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.
Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].
At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.
Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.
References
1. A growing crisis in patient access to emergency surgical care.
Bull. Am. Coll. Surg. 2006;91:8-19
2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at
http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.
4. Kellermann A. Crisis in the emergency department.
N. Engl. J. Med. 2006; 355:1300-3
5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.
6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266
8. Rotondo MF. At the center of the “perfect storm”: the patient.
9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.
11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.
12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.
J Am. Coll. Surg. 2008;206:782-8
Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.
Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.
Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.
Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.
EMERGENCE OF ACUTE CARE SURGERY
Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].
At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.
Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.
References
1. A growing crisis in patient access to emergency surgical care.
Bull. Am. Coll. Surg. 2006;91:8-19
2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at
http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.
4. Kellermann A. Crisis in the emergency department.
N. Engl. J. Med. 2006; 355:1300-3
5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.
6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf
7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266
8. Rotondo MF. At the center of the “perfect storm”: the patient.
9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.
J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.
11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.
12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.
J Am. Coll. Surg. 2008;206:782-8
Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.