Commentary

The prevalence of Lyme disease in the United States has steadily increased over the past several years. In 2013, the disease was reported in all but 8 states.¹ Prevention, as we know, is key.

Common preventive steps include using DEET insect repellent, wearing long pants and sleeves outdoors, tucking pants into socks, wearing light-colored clothing to make ticks more visible, and checking one’s body daily for ticks.^2,3 The next best way to prevent Lyme disease is timely tick removal, as it is believed that in most cases the Lyme disease bacterium can be transmitted after 36 to 48 hours of tick attachment.^2,3

The safest and most effective method of removal remains controversial. The Centers for Disease Control and Prevention (CDC) recommends using forceps or tweezers to grab the tick as close to the skin as possible, and without twisting, pulling it straight up with steady, even pressure.⁴

We have used an alternate method of removing ticks that can be done at home or in a clinic without the use of special tools. It has been 100% effective in the 9 patients who presented to our clinic with attached deer ticks. With a cotton swab, apply liquid soap in circles over the tick for about 30 to 60 seconds. Then, use a dry cotton swab to wipe away the soap. The tick will be found on the swab with its head intact. We found this “home remedy” to be fast, easy, and painless; it also doesn’t appear to rely on suffocation.

Because there is no squeezing or twisting, the risk of regurgitation is minimized, and thus, the process is much less frightening for children—and maybe even for some adults.

Dionna Rookey, PA-C
Lebanon, NH
Louis A. Kazal, Jr, MD, FAAFP
Hanover, NH

The prevalence of Lyme disease in the United States has steadily increased over the past several years. In 2013, the disease was reported in all but 8 states.¹ Prevention, as we know, is key.

Common preventive steps include using DEET insect repellent, wearing long pants and sleeves outdoors, tucking pants into socks, wearing light-colored clothing to make ticks more visible, and checking one’s body daily for ticks.^2,3 The next best way to prevent Lyme disease is timely tick removal, as it is believed that in most cases the Lyme disease bacterium can be transmitted after 36 to 48 hours of tick attachment.^2,3

The safest and most effective method of removal remains controversial. The Centers for Disease Control and Prevention (CDC) recommends using forceps or tweezers to grab the tick as close to the skin as possible, and without twisting, pulling it straight up with steady, even pressure.⁴

We have used an alternate method of removing ticks that can be done at home or in a clinic without the use of special tools. It has been 100% effective in the 9 patients who presented to our clinic with attached deer ticks. With a cotton swab, apply liquid soap in circles over the tick for about 30 to 60 seconds. Then, use a dry cotton swab to wipe away the soap. The tick will be found on the swab with its head intact. We found this “home remedy” to be fast, easy, and painless; it also doesn’t appear to rely on suffocation.

Because there is no squeezing or twisting, the risk of regurgitation is minimized, and thus, the process is much less frightening for children—and maybe even for some adults.

Dionna Rookey, PA-C
Lebanon, NH
Louis A. Kazal, Jr, MD, FAAFP
Hanover, NH

The prevalence of Lyme disease in the United States has steadily increased over the past several years. In 2013, the disease was reported in all but 8 states.¹ Prevention, as we know, is key.

Common preventive steps include using DEET insect repellent, wearing long pants and sleeves outdoors, tucking pants into socks, wearing light-colored clothing to make ticks more visible, and checking one’s body daily for ticks.^2,3 The next best way to prevent Lyme disease is timely tick removal, as it is believed that in most cases the Lyme disease bacterium can be transmitted after 36 to 48 hours of tick attachment.^2,3

The safest and most effective method of removal remains controversial. The Centers for Disease Control and Prevention (CDC) recommends using forceps or tweezers to grab the tick as close to the skin as possible, and without twisting, pulling it straight up with steady, even pressure.⁴

We have used an alternate method of removing ticks that can be done at home or in a clinic without the use of special tools. It has been 100% effective in the 9 patients who presented to our clinic with attached deer ticks. With a cotton swab, apply liquid soap in circles over the tick for about 30 to 60 seconds. Then, use a dry cotton swab to wipe away the soap. The tick will be found on the swab with its head intact. We found this “home remedy” to be fast, easy, and painless; it also doesn’t appear to rely on suffocation.

Because there is no squeezing or twisting, the risk of regurgitation is minimized, and thus, the process is much less frightening for children—and maybe even for some adults.

Dionna Rookey, PA-C
Lebanon, NH
Louis A. Kazal, Jr, MD, FAAFP
Hanover, NH

Dear readers, I assure you it is pure coincidence that your editors-in-chief would choose to write on similar topics in consecutive months. Although Randy Danielsen and I are simpatico in many ways, we do not actually sit down and coordinate our subject matter. It is simply a matter of similar tastes (ha) that leads me to present you with some musings on the same part of the anatomy that my counterpart focused on last month. Isn’t it about time the mouth got some attention?

So let me ask you: What is the first thing you notice about a person? I recently conducted a survey (albeit limited in scope and scientific rigor) to determine the answer to this question. What I found was that five out of six people notice someone’s face. Going one step further, I queried which specific component of the face they noticed; the majority said a person’s mouth and/or smile.

Smiling is a simple motion that requires only a fraction of the 36 facial muscles to produce. The pertinent percentage is source dependent—and controversial—so I will not include a specific percent or number here. What I will say is that having a smile to be proud of is not controversial at all. Moreover, what people evaluate (or, let’s be honest, pass judgment on) is the teeth as a component of that smile. Yet many children—who grow into adults, naturally—do not have healthy-looking teeth. And that, my friends, is a preventable indignity.

While conducting my research, I was intrigued to learn that Pierre Fauchard (1678-1761) was one of the first practitioners to promote scaling of the teeth and debridement of the root surfaces to prevent periodontal disease.¹ Another interesting finding was that the first oral hygiene school opened in Bridgeport, Connecticut, in 1913; the Bridgeport School Board employed the first graduating class to clean the schoolchildren’s teeth, which resulted in a decreased incidence of dental caries.² In 1945, Newburgh, New York, and Grand Rapids, Michigan, added fluoride to the public water supply, another step toward decreasing the incidence of dental caries.

Many of us recall the toothpaste commercial in which the young child comes home proudly announcing, “Look, Mom—no cavities.”³ That was more than 50 years ago, when having a cavity-free mouth was quite an accomplishment, given the limited access to dental care. And yet, sadly, access to oral health services—and the dental caries that result from lack of care—remain a serious public health problem.

But while we pride ourselves on (and admire) a beautiful smile, those pearly whites aren’t necessarily healthy. In fact, they can mask underlying oral health problems.⁴ It cannot be emphasized enough: Good dental health is essential to overall health.

In his editorial last month, Dr Danielsen reminded us that the mouth “is the gateway and window into health in our body.”⁵ We know that properly functioning teeth allow for good nutrition, which can contribute to overall health, while poor dentition can impede eating. (It can also cause speech impediments.) Unhealthy teeth and gums can contribute to pain syndromes and systemic conditions and can lead to bacterial infections in the gums, pharynx, and major organs.⁶ Moreover, chronic dental infections can compromise the treatment of patients with comprehensive medical conditions, including diabetes, hypertension, renal disease, or cancer.

Dental caries (or cavities) persist as the most common chronic condition among American children: 26% of preschoolers, 44% of kindergarteners, and more than half of adolescents experience preventable tooth decay.^7,8 Cavities occur when certain bacteria in oral plaque utilize dietary sugars to produce acid; this gradually erodes the tooth enamel, resulting in a cavity.⁹ When these same bacteria spread, they cause serious facial infections that result in swelling, toxicity, and sometimes death.

The impact of oral disease is a major public health problem that must not be ignored. The disparities in oral health care cannot be mitigated simply by performing more dental procedures.⁹ We, as primary care providers, must emphasize the importance of prevention. We already do this with other aspects of health care; to neglect the mouth as part of the body is a regretful oversight.

As health care providers, we need to understand, and communicate to our patients, the basics of common problems such as periodontal disease—including risk factors that compromise overall health and wellness.⁹ We can also share with them prevention practices that will help them to manage their disease. These elements merge well with routine health maintenance.

Nurse practitioners, nurse-midwives, and physician assistants, as frontline health care providers, are in a prime position to intercede and improve the dental health of all our patients. But while we are the most likely health professionals to take the lead in advancing patient-centered care that includes a dental evaluation, our formal curricula do not include the necessary skills.

The Affordable Care Act (ACA) provided an opportunity to expand dental coverage to millions of children nationwide. The provision to designate oral health services as “essential health benefits” establishes oral health as a critical piece of overall health.^10,11 Educational programs for NPs and PAs must follow suit and capitalize on the evidence-based knowledge and tools of our dental colleagues, so we can add oral health as an element of the health and wellness examination. The time has come to integrate the concepts of interprofessional oral health into the curriculum for NPs, PAs, and all health care providers.¹²

Remember, a “conscientiously applied program of oral hygiene and regular professional care” is an effective means of achieving a healthy smile!¹³ Let’s become providers of at least some of that professional care. Please share your thoughts with me at [email protected].

REFERENCES
1. Feinberg EM. A short history of modern dentistry. www.edwardfeinbergdmd.com/history-of-dentistry. Accessed April 8, 2015.
2. American Dental Association. History of dentistry timeline. www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline. Accessed April 8, 2015.
3. 1958 Crest toothpaste commercial. www.youtube.com/watch?v=v72NHYp8KD4. Accessed April 8, 2015.
4. Proctor & Gamble. Crest heritage. www.crest.com/about-crest/crestheritage.aspx. Ac­cessed April 8, 2015.
5. Danielsen RDD. It’s all about the spit! Clin Rev. 2015;25(4):4,6.
6. Feinberg EM. The importance of dentistry. www.edwardfeinbergdmd.com/adult-den tistry/importance-of-dentistry. Accessed April 8, 2015.
7. American Dental Association and the CDC. Water fluoridation: nature’s way to prevent tooth decay. www.cdc.gov/Fluoridation/pdf/natures_way.pdf. Accessed April 8, 2015.
8. Dye BA, Tan S, Smith V, et al; National Center for Health Statistics. (2007), Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248).
9. American  Dental Association. Four dental conditions—prevention summit primer (2013). www.ada.org/~/media/ADA/Public%20Programs/File/2013_Prevention_Summit_Primer_on_Four_Dental_Conditions.ashx. Accessed April 8, 2015.
10. Stahl EM, Reusch C. Ensuring access to pediatric dental benefits in the Affordable Care Act (ACA). http://neach.communitycatalyst.org/publications/asset/Pedi_dental_final_5-29-13.pdf. Accessed April 8, 2015.
11. Patient Protection and Affordable Care Act. Section 1302(b)(4)(F).
12. Haber J, Altman S, Moursi A, et al. Oral health challenges in pregnancy and childhood [webinar]. National Organization of Nurse Practi­tion­er Faculties. 2015.  www.nonpf.org/events/event_details.asp?id=508645. Accessed April 8, 2015.
13. American Dental Association, Council on Dental Therapeutics. Evaluation of Crest toothpaste. J Am Dent Assoc. 1960;61:272-274.

Dear readers, I assure you it is pure coincidence that your editors-in-chief would choose to write on similar topics in consecutive months. Although Randy Danielsen and I are simpatico in many ways, we do not actually sit down and coordinate our subject matter. It is simply a matter of similar tastes (ha) that leads me to present you with some musings on the same part of the anatomy that my counterpart focused on last month. Isn’t it about time the mouth got some attention?

So let me ask you: What is the first thing you notice about a person? I recently conducted a survey (albeit limited in scope and scientific rigor) to determine the answer to this question. What I found was that five out of six people notice someone’s face. Going one step further, I queried which specific component of the face they noticed; the majority said a person’s mouth and/or smile.

Smiling is a simple motion that requires only a fraction of the 36 facial muscles to produce. The pertinent percentage is source dependent—and controversial—so I will not include a specific percent or number here. What I will say is that having a smile to be proud of is not controversial at all. Moreover, what people evaluate (or, let’s be honest, pass judgment on) is the teeth as a component of that smile. Yet many children—who grow into adults, naturally—do not have healthy-looking teeth. And that, my friends, is a preventable indignity.

While conducting my research, I was intrigued to learn that Pierre Fauchard (1678-1761) was one of the first practitioners to promote scaling of the teeth and debridement of the root surfaces to prevent periodontal disease.¹ Another interesting finding was that the first oral hygiene school opened in Bridgeport, Connecticut, in 1913; the Bridgeport School Board employed the first graduating class to clean the schoolchildren’s teeth, which resulted in a decreased incidence of dental caries.² In 1945, Newburgh, New York, and Grand Rapids, Michigan, added fluoride to the public water supply, another step toward decreasing the incidence of dental caries.

Many of us recall the toothpaste commercial in which the young child comes home proudly announcing, “Look, Mom—no cavities.”³ That was more than 50 years ago, when having a cavity-free mouth was quite an accomplishment, given the limited access to dental care. And yet, sadly, access to oral health services—and the dental caries that result from lack of care—remain a serious public health problem.

But while we pride ourselves on (and admire) a beautiful smile, those pearly whites aren’t necessarily healthy. In fact, they can mask underlying oral health problems.⁴ It cannot be emphasized enough: Good dental health is essential to overall health.

In his editorial last month, Dr Danielsen reminded us that the mouth “is the gateway and window into health in our body.”⁵ We know that properly functioning teeth allow for good nutrition, which can contribute to overall health, while poor dentition can impede eating. (It can also cause speech impediments.) Unhealthy teeth and gums can contribute to pain syndromes and systemic conditions and can lead to bacterial infections in the gums, pharynx, and major organs.⁶ Moreover, chronic dental infections can compromise the treatment of patients with comprehensive medical conditions, including diabetes, hypertension, renal disease, or cancer.

Dental caries (or cavities) persist as the most common chronic condition among American children: 26% of preschoolers, 44% of kindergarteners, and more than half of adolescents experience preventable tooth decay.^7,8 Cavities occur when certain bacteria in oral plaque utilize dietary sugars to produce acid; this gradually erodes the tooth enamel, resulting in a cavity.⁹ When these same bacteria spread, they cause serious facial infections that result in swelling, toxicity, and sometimes death.

The impact of oral disease is a major public health problem that must not be ignored. The disparities in oral health care cannot be mitigated simply by performing more dental procedures.⁹ We, as primary care providers, must emphasize the importance of prevention. We already do this with other aspects of health care; to neglect the mouth as part of the body is a regretful oversight.

As health care providers, we need to understand, and communicate to our patients, the basics of common problems such as periodontal disease—including risk factors that compromise overall health and wellness.⁹ We can also share with them prevention practices that will help them to manage their disease. These elements merge well with routine health maintenance.

Nurse practitioners, nurse-midwives, and physician assistants, as frontline health care providers, are in a prime position to intercede and improve the dental health of all our patients. But while we are the most likely health professionals to take the lead in advancing patient-centered care that includes a dental evaluation, our formal curricula do not include the necessary skills.

The Affordable Care Act (ACA) provided an opportunity to expand dental coverage to millions of children nationwide. The provision to designate oral health services as “essential health benefits” establishes oral health as a critical piece of overall health.^10,11 Educational programs for NPs and PAs must follow suit and capitalize on the evidence-based knowledge and tools of our dental colleagues, so we can add oral health as an element of the health and wellness examination. The time has come to integrate the concepts of interprofessional oral health into the curriculum for NPs, PAs, and all health care providers.¹²

Remember, a “conscientiously applied program of oral hygiene and regular professional care” is an effective means of achieving a healthy smile!¹³ Let’s become providers of at least some of that professional care. Please share your thoughts with me at [email protected].

REFERENCES
1. Feinberg EM. A short history of modern dentistry. www.edwardfeinbergdmd.com/history-of-dentistry. Accessed April 8, 2015.
2. American Dental Association. History of dentistry timeline. www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline. Accessed April 8, 2015.
3. 1958 Crest toothpaste commercial. www.youtube.com/watch?v=v72NHYp8KD4. Accessed April 8, 2015.
4. Proctor & Gamble. Crest heritage. www.crest.com/about-crest/crestheritage.aspx. Ac­cessed April 8, 2015.
5. Danielsen RDD. It’s all about the spit! Clin Rev. 2015;25(4):4,6.
6. Feinberg EM. The importance of dentistry. www.edwardfeinbergdmd.com/adult-den tistry/importance-of-dentistry. Accessed April 8, 2015.
7. American Dental Association and the CDC. Water fluoridation: nature’s way to prevent tooth decay. www.cdc.gov/Fluoridation/pdf/natures_way.pdf. Accessed April 8, 2015.
8. Dye BA, Tan S, Smith V, et al; National Center for Health Statistics. (2007), Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248).
9. American  Dental Association. Four dental conditions—prevention summit primer (2013). www.ada.org/~/media/ADA/Public%20Programs/File/2013_Prevention_Summit_Primer_on_Four_Dental_Conditions.ashx. Accessed April 8, 2015.
10. Stahl EM, Reusch C. Ensuring access to pediatric dental benefits in the Affordable Care Act (ACA). http://neach.communitycatalyst.org/publications/asset/Pedi_dental_final_5-29-13.pdf. Accessed April 8, 2015.
11. Patient Protection and Affordable Care Act. Section 1302(b)(4)(F).
12. Haber J, Altman S, Moursi A, et al. Oral health challenges in pregnancy and childhood [webinar]. National Organization of Nurse Practi­tion­er Faculties. 2015.  www.nonpf.org/events/event_details.asp?id=508645. Accessed April 8, 2015.
13. American Dental Association, Council on Dental Therapeutics. Evaluation of Crest toothpaste. J Am Dent Assoc. 1960;61:272-274.

Dear readers, I assure you it is pure coincidence that your editors-in-chief would choose to write on similar topics in consecutive months. Although Randy Danielsen and I are simpatico in many ways, we do not actually sit down and coordinate our subject matter. It is simply a matter of similar tastes (ha) that leads me to present you with some musings on the same part of the anatomy that my counterpart focused on last month. Isn’t it about time the mouth got some attention?

So let me ask you: What is the first thing you notice about a person? I recently conducted a survey (albeit limited in scope and scientific rigor) to determine the answer to this question. What I found was that five out of six people notice someone’s face. Going one step further, I queried which specific component of the face they noticed; the majority said a person’s mouth and/or smile.

Smiling is a simple motion that requires only a fraction of the 36 facial muscles to produce. The pertinent percentage is source dependent—and controversial—so I will not include a specific percent or number here. What I will say is that having a smile to be proud of is not controversial at all. Moreover, what people evaluate (or, let’s be honest, pass judgment on) is the teeth as a component of that smile. Yet many children—who grow into adults, naturally—do not have healthy-looking teeth. And that, my friends, is a preventable indignity.

While conducting my research, I was intrigued to learn that Pierre Fauchard (1678-1761) was one of the first practitioners to promote scaling of the teeth and debridement of the root surfaces to prevent periodontal disease.¹ Another interesting finding was that the first oral hygiene school opened in Bridgeport, Connecticut, in 1913; the Bridgeport School Board employed the first graduating class to clean the schoolchildren’s teeth, which resulted in a decreased incidence of dental caries.² In 1945, Newburgh, New York, and Grand Rapids, Michigan, added fluoride to the public water supply, another step toward decreasing the incidence of dental caries.

Many of us recall the toothpaste commercial in which the young child comes home proudly announcing, “Look, Mom—no cavities.”³ That was more than 50 years ago, when having a cavity-free mouth was quite an accomplishment, given the limited access to dental care. And yet, sadly, access to oral health services—and the dental caries that result from lack of care—remain a serious public health problem.

But while we pride ourselves on (and admire) a beautiful smile, those pearly whites aren’t necessarily healthy. In fact, they can mask underlying oral health problems.⁴ It cannot be emphasized enough: Good dental health is essential to overall health.

In his editorial last month, Dr Danielsen reminded us that the mouth “is the gateway and window into health in our body.”⁵ We know that properly functioning teeth allow for good nutrition, which can contribute to overall health, while poor dentition can impede eating. (It can also cause speech impediments.) Unhealthy teeth and gums can contribute to pain syndromes and systemic conditions and can lead to bacterial infections in the gums, pharynx, and major organs.⁶ Moreover, chronic dental infections can compromise the treatment of patients with comprehensive medical conditions, including diabetes, hypertension, renal disease, or cancer.

Dental caries (or cavities) persist as the most common chronic condition among American children: 26% of preschoolers, 44% of kindergarteners, and more than half of adolescents experience preventable tooth decay.^7,8 Cavities occur when certain bacteria in oral plaque utilize dietary sugars to produce acid; this gradually erodes the tooth enamel, resulting in a cavity.⁹ When these same bacteria spread, they cause serious facial infections that result in swelling, toxicity, and sometimes death.

The impact of oral disease is a major public health problem that must not be ignored. The disparities in oral health care cannot be mitigated simply by performing more dental procedures.⁹ We, as primary care providers, must emphasize the importance of prevention. We already do this with other aspects of health care; to neglect the mouth as part of the body is a regretful oversight.

As health care providers, we need to understand, and communicate to our patients, the basics of common problems such as periodontal disease—including risk factors that compromise overall health and wellness.⁹ We can also share with them prevention practices that will help them to manage their disease. These elements merge well with routine health maintenance.

Nurse practitioners, nurse-midwives, and physician assistants, as frontline health care providers, are in a prime position to intercede and improve the dental health of all our patients. But while we are the most likely health professionals to take the lead in advancing patient-centered care that includes a dental evaluation, our formal curricula do not include the necessary skills.

The Affordable Care Act (ACA) provided an opportunity to expand dental coverage to millions of children nationwide. The provision to designate oral health services as “essential health benefits” establishes oral health as a critical piece of overall health.^10,11 Educational programs for NPs and PAs must follow suit and capitalize on the evidence-based knowledge and tools of our dental colleagues, so we can add oral health as an element of the health and wellness examination. The time has come to integrate the concepts of interprofessional oral health into the curriculum for NPs, PAs, and all health care providers.¹²

Remember, a “conscientiously applied program of oral hygiene and regular professional care” is an effective means of achieving a healthy smile!¹³ Let’s become providers of at least some of that professional care. Please share your thoughts with me at [email protected].

REFERENCES
1. Feinberg EM. A short history of modern dentistry. www.edwardfeinbergdmd.com/history-of-dentistry. Accessed April 8, 2015.
2. American Dental Association. History of dentistry timeline. www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline. Accessed April 8, 2015.
3. 1958 Crest toothpaste commercial. www.youtube.com/watch?v=v72NHYp8KD4. Accessed April 8, 2015.
4. Proctor & Gamble. Crest heritage. www.crest.com/about-crest/crestheritage.aspx. Ac­cessed April 8, 2015.
5. Danielsen RDD. It’s all about the spit! Clin Rev. 2015;25(4):4,6.
6. Feinberg EM. The importance of dentistry. www.edwardfeinbergdmd.com/adult-den tistry/importance-of-dentistry. Accessed April 8, 2015.
7. American Dental Association and the CDC. Water fluoridation: nature’s way to prevent tooth decay. www.cdc.gov/Fluoridation/pdf/natures_way.pdf. Accessed April 8, 2015.
8. Dye BA, Tan S, Smith V, et al; National Center for Health Statistics. (2007), Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248).
9. American  Dental Association. Four dental conditions—prevention summit primer (2013). www.ada.org/~/media/ADA/Public%20Programs/File/2013_Prevention_Summit_Primer_on_Four_Dental_Conditions.ashx. Accessed April 8, 2015.
10. Stahl EM, Reusch C. Ensuring access to pediatric dental benefits in the Affordable Care Act (ACA). http://neach.communitycatalyst.org/publications/asset/Pedi_dental_final_5-29-13.pdf. Accessed April 8, 2015.
11. Patient Protection and Affordable Care Act. Section 1302(b)(4)(F).
12. Haber J, Altman S, Moursi A, et al. Oral health challenges in pregnancy and childhood [webinar]. National Organization of Nurse Practi­tion­er Faculties. 2015.  www.nonpf.org/events/event_details.asp?id=508645. Accessed April 8, 2015.
13. American Dental Association, Council on Dental Therapeutics. Evaluation of Crest toothpaste. J Am Dent Assoc. 1960;61:272-274.

A chair of orthopedic surgery at Rochester General Hospital and a lifelong automobile enthusiast, Dr States was also the track physician at Watkins Glen International Speedway, where he soon realized that even though the speeds of car crashes on the track were far greater than those on the highways, race-car drivers, protected by seatbelts, helmets, and safety cages or rollbars, typically walked away from their crashes, while drivers and passengers in highway accidents often did not.

Dr States began to research and to document the causes and consequences of severe crashes on his own—even before he began to receive federal funding to establish accident investigation teams. He often interrupted family drives when he came upon a crash site in order to take measurements and obtain information and went on to develop the Abbreviated Injury Scale (AIS) used throughout the world to standardize the measurements of automobile-related trauma injuries. According to the Association for the Advancement of Automotive Medicine, an organization he helped to found and lead, Dr States became an expert in the biomechanics of knee, hip, and spinal injuries, enabling him to develop seatbelt, dashboard, and airbag designs to reduce injuries.

Although Dr States was consulted frequently by auto manufacturers on ways to make cars safer, they did not heed his advice to voluntarily install seatbelts and other safety devices before it became the law. Acting on Dr States’ recommendations, New York State required manufacturers to equip all new cars with seatbelts beginning in 1964 and in 1984 became the first state to mandate their use. Similar laws followed in all but one other state, and John D. States has since been known as “Dr Seatbelt.”

Although mandatory seatbelt usage has been estimated to save 12,000 lives a year, Dr States never suggested that seatbelts alone could prevent all deaths and injuries from automobile crashes. In one of the 83 papers he authored or coauthored, a 1994 Journal of Trauma study (1994;37[3]:404-447) found that the patterns of injury resulting in the deaths of 91 unrestrained and 27 restrained vehicle crash victims were largely the same, with the exception of a 19.8% decrease in injuries resulting from ejection and a lower incidence of cerebral contusions (37% vs 71%) in the restrained group. Head, thoracic, and abdominal injuries followed similar patterns, with cranial injuries being the most likely cause of death in almost two thirds of the victims of both groups. Dr States and his colleagues concluded that accidents involving crushing, intrusion, and significant deceleration exceed the ability of restraints alone to prevent many fatal injuries.

Some of the implications of this data have already resulted in more protective automobile passenger compartments and additional safety features such as side airbags, collapsible steering wheels, and recessed instrumentation. 

Along with increasing the numbers of crash victims reaching EDs alive, safety features now incorporated into automobiles based on Dr States’ work have resulted in significant economic benefits to society and to the auto manufacturers who would not voluntarily adopt the safety measures he had advocated. Of the 12,000 lives a year saved, many undoubtedly go on to purchase replacement vehicles and probably continue to purchase new vehicles for many years to come. And, should the next generation of vehicles incorporate sensors and systems to prevent impacts independently of driver-controlled measures, the ideas and principles that John D. States, MD, championed throughout his life may someday reduce ED overcrowding as well.

A chair of orthopedic surgery at Rochester General Hospital and a lifelong automobile enthusiast, Dr States was also the track physician at Watkins Glen International Speedway, where he soon realized that even though the speeds of car crashes on the track were far greater than those on the highways, race-car drivers, protected by seatbelts, helmets, and safety cages or rollbars, typically walked away from their crashes, while drivers and passengers in highway accidents often did not.

Dr States began to research and to document the causes and consequences of severe crashes on his own—even before he began to receive federal funding to establish accident investigation teams. He often interrupted family drives when he came upon a crash site in order to take measurements and obtain information and went on to develop the Abbreviated Injury Scale (AIS) used throughout the world to standardize the measurements of automobile-related trauma injuries. According to the Association for the Advancement of Automotive Medicine, an organization he helped to found and lead, Dr States became an expert in the biomechanics of knee, hip, and spinal injuries, enabling him to develop seatbelt, dashboard, and airbag designs to reduce injuries.

Although Dr States was consulted frequently by auto manufacturers on ways to make cars safer, they did not heed his advice to voluntarily install seatbelts and other safety devices before it became the law. Acting on Dr States’ recommendations, New York State required manufacturers to equip all new cars with seatbelts beginning in 1964 and in 1984 became the first state to mandate their use. Similar laws followed in all but one other state, and John D. States has since been known as “Dr Seatbelt.”

Although mandatory seatbelt usage has been estimated to save 12,000 lives a year, Dr States never suggested that seatbelts alone could prevent all deaths and injuries from automobile crashes. In one of the 83 papers he authored or coauthored, a 1994 Journal of Trauma study (1994;37[3]:404-447) found that the patterns of injury resulting in the deaths of 91 unrestrained and 27 restrained vehicle crash victims were largely the same, with the exception of a 19.8% decrease in injuries resulting from ejection and a lower incidence of cerebral contusions (37% vs 71%) in the restrained group. Head, thoracic, and abdominal injuries followed similar patterns, with cranial injuries being the most likely cause of death in almost two thirds of the victims of both groups. Dr States and his colleagues concluded that accidents involving crushing, intrusion, and significant deceleration exceed the ability of restraints alone to prevent many fatal injuries.

Some of the implications of this data have already resulted in more protective automobile passenger compartments and additional safety features such as side airbags, collapsible steering wheels, and recessed instrumentation. 

Along with increasing the numbers of crash victims reaching EDs alive, safety features now incorporated into automobiles based on Dr States’ work have resulted in significant economic benefits to society and to the auto manufacturers who would not voluntarily adopt the safety measures he had advocated. Of the 12,000 lives a year saved, many undoubtedly go on to purchase replacement vehicles and probably continue to purchase new vehicles for many years to come. And, should the next generation of vehicles incorporate sensors and systems to prevent impacts independently of driver-controlled measures, the ideas and principles that John D. States, MD, championed throughout his life may someday reduce ED overcrowding as well.

A chair of orthopedic surgery at Rochester General Hospital and a lifelong automobile enthusiast, Dr States was also the track physician at Watkins Glen International Speedway, where he soon realized that even though the speeds of car crashes on the track were far greater than those on the highways, race-car drivers, protected by seatbelts, helmets, and safety cages or rollbars, typically walked away from their crashes, while drivers and passengers in highway accidents often did not.

Dr States began to research and to document the causes and consequences of severe crashes on his own—even before he began to receive federal funding to establish accident investigation teams. He often interrupted family drives when he came upon a crash site in order to take measurements and obtain information and went on to develop the Abbreviated Injury Scale (AIS) used throughout the world to standardize the measurements of automobile-related trauma injuries. According to the Association for the Advancement of Automotive Medicine, an organization he helped to found and lead, Dr States became an expert in the biomechanics of knee, hip, and spinal injuries, enabling him to develop seatbelt, dashboard, and airbag designs to reduce injuries.

Although Dr States was consulted frequently by auto manufacturers on ways to make cars safer, they did not heed his advice to voluntarily install seatbelts and other safety devices before it became the law. Acting on Dr States’ recommendations, New York State required manufacturers to equip all new cars with seatbelts beginning in 1964 and in 1984 became the first state to mandate their use. Similar laws followed in all but one other state, and John D. States has since been known as “Dr Seatbelt.”

Although mandatory seatbelt usage has been estimated to save 12,000 lives a year, Dr States never suggested that seatbelts alone could prevent all deaths and injuries from automobile crashes. In one of the 83 papers he authored or coauthored, a 1994 Journal of Trauma study (1994;37[3]:404-447) found that the patterns of injury resulting in the deaths of 91 unrestrained and 27 restrained vehicle crash victims were largely the same, with the exception of a 19.8% decrease in injuries resulting from ejection and a lower incidence of cerebral contusions (37% vs 71%) in the restrained group. Head, thoracic, and abdominal injuries followed similar patterns, with cranial injuries being the most likely cause of death in almost two thirds of the victims of both groups. Dr States and his colleagues concluded that accidents involving crushing, intrusion, and significant deceleration exceed the ability of restraints alone to prevent many fatal injuries.

Some of the implications of this data have already resulted in more protective automobile passenger compartments and additional safety features such as side airbags, collapsible steering wheels, and recessed instrumentation. 

Along with increasing the numbers of crash victims reaching EDs alive, safety features now incorporated into automobiles based on Dr States’ work have resulted in significant economic benefits to society and to the auto manufacturers who would not voluntarily adopt the safety measures he had advocated. Of the 12,000 lives a year saved, many undoubtedly go on to purchase replacement vehicles and probably continue to purchase new vehicles for many years to come. And, should the next generation of vehicles incorporate sensors and systems to prevent impacts independently of driver-controlled measures, the ideas and principles that John D. States, MD, championed throughout his life may someday reduce ED overcrowding as well.

“UPDATE ON ABNORMAL UTERINE BLEEDING”
HOWARD T. SHARP, MD (MARCH 2015)

Still having reservations about ablation
We discussed Dr. Sharp’s update on abnormal uterine bleeding (AUB) at a recent clinical meeting in my office. I have long told my nurse practition-ers that I am not in favor of ablation for AUB associated with ovulatory dysfunction (AUB-O). I learned from recent recertification reading that the risks for failure of ablation are dysmenorrhea, tubal ligation, and obesity, not anovulation. Therefore I may be more lenient with the use of ablation in this situation.

I still have the same reservations about performing ablation in women with ongoing irregular bleeding: If patients continue to have irregular bleeding, which they often do, it can be difficult to evaluate the endometrial cavity due to scarring, even at the time of dilation and curettage. Therefore, if they have other risk factors for hyperplasia or endometrial cancer or have postmenopausal bleeding, I won’t offer them ablation.
Nancy Shumeyko, MD
Binghamton, New York

Dr. Sharp responds
I appreciate Dr. Shumeyko’s comments and concerns about endometrial sampling in patients with abnormal bleeding (specifically AUB-O)who may have endometrial scarring after endometrial ablation. This is one of the unsettling challenges of post-ablation bleeding that we must sometimes address. Unfortunately, this can occur even in patients who seem to be “ideal” candidates for endometrial ablation (AUB-E). With amenorrhea rates generally less than 50% with most ablative methods, this unintended consequence makes the levonorgestrel IUD look all the more appealing. Hence, I agree with Dr. Shumeyko, and would add that just because we can do something, doesn’t mean we should.

“HYSTEROTOMY INCISION AND REPAIR: MANY OPTIONS, MANY PERSONAL PREFERENCES”
ROBERT L. BARBIERI, MD (EDITORIAL; MARCH 2015)

The important question is how to repair the incision
I read with interest Dr. Barbieri’s March editorial about hysterotomy during cesarean delivery. In my opinion, the important question is not how to open but how to repair.

I cannot dictate or even encourage other surgeons to do as I do because our surgical skills differ. I create a bladder flap on primary cesarean sections out of habit, but I have performed a few without creating it, and without harming the patient.

Personally, I open the lower uterine segment sharply unless copious bleeding hampers my view. Most of the time, I can gain entrance to the uterine cavity without performing a concurrent amniotomy, which allows me to sharply perform the hystero­tomy without concern for injuring the fetus. If bleeding hampers my view, I do all the dissection bluntly.

Have I noticed a big difference one way or the other? Not at all.

It is my impression that a ­double-layered closure is beneficial to the patient. I close the hystero­tomy in this fashion even if the patient would not be a candidate for a trial of labor after cesarean in future pregnancies.

Maybe I am just lucky, but I only remember having injured 1 baby (a breech presentation fetus with severe oligohydramnios) since I finished my residency in 1986.
Tomas Hernandez, MD
Pasco, Washington

Dr. Barbieri responds
I respect Dr. Hernandez’s 30 years of clinical experience and appreciate his recommendations on opening and closing of the hysterotomy at cesarean delivery. My observation is that most US obstetricians close the hystero­tomy in 2 layers. Like Dr. Hernandez, I favor a double-layer closure even if the patient is not a candidate for a trial of labor in a future pregnancy.

ANSWERING YOUR CODING QUESTIONS
A reader recently requested assistance for a specific coding challenge. We’ve asked our reimbursement specialist, Melanie Witt, RN, CPC, COBGC, MA, to provide her insight.

How should we code when using CUSA on vulvar dysplasia?
I provide coding assistance for several ObGyn practices and have always found your Web site to be informative. My question concerns Current Procedural Terminology (CPT) coding for removal of vulvar dysplasia using the cavitron ultrasonic surgical aspirator. The device is used to remove diseased epithelium. Generally, acetic acid is applied to highlight the diseased area and the lesions are removed with the device. The aspirator also collects the removed tissue so that it can be sent to pathology. Silver sulfadiazine cream is applied to the areas treated, as in laser surgery. The treatment may take 10 to 15 minutes. Which code, 56620 or 56515, should be used to reflect the actual work involved?
Marie D. Pelino, CPC
Annapolis, Maryland

Ms. Witt responds
The clinical vignette that was used by the CPT Editorial Panel in valuing code 56620 (Vulvectomy simple; partial) reads¹:

The relative value units (RVUs) for this code are also fairly high at 14.86, and the procedure is designated as one that is performed in the hospital setting only. In addition, when valued, this procedure was assumed to represent 45 minutes of intraservice time (that is, the time for the actual surgery), and 56620 has a 90-day global period.

In contrast, 56515 (Destruction of lesion[s], vulva; extensive [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery]) can be performed either in the facility or office setting and represents extensive destruction of tissue. In some cases, the physician may take a sample of tissue prior to the destruction, but this would be considered included in the destruction and not separately reportable, as the destruction represents the most extensive procedure. The clinical vignette used to value this code reads¹:

The RVUs for this procedure are less at 5.75 in the facility setting and 6.45 in the office setting, but the intraservice time is also less than with 56620.

Given your description of the procedure in this case, I would consider 56515 to be the most correct code to report for this surgery.

Reference
1. American Medical Association. RBRVS DataManager Online. AMA Store Web site. https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod280002&navAction =push. Accessed March 17, 2015.

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

“UPDATE ON ABNORMAL UTERINE BLEEDING”
HOWARD T. SHARP, MD (MARCH 2015)

Still having reservations about ablation
We discussed Dr. Sharp’s update on abnormal uterine bleeding (AUB) at a recent clinical meeting in my office. I have long told my nurse practition-ers that I am not in favor of ablation for AUB associated with ovulatory dysfunction (AUB-O). I learned from recent recertification reading that the risks for failure of ablation are dysmenorrhea, tubal ligation, and obesity, not anovulation. Therefore I may be more lenient with the use of ablation in this situation.

I still have the same reservations about performing ablation in women with ongoing irregular bleeding: If patients continue to have irregular bleeding, which they often do, it can be difficult to evaluate the endometrial cavity due to scarring, even at the time of dilation and curettage. Therefore, if they have other risk factors for hyperplasia or endometrial cancer or have postmenopausal bleeding, I won’t offer them ablation.
Nancy Shumeyko, MD
Binghamton, New York

Dr. Sharp responds
I appreciate Dr. Shumeyko’s comments and concerns about endometrial sampling in patients with abnormal bleeding (specifically AUB-O)who may have endometrial scarring after endometrial ablation. This is one of the unsettling challenges of post-ablation bleeding that we must sometimes address. Unfortunately, this can occur even in patients who seem to be “ideal” candidates for endometrial ablation (AUB-E). With amenorrhea rates generally less than 50% with most ablative methods, this unintended consequence makes the levonorgestrel IUD look all the more appealing. Hence, I agree with Dr. Shumeyko, and would add that just because we can do something, doesn’t mean we should.

“HYSTEROTOMY INCISION AND REPAIR: MANY OPTIONS, MANY PERSONAL PREFERENCES”
ROBERT L. BARBIERI, MD (EDITORIAL; MARCH 2015)

The important question is how to repair the incision
I read with interest Dr. Barbieri’s March editorial about hysterotomy during cesarean delivery. In my opinion, the important question is not how to open but how to repair.

I cannot dictate or even encourage other surgeons to do as I do because our surgical skills differ. I create a bladder flap on primary cesarean sections out of habit, but I have performed a few without creating it, and without harming the patient.

Personally, I open the lower uterine segment sharply unless copious bleeding hampers my view. Most of the time, I can gain entrance to the uterine cavity without performing a concurrent amniotomy, which allows me to sharply perform the hystero­tomy without concern for injuring the fetus. If bleeding hampers my view, I do all the dissection bluntly.

Have I noticed a big difference one way or the other? Not at all.

It is my impression that a ­double-layered closure is beneficial to the patient. I close the hystero­tomy in this fashion even if the patient would not be a candidate for a trial of labor after cesarean in future pregnancies.

Maybe I am just lucky, but I only remember having injured 1 baby (a breech presentation fetus with severe oligohydramnios) since I finished my residency in 1986.
Tomas Hernandez, MD
Pasco, Washington

Dr. Barbieri responds
I respect Dr. Hernandez’s 30 years of clinical experience and appreciate his recommendations on opening and closing of the hysterotomy at cesarean delivery. My observation is that most US obstetricians close the hystero­tomy in 2 layers. Like Dr. Hernandez, I favor a double-layer closure even if the patient is not a candidate for a trial of labor in a future pregnancy.

ANSWERING YOUR CODING QUESTIONS
A reader recently requested assistance for a specific coding challenge. We’ve asked our reimbursement specialist, Melanie Witt, RN, CPC, COBGC, MA, to provide her insight.

How should we code when using CUSA on vulvar dysplasia?
I provide coding assistance for several ObGyn practices and have always found your Web site to be informative. My question concerns Current Procedural Terminology (CPT) coding for removal of vulvar dysplasia using the cavitron ultrasonic surgical aspirator. The device is used to remove diseased epithelium. Generally, acetic acid is applied to highlight the diseased area and the lesions are removed with the device. The aspirator also collects the removed tissue so that it can be sent to pathology. Silver sulfadiazine cream is applied to the areas treated, as in laser surgery. The treatment may take 10 to 15 minutes. Which code, 56620 or 56515, should be used to reflect the actual work involved?
Marie D. Pelino, CPC
Annapolis, Maryland

Ms. Witt responds
The clinical vignette that was used by the CPT Editorial Panel in valuing code 56620 (Vulvectomy simple; partial) reads¹:

The relative value units (RVUs) for this code are also fairly high at 14.86, and the procedure is designated as one that is performed in the hospital setting only. In addition, when valued, this procedure was assumed to represent 45 minutes of intraservice time (that is, the time for the actual surgery), and 56620 has a 90-day global period.

In contrast, 56515 (Destruction of lesion[s], vulva; extensive [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery]) can be performed either in the facility or office setting and represents extensive destruction of tissue. In some cases, the physician may take a sample of tissue prior to the destruction, but this would be considered included in the destruction and not separately reportable, as the destruction represents the most extensive procedure. The clinical vignette used to value this code reads¹:

The RVUs for this procedure are less at 5.75 in the facility setting and 6.45 in the office setting, but the intraservice time is also less than with 56620.

Given your description of the procedure in this case, I would consider 56515 to be the most correct code to report for this surgery.

Reference
1. American Medical Association. RBRVS DataManager Online. AMA Store Web site. https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod280002&navAction =push. Accessed March 17, 2015.

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

“UPDATE ON ABNORMAL UTERINE BLEEDING”
HOWARD T. SHARP, MD (MARCH 2015)

Still having reservations about ablation
We discussed Dr. Sharp’s update on abnormal uterine bleeding (AUB) at a recent clinical meeting in my office. I have long told my nurse practition-ers that I am not in favor of ablation for AUB associated with ovulatory dysfunction (AUB-O). I learned from recent recertification reading that the risks for failure of ablation are dysmenorrhea, tubal ligation, and obesity, not anovulation. Therefore I may be more lenient with the use of ablation in this situation.

I still have the same reservations about performing ablation in women with ongoing irregular bleeding: If patients continue to have irregular bleeding, which they often do, it can be difficult to evaluate the endometrial cavity due to scarring, even at the time of dilation and curettage. Therefore, if they have other risk factors for hyperplasia or endometrial cancer or have postmenopausal bleeding, I won’t offer them ablation.
Nancy Shumeyko, MD
Binghamton, New York

Dr. Sharp responds
I appreciate Dr. Shumeyko’s comments and concerns about endometrial sampling in patients with abnormal bleeding (specifically AUB-O)who may have endometrial scarring after endometrial ablation. This is one of the unsettling challenges of post-ablation bleeding that we must sometimes address. Unfortunately, this can occur even in patients who seem to be “ideal” candidates for endometrial ablation (AUB-E). With amenorrhea rates generally less than 50% with most ablative methods, this unintended consequence makes the levonorgestrel IUD look all the more appealing. Hence, I agree with Dr. Shumeyko, and would add that just because we can do something, doesn’t mean we should.

“HYSTEROTOMY INCISION AND REPAIR: MANY OPTIONS, MANY PERSONAL PREFERENCES”
ROBERT L. BARBIERI, MD (EDITORIAL; MARCH 2015)

The important question is how to repair the incision
I read with interest Dr. Barbieri’s March editorial about hysterotomy during cesarean delivery. In my opinion, the important question is not how to open but how to repair.

I cannot dictate or even encourage other surgeons to do as I do because our surgical skills differ. I create a bladder flap on primary cesarean sections out of habit, but I have performed a few without creating it, and without harming the patient.

Personally, I open the lower uterine segment sharply unless copious bleeding hampers my view. Most of the time, I can gain entrance to the uterine cavity without performing a concurrent amniotomy, which allows me to sharply perform the hystero­tomy without concern for injuring the fetus. If bleeding hampers my view, I do all the dissection bluntly.

Have I noticed a big difference one way or the other? Not at all.

It is my impression that a ­double-layered closure is beneficial to the patient. I close the hystero­tomy in this fashion even if the patient would not be a candidate for a trial of labor after cesarean in future pregnancies.

Maybe I am just lucky, but I only remember having injured 1 baby (a breech presentation fetus with severe oligohydramnios) since I finished my residency in 1986.
Tomas Hernandez, MD
Pasco, Washington

Dr. Barbieri responds
I respect Dr. Hernandez’s 30 years of clinical experience and appreciate his recommendations on opening and closing of the hysterotomy at cesarean delivery. My observation is that most US obstetricians close the hystero­tomy in 2 layers. Like Dr. Hernandez, I favor a double-layer closure even if the patient is not a candidate for a trial of labor in a future pregnancy.

ANSWERING YOUR CODING QUESTIONS
A reader recently requested assistance for a specific coding challenge. We’ve asked our reimbursement specialist, Melanie Witt, RN, CPC, COBGC, MA, to provide her insight.

How should we code when using CUSA on vulvar dysplasia?
I provide coding assistance for several ObGyn practices and have always found your Web site to be informative. My question concerns Current Procedural Terminology (CPT) coding for removal of vulvar dysplasia using the cavitron ultrasonic surgical aspirator. The device is used to remove diseased epithelium. Generally, acetic acid is applied to highlight the diseased area and the lesions are removed with the device. The aspirator also collects the removed tissue so that it can be sent to pathology. Silver sulfadiazine cream is applied to the areas treated, as in laser surgery. The treatment may take 10 to 15 minutes. Which code, 56620 or 56515, should be used to reflect the actual work involved?
Marie D. Pelino, CPC
Annapolis, Maryland

Ms. Witt responds
The clinical vignette that was used by the CPT Editorial Panel in valuing code 56620 (Vulvectomy simple; partial) reads¹:

The relative value units (RVUs) for this code are also fairly high at 14.86, and the procedure is designated as one that is performed in the hospital setting only. In addition, when valued, this procedure was assumed to represent 45 minutes of intraservice time (that is, the time for the actual surgery), and 56620 has a 90-day global period.

In contrast, 56515 (Destruction of lesion[s], vulva; extensive [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery]) can be performed either in the facility or office setting and represents extensive destruction of tissue. In some cases, the physician may take a sample of tissue prior to the destruction, but this would be considered included in the destruction and not separately reportable, as the destruction represents the most extensive procedure. The clinical vignette used to value this code reads¹:

The RVUs for this procedure are less at 5.75 in the facility setting and 6.45 in the office setting, but the intraservice time is also less than with 56620.

Given your description of the procedure in this case, I would consider 56515 to be the most correct code to report for this surgery.

Reference
1. American Medical Association. RBRVS DataManager Online. AMA Store Web site. https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod280002&navAction =push. Accessed March 17, 2015.

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

As a profession, I think it’s fair to say that dermatology has done a good job welcoming women and including them into this field of medicine. But how many of your physician colleagues are African Americans? How many are Latinos or Latinas?

Does the diversity of your clinician colleagues reflect our patient population? The 2013 census shows that 13.2% of Americans are African American and 17.1% are Latino. Because these populations are not represented in medicine at anything like these percentages, African American and Latino physicians are referred to as underrepresented in medicine (UIM).

A brochure for an upcoming medical conference states that by 2050, “half of the U.S. population will have skin of color.” This may well become a fact. But I argue that a professional workforce that is as diverse as the population we care for is a much better workforce.

I serve as the interim dean of the University of California, San Francisco (UCSF) School of Medicine, which is one of the great medical schools in the United States. The school has 632 students – 26% from underrepresented minorities, and 56% women – the most diverse student group in California and perhaps the United States. There are 2,180 full-time faculty members but less than 2% are underrepresented in medicine. The annual operating budget is more than $2 billion and the school is No. 1 in National Institutes of Health funding. But there are some important shortcomings.

Three things happened after I took the job as interim dean last year. First, the accrediting body of medical schools, the Liaison Committee on Medical Education, served us with a citation for our hiring practices and the lack of diversity among our faculty.

Second, I ran into something called the “climate survey.” We have all heard about climate change, but have you heard of a “climate survey”? No, it’s not an opportunity to complain about too much snow in Boston and too little water in San Francisco. People on every University of California campus were asked if they felt included in the organization that they worked in. Did they feel comfortable? Did they feel part of the club?

The UC survey found that at UCSF and its sister institutions, people from groups underrepresented in medicine – mainly Hispanics and African Americans, whether they were faculty, staff, or students – felt less comfortable than did their white counterparts. They did not feel our climate was inclusive. That’s not the same as being specifically excluded. It’s about not being included.

Third, there were the racially charged events in Ferguson, Missouri, and in Staten Island, New York, and the way our students responded to them. On December 9, 2014, our students organized a “die-in” protest to demonstrate their concern about racism in health care in our country. They called it WhiteCoats4BlackLives. So here I was, the dean of a medical school, and I find all of our students lying down in the street on campus in a very peaceful but profoundly moving demonstration to protest racism. Not only did our students protest at UCSF, they instigated the same WhiteCoats4BlackLives protest simultaneously at 83 medical schools across the country.

I recalled my own student days when we protested public events, and university administrators responded. But this time, as dean of medicine, I was the administrator. It gave me pause to think: What did those three pieces of evidence tell me? They made it clear that race matters. Once that realization finally became clear to me, the question was, what do we do? We were a few weeks away from our annual leadership retreat. The topic was going to be “strategic partnerships.” I sat down with the vice deans and said: Let’s talk about race instead.

And we did, and it turned into an amazing discussion. Just one example: Before the retreat, all of us took the Implicit Associations Test for race. This is a test designed to detect unconscious bias, the kind of bias we are not even aware of. Like me, many of us who considered ourselves fair and unbiased were shocked at the results. We were unconsciously biased for white people and against people of color.

Nicholas Kristof talked about this in the Feb. 21, 2015, edition of The New York Times, in a piece called “Straight Talk for White Men.” It’s worth reading the whole piece, but a study he cited especially struck me. Two scholars sent out fictitious résumés in response to help-wanted ads. Each résumé was given a name that sounded stereotypically black or white. The résumés were otherwise the same.

A résumé with a name like Emily or Greg received 50% more callbacks than the same résumé with a name like Lakisha or Jamal. Having a white-sounding name was more beneficial than 8 years’ work experience.

We heard stories from our students and faculty of color. I will highlight two. A medical student of color was called to the ED and was stopped by a nurse who thought he was a custodian. A senior faculty member was returning to his alma mater medical school in North Carolina as a visiting professor and was traveling from the airport to the medical school in a rental car. He was stopped and detained because he was black. His hosts came to his rescue and were required to prove that he was indeed visiting at their invitation. Needless to say these and other stories were startling in 2015. America is not post racial.

As a result of the retreat, we are now finishing a plan to make UCSF an inclusive institution for all who work here. The plan includes both short- and long-term elements, and an investment of at least $10 million to recruit and develop faculty from populations that are underrepresented in medicine.

Today’s doctor-patient relationship has become more and more collaborative. Patients actively look for doctors whom they feel they can talk to, who will understand their special concerns, their background, and their culture. There is neuroscience behind this. Research by Mahzarin Banaji, the coauthor of “Blind Spot,” found that we are in fact wired to react more positively to someone who looks like us.

All of us probably understand why a woman might want to choose a female gynecologist. Why a Chinese family will prefer a doctor who speaks their language. Our patients, too, are looking for physicians, for dermatologists, whose skin reflects theirs. They feel better if their doctor looks more like them.

The website Blackdermatologists.org is meant to help patients find exactly that. Guess how many black dermatologists are listed there in the whole State of California. Three. None of them are in San Francisco. None of them are across the bay in Oakland, a city with a large African American population. I did some research via other websites and found one African American dermatologist in the East Bay.

It’s one thing to be underrepresented in medicine, it’s another thing to be unrepresented. The lack of access to a physician who looks like our patients, whose background and experience might reflect theirs, is crucial. But what about the lack of research focused on African Americans, Latinos, and other underrepresented populations by people who understand the culture from the inside and what questions to ask?

I came across such an example in JAMA Dermatology, in an study titled, “Hair Care Practices as a Barrier to Physical Activity in African American Women” (JAMA Dermatol. 2013;149:310-4). My first reaction to this article was “what?” But that’s my unconscious bias talking. In fact, this study points to something significant. We know regular exercise is important for health. Research shows that African American women are the least likely to meet recommended levels of physical activity. Therefore, we want to be aware of any barriers to exercise for that population. But who would have imagined that one of the barriers to exercise for black women was hair care? This never would have occurred to me.

The people who did think to investigate this were in a team led by and including African American women dermatologists and researchers. So now that this is a known barrier, it can be addressed with patients. This is just one example of the type of knowledge we gain if we have a more diverse group of physicians and clinical researchers.

We know we don’t have enough practicing physicians of color in medicine in general, and in dermatology in particular. We easily fall back to the pipeline as the excuse for the situation. So, let’s look at the pipeline. Unfortunately, the current numbers are not encouraging. According to data from the Association of American Medical Colleges, from 1980 to 2013 the number of applicants to U.S. medical schools rose by 4,296. In 1980, 2,507 applicants were African American/black (7.1%), but by 2013 that number only rose to 3,490 (8.8%). During that same time period the number of Hispanic/Latino applicants rose from 5% to 10%.

How many of the applicants entered medical school? From 1980 to 2013 the number of African American/black students rose by 235: from 999 to 1,234, or 6.5% to 7%. At the same time, Hispanic/Latino students rose from 5.2% to 10.6% of entering students.

How many of the applicants matriculated? In 1980, 39.4% of African American/black applicants matriculated, but in 2013 the rate fell to 35%. What explains the data? Lack of role models? Lack of qualifications? Unconscious bias? An exclusive climate? Continued racism in our country? I don’t pretend to know the answer, but we always fall back on the pipeline as the excuse for the situation. So, what are we going to do about the pipeline?

Given the current state of the pipeline, the question may not be “what is the ideal” but “what is an achievable goal for dermatology?” In 2014, 47 of 731 applicants to dermatology programs were African American and another 47 were Latino. I don’t know how many of these finally matched, but only 6.4% of the applicants were either African American or Latino. This is well below their representation in the population at large.

There may be many reasons why physicians of color are not choosing dermatology as a specialty. Not surprisingly, many of them go into primary care. There is nothing wrong with that. You could argue that having African American and Latino doctors in primary care is where they are most needed, where personal relationships are most crucial. But that should not be an argument against trying to improve the general pipeline and diversify our own specialty pipeline. One goal could be to double the annual number of UIM applicants. I think this is achievable and would have an impact.

Here’s how we might get there. For those of us who are involved in the training of new dermatologists, we have to “lean forward.” Instead of receiving those who choose to come to us, we have to reach out to them. We have to engage, mentor, and ask questions. Find out about hidden bias, your own and others. Understand how your organization or institution can be enriched by having a more diverse pool of learners and leaders.

For those of you who are in practice, there is something you can do as well: You can plant a seed. You all see young people with skin problems. Many of them are and will be from underrepresented populations. Some of them may strike you as particularly bright and lively. So when you have the opportunity to talk to such a bright young woman or young man, ask, “Have you ever thought about becoming a doctor?” And if that strikes a spark, ask, “Have you thought about becoming a dermatologist?” Do this twice a day, 10 times a week, and 500 times each year.

If you do only that, whenever you have an opportunity, you may just plant a few seeds that will make a difference down the line. You will never know the outcome, but it’s worth doing. There’s no downside.

For those of you who are involved in organizations such as the American Academy of Dermatology or the Dermatology Foundation, what can the leadership in our field do? Think about mentorship, role models, scholarships, outreach, and pipeline programs. Think about recruiting colleagues who are UIMs into leadership positions. Let’s be the most inclusive specialty in medicine.

Ultimately, our goal is to have a workforce that mirrors our population. I know this is not achievable in the short term. It will take decades. But this will never occur if we don’t take the first step. To ensure the future of dermatology, let’s all lean forward and embrace this task. Diversity matters in medicine.

A board-certified dermatologist, Dr. Bruce U. Wintroub is interim dean of the University of California, San Francisco School of Medicine. He has been professor and chair of the department of dermatology at UCSF since 1985. This text was extracted from a plenary presentation he delivered at the 2015 annual meeting of the American Academy of Dermatology meeting in San Francisco.

As a profession, I think it’s fair to say that dermatology has done a good job welcoming women and including them into this field of medicine. But how many of your physician colleagues are African Americans? How many are Latinos or Latinas?

Does the diversity of your clinician colleagues reflect our patient population? The 2013 census shows that 13.2% of Americans are African American and 17.1% are Latino. Because these populations are not represented in medicine at anything like these percentages, African American and Latino physicians are referred to as underrepresented in medicine (UIM).

A brochure for an upcoming medical conference states that by 2050, “half of the U.S. population will have skin of color.” This may well become a fact. But I argue that a professional workforce that is as diverse as the population we care for is a much better workforce.

I serve as the interim dean of the University of California, San Francisco (UCSF) School of Medicine, which is one of the great medical schools in the United States. The school has 632 students – 26% from underrepresented minorities, and 56% women – the most diverse student group in California and perhaps the United States. There are 2,180 full-time faculty members but less than 2% are underrepresented in medicine. The annual operating budget is more than $2 billion and the school is No. 1 in National Institutes of Health funding. But there are some important shortcomings.

Three things happened after I took the job as interim dean last year. First, the accrediting body of medical schools, the Liaison Committee on Medical Education, served us with a citation for our hiring practices and the lack of diversity among our faculty.

Second, I ran into something called the “climate survey.” We have all heard about climate change, but have you heard of a “climate survey”? No, it’s not an opportunity to complain about too much snow in Boston and too little water in San Francisco. People on every University of California campus were asked if they felt included in the organization that they worked in. Did they feel comfortable? Did they feel part of the club?

The UC survey found that at UCSF and its sister institutions, people from groups underrepresented in medicine – mainly Hispanics and African Americans, whether they were faculty, staff, or students – felt less comfortable than did their white counterparts. They did not feel our climate was inclusive. That’s not the same as being specifically excluded. It’s about not being included.

Third, there were the racially charged events in Ferguson, Missouri, and in Staten Island, New York, and the way our students responded to them. On December 9, 2014, our students organized a “die-in” protest to demonstrate their concern about racism in health care in our country. They called it WhiteCoats4BlackLives. So here I was, the dean of a medical school, and I find all of our students lying down in the street on campus in a very peaceful but profoundly moving demonstration to protest racism. Not only did our students protest at UCSF, they instigated the same WhiteCoats4BlackLives protest simultaneously at 83 medical schools across the country.

I recalled my own student days when we protested public events, and university administrators responded. But this time, as dean of medicine, I was the administrator. It gave me pause to think: What did those three pieces of evidence tell me? They made it clear that race matters. Once that realization finally became clear to me, the question was, what do we do? We were a few weeks away from our annual leadership retreat. The topic was going to be “strategic partnerships.” I sat down with the vice deans and said: Let’s talk about race instead.

And we did, and it turned into an amazing discussion. Just one example: Before the retreat, all of us took the Implicit Associations Test for race. This is a test designed to detect unconscious bias, the kind of bias we are not even aware of. Like me, many of us who considered ourselves fair and unbiased were shocked at the results. We were unconsciously biased for white people and against people of color.

Nicholas Kristof talked about this in the Feb. 21, 2015, edition of The New York Times, in a piece called “Straight Talk for White Men.” It’s worth reading the whole piece, but a study he cited especially struck me. Two scholars sent out fictitious résumés in response to help-wanted ads. Each résumé was given a name that sounded stereotypically black or white. The résumés were otherwise the same.

A résumé with a name like Emily or Greg received 50% more callbacks than the same résumé with a name like Lakisha or Jamal. Having a white-sounding name was more beneficial than 8 years’ work experience.

We heard stories from our students and faculty of color. I will highlight two. A medical student of color was called to the ED and was stopped by a nurse who thought he was a custodian. A senior faculty member was returning to his alma mater medical school in North Carolina as a visiting professor and was traveling from the airport to the medical school in a rental car. He was stopped and detained because he was black. His hosts came to his rescue and were required to prove that he was indeed visiting at their invitation. Needless to say these and other stories were startling in 2015. America is not post racial.

As a result of the retreat, we are now finishing a plan to make UCSF an inclusive institution for all who work here. The plan includes both short- and long-term elements, and an investment of at least $10 million to recruit and develop faculty from populations that are underrepresented in medicine.

Today’s doctor-patient relationship has become more and more collaborative. Patients actively look for doctors whom they feel they can talk to, who will understand their special concerns, their background, and their culture. There is neuroscience behind this. Research by Mahzarin Banaji, the coauthor of “Blind Spot,” found that we are in fact wired to react more positively to someone who looks like us.

All of us probably understand why a woman might want to choose a female gynecologist. Why a Chinese family will prefer a doctor who speaks their language. Our patients, too, are looking for physicians, for dermatologists, whose skin reflects theirs. They feel better if their doctor looks more like them.

The website Blackdermatologists.org is meant to help patients find exactly that. Guess how many black dermatologists are listed there in the whole State of California. Three. None of them are in San Francisco. None of them are across the bay in Oakland, a city with a large African American population. I did some research via other websites and found one African American dermatologist in the East Bay.

It’s one thing to be underrepresented in medicine, it’s another thing to be unrepresented. The lack of access to a physician who looks like our patients, whose background and experience might reflect theirs, is crucial. But what about the lack of research focused on African Americans, Latinos, and other underrepresented populations by people who understand the culture from the inside and what questions to ask?

I came across such an example in JAMA Dermatology, in an study titled, “Hair Care Practices as a Barrier to Physical Activity in African American Women” (JAMA Dermatol. 2013;149:310-4). My first reaction to this article was “what?” But that’s my unconscious bias talking. In fact, this study points to something significant. We know regular exercise is important for health. Research shows that African American women are the least likely to meet recommended levels of physical activity. Therefore, we want to be aware of any barriers to exercise for that population. But who would have imagined that one of the barriers to exercise for black women was hair care? This never would have occurred to me.

The people who did think to investigate this were in a team led by and including African American women dermatologists and researchers. So now that this is a known barrier, it can be addressed with patients. This is just one example of the type of knowledge we gain if we have a more diverse group of physicians and clinical researchers.

We know we don’t have enough practicing physicians of color in medicine in general, and in dermatology in particular. We easily fall back to the pipeline as the excuse for the situation. So, let’s look at the pipeline. Unfortunately, the current numbers are not encouraging. According to data from the Association of American Medical Colleges, from 1980 to 2013 the number of applicants to U.S. medical schools rose by 4,296. In 1980, 2,507 applicants were African American/black (7.1%), but by 2013 that number only rose to 3,490 (8.8%). During that same time period the number of Hispanic/Latino applicants rose from 5% to 10%.

How many of the applicants entered medical school? From 1980 to 2013 the number of African American/black students rose by 235: from 999 to 1,234, or 6.5% to 7%. At the same time, Hispanic/Latino students rose from 5.2% to 10.6% of entering students.

How many of the applicants matriculated? In 1980, 39.4% of African American/black applicants matriculated, but in 2013 the rate fell to 35%. What explains the data? Lack of role models? Lack of qualifications? Unconscious bias? An exclusive climate? Continued racism in our country? I don’t pretend to know the answer, but we always fall back on the pipeline as the excuse for the situation. So, what are we going to do about the pipeline?

Given the current state of the pipeline, the question may not be “what is the ideal” but “what is an achievable goal for dermatology?” In 2014, 47 of 731 applicants to dermatology programs were African American and another 47 were Latino. I don’t know how many of these finally matched, but only 6.4% of the applicants were either African American or Latino. This is well below their representation in the population at large.

There may be many reasons why physicians of color are not choosing dermatology as a specialty. Not surprisingly, many of them go into primary care. There is nothing wrong with that. You could argue that having African American and Latino doctors in primary care is where they are most needed, where personal relationships are most crucial. But that should not be an argument against trying to improve the general pipeline and diversify our own specialty pipeline. One goal could be to double the annual number of UIM applicants. I think this is achievable and would have an impact.

Here’s how we might get there. For those of us who are involved in the training of new dermatologists, we have to “lean forward.” Instead of receiving those who choose to come to us, we have to reach out to them. We have to engage, mentor, and ask questions. Find out about hidden bias, your own and others. Understand how your organization or institution can be enriched by having a more diverse pool of learners and leaders.

For those of you who are in practice, there is something you can do as well: You can plant a seed. You all see young people with skin problems. Many of them are and will be from underrepresented populations. Some of them may strike you as particularly bright and lively. So when you have the opportunity to talk to such a bright young woman or young man, ask, “Have you ever thought about becoming a doctor?” And if that strikes a spark, ask, “Have you thought about becoming a dermatologist?” Do this twice a day, 10 times a week, and 500 times each year.

If you do only that, whenever you have an opportunity, you may just plant a few seeds that will make a difference down the line. You will never know the outcome, but it’s worth doing. There’s no downside.

For those of you who are involved in organizations such as the American Academy of Dermatology or the Dermatology Foundation, what can the leadership in our field do? Think about mentorship, role models, scholarships, outreach, and pipeline programs. Think about recruiting colleagues who are UIMs into leadership positions. Let’s be the most inclusive specialty in medicine.

Ultimately, our goal is to have a workforce that mirrors our population. I know this is not achievable in the short term. It will take decades. But this will never occur if we don’t take the first step. To ensure the future of dermatology, let’s all lean forward and embrace this task. Diversity matters in medicine.

A board-certified dermatologist, Dr. Bruce U. Wintroub is interim dean of the University of California, San Francisco School of Medicine. He has been professor and chair of the department of dermatology at UCSF since 1985. This text was extracted from a plenary presentation he delivered at the 2015 annual meeting of the American Academy of Dermatology meeting in San Francisco.

As a profession, I think it’s fair to say that dermatology has done a good job welcoming women and including them into this field of medicine. But how many of your physician colleagues are African Americans? How many are Latinos or Latinas?

Does the diversity of your clinician colleagues reflect our patient population? The 2013 census shows that 13.2% of Americans are African American and 17.1% are Latino. Because these populations are not represented in medicine at anything like these percentages, African American and Latino physicians are referred to as underrepresented in medicine (UIM).

A brochure for an upcoming medical conference states that by 2050, “half of the U.S. population will have skin of color.” This may well become a fact. But I argue that a professional workforce that is as diverse as the population we care for is a much better workforce.

I serve as the interim dean of the University of California, San Francisco (UCSF) School of Medicine, which is one of the great medical schools in the United States. The school has 632 students – 26% from underrepresented minorities, and 56% women – the most diverse student group in California and perhaps the United States. There are 2,180 full-time faculty members but less than 2% are underrepresented in medicine. The annual operating budget is more than $2 billion and the school is No. 1 in National Institutes of Health funding. But there are some important shortcomings.

Three things happened after I took the job as interim dean last year. First, the accrediting body of medical schools, the Liaison Committee on Medical Education, served us with a citation for our hiring practices and the lack of diversity among our faculty.

Second, I ran into something called the “climate survey.” We have all heard about climate change, but have you heard of a “climate survey”? No, it’s not an opportunity to complain about too much snow in Boston and too little water in San Francisco. People on every University of California campus were asked if they felt included in the organization that they worked in. Did they feel comfortable? Did they feel part of the club?

The UC survey found that at UCSF and its sister institutions, people from groups underrepresented in medicine – mainly Hispanics and African Americans, whether they were faculty, staff, or students – felt less comfortable than did their white counterparts. They did not feel our climate was inclusive. That’s not the same as being specifically excluded. It’s about not being included.

Third, there were the racially charged events in Ferguson, Missouri, and in Staten Island, New York, and the way our students responded to them. On December 9, 2014, our students organized a “die-in” protest to demonstrate their concern about racism in health care in our country. They called it WhiteCoats4BlackLives. So here I was, the dean of a medical school, and I find all of our students lying down in the street on campus in a very peaceful but profoundly moving demonstration to protest racism. Not only did our students protest at UCSF, they instigated the same WhiteCoats4BlackLives protest simultaneously at 83 medical schools across the country.

I recalled my own student days when we protested public events, and university administrators responded. But this time, as dean of medicine, I was the administrator. It gave me pause to think: What did those three pieces of evidence tell me? They made it clear that race matters. Once that realization finally became clear to me, the question was, what do we do? We were a few weeks away from our annual leadership retreat. The topic was going to be “strategic partnerships.” I sat down with the vice deans and said: Let’s talk about race instead.

And we did, and it turned into an amazing discussion. Just one example: Before the retreat, all of us took the Implicit Associations Test for race. This is a test designed to detect unconscious bias, the kind of bias we are not even aware of. Like me, many of us who considered ourselves fair and unbiased were shocked at the results. We were unconsciously biased for white people and against people of color.

Nicholas Kristof talked about this in the Feb. 21, 2015, edition of The New York Times, in a piece called “Straight Talk for White Men.” It’s worth reading the whole piece, but a study he cited especially struck me. Two scholars sent out fictitious résumés in response to help-wanted ads. Each résumé was given a name that sounded stereotypically black or white. The résumés were otherwise the same.

A résumé with a name like Emily or Greg received 50% more callbacks than the same résumé with a name like Lakisha or Jamal. Having a white-sounding name was more beneficial than 8 years’ work experience.

We heard stories from our students and faculty of color. I will highlight two. A medical student of color was called to the ED and was stopped by a nurse who thought he was a custodian. A senior faculty member was returning to his alma mater medical school in North Carolina as a visiting professor and was traveling from the airport to the medical school in a rental car. He was stopped and detained because he was black. His hosts came to his rescue and were required to prove that he was indeed visiting at their invitation. Needless to say these and other stories were startling in 2015. America is not post racial.

As a result of the retreat, we are now finishing a plan to make UCSF an inclusive institution for all who work here. The plan includes both short- and long-term elements, and an investment of at least $10 million to recruit and develop faculty from populations that are underrepresented in medicine.

Today’s doctor-patient relationship has become more and more collaborative. Patients actively look for doctors whom they feel they can talk to, who will understand their special concerns, their background, and their culture. There is neuroscience behind this. Research by Mahzarin Banaji, the coauthor of “Blind Spot,” found that we are in fact wired to react more positively to someone who looks like us.

All of us probably understand why a woman might want to choose a female gynecologist. Why a Chinese family will prefer a doctor who speaks their language. Our patients, too, are looking for physicians, for dermatologists, whose skin reflects theirs. They feel better if their doctor looks more like them.

The website Blackdermatologists.org is meant to help patients find exactly that. Guess how many black dermatologists are listed there in the whole State of California. Three. None of them are in San Francisco. None of them are across the bay in Oakland, a city with a large African American population. I did some research via other websites and found one African American dermatologist in the East Bay.

It’s one thing to be underrepresented in medicine, it’s another thing to be unrepresented. The lack of access to a physician who looks like our patients, whose background and experience might reflect theirs, is crucial. But what about the lack of research focused on African Americans, Latinos, and other underrepresented populations by people who understand the culture from the inside and what questions to ask?

I came across such an example in JAMA Dermatology, in an study titled, “Hair Care Practices as a Barrier to Physical Activity in African American Women” (JAMA Dermatol. 2013;149:310-4). My first reaction to this article was “what?” But that’s my unconscious bias talking. In fact, this study points to something significant. We know regular exercise is important for health. Research shows that African American women are the least likely to meet recommended levels of physical activity. Therefore, we want to be aware of any barriers to exercise for that population. But who would have imagined that one of the barriers to exercise for black women was hair care? This never would have occurred to me.

The people who did think to investigate this were in a team led by and including African American women dermatologists and researchers. So now that this is a known barrier, it can be addressed with patients. This is just one example of the type of knowledge we gain if we have a more diverse group of physicians and clinical researchers.

We know we don’t have enough practicing physicians of color in medicine in general, and in dermatology in particular. We easily fall back to the pipeline as the excuse for the situation. So, let’s look at the pipeline. Unfortunately, the current numbers are not encouraging. According to data from the Association of American Medical Colleges, from 1980 to 2013 the number of applicants to U.S. medical schools rose by 4,296. In 1980, 2,507 applicants were African American/black (7.1%), but by 2013 that number only rose to 3,490 (8.8%). During that same time period the number of Hispanic/Latino applicants rose from 5% to 10%.

How many of the applicants entered medical school? From 1980 to 2013 the number of African American/black students rose by 235: from 999 to 1,234, or 6.5% to 7%. At the same time, Hispanic/Latino students rose from 5.2% to 10.6% of entering students.

How many of the applicants matriculated? In 1980, 39.4% of African American/black applicants matriculated, but in 2013 the rate fell to 35%. What explains the data? Lack of role models? Lack of qualifications? Unconscious bias? An exclusive climate? Continued racism in our country? I don’t pretend to know the answer, but we always fall back on the pipeline as the excuse for the situation. So, what are we going to do about the pipeline?

Given the current state of the pipeline, the question may not be “what is the ideal” but “what is an achievable goal for dermatology?” In 2014, 47 of 731 applicants to dermatology programs were African American and another 47 were Latino. I don’t know how many of these finally matched, but only 6.4% of the applicants were either African American or Latino. This is well below their representation in the population at large.

There may be many reasons why physicians of color are not choosing dermatology as a specialty. Not surprisingly, many of them go into primary care. There is nothing wrong with that. You could argue that having African American and Latino doctors in primary care is where they are most needed, where personal relationships are most crucial. But that should not be an argument against trying to improve the general pipeline and diversify our own specialty pipeline. One goal could be to double the annual number of UIM applicants. I think this is achievable and would have an impact.

Here’s how we might get there. For those of us who are involved in the training of new dermatologists, we have to “lean forward.” Instead of receiving those who choose to come to us, we have to reach out to them. We have to engage, mentor, and ask questions. Find out about hidden bias, your own and others. Understand how your organization or institution can be enriched by having a more diverse pool of learners and leaders.

For those of you who are in practice, there is something you can do as well: You can plant a seed. You all see young people with skin problems. Many of them are and will be from underrepresented populations. Some of them may strike you as particularly bright and lively. So when you have the opportunity to talk to such a bright young woman or young man, ask, “Have you ever thought about becoming a doctor?” And if that strikes a spark, ask, “Have you thought about becoming a dermatologist?” Do this twice a day, 10 times a week, and 500 times each year.

If you do only that, whenever you have an opportunity, you may just plant a few seeds that will make a difference down the line. You will never know the outcome, but it’s worth doing. There’s no downside.

For those of you who are involved in organizations such as the American Academy of Dermatology or the Dermatology Foundation, what can the leadership in our field do? Think about mentorship, role models, scholarships, outreach, and pipeline programs. Think about recruiting colleagues who are UIMs into leadership positions. Let’s be the most inclusive specialty in medicine.

Ultimately, our goal is to have a workforce that mirrors our population. I know this is not achievable in the short term. It will take decades. But this will never occur if we don’t take the first step. To ensure the future of dermatology, let’s all lean forward and embrace this task. Diversity matters in medicine.

A board-certified dermatologist, Dr. Bruce U. Wintroub is interim dean of the University of California, San Francisco School of Medicine. He has been professor and chair of the department of dermatology at UCSF since 1985. This text was extracted from a plenary presentation he delivered at the 2015 annual meeting of the American Academy of Dermatology meeting in San Francisco.

It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.

Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.

©Fuse/thinkstockphotos.com

But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?

The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.

Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.

Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.

Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.

In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.

Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.

In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.

Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.

For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.

However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.

Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.

Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at [email protected].

It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.

Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.

©Fuse/thinkstockphotos.com

But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?

The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.

Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.

Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.

Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.

In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.

Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.

In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.

Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.

For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.

However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.

Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.

Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at [email protected].

It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.

Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.

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But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?

The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.

Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.

Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.

Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.

In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.

Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.

In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.

Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.

For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.

However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.

Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.

Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at [email protected].