Commentary

Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.

Case Summary

Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.

Discussion

Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.

The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.

Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.

The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.

The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.

Case follow-up

Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.

Case Summary

Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.

Discussion

Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.

The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.

Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.

The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.

The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.

Case follow-up

Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.

Case Summary

Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.

Discussion

Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.

The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.

Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.

The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.

The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.

Case follow-up

Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

When doctors become patients, the experience forces us to better our ability to practice the art of medicine because we gain more empathy and are able to relate to our patients’ feelings on a different level.

It’s one thing to read about the conditions we treat, and quite another when we are the ones lying flat on our backs looking up at the faces of complete strangers whom we are expected to trust for compassionate, competent, and sometimes life-altering care.

One of my first brushes with walking in my patients’ shoes was undergoing an MRI. Patients’ concerns that I had considered irrational and unfounded became understandable as I lay in the machine, unable to see anything but the inside of a tube or to move more than a few inches in any direction. All I could hear was the incessant, loud clicking of the machine as it took image after image. Alone with my thoughts, and the uncertainty of the test results, I could truly empathize with my patients’ anxieties about the procedure.

If you have never personally experienced a significant illness, I strongly recommend watching a movie called “The Doctor.” Early in my career, I remember watching this movie and it had a profound impact, the next best thing to getting sick myself, so to speak. The main character, played by William Hurt, is a brilliant, albeit insensitive doctor who is diagnosed with cancer and forced to deal in his most vulnerable state with the frustration of an inefficient medical system. Perhaps most intriguing, he is confronted head on with his own mortality and must seemingly place his trust in the hands of another brilliant and cold clinician. The result is a moving storyline; if you have never been seriously ill, this movie might just forever change your practice style.

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

When doctors become patients, the experience forces us to better our ability to practice the art of medicine because we gain more empathy and are able to relate to our patients’ feelings on a different level.

It’s one thing to read about the conditions we treat, and quite another when we are the ones lying flat on our backs looking up at the faces of complete strangers whom we are expected to trust for compassionate, competent, and sometimes life-altering care.

One of my first brushes with walking in my patients’ shoes was undergoing an MRI. Patients’ concerns that I had considered irrational and unfounded became understandable as I lay in the machine, unable to see anything but the inside of a tube or to move more than a few inches in any direction. All I could hear was the incessant, loud clicking of the machine as it took image after image. Alone with my thoughts, and the uncertainty of the test results, I could truly empathize with my patients’ anxieties about the procedure.

If you have never personally experienced a significant illness, I strongly recommend watching a movie called “The Doctor.” Early in my career, I remember watching this movie and it had a profound impact, the next best thing to getting sick myself, so to speak. The main character, played by William Hurt, is a brilliant, albeit insensitive doctor who is diagnosed with cancer and forced to deal in his most vulnerable state with the frustration of an inefficient medical system. Perhaps most intriguing, he is confronted head on with his own mortality and must seemingly place his trust in the hands of another brilliant and cold clinician. The result is a moving storyline; if you have never been seriously ill, this movie might just forever change your practice style.

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

When doctors become patients, the experience forces us to better our ability to practice the art of medicine because we gain more empathy and are able to relate to our patients’ feelings on a different level.

It’s one thing to read about the conditions we treat, and quite another when we are the ones lying flat on our backs looking up at the faces of complete strangers whom we are expected to trust for compassionate, competent, and sometimes life-altering care.

One of my first brushes with walking in my patients’ shoes was undergoing an MRI. Patients’ concerns that I had considered irrational and unfounded became understandable as I lay in the machine, unable to see anything but the inside of a tube or to move more than a few inches in any direction. All I could hear was the incessant, loud clicking of the machine as it took image after image. Alone with my thoughts, and the uncertainty of the test results, I could truly empathize with my patients’ anxieties about the procedure.

If you have never personally experienced a significant illness, I strongly recommend watching a movie called “The Doctor.” Early in my career, I remember watching this movie and it had a profound impact, the next best thing to getting sick myself, so to speak. The main character, played by William Hurt, is a brilliant, albeit insensitive doctor who is diagnosed with cancer and forced to deal in his most vulnerable state with the frustration of an inefficient medical system. Perhaps most intriguing, he is confronted head on with his own mortality and must seemingly place his trust in the hands of another brilliant and cold clinician. The result is a moving storyline; if you have never been seriously ill, this movie might just forever change your practice style.

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

Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.

I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.

Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).

What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.

As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.

I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.

Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).

What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.

As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.

I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.

Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).

What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.

As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

The challenges in primary care are many, and one of increasing importance is what to say to vaccine refusers. After much debate and thoughtful discussion, my medical partner, Dr. Janet Casey at Legacy Pediatrics, decided that the practice would refuse to care for the refusers.

Over the years, I have accepted such patients into my practice and worked with them to gain their confidence and debunk the many myths about the safety of vaccination that are so visible on the Internet. The approach worked well, and by the time the children were 1 year of age, I cannot remember but a handful of parents who did not come around to realize that it was best to vaccinate. However, with the recent measles outbreak at Disneyland in California, pertussis at epidemic proportions in pockets of the United States and elsewhere in the world, and the antivaccine voices gaining more and more attention, I agree, it is time to take a stand.

When a family brings their unvaccinated or undervaccinated child into the waiting room of a physician’s practice, that family is potentially exposing others in that waiting room to serious infectious diseases – that is not fair. In the waiting room may well be a patient who is on chemotherapy or immunotherapy or otherwise immunocompromised, and he relies on the “herd immunity” achieved by vaccinations of those who can safely be vaccinated for individual protection and public health. Those patients who have weakened immune systems did not choose to have their medical condition, whereas the vaccine refusers are choosing not to vaccinate their child (or typically themselves as well). And the reasons they are choosing not to vaccinate are based on misrepresentation of medical facts, fabrications of safety concerns, long ago disproven speculations by well-meaning and not so well-meaning physicians and scientists, pseudoscience published in pseudoscientific journals, and/or general distrust of the federal government that mandates vaccinations for the good of the public health.

My personal experience with vaccine scares dates back to a time when whole-cell pertussis vaccine was the only pertussis vaccine available. I was a medical student, resident, and then an infectious diseases fellow during the escalating debate about the significant side effects of vaccines. I joined in the chorus of voices questioning the need for clear data on the problem, and then the pursuit of a safer acellular pertussis vaccine. The physician community and the public were ready for change, and the National Institutes of Health took the lead in organizing multiple studies and clinical trials leading to eventual replacement of the whole cell pertussis vaccine with the current acellular vaccines.

Much more recently, at the request of National Institutes of Health, I led studies of the safety of thimerosal preservative in multidose vaccine vials that appeared in the Lancet (2002;360:1737-41); Pediatrics (2008;121:e208-14) and the Journal of Pediatrics (2009;155:495-9). Using the data from those three studies, the World Health Organization (WHO), the United Nations, the Institute of Medicine, and other organizations were able to see that the metabolism and elimination from the body of ethylmercury in thimerosal was dramatically faster, compared with methylmercury in fish. Therefore, the presumption of possible accumulation of mercury in the body of infants receiving vaccines from multidose vials when such vaccines were closely spaced was disproven by scientific data.

In plain language, there was never a known risk from thimerosal, but a premature, hurried decision was made to mandate removal of thimerosal from vaccines given to children in the United States and western Europe; thereby the myth lives on that thimerosal is not safe. Yet thimerosal is safe, and the WHO continues to advocate use of thimerosal in multidose vaccine vials. Nevertheless, I have been criticized personally on the Internet for this work. The accusation is that I, the rest of the scientists who participated in the study, and the NIH oversight were biased because our academic institutions had previously received funding from vaccine companies to perform clinical and translational research. I received many hate e-mails and even a death threat.

To close this column with a sense of humor, I suggest you Google the responses by U.S. presidential hopefuls on their stand with regard to vaccine refusers. The comments, then the reversal and “corrections” to their comments is amusing. The presidential hopefuls quickly recognized that the right to choose may not be the best policy for the public health of American citizens. Refusing to vaccinate a child potentially harms the child and may harm others!

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures. E-mail him at [email protected].

The challenges in primary care are many, and one of increasing importance is what to say to vaccine refusers. After much debate and thoughtful discussion, my medical partner, Dr. Janet Casey at Legacy Pediatrics, decided that the practice would refuse to care for the refusers.

Over the years, I have accepted such patients into my practice and worked with them to gain their confidence and debunk the many myths about the safety of vaccination that are so visible on the Internet. The approach worked well, and by the time the children were 1 year of age, I cannot remember but a handful of parents who did not come around to realize that it was best to vaccinate. However, with the recent measles outbreak at Disneyland in California, pertussis at epidemic proportions in pockets of the United States and elsewhere in the world, and the antivaccine voices gaining more and more attention, I agree, it is time to take a stand.

When a family brings their unvaccinated or undervaccinated child into the waiting room of a physician’s practice, that family is potentially exposing others in that waiting room to serious infectious diseases – that is not fair. In the waiting room may well be a patient who is on chemotherapy or immunotherapy or otherwise immunocompromised, and he relies on the “herd immunity” achieved by vaccinations of those who can safely be vaccinated for individual protection and public health. Those patients who have weakened immune systems did not choose to have their medical condition, whereas the vaccine refusers are choosing not to vaccinate their child (or typically themselves as well). And the reasons they are choosing not to vaccinate are based on misrepresentation of medical facts, fabrications of safety concerns, long ago disproven speculations by well-meaning and not so well-meaning physicians and scientists, pseudoscience published in pseudoscientific journals, and/or general distrust of the federal government that mandates vaccinations for the good of the public health.

My personal experience with vaccine scares dates back to a time when whole-cell pertussis vaccine was the only pertussis vaccine available. I was a medical student, resident, and then an infectious diseases fellow during the escalating debate about the significant side effects of vaccines. I joined in the chorus of voices questioning the need for clear data on the problem, and then the pursuit of a safer acellular pertussis vaccine. The physician community and the public were ready for change, and the National Institutes of Health took the lead in organizing multiple studies and clinical trials leading to eventual replacement of the whole cell pertussis vaccine with the current acellular vaccines.

Much more recently, at the request of National Institutes of Health, I led studies of the safety of thimerosal preservative in multidose vaccine vials that appeared in the Lancet (2002;360:1737-41); Pediatrics (2008;121:e208-14) and the Journal of Pediatrics (2009;155:495-9). Using the data from those three studies, the World Health Organization (WHO), the United Nations, the Institute of Medicine, and other organizations were able to see that the metabolism and elimination from the body of ethylmercury in thimerosal was dramatically faster, compared with methylmercury in fish. Therefore, the presumption of possible accumulation of mercury in the body of infants receiving vaccines from multidose vials when such vaccines were closely spaced was disproven by scientific data.

In plain language, there was never a known risk from thimerosal, but a premature, hurried decision was made to mandate removal of thimerosal from vaccines given to children in the United States and western Europe; thereby the myth lives on that thimerosal is not safe. Yet thimerosal is safe, and the WHO continues to advocate use of thimerosal in multidose vaccine vials. Nevertheless, I have been criticized personally on the Internet for this work. The accusation is that I, the rest of the scientists who participated in the study, and the NIH oversight were biased because our academic institutions had previously received funding from vaccine companies to perform clinical and translational research. I received many hate e-mails and even a death threat.

To close this column with a sense of humor, I suggest you Google the responses by U.S. presidential hopefuls on their stand with regard to vaccine refusers. The comments, then the reversal and “corrections” to their comments is amusing. The presidential hopefuls quickly recognized that the right to choose may not be the best policy for the public health of American citizens. Refusing to vaccinate a child potentially harms the child and may harm others!

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures. E-mail him at [email protected].

The challenges in primary care are many, and one of increasing importance is what to say to vaccine refusers. After much debate and thoughtful discussion, my medical partner, Dr. Janet Casey at Legacy Pediatrics, decided that the practice would refuse to care for the refusers.

Over the years, I have accepted such patients into my practice and worked with them to gain their confidence and debunk the many myths about the safety of vaccination that are so visible on the Internet. The approach worked well, and by the time the children were 1 year of age, I cannot remember but a handful of parents who did not come around to realize that it was best to vaccinate. However, with the recent measles outbreak at Disneyland in California, pertussis at epidemic proportions in pockets of the United States and elsewhere in the world, and the antivaccine voices gaining more and more attention, I agree, it is time to take a stand.

When a family brings their unvaccinated or undervaccinated child into the waiting room of a physician’s practice, that family is potentially exposing others in that waiting room to serious infectious diseases – that is not fair. In the waiting room may well be a patient who is on chemotherapy or immunotherapy or otherwise immunocompromised, and he relies on the “herd immunity” achieved by vaccinations of those who can safely be vaccinated for individual protection and public health. Those patients who have weakened immune systems did not choose to have their medical condition, whereas the vaccine refusers are choosing not to vaccinate their child (or typically themselves as well). And the reasons they are choosing not to vaccinate are based on misrepresentation of medical facts, fabrications of safety concerns, long ago disproven speculations by well-meaning and not so well-meaning physicians and scientists, pseudoscience published in pseudoscientific journals, and/or general distrust of the federal government that mandates vaccinations for the good of the public health.

My personal experience with vaccine scares dates back to a time when whole-cell pertussis vaccine was the only pertussis vaccine available. I was a medical student, resident, and then an infectious diseases fellow during the escalating debate about the significant side effects of vaccines. I joined in the chorus of voices questioning the need for clear data on the problem, and then the pursuit of a safer acellular pertussis vaccine. The physician community and the public were ready for change, and the National Institutes of Health took the lead in organizing multiple studies and clinical trials leading to eventual replacement of the whole cell pertussis vaccine with the current acellular vaccines.

Much more recently, at the request of National Institutes of Health, I led studies of the safety of thimerosal preservative in multidose vaccine vials that appeared in the Lancet (2002;360:1737-41); Pediatrics (2008;121:e208-14) and the Journal of Pediatrics (2009;155:495-9). Using the data from those three studies, the World Health Organization (WHO), the United Nations, the Institute of Medicine, and other organizations were able to see that the metabolism and elimination from the body of ethylmercury in thimerosal was dramatically faster, compared with methylmercury in fish. Therefore, the presumption of possible accumulation of mercury in the body of infants receiving vaccines from multidose vials when such vaccines were closely spaced was disproven by scientific data.

In plain language, there was never a known risk from thimerosal, but a premature, hurried decision was made to mandate removal of thimerosal from vaccines given to children in the United States and western Europe; thereby the myth lives on that thimerosal is not safe. Yet thimerosal is safe, and the WHO continues to advocate use of thimerosal in multidose vaccine vials. Nevertheless, I have been criticized personally on the Internet for this work. The accusation is that I, the rest of the scientists who participated in the study, and the NIH oversight were biased because our academic institutions had previously received funding from vaccine companies to perform clinical and translational research. I received many hate e-mails and even a death threat.

To close this column with a sense of humor, I suggest you Google the responses by U.S. presidential hopefuls on their stand with regard to vaccine refusers. The comments, then the reversal and “corrections” to their comments is amusing. The presidential hopefuls quickly recognized that the right to choose may not be the best policy for the public health of American citizens. Refusing to vaccinate a child potentially harms the child and may harm others!

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures. E-mail him at [email protected].

Reform of graduate medical education has been raised as a potential agenda item for the 114th Congress.

In an open letter released Dec. 6, 2014, eight members of the House Energy and Commerce Committee’s Health Subcommittee requested input on the structure, financing, and governance of graduate medical education. In order to frame and organize the responses, the members posed seven specific questions. Over a period of several weeks, through a process incorporating input from more than 250 Fellows in leadership positions, the ACS Health Policy and Advocacy Group, faculty of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, Chapel Hill, and ACS staff of both the Chicago and Washington offices, a letter on behalf of ACS was drafted and submitted on Jan. 15, 2015. The submitted response not only provided answers to the seven questions but also included a set of principles that ACS advocates should guide reform efforts. Those principles are as follows:

1. Education and training are essential mechanisms in the process by which new medical discovery and excellence in new therapy are achieved. In order to foster and preserve the innovation for which our country’s medical system is noted, graduate medical education (GME) should continue to be supported as a public good.

2. Surgical GME has unique needs linked to the skills training required for an additional set of technical competencies. Accordingly, in order to acquire and achieve mastery of those skills, it is imperative that those unique training needs be recognized.

3. Reforms should focus on creating a system that produces the optimal workforce of physicians to meet our country’s medical needs. The population of the United States deserves consistent service across the board.

4. Given that the practice of medicine is dynamic and therefore what we need today is not necessarily what we will need in 10 years, the system should be nimble enough to adjust rapidly to the changing medical landscape. Methodologies to project workforce needs will need to be developed and continually refined as data becomes available. This methodology should be used to distribute funding in a way that meets workforce needs, not vested political or financial interests.

5. There must be accountability and transparency built into the system, not only to certify that funds are being spent appropriately to support the training of physicians, but also to ensure quality and the readiness of the physicians emerging from training. A combined governance system with articulated goals and measured outcomes is needed.

6. Programs that produce high-quality graduates in an efficient manner and consistent with workforce needs should be rewarded through financial incentives or higher levels of support. Similarly, funds should be set aside to support innovation in GME, which will incentivize higher quality training.

It is our intent that these principles be used to inform decisions on any proposal affecting how surgeons and other physicians are trained and how such training is financed. The Energy and Commerce Committee is currently reviewing the responses received from ACS and other stakeholders and is expected to use the information received to compose draft reform legislation in the late spring or early summer.

As of yet, neither of the other two committees with jurisdiction over GME reform, (House Ways and Means or Senate Finance), have expressed interest in the topic in the new 114th Congress just underway. However, it is entirely possible such could change if hearings held by the Energy and Commerce Committee generate such interest or if there are broader conversations about Medicare financing in general.

In addition to plans for ACS Division of Advocacy and Health Policy (DAHP) staff to visit and personally present the ACS perspective on GME reform to each member office of the Energy and Commerce Committee, the DAHP is also in the early stages of planning a summit in the Washington office to further explore the topic. The goal would be the development and proposal of innovative solutions designed to improve the way our physician workforce is trained based on our principles listed above.

The topic of GME has long been one of the top priorities for the College and accordingly, this office. Fellows can be assured that the staff of the DAHP recognize such and are diligently directing their efforts into assuring that the surgeon’s perspective is well represented as discussions and deliberations on GME reform get underway on Capitol Hill.

Until next month ...

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

Reform of graduate medical education has been raised as a potential agenda item for the 114th Congress.

In an open letter released Dec. 6, 2014, eight members of the House Energy and Commerce Committee’s Health Subcommittee requested input on the structure, financing, and governance of graduate medical education. In order to frame and organize the responses, the members posed seven specific questions. Over a period of several weeks, through a process incorporating input from more than 250 Fellows in leadership positions, the ACS Health Policy and Advocacy Group, faculty of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, Chapel Hill, and ACS staff of both the Chicago and Washington offices, a letter on behalf of ACS was drafted and submitted on Jan. 15, 2015. The submitted response not only provided answers to the seven questions but also included a set of principles that ACS advocates should guide reform efforts. Those principles are as follows:

1. Education and training are essential mechanisms in the process by which new medical discovery and excellence in new therapy are achieved. In order to foster and preserve the innovation for which our country’s medical system is noted, graduate medical education (GME) should continue to be supported as a public good.

2. Surgical GME has unique needs linked to the skills training required for an additional set of technical competencies. Accordingly, in order to acquire and achieve mastery of those skills, it is imperative that those unique training needs be recognized.

3. Reforms should focus on creating a system that produces the optimal workforce of physicians to meet our country’s medical needs. The population of the United States deserves consistent service across the board.

4. Given that the practice of medicine is dynamic and therefore what we need today is not necessarily what we will need in 10 years, the system should be nimble enough to adjust rapidly to the changing medical landscape. Methodologies to project workforce needs will need to be developed and continually refined as data becomes available. This methodology should be used to distribute funding in a way that meets workforce needs, not vested political or financial interests.

5. There must be accountability and transparency built into the system, not only to certify that funds are being spent appropriately to support the training of physicians, but also to ensure quality and the readiness of the physicians emerging from training. A combined governance system with articulated goals and measured outcomes is needed.

6. Programs that produce high-quality graduates in an efficient manner and consistent with workforce needs should be rewarded through financial incentives or higher levels of support. Similarly, funds should be set aside to support innovation in GME, which will incentivize higher quality training.

It is our intent that these principles be used to inform decisions on any proposal affecting how surgeons and other physicians are trained and how such training is financed. The Energy and Commerce Committee is currently reviewing the responses received from ACS and other stakeholders and is expected to use the information received to compose draft reform legislation in the late spring or early summer.

As of yet, neither of the other two committees with jurisdiction over GME reform, (House Ways and Means or Senate Finance), have expressed interest in the topic in the new 114th Congress just underway. However, it is entirely possible such could change if hearings held by the Energy and Commerce Committee generate such interest or if there are broader conversations about Medicare financing in general.

In addition to plans for ACS Division of Advocacy and Health Policy (DAHP) staff to visit and personally present the ACS perspective on GME reform to each member office of the Energy and Commerce Committee, the DAHP is also in the early stages of planning a summit in the Washington office to further explore the topic. The goal would be the development and proposal of innovative solutions designed to improve the way our physician workforce is trained based on our principles listed above.

The topic of GME has long been one of the top priorities for the College and accordingly, this office. Fellows can be assured that the staff of the DAHP recognize such and are diligently directing their efforts into assuring that the surgeon’s perspective is well represented as discussions and deliberations on GME reform get underway on Capitol Hill.

Until next month ...

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

Reform of graduate medical education has been raised as a potential agenda item for the 114th Congress.

In an open letter released Dec. 6, 2014, eight members of the House Energy and Commerce Committee’s Health Subcommittee requested input on the structure, financing, and governance of graduate medical education. In order to frame and organize the responses, the members posed seven specific questions. Over a period of several weeks, through a process incorporating input from more than 250 Fellows in leadership positions, the ACS Health Policy and Advocacy Group, faculty of the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, Chapel Hill, and ACS staff of both the Chicago and Washington offices, a letter on behalf of ACS was drafted and submitted on Jan. 15, 2015. The submitted response not only provided answers to the seven questions but also included a set of principles that ACS advocates should guide reform efforts. Those principles are as follows:

1. Education and training are essential mechanisms in the process by which new medical discovery and excellence in new therapy are achieved. In order to foster and preserve the innovation for which our country’s medical system is noted, graduate medical education (GME) should continue to be supported as a public good.

2. Surgical GME has unique needs linked to the skills training required for an additional set of technical competencies. Accordingly, in order to acquire and achieve mastery of those skills, it is imperative that those unique training needs be recognized.

3. Reforms should focus on creating a system that produces the optimal workforce of physicians to meet our country’s medical needs. The population of the United States deserves consistent service across the board.

4. Given that the practice of medicine is dynamic and therefore what we need today is not necessarily what we will need in 10 years, the system should be nimble enough to adjust rapidly to the changing medical landscape. Methodologies to project workforce needs will need to be developed and continually refined as data becomes available. This methodology should be used to distribute funding in a way that meets workforce needs, not vested political or financial interests.

5. There must be accountability and transparency built into the system, not only to certify that funds are being spent appropriately to support the training of physicians, but also to ensure quality and the readiness of the physicians emerging from training. A combined governance system with articulated goals and measured outcomes is needed.

6. Programs that produce high-quality graduates in an efficient manner and consistent with workforce needs should be rewarded through financial incentives or higher levels of support. Similarly, funds should be set aside to support innovation in GME, which will incentivize higher quality training.

It is our intent that these principles be used to inform decisions on any proposal affecting how surgeons and other physicians are trained and how such training is financed. The Energy and Commerce Committee is currently reviewing the responses received from ACS and other stakeholders and is expected to use the information received to compose draft reform legislation in the late spring or early summer.

As of yet, neither of the other two committees with jurisdiction over GME reform, (House Ways and Means or Senate Finance), have expressed interest in the topic in the new 114th Congress just underway. However, it is entirely possible such could change if hearings held by the Energy and Commerce Committee generate such interest or if there are broader conversations about Medicare financing in general.

In addition to plans for ACS Division of Advocacy and Health Policy (DAHP) staff to visit and personally present the ACS perspective on GME reform to each member office of the Energy and Commerce Committee, the DAHP is also in the early stages of planning a summit in the Washington office to further explore the topic. The goal would be the development and proposal of innovative solutions designed to improve the way our physician workforce is trained based on our principles listed above.

The topic of GME has long been one of the top priorities for the College and accordingly, this office. Fellows can be assured that the staff of the DAHP recognize such and are diligently directing their efforts into assuring that the surgeon’s perspective is well represented as discussions and deliberations on GME reform get underway on Capitol Hill.

Until next month ...

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.