Commentary

For years, I (MKC) have been teaching medical students and family medicine residents at my facility a modified anterior approach to examining the thyroid, and they are surprised at how much easier it is than the standard approach. Our modified anterior approach, which we demonstrate at https://www.youtube.com/watch?v=A6xVV8wiXZo, allows simultaneous visualization of both lobes and the isthmus of the thyroid gland. It differs from standard techniques because it involves simultaneously moving both sternocleidomastoid muscles farther apart, which causes the skin to be stretched over the thyroid gland, bringing it into relief and allowing for enhanced inspection and easier palpation.

A literature search that included PubMed and textbooks such as The Rational Clinical Examination: Evidence-Based Clinical Diagnosis¹ and Bates’ Guide to the Physical Examination and History Taking² suggests that this modified anterior approach hasn’t been described before. We believe this approach will correlate more closely with ultrasound examinations than currently used techniques, and we encourage readers to help us empirically test this assertion.

M. Kyu Chung, MD
Camden, NJ

Christina Chung Patrone, medical student
New York, NY

Patrick J. LaRiccia, MD, MSCE
Philadelphia, Pa

For years, I (MKC) have been teaching medical students and family medicine residents at my facility a modified anterior approach to examining the thyroid, and they are surprised at how much easier it is than the standard approach. Our modified anterior approach, which we demonstrate at https://www.youtube.com/watch?v=A6xVV8wiXZo, allows simultaneous visualization of both lobes and the isthmus of the thyroid gland. It differs from standard techniques because it involves simultaneously moving both sternocleidomastoid muscles farther apart, which causes the skin to be stretched over the thyroid gland, bringing it into relief and allowing for enhanced inspection and easier palpation.

A literature search that included PubMed and textbooks such as The Rational Clinical Examination: Evidence-Based Clinical Diagnosis¹ and Bates’ Guide to the Physical Examination and History Taking² suggests that this modified anterior approach hasn’t been described before. We believe this approach will correlate more closely with ultrasound examinations than currently used techniques, and we encourage readers to help us empirically test this assertion.

M. Kyu Chung, MD
Camden, NJ

Christina Chung Patrone, medical student
New York, NY

Patrick J. LaRiccia, MD, MSCE
Philadelphia, Pa

For years, I (MKC) have been teaching medical students and family medicine residents at my facility a modified anterior approach to examining the thyroid, and they are surprised at how much easier it is than the standard approach. Our modified anterior approach, which we demonstrate at https://www.youtube.com/watch?v=A6xVV8wiXZo, allows simultaneous visualization of both lobes and the isthmus of the thyroid gland. It differs from standard techniques because it involves simultaneously moving both sternocleidomastoid muscles farther apart, which causes the skin to be stretched over the thyroid gland, bringing it into relief and allowing for enhanced inspection and easier palpation.

A literature search that included PubMed and textbooks such as The Rational Clinical Examination: Evidence-Based Clinical Diagnosis¹ and Bates’ Guide to the Physical Examination and History Taking² suggests that this modified anterior approach hasn’t been described before. We believe this approach will correlate more closely with ultrasound examinations than currently used techniques, and we encourage readers to help us empirically test this assertion.

M. Kyu Chung, MD
Camden, NJ

Christina Chung Patrone, medical student
New York, NY

Patrick J. LaRiccia, MD, MSCE
Philadelphia, Pa

Recently I read a blog by Dr. Ira Nash at the blog site, KevinMD, where Dr. Nash suggests that it behooves physicians to fully inform patients with carotid stenosis about the pros and cons of proposed treatment. This is in keeping with a general crusade to involve patients in so-called shared decision making.

Dr. Nash points out that “it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists.” This is especially relevant when one considers treatment for an asymptomatic carotid stenosis.

Depending on the point of view of either the physician or patient, the most important outcome may be long-term survival, prevention of cardiac events or the avoidance of short- or long-term stroke. On the other hand, a trumpet player or opera singer may be more concerned about a career-ending cranial nerve injury. Further, there still is considerable debate about the treatment of asymptomatic carotid stenosis.

I do not want to trivialize this important issue, but if we are to follow Dr. Nash’s directive, perhaps the following scenario could be an example of my future office consultations.

8 a.m.: “Mrs. Jones, our duplex scan has shown that you have an 80% stenosis of your carotid artery and we are concerned this may lead to a stroke. Oh, you want to know how we can tell it’s showing an 80% stenosis that can cause a stroke. Well, that’s complicated. It’s all about blood flow and the Circle of Willis. No, that’s not the roundabout where you had that traffic accident. It’s an anatomical structure in your brain. OK let me explain....”

8:45 a.m.: “So, that’s how it works. Some doctors believe that we should operate now and some believe we should wait until the blockage reaches 90%, and some even think we should not operate at all. You probably need to know how they come to those conclusions. OK, let’s see …. Well there were some studies such as NASCET, SAPPHIRE, and CREST and many others. No, Mrs. Jones, they have nothing to do with the stock market, jewelry and toothpaste!!! Yes, I know it’s very confusing even for me.”

9:50 a.m.: “That’s the problem with those studies. Some people think we should repeat them with patients getting statins and antiplatelet agents. What are statins? You read in the National Enquirer that thousands of patients died because of statins. Hmmm, that’s not really accurate.”

10:45 a.m.: “Yes, I have heard of carotid stents. Of course, I do them myself. You want to know why I’m not recommending one for you. Well, let’s see .… You are an 85-year old female with a type III aorta. Yes, that’s just like the drawing I made of your aortic arch. How do I know that’s what it looks like? You want to see for yourself? OK, come over to this monitor...”

1:10 p.m.: “You agree perhaps a carotid endarterectomy is best but you want to know if I use a shunt. Do you know what a shunt is? Your friend told you it’s a plastic tube that I put in your brain!”

2:14 p.m.: “You heard most surgeons are using a patch. Can your husband donate his leg vein? No that’s not a good idea. Why? Well ….”

2:45 p.m.: “You’re hungry? OK, let’s get a bite and resume at 3 p.m.”

3:00 p.m.: “You forgot what I told you and you want me to refresh. You’re kidding right? No? OK then…”

Certainly, this inane scenario should not happen. No patient needs such detailed information and no surgeon could provide such in-depth information. But proponents of shared decision making insist we make the patient an equal partner in treatment. The claim is that without such involvement patients would not make the right choices nor would they be fully committed to the therapy.

Thus we are faced with a dilemma. The benefit of CEA or CAS for asymptomatic carotid stenosis may be minimal in comparison to medical therapy alone. Yet based on the information we provide, patients are expected to make a decision on one regimen or another in spite of the complexity of the arguments. So, how do we discuss treatment options? How much information do we provide and on what data do we base this discussion?

Do we quote NASCET or some other trial? What about SAPPHIRE and CREST? Do we let them know that CREST II is in the works? Do we quote published results from Centers of Excellence or our own results, and, if so, how many of us have accurate data about our short-term results let alone long-term outcomes? Further, how do we avoid our own subjective bias in the discussion, and how do we phrase statistics? This is especially relevant in discussing stroke rates.

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.

Recently I read a blog by Dr. Ira Nash at the blog site, KevinMD, where Dr. Nash suggests that it behooves physicians to fully inform patients with carotid stenosis about the pros and cons of proposed treatment. This is in keeping with a general crusade to involve patients in so-called shared decision making.

Dr. Nash points out that “it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists.” This is especially relevant when one considers treatment for an asymptomatic carotid stenosis.

Depending on the point of view of either the physician or patient, the most important outcome may be long-term survival, prevention of cardiac events or the avoidance of short- or long-term stroke. On the other hand, a trumpet player or opera singer may be more concerned about a career-ending cranial nerve injury. Further, there still is considerable debate about the treatment of asymptomatic carotid stenosis.

I do not want to trivialize this important issue, but if we are to follow Dr. Nash’s directive, perhaps the following scenario could be an example of my future office consultations.

8 a.m.: “Mrs. Jones, our duplex scan has shown that you have an 80% stenosis of your carotid artery and we are concerned this may lead to a stroke. Oh, you want to know how we can tell it’s showing an 80% stenosis that can cause a stroke. Well, that’s complicated. It’s all about blood flow and the Circle of Willis. No, that’s not the roundabout where you had that traffic accident. It’s an anatomical structure in your brain. OK let me explain....”

8:45 a.m.: “So, that’s how it works. Some doctors believe that we should operate now and some believe we should wait until the blockage reaches 90%, and some even think we should not operate at all. You probably need to know how they come to those conclusions. OK, let’s see …. Well there were some studies such as NASCET, SAPPHIRE, and CREST and many others. No, Mrs. Jones, they have nothing to do with the stock market, jewelry and toothpaste!!! Yes, I know it’s very confusing even for me.”

9:50 a.m.: “That’s the problem with those studies. Some people think we should repeat them with patients getting statins and antiplatelet agents. What are statins? You read in the National Enquirer that thousands of patients died because of statins. Hmmm, that’s not really accurate.”

10:45 a.m.: “Yes, I have heard of carotid stents. Of course, I do them myself. You want to know why I’m not recommending one for you. Well, let’s see .… You are an 85-year old female with a type III aorta. Yes, that’s just like the drawing I made of your aortic arch. How do I know that’s what it looks like? You want to see for yourself? OK, come over to this monitor...”

1:10 p.m.: “You agree perhaps a carotid endarterectomy is best but you want to know if I use a shunt. Do you know what a shunt is? Your friend told you it’s a plastic tube that I put in your brain!”

2:14 p.m.: “You heard most surgeons are using a patch. Can your husband donate his leg vein? No that’s not a good idea. Why? Well ….”

2:45 p.m.: “You’re hungry? OK, let’s get a bite and resume at 3 p.m.”

3:00 p.m.: “You forgot what I told you and you want me to refresh. You’re kidding right? No? OK then…”

Certainly, this inane scenario should not happen. No patient needs such detailed information and no surgeon could provide such in-depth information. But proponents of shared decision making insist we make the patient an equal partner in treatment. The claim is that without such involvement patients would not make the right choices nor would they be fully committed to the therapy.

Thus we are faced with a dilemma. The benefit of CEA or CAS for asymptomatic carotid stenosis may be minimal in comparison to medical therapy alone. Yet based on the information we provide, patients are expected to make a decision on one regimen or another in spite of the complexity of the arguments. So, how do we discuss treatment options? How much information do we provide and on what data do we base this discussion?

Do we quote NASCET or some other trial? What about SAPPHIRE and CREST? Do we let them know that CREST II is in the works? Do we quote published results from Centers of Excellence or our own results, and, if so, how many of us have accurate data about our short-term results let alone long-term outcomes? Further, how do we avoid our own subjective bias in the discussion, and how do we phrase statistics? This is especially relevant in discussing stroke rates.

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.

Recently I read a blog by Dr. Ira Nash at the blog site, KevinMD, where Dr. Nash suggests that it behooves physicians to fully inform patients with carotid stenosis about the pros and cons of proposed treatment. This is in keeping with a general crusade to involve patients in so-called shared decision making.

Dr. Nash points out that “it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists.” This is especially relevant when one considers treatment for an asymptomatic carotid stenosis.

Depending on the point of view of either the physician or patient, the most important outcome may be long-term survival, prevention of cardiac events or the avoidance of short- or long-term stroke. On the other hand, a trumpet player or opera singer may be more concerned about a career-ending cranial nerve injury. Further, there still is considerable debate about the treatment of asymptomatic carotid stenosis.

I do not want to trivialize this important issue, but if we are to follow Dr. Nash’s directive, perhaps the following scenario could be an example of my future office consultations.

8 a.m.: “Mrs. Jones, our duplex scan has shown that you have an 80% stenosis of your carotid artery and we are concerned this may lead to a stroke. Oh, you want to know how we can tell it’s showing an 80% stenosis that can cause a stroke. Well, that’s complicated. It’s all about blood flow and the Circle of Willis. No, that’s not the roundabout where you had that traffic accident. It’s an anatomical structure in your brain. OK let me explain....”

8:45 a.m.: “So, that’s how it works. Some doctors believe that we should operate now and some believe we should wait until the blockage reaches 90%, and some even think we should not operate at all. You probably need to know how they come to those conclusions. OK, let’s see …. Well there were some studies such as NASCET, SAPPHIRE, and CREST and many others. No, Mrs. Jones, they have nothing to do with the stock market, jewelry and toothpaste!!! Yes, I know it’s very confusing even for me.”

9:50 a.m.: “That’s the problem with those studies. Some people think we should repeat them with patients getting statins and antiplatelet agents. What are statins? You read in the National Enquirer that thousands of patients died because of statins. Hmmm, that’s not really accurate.”

10:45 a.m.: “Yes, I have heard of carotid stents. Of course, I do them myself. You want to know why I’m not recommending one for you. Well, let’s see .… You are an 85-year old female with a type III aorta. Yes, that’s just like the drawing I made of your aortic arch. How do I know that’s what it looks like? You want to see for yourself? OK, come over to this monitor...”

1:10 p.m.: “You agree perhaps a carotid endarterectomy is best but you want to know if I use a shunt. Do you know what a shunt is? Your friend told you it’s a plastic tube that I put in your brain!”

2:14 p.m.: “You heard most surgeons are using a patch. Can your husband donate his leg vein? No that’s not a good idea. Why? Well ….”

2:45 p.m.: “You’re hungry? OK, let’s get a bite and resume at 3 p.m.”

3:00 p.m.: “You forgot what I told you and you want me to refresh. You’re kidding right? No? OK then…”

Certainly, this inane scenario should not happen. No patient needs such detailed information and no surgeon could provide such in-depth information. But proponents of shared decision making insist we make the patient an equal partner in treatment. The claim is that without such involvement patients would not make the right choices nor would they be fully committed to the therapy.

Thus we are faced with a dilemma. The benefit of CEA or CAS for asymptomatic carotid stenosis may be minimal in comparison to medical therapy alone. Yet based on the information we provide, patients are expected to make a decision on one regimen or another in spite of the complexity of the arguments. So, how do we discuss treatment options? How much information do we provide and on what data do we base this discussion?

Do we quote NASCET or some other trial? What about SAPPHIRE and CREST? Do we let them know that CREST II is in the works? Do we quote published results from Centers of Excellence or our own results, and, if so, how many of us have accurate data about our short-term results let alone long-term outcomes? Further, how do we avoid our own subjective bias in the discussion, and how do we phrase statistics? This is especially relevant in discussing stroke rates.

A surgeon may tell a patient that without surgery there is a 2% risk of stroke a year, whereas someone motivated toward medical therapy may rather state that there is a 98% likelihood that the patient will not have a stroke. Confusing? You bet!

As physicians and surgeons, we reach our conclusions after diligently evaluating the literature and our own clinical experience. Our judgment may take years to hone and may change as new developments occur, making it almost impossible to discuss options with a patient on a peer-to-peer level. It is therefore inappropriate to expect that we will be able to instruct the patient enough for them to make a truly educated decision. But in the spirit of “shared decision making,” we all should develop a simplified method of informing our patients so that they will be advised without becoming overly confused.

In my practice I make a point of discussing the controversy regarding asymptomatic carotid stenosis. I let them know that there are surgeons who operate for 60%, 70%, 80%,or not at all. I also try to instruct them on how difficult it is to be sure how tight the stenosis actually is. I discuss the difference between CEA and CAS and the pros and cons of each. I explain that many patients that we treat by CEA or CAS may never have needed the procedure, even if their carotid artery eventually occluded.

I tell them that over the years I believe I have helped prevent strokes but equally, some of the patients I treated may never have had a stroke even without CEA or CAS. And, of course, in trying to prevent strokes, I have caused them with my surgery. Lastly, I almost never tell patients what they should do, but leave the decision entirely up to them because they may be making the most important gamble of their lives, since the outcome of therapy is an odds game. By now you may be wondering how on earth any of my patients actually come to a decision. I am sure most patients would prefer that I make their choice easier by being more forceful in my recommendation. Unfortunately, their insecurity is the price they must pay for sharing in the decision-making process.

It’s also true that many of our patients are depressed or anxious, or have a diagnosed mental illness. During hospital rounds this morning, the first 3 patients presented by the resident complained of overwhelming stress. Add in patients with chronic fatigue, chronic pain, and somatization disorders, and it is clear that we are making daily use of the biopsychosocial model of illness.

When I act as a health coach and meet my patients where they are, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet.That said, we are not card-carrying psychologists, psychiatrists, or social workers, and there is precious little time for us to address behavioral and psychological issues in depth while seeing 20 to 25 patients a day, even if we have the skills to do so. I often take the easy route—referral to someone else. For many patients, referral is a good option, but many others won’t go and want us to help them. And brief therapy from physicians can have a significant impact on patients’ unhealthy behaviors, as was demonstrated years ago in a smoking cessation trial, where brief advice from family physicians increased the quit rate by 5%.²

Now a large body of research can help guide us to effective brief interventions for behavior change. Raddock and colleagues summarize a number of effective techniques in their review, "7 tools to help patients adopt healthier behaviors." Another way to increase our effectiveness as behavior change agents is sharing the load with nurses and medical assistants who are trained in these techniques.

When I act as a health coach and advocate and meet my patients where they are, using either the 5 As model or motivational interviewing, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet, with strengths and frailties just like me.

Please pass the cheesecake.

It’s also true that many of our patients are depressed or anxious, or have a diagnosed mental illness. During hospital rounds this morning, the first 3 patients presented by the resident complained of overwhelming stress. Add in patients with chronic fatigue, chronic pain, and somatization disorders, and it is clear that we are making daily use of the biopsychosocial model of illness.

When I act as a health coach and meet my patients where they are, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet.That said, we are not card-carrying psychologists, psychiatrists, or social workers, and there is precious little time for us to address behavioral and psychological issues in depth while seeing 20 to 25 patients a day, even if we have the skills to do so. I often take the easy route—referral to someone else. For many patients, referral is a good option, but many others won’t go and want us to help them. And brief therapy from physicians can have a significant impact on patients’ unhealthy behaviors, as was demonstrated years ago in a smoking cessation trial, where brief advice from family physicians increased the quit rate by 5%.²

Now a large body of research can help guide us to effective brief interventions for behavior change. Raddock and colleagues summarize a number of effective techniques in their review, "7 tools to help patients adopt healthier behaviors." Another way to increase our effectiveness as behavior change agents is sharing the load with nurses and medical assistants who are trained in these techniques.

When I act as a health coach and advocate and meet my patients where they are, using either the 5 As model or motivational interviewing, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet, with strengths and frailties just like me.

Please pass the cheesecake.

It’s also true that many of our patients are depressed or anxious, or have a diagnosed mental illness. During hospital rounds this morning, the first 3 patients presented by the resident complained of overwhelming stress. Add in patients with chronic fatigue, chronic pain, and somatization disorders, and it is clear that we are making daily use of the biopsychosocial model of illness.

When I act as a health coach and meet my patients where they are, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet.That said, we are not card-carrying psychologists, psychiatrists, or social workers, and there is precious little time for us to address behavioral and psychological issues in depth while seeing 20 to 25 patients a day, even if we have the skills to do so. I often take the easy route—referral to someone else. For many patients, referral is a good option, but many others won’t go and want us to help them. And brief therapy from physicians can have a significant impact on patients’ unhealthy behaviors, as was demonstrated years ago in a smoking cessation trial, where brief advice from family physicians increased the quit rate by 5%.²

Now a large body of research can help guide us to effective brief interventions for behavior change. Raddock and colleagues summarize a number of effective techniques in their review, "7 tools to help patients adopt healthier behaviors." Another way to increase our effectiveness as behavior change agents is sharing the load with nurses and medical assistants who are trained in these techniques.

When I act as a health coach and advocate and meet my patients where they are, using either the 5 As model or motivational interviewing, I feel less stressed and more able to enjoy my patients as fellow travelers on this planet, with strengths and frailties just like me.

Please pass the cheesecake.

If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.  

If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.  

If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.  

“THE FDA’S REVIEW OF THE DATA ON OPEN POWER MORCELLATION WAS INADEQUATE”
WILLIAM H. PARKER, MD (AUDIO; NOVEMBER 2014)

Why is traditional open myomectomy acceptable if power morcellation isn’t?
The actions taken by the US Food and Drug Administration (FDA) and medical device companies to limit use of power morcellation have effectively led to a halt in the use of minimally invasive surgery for removal of large uterine fibroids. This would seem to leave open laparotomy as the only viable choice for the conservative removal of these benign tumors in women who choose to retain their uterus for personal, cultural, or childbearing reasons. Or does it?

Any open myomectomy of an intramural or subserosal myoma involves an incision into the uterine serosa and muscularis, thus exposing the surface of the tumor to the peritoneal environment. The mass is then grasped with penetrating instruments and manipulated free of its myometrial attachments with other instruments such as forceps, scissors, and electrocautery devices. Suction instruments are freely employed over the operative field. The gloved digits of the surgeon are frequently used to bluntly dissect the tumor from the surrounding myometrial bed.

Because of the desire to maximize future fertility potential by minimizing adhesions, frequent irrigation is considered by most reproductive surgeons to be a necessary part of good surgical technique. Irrigation hydrates the tissues and carries away blood, but it can be counted on to disperse countless cells from the exposed surface of the tumor. After resection, the tumor is removed from the operative field and handed off, usually to the gloved hand of an assistant who will be handling all of the tools that are used from that point forward. If an abscess is a “dirty case” from the standpoint of the spread of infection, then any myomectomy is a potentially “dirty case” from the standpoint of the spread of neoplasia. Given the fundamental nature of this procedure, there seems to be no way to do a “clean” myomectomy. 

Since any form of myomectomy involves at least as much manipulation of the tumor mass as morcellation, it should be at least as likely as morcellation to spread aberrant cells. An inadvertent exposure of the unprotected surface of a leiomyosarcoma at the time of a traditional open myomectomy is not different in any essential way from the exposure of the surface of the same tumor at the time of a myomectomy followed by any type of morcellation. 

It is logical then that if morcellation can be proscribed by regulation and litigation, myomectomy itself will be proscribed on the exact same lines of reasoning.

Despite the widespread use of either abdominal or minimally invasive myomectomy over the last 75 years, disseminated uterine leiomyosarcoma is now and always has been a rare disease. This fact has always been accounted for in our risk assessments of leiomyoma surgeries. In addition, there is no scientific evidence that power morcellation, nonpowered morcellation, or abdominal myomectomy without morcellation has ever been causative in the spread of even one patient’s leiomyosarcoma. Leiomyosarcoma is by definition capable of disseminating by itself.

No medical authority would recommend total hysterectomy for every patient with any myoma, based on the possibility that any individual patient might be harboring a uterine cancer that can spread. This is, however, the exact evolutionary endpoint of the reasoning of the FDA and our legal system. The device companies are to be the deep pockets of the morcellation lawsuits and physicians will be the deep pockets of future myomectomy lawsuits. Gynecologists have always considered risk/reward factors in decisions regarding myomectomy and morcellation. We have an obligation to defend the reproductive rights of our patients. Lawyers, regulators, and even the corporations that dominate the medical device market are motivated by other concerns.

The practice of modern medicine aggressively challenges clinical decision-making based solely on anecdotal evidence. It has done so for well over a century now. It is one of the few standards that still unites good doctors under the battered and tattered umbrella of our professionalism. Our challenge as modern physicians is to stand fast against our new regulatory masters (as well as their former and future law partners) with their grave misunderstandings of the very character of gynecologic decision-making.
Michael C. Doody, MD, PhD
Knoxville, Tennessee
 

“THE EXTRACORPOREAL C-INCISION TISSUE EXTRACTION (EXCITE) TECHNIQUE”
MIREILLE D. TRUONG, MD, AND ARNOLD P. ADVINCULA, MD (VIDEO; NOVEMBER 2014)

Awesome video!
I tried this technique as outlined in the video—totally awesome! It worked really well! Thanks to the surgeons who came up with it!
Ravindhra Mamilla, MD
Thief River Falls, Minnesota
 

“HOW USEFUL IS RANDOM BIOPSY WHEN NO COLPOSCOPIC LESIONS ARE SEEN?”
ANDREW M. KAUNITZ, MD (EXAMINING THE EVIDENCE; OCTOBER 2014)

Additional clarification would be appreciated
According to Dr. Kaunitz’s summary of the findings of Huh and colleagues,¹ the population group included women with low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL) (ie, anything above atypical cells of undetermined significance [ASCUS]), along with women who tested positive for human papillomavirus (HPV) 16/18, regardless of cytology.

It would have been useful to have the LSIL and HSIL populations (independent or dependent of HPV status) broken down into subgroups.

The expert commentary does not indicate whether the 2.7% of biopsy-proven cervical ­intraepithelial neoplasia (CIN) 2 and CIN 3 were predominantly confined to women with HSIL or equally prevalent in the LSIL population.

Without this information, I am not convinced that LSIL requires a random biopsy when colposcopy is adequate and normal, regardless of HPV status.
Jonathan Kew
Maitland, New South Wales, Australia

Reference
1. Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

Are we reverting to past practices?
For someone who has done colposcopy for about 35 years, I find the conclusions of Huh and colleagues nonsensical. If the squamocolumnar junction is visible and an endocervical curettage is done, this is adequate. Performing random biopsies takes us back to the days before we had the colposcope. I was there, and I’m not proud of how we handled abnormal Pap results.

Another issue: If you find severe dysplasia on random biopsy in a 40-year-old woman, how and what do you treat? Is this a case of treating the lab and not the patient? Or is this a case of inadequately trained gynecologists and/or pathologists?
Anton Strocel, MD
Grand Blanc, Michigan
 

Dr. Kaunitz responds
I thank Dr. Kew and Dr. Strocel for their interest in this commentary on the value of random biopsies during colposcopy when lesions are not visualized. Dr. Kew is correct that the authors did not separate findings in women with low-grade versus high-grade intraepithelial cytology. Dr. Strocel refers to the value of ­clinical experience when performing colposcopy. Both the current article by Huh and colleagues,¹ as well an earlier high-quality report by Gage and colleagues,² point out that, even in skilled hands, colposcopy is not as sensitive in detecting CIN as we have believed in the past. These reports present convincing evidence that, regardless of clinical experience, when no lesion is seen at the time of colposcopy, performing one or two random biopsies substantially increases diagnostic yield of clinically actionable (CIN 2 or worse) disease. 

References
1. Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

2. Gage JC, Hanson VW, Abbey K, et al. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol. 2006;108(2):264–272.
 

“CONJUGATED ESTROGEN PLUS BAZEDOXIFENE—A NEW APPROACH TO ESTROGEN THERAPY”
ANNE A. MOORE, DNP, APN (CASES IN MENOPAUSE; OCTOBER 2014)

Why not encourage soy intake?
Thanks for an interesting discussion on conjugated estrogen/bazedoxifene (CE/BZA; Duavee). I note that:

• CE/BZA is manufactured by Pfizer
• Dr. JoAnn Pinkerton, who is interviewed by Anne Moore, DNP, APN, is affiliated with Pfizer, and
• CE/BZA costs $120 per month.

Since menopausal symptoms are caused by the decreased production of ovarian estradiol, why not prescribe estradiol 0.5–1 mg, which costs only $4 monthly?

Another point to consider: Over several decades of providing care to ethnically diverse women, my observation is that Japanese/Korean and Latina women report far fewer hot flushes than their white sisters.

I believe that it is because of their soy and yam intake. I personally eat about 0.25 lb of tofu per week. It can be diced for salad or soup or served with soy sauce, ginger, and bonito (fish) flakes. It can also be crushed and mixed with lean ground beef, pork, chicken, or turkey to make lean, healthy meatloaf.

Tofu is rich in phytoestrogens, lowers cholesterol, and promotes local soy farmers—a win-win situation.
Yasuo Ishida, MD
St. Louis, Missouri
 

‡‡Dr. Barbieri responds
Dr. Ishida raises an important issue of managing conflicts of interest in medical publications. Dr. Ishida notes that, in the past, Dr. Pinkerton was supported by Pfizer, the company that manufactures (CE/BZA, Duavee). Dr. Ishida also points out that, in a recent OBG Management article, Dr. Pinkerton provided her clinical perspective on the use of CE/BZA in practice.

Often, with a new medication, the physicians with the most expertise in using it have helped with key clinical trials. The results of these trials provide the basis for FDA approval of the medication. Prior to FDA approval of a drug, only experts involved in the clinical trial have first-hand experience with the new treatment.

Dr. Pinkerton is an internationally respected expert in the field and provided a balanced overview of CE/BZA and how it might be used in practice. Dr. Pinkerton disclosed that she personally receives no current support from Pfizer, but that she was supported by Pfizer years ago.

This potential conflict of interest was reported in the article.

Dr. Pinkerton responds
I am proud to serve as a key researcher, consultant, and writer for publications exploring the newest hormonal option for menopausal women—CE/BZA. All of my contracting and fees for my research and consulting with Pfizer have been paid through the University of Virginia, not to me personally. This allows me to be involved in innovative women’s health research and disseminate results without the same conflicts as those who receive reimbursements directly from Pfizer. My relationship to any pharmaceutical company with which I am involved is always through my university and disclosed on every paper, presentation, and talk that I give.

The best way to learn about the pros and cons of a product is to be involved in the sentinel research, to have access to all data, including adverse effects, and to be able to evaluate who might be the best candidates for a new product in women’s health.

Although oral estradiol is inexpensive, women with a uterus also need a progestogen to protect against uterine cancer. It appears that the combination of estrogen and synthetic progestins carry a greater risk of breast cancer than estrogen alone. Estradiol is also available as a patch, gel, lotion, and ring but, again, needs to be paired with a progestogen if a woman has a uterus.

This new drug is well established in published randomized clinical trial data as an effective alternative to traditional estrogen-progestogen therapy (EPT) in symptomatic postmenopausal women with a uterus. Results from Selective Estrogens, Menopause, and Response to Therapy (SMART)¹ randomized controlled trials (RCTs) have shown improvements in symptoms similar to those seen with EPT. These include a reduction in hot flash frequency and severity; a reduction in night sweats, with fewer sleep disruptions; and bone loss prevention. The effects on total cholesterol (an increase in triglycerides) and the drug’s mild effect on vulvovaginal atrophy (VVA) also are similar to those observed with EPT. The drug has a neutral effect on breast tenderness, breast density, and the risk of breast cancer.^1,2 It also protects against endometrial hyperplasia and cancer and increases amenorrhea rates. VTE and stroke risks are expected to be similar to traditional oral hormone therapy (HT). The major benefit of CE/BZA, compared with traditional EPT, is the lack of significant breast tenderness and changes in breast density or vaginal bleeding often seen with traditional EPT.³ 

As for the benefits of soy for menopausal women, clinical data imply that phytoestrogens and soy foods may be of benefit for postmenopausal women. According to a recent review article by Messina⁴ (an international authority on phytoestrogens), isoflavone supplements relieve menopausal hot flashes if they have enough of the isoflavone genistein. Soy has shown benefits with regard to ischemic heart disease—by lowering low-density lipoprotein (LDL) levels and providing a source of omega fatty acids. However, no clear effect has been seen with soy for the prevention of bone loss. The effect on breast cancer risk is unclear. Soy binds to estrogen receptors, which could be harmful. However, soy may bind preferentially to estrogen-receptor beta, thus acting more SERM-like or protective, particularly if given during childhood or adolescence.

For any woman, the decision about using a food source, such as tofu, or isoflavone-rich supplements, such as one containing equol, should be based on a discussion with her clinician regarding her individual needs and the risks and benefits of all options.

In our Midlife Clinic at University of Virginia, we discuss over-the-counter products, lifestyle and dietary changes, and nonhormonal and hormonal options with our patients to help them identify the best choices.

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.

“THE FDA’S REVIEW OF THE DATA ON OPEN POWER MORCELLATION WAS INADEQUATE”
WILLIAM H. PARKER, MD (AUDIO; NOVEMBER 2014)

Why is traditional open myomectomy acceptable if power morcellation isn’t?
The actions taken by the US Food and Drug Administration (FDA) and medical device companies to limit use of power morcellation have effectively led to a halt in the use of minimally invasive surgery for removal of large uterine fibroids. This would seem to leave open laparotomy as the only viable choice for the conservative removal of these benign tumors in women who choose to retain their uterus for personal, cultural, or childbearing reasons. Or does it?

Any open myomectomy of an intramural or subserosal myoma involves an incision into the uterine serosa and muscularis, thus exposing the surface of the tumor to the peritoneal environment. The mass is then grasped with penetrating instruments and manipulated free of its myometrial attachments with other instruments such as forceps, scissors, and electrocautery devices. Suction instruments are freely employed over the operative field. The gloved digits of the surgeon are frequently used to bluntly dissect the tumor from the surrounding myometrial bed.

Because of the desire to maximize future fertility potential by minimizing adhesions, frequent irrigation is considered by most reproductive surgeons to be a necessary part of good surgical technique. Irrigation hydrates the tissues and carries away blood, but it can be counted on to disperse countless cells from the exposed surface of the tumor. After resection, the tumor is removed from the operative field and handed off, usually to the gloved hand of an assistant who will be handling all of the tools that are used from that point forward. If an abscess is a “dirty case” from the standpoint of the spread of infection, then any myomectomy is a potentially “dirty case” from the standpoint of the spread of neoplasia. Given the fundamental nature of this procedure, there seems to be no way to do a “clean” myomectomy. 

Since any form of myomectomy involves at least as much manipulation of the tumor mass as morcellation, it should be at least as likely as morcellation to spread aberrant cells. An inadvertent exposure of the unprotected surface of a leiomyosarcoma at the time of a traditional open myomectomy is not different in any essential way from the exposure of the surface of the same tumor at the time of a myomectomy followed by any type of morcellation. 

It is logical then that if morcellation can be proscribed by regulation and litigation, myomectomy itself will be proscribed on the exact same lines of reasoning.

Despite the widespread use of either abdominal or minimally invasive myomectomy over the last 75 years, disseminated uterine leiomyosarcoma is now and always has been a rare disease. This fact has always been accounted for in our risk assessments of leiomyoma surgeries. In addition, there is no scientific evidence that power morcellation, nonpowered morcellation, or abdominal myomectomy without morcellation has ever been causative in the spread of even one patient’s leiomyosarcoma. Leiomyosarcoma is by definition capable of disseminating by itself.

No medical authority would recommend total hysterectomy for every patient with any myoma, based on the possibility that any individual patient might be harboring a uterine cancer that can spread. This is, however, the exact evolutionary endpoint of the reasoning of the FDA and our legal system. The device companies are to be the deep pockets of the morcellation lawsuits and physicians will be the deep pockets of future myomectomy lawsuits. Gynecologists have always considered risk/reward factors in decisions regarding myomectomy and morcellation. We have an obligation to defend the reproductive rights of our patients. Lawyers, regulators, and even the corporations that dominate the medical device market are motivated by other concerns.

The practice of modern medicine aggressively challenges clinical decision-making based solely on anecdotal evidence. It has done so for well over a century now. It is one of the few standards that still unites good doctors under the battered and tattered umbrella of our professionalism. Our challenge as modern physicians is to stand fast against our new regulatory masters (as well as their former and future law partners) with their grave misunderstandings of the very character of gynecologic decision-making.
Michael C. Doody, MD, PhD
Knoxville, Tennessee
 

“THE EXTRACORPOREAL C-INCISION TISSUE EXTRACTION (EXCITE) TECHNIQUE”
MIREILLE D. TRUONG, MD, AND ARNOLD P. ADVINCULA, MD (VIDEO; NOVEMBER 2014)

Awesome video!
I tried this technique as outlined in the video—totally awesome! It worked really well! Thanks to the surgeons who came up with it!
Ravindhra Mamilla, MD
Thief River Falls, Minnesota
 

“HOW USEFUL IS RANDOM BIOPSY WHEN NO COLPOSCOPIC LESIONS ARE SEEN?”
ANDREW M. KAUNITZ, MD (EXAMINING THE EVIDENCE; OCTOBER 2014)

Additional clarification would be appreciated
According to Dr. Kaunitz’s summary of the findings of Huh and colleagues,¹ the population group included women with low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL) (ie, anything above atypical cells of undetermined significance [ASCUS]), along with women who tested positive for human papillomavirus (HPV) 16/18, regardless of cytology.

It would have been useful to have the LSIL and HSIL populations (independent or dependent of HPV status) broken down into subgroups.

The expert commentary does not indicate whether the 2.7% of biopsy-proven cervical ­intraepithelial neoplasia (CIN) 2 and CIN 3 were predominantly confined to women with HSIL or equally prevalent in the LSIL population.

Without this information, I am not convinced that LSIL requires a random biopsy when colposcopy is adequate and normal, regardless of HPV status.
Jonathan Kew
Maitland, New South Wales, Australia

Reference
1. Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

Are we reverting to past practices?
For someone who has done colposcopy for about 35 years, I find the conclusions of Huh and colleagues nonsensical. If the squamocolumnar junction is visible and an endocervical curettage is done, this is adequate. Performing random biopsies takes us back to the days before we had the colposcope. I was there, and I’m not proud of how we handled abnormal Pap results.

Another issue: If you find severe dysplasia on random biopsy in a 40-year-old woman, how and what do you treat? Is this a case of treating the lab and not the patient? Or is this a case of inadequately trained gynecologists and/or pathologists?
Anton Strocel, MD
Grand Blanc, Michigan
 

Dr. Kaunitz responds
I thank Dr. Kew and Dr. Strocel for their interest in this commentary on the value of random biopsies during colposcopy when lesions are not visualized. Dr. Kew is correct that the authors did not separate findings in women with low-grade versus high-grade intraepithelial cytology. Dr. Strocel refers to the value of ­clinical experience when performing colposcopy. Both the current article by Huh and colleagues,¹ as well an earlier high-quality report by Gage and colleagues,² point out that, even in skilled hands, colposcopy is not as sensitive in detecting CIN as we have believed in the past. These reports present convincing evidence that, regardless of clinical experience, when no lesion is seen at the time of colposcopy, performing one or two random biopsies substantially increases diagnostic yield of clinically actionable (CIN 2 or worse) disease. 

References
1. Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

2. Gage JC, Hanson VW, Abbey K, et al. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol. 2006;108(2):264–272.
 

“CONJUGATED ESTROGEN PLUS BAZEDOXIFENE—A NEW APPROACH TO ESTROGEN THERAPY”
ANNE A. MOORE, DNP, APN (CASES IN MENOPAUSE; OCTOBER 2014)

Why not encourage soy intake?
Thanks for an interesting discussion on conjugated estrogen/bazedoxifene (CE/BZA; Duavee). I note that:

• CE/BZA is manufactured by Pfizer
• Dr. JoAnn Pinkerton, who is interviewed by Anne Moore, DNP, APN, is affiliated with Pfizer, and
• CE/BZA costs $120 per month.

Since menopausal symptoms are caused by the decreased production of ovarian estradiol, why not prescribe estradiol 0.5–1 mg, which costs only $4 monthly?

Another point to consider: Over several decades of providing care to ethnically diverse women, my observation is that Japanese/Korean and Latina women report far fewer hot flushes than their white sisters.

I believe that it is because of their soy and yam intake. I personally eat about 0.25 lb of tofu per week. It can be diced for salad or soup or served with soy sauce, ginger, and bonito (fish) flakes. It can also be crushed and mixed with lean ground beef, pork, chicken, or turkey to make lean, healthy meatloaf.

Tofu is rich in phytoestrogens, lowers cholesterol, and promotes local soy farmers—a win-win situation.
Yasuo Ishida, MD
St. Louis, Missouri
 

‡‡Dr. Barbieri responds
Dr. Ishida raises an important issue of managing conflicts of interest in medical publications. Dr. Ishida notes that, in the past, Dr. Pinkerton was supported by Pfizer, the company that manufactures (CE/BZA, Duavee). Dr. Ishida also points out that, in a recent OBG Management article, Dr. Pinkerton provided her clinical perspective on the use of CE/BZA in practice.

Often, with a new medication, the physicians with the most expertise in using it have helped with key clinical trials. The results of these trials provide the basis for FDA approval of the medication. Prior to FDA approval of a drug, only experts involved in the clinical trial have first-hand experience with the new treatment.

Dr. Pinkerton is an internationally respected expert in the field and provided a balanced overview of CE/BZA and how it might be used in practice. Dr. Pinkerton disclosed that she personally receives no current support from Pfizer, but that she was supported by Pfizer years ago.

This potential conflict of interest was reported in the article.

Dr. Pinkerton responds
I am proud to serve as a key researcher, consultant, and writer for publications exploring the newest hormonal option for menopausal women—CE/BZA. All of my contracting and fees for my research and consulting with Pfizer have been paid through the University of Virginia, not to me personally. This allows me to be involved in innovative women’s health research and disseminate results without the same conflicts as those who receive reimbursements directly from Pfizer. My relationship to any pharmaceutical company with which I am involved is always through my university and disclosed on every paper, presentation, and talk that I give.

The best way to learn about the pros and cons of a product is to be involved in the sentinel research, to have access to all data, including adverse effects, and to be able to evaluate who might be the best candidates for a new product in women’s health.

Although oral estradiol is inexpensive, women with a uterus also need a progestogen to protect against uterine cancer. It appears that the combination of estrogen and synthetic progestins carry a greater risk of breast cancer than estrogen alone. Estradiol is also available as a patch, gel, lotion, and ring but, again, needs to be paired with a progestogen if a woman has a uterus.

This new drug is well established in published randomized clinical trial data as an effective alternative to traditional estrogen-progestogen therapy (EPT) in symptomatic postmenopausal women with a uterus. Results from Selective Estrogens, Menopause, and Response to Therapy (SMART)¹ randomized controlled trials (RCTs) have shown improvements in symptoms similar to those seen with EPT. These include a reduction in hot flash frequency and severity; a reduction in night sweats, with fewer sleep disruptions; and bone loss prevention. The effects on total cholesterol (an increase in triglycerides) and the drug’s mild effect on vulvovaginal atrophy (VVA) also are similar to those observed with EPT. The drug has a neutral effect on breast tenderness, breast density, and the risk of breast cancer.^1,2 It also protects against endometrial hyperplasia and cancer and increases amenorrhea rates. VTE and stroke risks are expected to be similar to traditional oral hormone therapy (HT). The major benefit of CE/BZA, compared with traditional EPT, is the lack of significant breast tenderness and changes in breast density or vaginal bleeding often seen with traditional EPT.³ 

As for the benefits of soy for menopausal women, clinical data imply that phytoestrogens and soy foods may be of benefit for postmenopausal women. According to a recent review article by Messina⁴ (an international authority on phytoestrogens), isoflavone supplements relieve menopausal hot flashes if they have enough of the isoflavone genistein. Soy has shown benefits with regard to ischemic heart disease—by lowering low-density lipoprotein (LDL) levels and providing a source of omega fatty acids. However, no clear effect has been seen with soy for the prevention of bone loss. The effect on breast cancer risk is unclear. Soy binds to estrogen receptors, which could be harmful. However, soy may bind preferentially to estrogen-receptor beta, thus acting more SERM-like or protective, particularly if given during childhood or adolescence.

For any woman, the decision about using a food source, such as tofu, or isoflavone-rich supplements, such as one containing equol, should be based on a discussion with her clinician regarding her individual needs and the risks and benefits of all options.

In our Midlife Clinic at University of Virginia, we discuss over-the-counter products, lifestyle and dietary changes, and nonhormonal and hormonal options with our patients to help them identify the best choices.

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.

“THE FDA’S REVIEW OF THE DATA ON OPEN POWER MORCELLATION WAS INADEQUATE”
WILLIAM H. PARKER, MD (AUDIO; NOVEMBER 2014)

Why is traditional open myomectomy acceptable if power morcellation isn’t?
The actions taken by the US Food and Drug Administration (FDA) and medical device companies to limit use of power morcellation have effectively led to a halt in the use of minimally invasive surgery for removal of large uterine fibroids. This would seem to leave open laparotomy as the only viable choice for the conservative removal of these benign tumors in women who choose to retain their uterus for personal, cultural, or childbearing reasons. Or does it?

Any open myomectomy of an intramural or subserosal myoma involves an incision into the uterine serosa and muscularis, thus exposing the surface of the tumor to the peritoneal environment. The mass is then grasped with penetrating instruments and manipulated free of its myometrial attachments with other instruments such as forceps, scissors, and electrocautery devices. Suction instruments are freely employed over the operative field. The gloved digits of the surgeon are frequently used to bluntly dissect the tumor from the surrounding myometrial bed.

Because of the desire to maximize future fertility potential by minimizing adhesions, frequent irrigation is considered by most reproductive surgeons to be a necessary part of good surgical technique. Irrigation hydrates the tissues and carries away blood, but it can be counted on to disperse countless cells from the exposed surface of the tumor. After resection, the tumor is removed from the operative field and handed off, usually to the gloved hand of an assistant who will be handling all of the tools that are used from that point forward. If an abscess is a “dirty case” from the standpoint of the spread of infection, then any myomectomy is a potentially “dirty case” from the standpoint of the spread of neoplasia. Given the fundamental nature of this procedure, there seems to be no way to do a “clean” myomectomy. 

Since any form of myomectomy involves at least as much manipulation of the tumor mass as morcellation, it should be at least as likely as morcellation to spread aberrant cells. An inadvertent exposure of the unprotected surface of a leiomyosarcoma at the time of a traditional open myomectomy is not different in any essential way from the exposure of the surface of the same tumor at the time of a myomectomy followed by any type of morcellation. 

It is logical then that if morcellation can be proscribed by regulation and litigation, myomectomy itself will be proscribed on the exact same lines of reasoning.

Despite the widespread use of either abdominal or minimally invasive myomectomy over the last 75 years, disseminated uterine leiomyosarcoma is now and always has been a rare disease. This fact has always been accounted for in our risk assessments of leiomyoma surgeries. In addition, there is no scientific evidence that power morcellation, nonpowered morcellation, or abdominal myomectomy without morcellation has ever been causative in the spread of even one patient’s leiomyosarcoma. Leiomyosarcoma is by definition capable of disseminating by itself.

No medical authority would recommend total hysterectomy for every patient with any myoma, based on the possibility that any individual patient might be harboring a uterine cancer that can spread. This is, however, the exact evolutionary endpoint of the reasoning of the FDA and our legal system. The device companies are to be the deep pockets of the morcellation lawsuits and physicians will be the deep pockets of future myomectomy lawsuits. Gynecologists have always considered risk/reward factors in decisions regarding myomectomy and morcellation. We have an obligation to defend the reproductive rights of our patients. Lawyers, regulators, and even the corporations that dominate the medical device market are motivated by other concerns.

The practice of modern medicine aggressively challenges clinical decision-making based solely on anecdotal evidence. It has done so for well over a century now. It is one of the few standards that still unites good doctors under the battered and tattered umbrella of our professionalism. Our challenge as modern physicians is to stand fast against our new regulatory masters (as well as their former and future law partners) with their grave misunderstandings of the very character of gynecologic decision-making.
Michael C. Doody, MD, PhD
Knoxville, Tennessee
 

“THE EXTRACORPOREAL C-INCISION TISSUE EXTRACTION (EXCITE) TECHNIQUE”
MIREILLE D. TRUONG, MD, AND ARNOLD P. ADVINCULA, MD (VIDEO; NOVEMBER 2014)

Awesome video!
I tried this technique as outlined in the video—totally awesome! It worked really well! Thanks to the surgeons who came up with it!
Ravindhra Mamilla, MD
Thief River Falls, Minnesota
 

“HOW USEFUL IS RANDOM BIOPSY WHEN NO COLPOSCOPIC LESIONS ARE SEEN?”
ANDREW M. KAUNITZ, MD (EXAMINING THE EVIDENCE; OCTOBER 2014)

Additional clarification would be appreciated
According to Dr. Kaunitz’s summary of the findings of Huh and colleagues,¹ the population group included women with low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL) (ie, anything above atypical cells of undetermined significance [ASCUS]), along with women who tested positive for human papillomavirus (HPV) 16/18, regardless of cytology.

It would have been useful to have the LSIL and HSIL populations (independent or dependent of HPV status) broken down into subgroups.

The expert commentary does not indicate whether the 2.7% of biopsy-proven cervical ­intraepithelial neoplasia (CIN) 2 and CIN 3 were predominantly confined to women with HSIL or equally prevalent in the LSIL population.

Without this information, I am not convinced that LSIL requires a random biopsy when colposcopy is adequate and normal, regardless of HPV status.
Jonathan Kew
Maitland, New South Wales, Australia

Reference
1. Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

Are we reverting to past practices?
For someone who has done colposcopy for about 35 years, I find the conclusions of Huh and colleagues nonsensical. If the squamocolumnar junction is visible and an endocervical curettage is done, this is adequate. Performing random biopsies takes us back to the days before we had the colposcope. I was there, and I’m not proud of how we handled abnormal Pap results.

Another issue: If you find severe dysplasia on random biopsy in a 40-year-old woman, how and what do you treat? Is this a case of treating the lab and not the patient? Or is this a case of inadequately trained gynecologists and/or pathologists?
Anton Strocel, MD
Grand Blanc, Michigan
 

Dr. Kaunitz responds
I thank Dr. Kew and Dr. Strocel for their interest in this commentary on the value of random biopsies during colposcopy when lesions are not visualized. Dr. Kew is correct that the authors did not separate findings in women with low-grade versus high-grade intraepithelial cytology. Dr. Strocel refers to the value of ­clinical experience when performing colposcopy. Both the current article by Huh and colleagues,¹ as well an earlier high-quality report by Gage and colleagues,² point out that, even in skilled hands, colposcopy is not as sensitive in detecting CIN as we have believed in the past. These reports present convincing evidence that, regardless of clinical experience, when no lesion is seen at the time of colposcopy, performing one or two random biopsies substantially increases diagnostic yield of clinically actionable (CIN 2 or worse) disease. 

References
1. Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

2. Gage JC, Hanson VW, Abbey K, et al. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol. 2006;108(2):264–272.
 

“CONJUGATED ESTROGEN PLUS BAZEDOXIFENE—A NEW APPROACH TO ESTROGEN THERAPY”
ANNE A. MOORE, DNP, APN (CASES IN MENOPAUSE; OCTOBER 2014)

Why not encourage soy intake?
Thanks for an interesting discussion on conjugated estrogen/bazedoxifene (CE/BZA; Duavee). I note that:

• CE/BZA is manufactured by Pfizer
• Dr. JoAnn Pinkerton, who is interviewed by Anne Moore, DNP, APN, is affiliated with Pfizer, and
• CE/BZA costs $120 per month.

Since menopausal symptoms are caused by the decreased production of ovarian estradiol, why not prescribe estradiol 0.5–1 mg, which costs only $4 monthly?

Another point to consider: Over several decades of providing care to ethnically diverse women, my observation is that Japanese/Korean and Latina women report far fewer hot flushes than their white sisters.

I believe that it is because of their soy and yam intake. I personally eat about 0.25 lb of tofu per week. It can be diced for salad or soup or served with soy sauce, ginger, and bonito (fish) flakes. It can also be crushed and mixed with lean ground beef, pork, chicken, or turkey to make lean, healthy meatloaf.

Tofu is rich in phytoestrogens, lowers cholesterol, and promotes local soy farmers—a win-win situation.
Yasuo Ishida, MD
St. Louis, Missouri
 

‡‡Dr. Barbieri responds
Dr. Ishida raises an important issue of managing conflicts of interest in medical publications. Dr. Ishida notes that, in the past, Dr. Pinkerton was supported by Pfizer, the company that manufactures (CE/BZA, Duavee). Dr. Ishida also points out that, in a recent OBG Management article, Dr. Pinkerton provided her clinical perspective on the use of CE/BZA in practice.

Often, with a new medication, the physicians with the most expertise in using it have helped with key clinical trials. The results of these trials provide the basis for FDA approval of the medication. Prior to FDA approval of a drug, only experts involved in the clinical trial have first-hand experience with the new treatment.

Dr. Pinkerton is an internationally respected expert in the field and provided a balanced overview of CE/BZA and how it might be used in practice. Dr. Pinkerton disclosed that she personally receives no current support from Pfizer, but that she was supported by Pfizer years ago.

This potential conflict of interest was reported in the article.

Dr. Pinkerton responds
I am proud to serve as a key researcher, consultant, and writer for publications exploring the newest hormonal option for menopausal women—CE/BZA. All of my contracting and fees for my research and consulting with Pfizer have been paid through the University of Virginia, not to me personally. This allows me to be involved in innovative women’s health research and disseminate results without the same conflicts as those who receive reimbursements directly from Pfizer. My relationship to any pharmaceutical company with which I am involved is always through my university and disclosed on every paper, presentation, and talk that I give.

The best way to learn about the pros and cons of a product is to be involved in the sentinel research, to have access to all data, including adverse effects, and to be able to evaluate who might be the best candidates for a new product in women’s health.

Although oral estradiol is inexpensive, women with a uterus also need a progestogen to protect against uterine cancer. It appears that the combination of estrogen and synthetic progestins carry a greater risk of breast cancer than estrogen alone. Estradiol is also available as a patch, gel, lotion, and ring but, again, needs to be paired with a progestogen if a woman has a uterus.

This new drug is well established in published randomized clinical trial data as an effective alternative to traditional estrogen-progestogen therapy (EPT) in symptomatic postmenopausal women with a uterus. Results from Selective Estrogens, Menopause, and Response to Therapy (SMART)¹ randomized controlled trials (RCTs) have shown improvements in symptoms similar to those seen with EPT. These include a reduction in hot flash frequency and severity; a reduction in night sweats, with fewer sleep disruptions; and bone loss prevention. The effects on total cholesterol (an increase in triglycerides) and the drug’s mild effect on vulvovaginal atrophy (VVA) also are similar to those observed with EPT. The drug has a neutral effect on breast tenderness, breast density, and the risk of breast cancer.^1,2 It also protects against endometrial hyperplasia and cancer and increases amenorrhea rates. VTE and stroke risks are expected to be similar to traditional oral hormone therapy (HT). The major benefit of CE/BZA, compared with traditional EPT, is the lack of significant breast tenderness and changes in breast density or vaginal bleeding often seen with traditional EPT.³ 

As for the benefits of soy for menopausal women, clinical data imply that phytoestrogens and soy foods may be of benefit for postmenopausal women. According to a recent review article by Messina⁴ (an international authority on phytoestrogens), isoflavone supplements relieve menopausal hot flashes if they have enough of the isoflavone genistein. Soy has shown benefits with regard to ischemic heart disease—by lowering low-density lipoprotein (LDL) levels and providing a source of omega fatty acids. However, no clear effect has been seen with soy for the prevention of bone loss. The effect on breast cancer risk is unclear. Soy binds to estrogen receptors, which could be harmful. However, soy may bind preferentially to estrogen-receptor beta, thus acting more SERM-like or protective, particularly if given during childhood or adolescence.

For any woman, the decision about using a food source, such as tofu, or isoflavone-rich supplements, such as one containing equol, should be based on a discussion with her clinician regarding her individual needs and the risks and benefits of all options.

In our Midlife Clinic at University of Virginia, we discuss over-the-counter products, lifestyle and dietary changes, and nonhormonal and hormonal options with our patients to help them identify the best choices.

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.

Dr. Wilkoff gives all the good reasons for NOT allowing one’s son to play football in his Letters From Maine column entitled “Your son and football” in the December 2014 issue of Pediatric News, and then rationalizes the opposite. As society evolves from gladiators killing their defeated opponents to abolishing boxing as a college sport, so too should we encourage our children to engage in safer sports. Soccer without head-butting and hockey without fighting and body checking would be a good start. There’s no way to make football safe. It just gets more dangerous, as 350-pound gorillas run smack-dab into each other. But humans evolve slowly. We have not been down very long from the trees in evolutionary terms, when the “accepted” way to get a female mate was to club her senseless and carry her off (as the chroniclers of primitive societies have repeatedly shown). Nor do we tolerate dueling, or drawing and quartering or torture any longer. Watching the development of MMA (mixed marital arts) and female boxing just goes to show how primitive and inconsistent we can still be. So, just like Dr. Wilkoff, I confess to being inconsistent, and addicted to watching the genius play of the Aaron Rodgers and Peyton Mannings of football. Maybe we just need a few more centuries to evolve into a civilized society, a bit of help from female leadership to encourage alternative sports to develop. This retired pediatrician, who also was a team football physician, and who also was nonchalant about concussions, now comes down solidly against allowing any of our sons to play football in light of the new scientific evidence. Guess I’m not too old to learn.

Michael L. McCann, M.D.

Duluth, Minn.

Dr. Wilkoff responds: Thanks for your great e-mail. Obviously, we are both conflicted in our own ways. I guess I should have ended my column with the unrealistic wish that football could remain as a sport for young kids so they could play rough and still be protected by their equipment. Then, eliminate it as a division one and professional activity. Obviously, it’s not going to happen because otherwise what would all those folks on their couches do on Saturday and Sunday afternoons?

A benefit of football

Dr. Wilkoff, thank you for being a sane man in a sea of fear and ill thought out conclusions. As a pediatrician for over 40 years and as a postcollegiate football player, I do appreciate the sincere fear of major injuries to any child. However, eliminating a sport because it has some inherent potential for serious damage is not the right answer. All these years I have been preaching both to my patients and to younger physicians the balance of risk versus benefit in all decision making. Now you may or may not agree with me, but the benefits of football experience are tremendous, whether it stops at the high school or the collegiate level. I noticed that you listed many of these benefits of football in your article, but the major one I did not see is the understanding that one’s input into a project, whether football competition or treating a complicated patient, often determines the outcome of the project. Call it “cause and effect” if you like. Certainly one begins learning these lessons in a home in which personal responsibility is stressed, but I wholeheartedly believe that this specific lesson was reinforced time and again during my football upbringing, and I tend to credit a successful career in pediatrics with that education. Just to be as direct as possible, I too played other high school sports, but football was a unique experience in my mind, and I have encouraged my son and grandsons to participate, mainly because the sport and most of the men that gathered around our youth in this area are teachers. They teach hard work, they teach desire for success, and they teach personal responsibility for actions. Yes, we have all viewed those screaming poor sports who occasionally don a coach’s uniform, but they are far less frequent that the good guys who give their time to our children. Thanks again for a well thought out article. Your articles are consistently written well and thoughtful.

Stuart J. Yoffe, M.D.

Brenham, Texas

Dr Wilkoff responds: Thanks for your kind and thoughtful comments. It is hard to get many people to understand the kind of formative experiences that you and I shared playing football. My wife still doesn’t get it.

Each week’s game was a project that involved planning, preparation, cooperation, and commitment to execute.

No to football

Would I let my son play football? No.

A few years ago I had a patient who won a full ride football scholarship to a division 3 college. He wasn’t National Football League material and knew it. He was a brilliant student who majored in engineering and wanted a free education. After a big time concussion in practice his freshman year, he’s had to drop out of college. He can’t do the work anymore.

I’ve been at pediatrics for 35 years and when I ask kids (in front of their parents) why they want to change from soccer to American football, they say it’s because they like the 49ers or Raiders (I practice in the periphery of the San Francisco Bay Area). When I ask them alone, the answer is different –“because I want to hit someone.”

I have a couple of Dads who are coaches and both suggested the answer is to eliminate helmets and protective padding. They think it would make the kids more careful. I worry more about steroids. When you were playing, how many 300 plus pounds opponents did you face? I think the high schools need to do random drug testing.

Some of the local Pop Warner leagues are having trouble getting liability insurance. I suspect that’ll spread to the schools soon as well. In a state such as California, I suspect that schools will drop football as well for insurance reasons soon.

It’s too bad; I’ve enjoyed watching football. But then, when younger, I used to watch and root for Mohammad Ali. Look what’s happened to him. I don’t believe it’s all Parkinson’s disease.

Steve Jacobs M.D.

Modesto, Calif.

Dr. Wilkoff responds: There weren’t any 300 pounders when I played because they couldn’t make the team. There are some pretty hefty guys on our high school team here in Brunswick, but they are more like Pillsbury Doughboys and aren’t going to do much harm. I agree that eliminating helmets and pads makes a lot of sense. Which would make it rugby, a much more interesting game that requires more conditioning.

The bulk of the e-mails I have received about the column have supported football. As I think more about, I think a solution – but not one that will fly – is to eliminate football beyond high school or maybe even middle school when it begins to get ugly and dangerous. Young boys do like to hit, tussle, and knock each other around, and seldom do much harm, with or without equipment.

No to football – again

Nearly everyone in our University of California, Los Angeles, pediatric faculty won’t allow their child to play Pop Warner football. It is just too dangerous.

I fortunately was too thin to play football, but agree completely that athletics were a good influence growing up in a fatherless home in Madison, Wisc. I played tennis and basketball instead.

The American Academy of Pediatrics should take a stand. No kids should play football.

As someone said, everyone in 1936 knew who the heavy weight boxing champion was – now no one knows. My alma mater, the University of Wisconsin, gave up boxing after someone died after a blow to the head.

How many cord transections, concussions, and sudden deaths can we tolerate?

Richard Stiehm, M.D.

Distinguished Research Professor of Pediatrics Emeritus

University of California, Los Angeles

Dr. Wilkoff responds: I agree that very few people know the names of professional fighters today, but many people (none of them with whom you and I are likely on a first name basis) know the names of successful mixed-martial arts/cage fighters. Now that is a brutal sport. The fact that it is popular should remind us that the desire to watch and participate in those activities runs pretty deep in us – which of course doesn’t make it right.

In response to your question of how many cord transections, concussions, and sudden deaths will we tolerate, I would be interested in your response. If the number is zero, then we have to broaden the discussion to a consideration of what activities we should allow children (particularly boys) to pursue to be physically active and receive the enjoyment that (for lack of a better term) rough housing provides. Zero tolerance can be a double-edged sword.

[Dr. Stiehm responds: Yes to soccer, basketball, and lacrosse, where the object is not to hurt the opponent – unlike boxing and tackle football.

Dr. Wilkoff replies: My perspective is colored by being here in Maine, where football is small time and even smaller in our community. One solution, but of course one that wouldn’t fly, is to make football a sport that ends at or just after middle school. It would allow young children to rough house in the context of a fun game protected by equipment before the g-forces that come with puberty create the serious dangers. Well coached and refereed football needn’t be a sport where one of the goals is to injure.]

An honest column

I want to thank you for your column entitled “Your son and football.” I am a pediatric primary care sports physician who runs a sports medicine clinic and a concussion clinic through Children’s Hospital of Wisconsin and the Medical College of Wisconsin. I am happy that you wrote about pro football and youth sports honestly – the perceived lack of moral character of many professional athletes and the craziness / win at all costs attitude of some youth coaches (and parents). And the fact that most kids will not become professional athletes. I believe treating kids just like a “collegiate or pro athlete” is a disservice to the child, as they are not at that level of emotional or physical maturity. I like the benefits of football and other contact sports – when taught and coached well, played well, and done under the realistic vision that this is for fun, and you learn life’s lessons and how to compete, win, and lose – not just done to win and earn a scholarship.

Kevin D. Walter, M.D.

Medical College of Wisconsin

Milwaukee

Sports role models

It is too bad Maine, where Dr. Wilkoff lives, does not have a professional sports team; Peyton Manning, the quarterback for the Denver Broncos, is one of the most “admirable role models in the ranks of high-profile athletes.” He is well respected and loved both here and still in the Indianapolis area and in Tennessee, where he played college football. Missy Franklin, a high profile athlete, just finished a day visiting patients at Children’s Hospital of Colorado. It was on the news last night. She is beloved here in Colorado for her smile, enthusiasm, professionalism, kindness, and overall just for being a wonderful person and amazing athlete. Although the high-profile headlines dominate, the acts of kindness and compassion by many athletes at many levels are not covered to the same degree.

It has been shown that high school and college athletes do better than their counterparts in school. My daughter was a swimmer in high school and thus avoided the drug crowd for which her class was known locally. I hope Dr. Wilkoff’s son learns the same lessons so many athletes learn in competition: teamwork, hard work, meeting and exceeding goals, and learning to deal with disappointment and victory – lessons that are hard to learn in the classroom. He will be a better person for that.

Stephen Fries, M.D.

Boulder, Colo.

Dr. Wilkoff responds: I agree there are still some shining stars in pro sports, but it seems to me that they are badly overshadowed by the bad apples. That may simply be a function of media exposure, but that’s what the kids see. My son was and still is at age 39 a hockey player and a fine young man in some part because of his athletic past.

Dr. Wilkoff gives all the good reasons for NOT allowing one’s son to play football in his Letters From Maine column entitled “Your son and football” in the December 2014 issue of Pediatric News, and then rationalizes the opposite. As society evolves from gladiators killing their defeated opponents to abolishing boxing as a college sport, so too should we encourage our children to engage in safer sports. Soccer without head-butting and hockey without fighting and body checking would be a good start. There’s no way to make football safe. It just gets more dangerous, as 350-pound gorillas run smack-dab into each other. But humans evolve slowly. We have not been down very long from the trees in evolutionary terms, when the “accepted” way to get a female mate was to club her senseless and carry her off (as the chroniclers of primitive societies have repeatedly shown). Nor do we tolerate dueling, or drawing and quartering or torture any longer. Watching the development of MMA (mixed marital arts) and female boxing just goes to show how primitive and inconsistent we can still be. So, just like Dr. Wilkoff, I confess to being inconsistent, and addicted to watching the genius play of the Aaron Rodgers and Peyton Mannings of football. Maybe we just need a few more centuries to evolve into a civilized society, a bit of help from female leadership to encourage alternative sports to develop. This retired pediatrician, who also was a team football physician, and who also was nonchalant about concussions, now comes down solidly against allowing any of our sons to play football in light of the new scientific evidence. Guess I’m not too old to learn.

Michael L. McCann, M.D.

Duluth, Minn.

Dr. Wilkoff responds: Thanks for your great e-mail. Obviously, we are both conflicted in our own ways. I guess I should have ended my column with the unrealistic wish that football could remain as a sport for young kids so they could play rough and still be protected by their equipment. Then, eliminate it as a division one and professional activity. Obviously, it’s not going to happen because otherwise what would all those folks on their couches do on Saturday and Sunday afternoons?

A benefit of football

Dr. Wilkoff, thank you for being a sane man in a sea of fear and ill thought out conclusions. As a pediatrician for over 40 years and as a postcollegiate football player, I do appreciate the sincere fear of major injuries to any child. However, eliminating a sport because it has some inherent potential for serious damage is not the right answer. All these years I have been preaching both to my patients and to younger physicians the balance of risk versus benefit in all decision making. Now you may or may not agree with me, but the benefits of football experience are tremendous, whether it stops at the high school or the collegiate level. I noticed that you listed many of these benefits of football in your article, but the major one I did not see is the understanding that one’s input into a project, whether football competition or treating a complicated patient, often determines the outcome of the project. Call it “cause and effect” if you like. Certainly one begins learning these lessons in a home in which personal responsibility is stressed, but I wholeheartedly believe that this specific lesson was reinforced time and again during my football upbringing, and I tend to credit a successful career in pediatrics with that education. Just to be as direct as possible, I too played other high school sports, but football was a unique experience in my mind, and I have encouraged my son and grandsons to participate, mainly because the sport and most of the men that gathered around our youth in this area are teachers. They teach hard work, they teach desire for success, and they teach personal responsibility for actions. Yes, we have all viewed those screaming poor sports who occasionally don a coach’s uniform, but they are far less frequent that the good guys who give their time to our children. Thanks again for a well thought out article. Your articles are consistently written well and thoughtful.

Stuart J. Yoffe, M.D.

Brenham, Texas

Dr Wilkoff responds: Thanks for your kind and thoughtful comments. It is hard to get many people to understand the kind of formative experiences that you and I shared playing football. My wife still doesn’t get it.

Each week’s game was a project that involved planning, preparation, cooperation, and commitment to execute.

No to football

Would I let my son play football? No.

A few years ago I had a patient who won a full ride football scholarship to a division 3 college. He wasn’t National Football League material and knew it. He was a brilliant student who majored in engineering and wanted a free education. After a big time concussion in practice his freshman year, he’s had to drop out of college. He can’t do the work anymore.

I’ve been at pediatrics for 35 years and when I ask kids (in front of their parents) why they want to change from soccer to American football, they say it’s because they like the 49ers or Raiders (I practice in the periphery of the San Francisco Bay Area). When I ask them alone, the answer is different –“because I want to hit someone.”

I have a couple of Dads who are coaches and both suggested the answer is to eliminate helmets and protective padding. They think it would make the kids more careful. I worry more about steroids. When you were playing, how many 300 plus pounds opponents did you face? I think the high schools need to do random drug testing.

Some of the local Pop Warner leagues are having trouble getting liability insurance. I suspect that’ll spread to the schools soon as well. In a state such as California, I suspect that schools will drop football as well for insurance reasons soon.

It’s too bad; I’ve enjoyed watching football. But then, when younger, I used to watch and root for Mohammad Ali. Look what’s happened to him. I don’t believe it’s all Parkinson’s disease.

Steve Jacobs M.D.

Modesto, Calif.

Dr. Wilkoff responds: There weren’t any 300 pounders when I played because they couldn’t make the team. There are some pretty hefty guys on our high school team here in Brunswick, but they are more like Pillsbury Doughboys and aren’t going to do much harm. I agree that eliminating helmets and pads makes a lot of sense. Which would make it rugby, a much more interesting game that requires more conditioning.

The bulk of the e-mails I have received about the column have supported football. As I think more about, I think a solution – but not one that will fly – is to eliminate football beyond high school or maybe even middle school when it begins to get ugly and dangerous. Young boys do like to hit, tussle, and knock each other around, and seldom do much harm, with or without equipment.

No to football – again

Nearly everyone in our University of California, Los Angeles, pediatric faculty won’t allow their child to play Pop Warner football. It is just too dangerous.

I fortunately was too thin to play football, but agree completely that athletics were a good influence growing up in a fatherless home in Madison, Wisc. I played tennis and basketball instead.

The American Academy of Pediatrics should take a stand. No kids should play football.

As someone said, everyone in 1936 knew who the heavy weight boxing champion was – now no one knows. My alma mater, the University of Wisconsin, gave up boxing after someone died after a blow to the head.

How many cord transections, concussions, and sudden deaths can we tolerate?

Richard Stiehm, M.D.

Distinguished Research Professor of Pediatrics Emeritus

University of California, Los Angeles

Dr. Wilkoff responds: I agree that very few people know the names of professional fighters today, but many people (none of them with whom you and I are likely on a first name basis) know the names of successful mixed-martial arts/cage fighters. Now that is a brutal sport. The fact that it is popular should remind us that the desire to watch and participate in those activities runs pretty deep in us – which of course doesn’t make it right.

In response to your question of how many cord transections, concussions, and sudden deaths will we tolerate, I would be interested in your response. If the number is zero, then we have to broaden the discussion to a consideration of what activities we should allow children (particularly boys) to pursue to be physically active and receive the enjoyment that (for lack of a better term) rough housing provides. Zero tolerance can be a double-edged sword.

[Dr. Stiehm responds: Yes to soccer, basketball, and lacrosse, where the object is not to hurt the opponent – unlike boxing and tackle football.

Dr. Wilkoff replies: My perspective is colored by being here in Maine, where football is small time and even smaller in our community. One solution, but of course one that wouldn’t fly, is to make football a sport that ends at or just after middle school. It would allow young children to rough house in the context of a fun game protected by equipment before the g-forces that come with puberty create the serious dangers. Well coached and refereed football needn’t be a sport where one of the goals is to injure.]

An honest column

I want to thank you for your column entitled “Your son and football.” I am a pediatric primary care sports physician who runs a sports medicine clinic and a concussion clinic through Children’s Hospital of Wisconsin and the Medical College of Wisconsin. I am happy that you wrote about pro football and youth sports honestly – the perceived lack of moral character of many professional athletes and the craziness / win at all costs attitude of some youth coaches (and parents). And the fact that most kids will not become professional athletes. I believe treating kids just like a “collegiate or pro athlete” is a disservice to the child, as they are not at that level of emotional or physical maturity. I like the benefits of football and other contact sports – when taught and coached well, played well, and done under the realistic vision that this is for fun, and you learn life’s lessons and how to compete, win, and lose – not just done to win and earn a scholarship.

Kevin D. Walter, M.D.

Medical College of Wisconsin

Milwaukee

Sports role models

It is too bad Maine, where Dr. Wilkoff lives, does not have a professional sports team; Peyton Manning, the quarterback for the Denver Broncos, is one of the most “admirable role models in the ranks of high-profile athletes.” He is well respected and loved both here and still in the Indianapolis area and in Tennessee, where he played college football. Missy Franklin, a high profile athlete, just finished a day visiting patients at Children’s Hospital of Colorado. It was on the news last night. She is beloved here in Colorado for her smile, enthusiasm, professionalism, kindness, and overall just for being a wonderful person and amazing athlete. Although the high-profile headlines dominate, the acts of kindness and compassion by many athletes at many levels are not covered to the same degree.

It has been shown that high school and college athletes do better than their counterparts in school. My daughter was a swimmer in high school and thus avoided the drug crowd for which her class was known locally. I hope Dr. Wilkoff’s son learns the same lessons so many athletes learn in competition: teamwork, hard work, meeting and exceeding goals, and learning to deal with disappointment and victory – lessons that are hard to learn in the classroom. He will be a better person for that.

Stephen Fries, M.D.

Boulder, Colo.

Dr. Wilkoff responds: I agree there are still some shining stars in pro sports, but it seems to me that they are badly overshadowed by the bad apples. That may simply be a function of media exposure, but that’s what the kids see. My son was and still is at age 39 a hockey player and a fine young man in some part because of his athletic past.

Dr. Wilkoff gives all the good reasons for NOT allowing one’s son to play football in his Letters From Maine column entitled “Your son and football” in the December 2014 issue of Pediatric News, and then rationalizes the opposite. As society evolves from gladiators killing their defeated opponents to abolishing boxing as a college sport, so too should we encourage our children to engage in safer sports. Soccer without head-butting and hockey without fighting and body checking would be a good start. There’s no way to make football safe. It just gets more dangerous, as 350-pound gorillas run smack-dab into each other. But humans evolve slowly. We have not been down very long from the trees in evolutionary terms, when the “accepted” way to get a female mate was to club her senseless and carry her off (as the chroniclers of primitive societies have repeatedly shown). Nor do we tolerate dueling, or drawing and quartering or torture any longer. Watching the development of MMA (mixed marital arts) and female boxing just goes to show how primitive and inconsistent we can still be. So, just like Dr. Wilkoff, I confess to being inconsistent, and addicted to watching the genius play of the Aaron Rodgers and Peyton Mannings of football. Maybe we just need a few more centuries to evolve into a civilized society, a bit of help from female leadership to encourage alternative sports to develop. This retired pediatrician, who also was a team football physician, and who also was nonchalant about concussions, now comes down solidly against allowing any of our sons to play football in light of the new scientific evidence. Guess I’m not too old to learn.

Michael L. McCann, M.D.

Duluth, Minn.

Dr. Wilkoff responds: Thanks for your great e-mail. Obviously, we are both conflicted in our own ways. I guess I should have ended my column with the unrealistic wish that football could remain as a sport for young kids so they could play rough and still be protected by their equipment. Then, eliminate it as a division one and professional activity. Obviously, it’s not going to happen because otherwise what would all those folks on their couches do on Saturday and Sunday afternoons?

A benefit of football

Dr. Wilkoff, thank you for being a sane man in a sea of fear and ill thought out conclusions. As a pediatrician for over 40 years and as a postcollegiate football player, I do appreciate the sincere fear of major injuries to any child. However, eliminating a sport because it has some inherent potential for serious damage is not the right answer. All these years I have been preaching both to my patients and to younger physicians the balance of risk versus benefit in all decision making. Now you may or may not agree with me, but the benefits of football experience are tremendous, whether it stops at the high school or the collegiate level. I noticed that you listed many of these benefits of football in your article, but the major one I did not see is the understanding that one’s input into a project, whether football competition or treating a complicated patient, often determines the outcome of the project. Call it “cause and effect” if you like. Certainly one begins learning these lessons in a home in which personal responsibility is stressed, but I wholeheartedly believe that this specific lesson was reinforced time and again during my football upbringing, and I tend to credit a successful career in pediatrics with that education. Just to be as direct as possible, I too played other high school sports, but football was a unique experience in my mind, and I have encouraged my son and grandsons to participate, mainly because the sport and most of the men that gathered around our youth in this area are teachers. They teach hard work, they teach desire for success, and they teach personal responsibility for actions. Yes, we have all viewed those screaming poor sports who occasionally don a coach’s uniform, but they are far less frequent that the good guys who give their time to our children. Thanks again for a well thought out article. Your articles are consistently written well and thoughtful.

Stuart J. Yoffe, M.D.

Brenham, Texas

Dr Wilkoff responds: Thanks for your kind and thoughtful comments. It is hard to get many people to understand the kind of formative experiences that you and I shared playing football. My wife still doesn’t get it.

Each week’s game was a project that involved planning, preparation, cooperation, and commitment to execute.

No to football

Would I let my son play football? No.

A few years ago I had a patient who won a full ride football scholarship to a division 3 college. He wasn’t National Football League material and knew it. He was a brilliant student who majored in engineering and wanted a free education. After a big time concussion in practice his freshman year, he’s had to drop out of college. He can’t do the work anymore.

I’ve been at pediatrics for 35 years and when I ask kids (in front of their parents) why they want to change from soccer to American football, they say it’s because they like the 49ers or Raiders (I practice in the periphery of the San Francisco Bay Area). When I ask them alone, the answer is different –“because I want to hit someone.”

I have a couple of Dads who are coaches and both suggested the answer is to eliminate helmets and protective padding. They think it would make the kids more careful. I worry more about steroids. When you were playing, how many 300 plus pounds opponents did you face? I think the high schools need to do random drug testing.

Some of the local Pop Warner leagues are having trouble getting liability insurance. I suspect that’ll spread to the schools soon as well. In a state such as California, I suspect that schools will drop football as well for insurance reasons soon.

It’s too bad; I’ve enjoyed watching football. But then, when younger, I used to watch and root for Mohammad Ali. Look what’s happened to him. I don’t believe it’s all Parkinson’s disease.

Steve Jacobs M.D.

Modesto, Calif.

Dr. Wilkoff responds: There weren’t any 300 pounders when I played because they couldn’t make the team. There are some pretty hefty guys on our high school team here in Brunswick, but they are more like Pillsbury Doughboys and aren’t going to do much harm. I agree that eliminating helmets and pads makes a lot of sense. Which would make it rugby, a much more interesting game that requires more conditioning.

The bulk of the e-mails I have received about the column have supported football. As I think more about, I think a solution – but not one that will fly – is to eliminate football beyond high school or maybe even middle school when it begins to get ugly and dangerous. Young boys do like to hit, tussle, and knock each other around, and seldom do much harm, with or without equipment.

No to football – again

Nearly everyone in our University of California, Los Angeles, pediatric faculty won’t allow their child to play Pop Warner football. It is just too dangerous.

I fortunately was too thin to play football, but agree completely that athletics were a good influence growing up in a fatherless home in Madison, Wisc. I played tennis and basketball instead.

The American Academy of Pediatrics should take a stand. No kids should play football.

As someone said, everyone in 1936 knew who the heavy weight boxing champion was – now no one knows. My alma mater, the University of Wisconsin, gave up boxing after someone died after a blow to the head.

How many cord transections, concussions, and sudden deaths can we tolerate?

Richard Stiehm, M.D.

Distinguished Research Professor of Pediatrics Emeritus

University of California, Los Angeles

Dr. Wilkoff responds: I agree that very few people know the names of professional fighters today, but many people (none of them with whom you and I are likely on a first name basis) know the names of successful mixed-martial arts/cage fighters. Now that is a brutal sport. The fact that it is popular should remind us that the desire to watch and participate in those activities runs pretty deep in us – which of course doesn’t make it right.

In response to your question of how many cord transections, concussions, and sudden deaths will we tolerate, I would be interested in your response. If the number is zero, then we have to broaden the discussion to a consideration of what activities we should allow children (particularly boys) to pursue to be physically active and receive the enjoyment that (for lack of a better term) rough housing provides. Zero tolerance can be a double-edged sword.

[Dr. Stiehm responds: Yes to soccer, basketball, and lacrosse, where the object is not to hurt the opponent – unlike boxing and tackle football.

Dr. Wilkoff replies: My perspective is colored by being here in Maine, where football is small time and even smaller in our community. One solution, but of course one that wouldn’t fly, is to make football a sport that ends at or just after middle school. It would allow young children to rough house in the context of a fun game protected by equipment before the g-forces that come with puberty create the serious dangers. Well coached and refereed football needn’t be a sport where one of the goals is to injure.]

An honest column

I want to thank you for your column entitled “Your son and football.” I am a pediatric primary care sports physician who runs a sports medicine clinic and a concussion clinic through Children’s Hospital of Wisconsin and the Medical College of Wisconsin. I am happy that you wrote about pro football and youth sports honestly – the perceived lack of moral character of many professional athletes and the craziness / win at all costs attitude of some youth coaches (and parents). And the fact that most kids will not become professional athletes. I believe treating kids just like a “collegiate or pro athlete” is a disservice to the child, as they are not at that level of emotional or physical maturity. I like the benefits of football and other contact sports – when taught and coached well, played well, and done under the realistic vision that this is for fun, and you learn life’s lessons and how to compete, win, and lose – not just done to win and earn a scholarship.

Kevin D. Walter, M.D.

Medical College of Wisconsin

Milwaukee

Sports role models

It is too bad Maine, where Dr. Wilkoff lives, does not have a professional sports team; Peyton Manning, the quarterback for the Denver Broncos, is one of the most “admirable role models in the ranks of high-profile athletes.” He is well respected and loved both here and still in the Indianapolis area and in Tennessee, where he played college football. Missy Franklin, a high profile athlete, just finished a day visiting patients at Children’s Hospital of Colorado. It was on the news last night. She is beloved here in Colorado for her smile, enthusiasm, professionalism, kindness, and overall just for being a wonderful person and amazing athlete. Although the high-profile headlines dominate, the acts of kindness and compassion by many athletes at many levels are not covered to the same degree.

It has been shown that high school and college athletes do better than their counterparts in school. My daughter was a swimmer in high school and thus avoided the drug crowd for which her class was known locally. I hope Dr. Wilkoff’s son learns the same lessons so many athletes learn in competition: teamwork, hard work, meeting and exceeding goals, and learning to deal with disappointment and victory – lessons that are hard to learn in the classroom. He will be a better person for that.

Stephen Fries, M.D.

Boulder, Colo.

Dr. Wilkoff responds: I agree there are still some shining stars in pro sports, but it seems to me that they are badly overshadowed by the bad apples. That may simply be a function of media exposure, but that’s what the kids see. My son was and still is at age 39 a hockey player and a fine young man in some part because of his athletic past.