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Vitamin D deficiency associated with Alzheimer’s
Our relationship with vitamins and supplements may be approach-avoidance. On one hand, if they are beneficial and patients are motivated to take them, we do not complain. This is likely a marker of motivated patient who may heed other health promotional advice that we proffer. On the other hand, it is difficult to keep up with the massive amount of good and bad literature about them. Patients can challenge us on our medical knowledge, pinging our opinions about the latest findings tweeted out while we struggle to keep up with all the wheelchair forms.
Vitamins are clearly not consistently beneficial. B vitamins may increase lung cancer risk in smokers. Vitamin D, however, seems to have some of the greatest “staying power” in the clinical realm and has a good reputation as far as vitamins go. Vitamin D is probably good for the heart, but how about the head? Could low D cause dementia? If so, how?
Previous studies of the relationship between vitamin D and dementia have not shown consistent results. Thomas Littlejohns, M.Sc., and colleagues have published a fantastic piece of work (Neurology 2014 Aug. 6 [doi: 10.1212/WNL.0000000000000755]) that sheds some light. They evaluated a prospective cohort of 1,658 elderly ambulatory adults with no history of dementia, CVD, or stroke who had baseline 25-hydroxyvitamin D [25(OH)D] concentrations at baseline. Severely low levels of 25(OH)D and deficiency (≥25 to <50 nmol/L) were associated with a significantly increased risk for all-cause dementia and Alzheimer’s dementia.
Several hypotheses exist as to why vitamin D helps the brain. Vitamin D may attenuate amyloid-induced cytotoxicity and neural apoptosis. It also may reduce the risk of strokes by promoting healthy cerebral vasculature.
The Institute of Medicine recommends a serum concentration of 25(OH)D at 50 nmol/L. This study would suggest that sufficiency to this level is neuroprotective. The next step is to see if supplementation can modify baseline risk, but many of my patients may wait for these data to come out before starting their vitamin D supplements.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Our relationship with vitamins and supplements may be approach-avoidance. On one hand, if they are beneficial and patients are motivated to take them, we do not complain. This is likely a marker of motivated patient who may heed other health promotional advice that we proffer. On the other hand, it is difficult to keep up with the massive amount of good and bad literature about them. Patients can challenge us on our medical knowledge, pinging our opinions about the latest findings tweeted out while we struggle to keep up with all the wheelchair forms.
Vitamins are clearly not consistently beneficial. B vitamins may increase lung cancer risk in smokers. Vitamin D, however, seems to have some of the greatest “staying power” in the clinical realm and has a good reputation as far as vitamins go. Vitamin D is probably good for the heart, but how about the head? Could low D cause dementia? If so, how?
Previous studies of the relationship between vitamin D and dementia have not shown consistent results. Thomas Littlejohns, M.Sc., and colleagues have published a fantastic piece of work (Neurology 2014 Aug. 6 [doi: 10.1212/WNL.0000000000000755]) that sheds some light. They evaluated a prospective cohort of 1,658 elderly ambulatory adults with no history of dementia, CVD, or stroke who had baseline 25-hydroxyvitamin D [25(OH)D] concentrations at baseline. Severely low levels of 25(OH)D and deficiency (≥25 to <50 nmol/L) were associated with a significantly increased risk for all-cause dementia and Alzheimer’s dementia.
Several hypotheses exist as to why vitamin D helps the brain. Vitamin D may attenuate amyloid-induced cytotoxicity and neural apoptosis. It also may reduce the risk of strokes by promoting healthy cerebral vasculature.
The Institute of Medicine recommends a serum concentration of 25(OH)D at 50 nmol/L. This study would suggest that sufficiency to this level is neuroprotective. The next step is to see if supplementation can modify baseline risk, but many of my patients may wait for these data to come out before starting their vitamin D supplements.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Our relationship with vitamins and supplements may be approach-avoidance. On one hand, if they are beneficial and patients are motivated to take them, we do not complain. This is likely a marker of motivated patient who may heed other health promotional advice that we proffer. On the other hand, it is difficult to keep up with the massive amount of good and bad literature about them. Patients can challenge us on our medical knowledge, pinging our opinions about the latest findings tweeted out while we struggle to keep up with all the wheelchair forms.
Vitamins are clearly not consistently beneficial. B vitamins may increase lung cancer risk in smokers. Vitamin D, however, seems to have some of the greatest “staying power” in the clinical realm and has a good reputation as far as vitamins go. Vitamin D is probably good for the heart, but how about the head? Could low D cause dementia? If so, how?
Previous studies of the relationship between vitamin D and dementia have not shown consistent results. Thomas Littlejohns, M.Sc., and colleagues have published a fantastic piece of work (Neurology 2014 Aug. 6 [doi: 10.1212/WNL.0000000000000755]) that sheds some light. They evaluated a prospective cohort of 1,658 elderly ambulatory adults with no history of dementia, CVD, or stroke who had baseline 25-hydroxyvitamin D [25(OH)D] concentrations at baseline. Severely low levels of 25(OH)D and deficiency (≥25 to <50 nmol/L) were associated with a significantly increased risk for all-cause dementia and Alzheimer’s dementia.
Several hypotheses exist as to why vitamin D helps the brain. Vitamin D may attenuate amyloid-induced cytotoxicity and neural apoptosis. It also may reduce the risk of strokes by promoting healthy cerebral vasculature.
The Institute of Medicine recommends a serum concentration of 25(OH)D at 50 nmol/L. This study would suggest that sufficiency to this level is neuroprotective. The next step is to see if supplementation can modify baseline risk, but many of my patients may wait for these data to come out before starting their vitamin D supplements.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Selling your practice
A generation ago, the sale of a medical practice was much like the sale of any other business: A retiring physician would sell his or her practice to a young doctor, and the practice would continue on as before. Occasionally that still happens, but changes in the business of medicine – most significantly the growth of managed care – have had a big impact on the way medical practices are bought and sold.
For one thing, there are far fewer solo practitioners these days, and polls indicate that most young physicians intend to continue that trend. The buyer of a medical practice today is more likely to be an institution, such as a hospital, an HMO, or a large practice group, rather than an individual physician.
Also, because the rules governing such sales have become so numbingly complex, the services of expert (and expensive) third parties are essential.
While these issues may complicate matters, there is still a market for the sale of medical practices. However, you must do everything possible to ensure you identify the best possible buyer and structure the best deal.
The first hurdle is the accurate valuation of your practice, which was covered in some detail last month. For the protection of both parties, it is important that the appraisal be done by an experienced and neutral financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation be supplied to support the conclusions reached.
Keep in mind that the valuation will not necessarily equal the purchase price; other factors may need to be considered before a final price can be agreed upon. Keep in mind, too, that there may be legal constraints on the purchase price. For example, if the buyer is a nonprofit corporation, such as a hospital or HMO, by law it cannot pay in excess of fair market value for the practice – which may rule out any valuation of “good will.” In some states, such as mine (New Jersey), the purchase of private practices by hospitals is prohibited altogether – so you might need to consider a long-term lease rather than a sale.
Once a value has been agreed upon, you must consider how the transaction will be structured. The most popular structures include purchase of assets, purchase of corporate stock, or merger.
Buyers, especially institutional buyers, prefer to purchase assets, because it allows them to pick and choose only those items that have value to them. This can leave the seller with a bunch of “odd lots” to dispose of. But depending on the circumstances, an asset sale may be to the advantage of both parties.
Sellers typically prefer to sell stock because it allows them to sell their entire practice, which is often worth more than the sum of its parts, and often provides tax advantages.
The third option, merger, continues to grow in popularity. I’ll cover some of the more common merger variants in a future column.
Tax issues must always be considered. Most private practices are corporations, and the sale of corporate stock will result in a long-term capital gain which will be taxed (under current law) at 28%. As the saying goes, it’s not what you earn, it’s what you keep; so it may benefit the seller to accept a slightly lower price if the sale can be structured to provide significantly lower tax treatment. However, any gain that does not qualify as a long-term capital gain will be taxed as regular income – currently around 40% – plus a social security tax of about 15%.
Payment in installments is a popular way to defer taxes, since they are incurred on each installment as it is paid. However, such payments may be mistaken by the Internal Revenue Service for payments for referrals, which is illegal. And there is always the problem of making certain all the payments are made.
The seller may wish to continue working at the practice as an employee, and this is often to the buyer’s advantage as well. Transitioning to new ownership in stages often maximizes the value of the business by improving patient retention, and allows patients to become accustomed to the transition. However, care must be taken, with the aid of good legal advice, to structure such an arrangement in a way that minimizes concerns of fraud and abuse.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Skin & Allergy News. Additional columns are available online at edermatologynews.com.
A generation ago, the sale of a medical practice was much like the sale of any other business: A retiring physician would sell his or her practice to a young doctor, and the practice would continue on as before. Occasionally that still happens, but changes in the business of medicine – most significantly the growth of managed care – have had a big impact on the way medical practices are bought and sold.
For one thing, there are far fewer solo practitioners these days, and polls indicate that most young physicians intend to continue that trend. The buyer of a medical practice today is more likely to be an institution, such as a hospital, an HMO, or a large practice group, rather than an individual physician.
Also, because the rules governing such sales have become so numbingly complex, the services of expert (and expensive) third parties are essential.
While these issues may complicate matters, there is still a market for the sale of medical practices. However, you must do everything possible to ensure you identify the best possible buyer and structure the best deal.
The first hurdle is the accurate valuation of your practice, which was covered in some detail last month. For the protection of both parties, it is important that the appraisal be done by an experienced and neutral financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation be supplied to support the conclusions reached.
Keep in mind that the valuation will not necessarily equal the purchase price; other factors may need to be considered before a final price can be agreed upon. Keep in mind, too, that there may be legal constraints on the purchase price. For example, if the buyer is a nonprofit corporation, such as a hospital or HMO, by law it cannot pay in excess of fair market value for the practice – which may rule out any valuation of “good will.” In some states, such as mine (New Jersey), the purchase of private practices by hospitals is prohibited altogether – so you might need to consider a long-term lease rather than a sale.
Once a value has been agreed upon, you must consider how the transaction will be structured. The most popular structures include purchase of assets, purchase of corporate stock, or merger.
Buyers, especially institutional buyers, prefer to purchase assets, because it allows them to pick and choose only those items that have value to them. This can leave the seller with a bunch of “odd lots” to dispose of. But depending on the circumstances, an asset sale may be to the advantage of both parties.
Sellers typically prefer to sell stock because it allows them to sell their entire practice, which is often worth more than the sum of its parts, and often provides tax advantages.
The third option, merger, continues to grow in popularity. I’ll cover some of the more common merger variants in a future column.
Tax issues must always be considered. Most private practices are corporations, and the sale of corporate stock will result in a long-term capital gain which will be taxed (under current law) at 28%. As the saying goes, it’s not what you earn, it’s what you keep; so it may benefit the seller to accept a slightly lower price if the sale can be structured to provide significantly lower tax treatment. However, any gain that does not qualify as a long-term capital gain will be taxed as regular income – currently around 40% – plus a social security tax of about 15%.
Payment in installments is a popular way to defer taxes, since they are incurred on each installment as it is paid. However, such payments may be mistaken by the Internal Revenue Service for payments for referrals, which is illegal. And there is always the problem of making certain all the payments are made.
The seller may wish to continue working at the practice as an employee, and this is often to the buyer’s advantage as well. Transitioning to new ownership in stages often maximizes the value of the business by improving patient retention, and allows patients to become accustomed to the transition. However, care must be taken, with the aid of good legal advice, to structure such an arrangement in a way that minimizes concerns of fraud and abuse.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Skin & Allergy News. Additional columns are available online at edermatologynews.com.
A generation ago, the sale of a medical practice was much like the sale of any other business: A retiring physician would sell his or her practice to a young doctor, and the practice would continue on as before. Occasionally that still happens, but changes in the business of medicine – most significantly the growth of managed care – have had a big impact on the way medical practices are bought and sold.
For one thing, there are far fewer solo practitioners these days, and polls indicate that most young physicians intend to continue that trend. The buyer of a medical practice today is more likely to be an institution, such as a hospital, an HMO, or a large practice group, rather than an individual physician.
Also, because the rules governing such sales have become so numbingly complex, the services of expert (and expensive) third parties are essential.
While these issues may complicate matters, there is still a market for the sale of medical practices. However, you must do everything possible to ensure you identify the best possible buyer and structure the best deal.
The first hurdle is the accurate valuation of your practice, which was covered in some detail last month. For the protection of both parties, it is important that the appraisal be done by an experienced and neutral financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation be supplied to support the conclusions reached.
Keep in mind that the valuation will not necessarily equal the purchase price; other factors may need to be considered before a final price can be agreed upon. Keep in mind, too, that there may be legal constraints on the purchase price. For example, if the buyer is a nonprofit corporation, such as a hospital or HMO, by law it cannot pay in excess of fair market value for the practice – which may rule out any valuation of “good will.” In some states, such as mine (New Jersey), the purchase of private practices by hospitals is prohibited altogether – so you might need to consider a long-term lease rather than a sale.
Once a value has been agreed upon, you must consider how the transaction will be structured. The most popular structures include purchase of assets, purchase of corporate stock, or merger.
Buyers, especially institutional buyers, prefer to purchase assets, because it allows them to pick and choose only those items that have value to them. This can leave the seller with a bunch of “odd lots” to dispose of. But depending on the circumstances, an asset sale may be to the advantage of both parties.
Sellers typically prefer to sell stock because it allows them to sell their entire practice, which is often worth more than the sum of its parts, and often provides tax advantages.
The third option, merger, continues to grow in popularity. I’ll cover some of the more common merger variants in a future column.
Tax issues must always be considered. Most private practices are corporations, and the sale of corporate stock will result in a long-term capital gain which will be taxed (under current law) at 28%. As the saying goes, it’s not what you earn, it’s what you keep; so it may benefit the seller to accept a slightly lower price if the sale can be structured to provide significantly lower tax treatment. However, any gain that does not qualify as a long-term capital gain will be taxed as regular income – currently around 40% – plus a social security tax of about 15%.
Payment in installments is a popular way to defer taxes, since they are incurred on each installment as it is paid. However, such payments may be mistaken by the Internal Revenue Service for payments for referrals, which is illegal. And there is always the problem of making certain all the payments are made.
The seller may wish to continue working at the practice as an employee, and this is often to the buyer’s advantage as well. Transitioning to new ownership in stages often maximizes the value of the business by improving patient retention, and allows patients to become accustomed to the transition. However, care must be taken, with the aid of good legal advice, to structure such an arrangement in a way that minimizes concerns of fraud and abuse.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Skin & Allergy News. Additional columns are available online at edermatologynews.com.
Cancer Survivorship Care
Skolarus and Hawley alerted us to the large numbers of prostate cancer survivors in the VA.1 Prostate cancer is the most common male cancer. Many are cured, and those not cured generally have a long survival. There are adverse effects (AEs) to the curative procedures, including erectile dysfunction, urinary incontinence, and proctitis after radiation therapy. All those AEs require patients to seek professional attention over many years from their primary care providers (PCPs) and their oncologist/urologist. But fulfilling survivors' needs goes beyond those doctors who can effectively address physical impairments.
According to the Institute of Medicine, hospital discharge requires not only a warm goodbye, but also a written document that includes in lay terms the precise cancer and the precise treatment(s).2 This care plan must include a shared recognition of possible recurrence, how that might be detected early, and a list of recommended periodic tests (mammogram, PSA, etc). The plans should serve to lessen the anxiety and may suggest sources of support, of job finding, of retraining. It may also mention the remarkable collaborative role local American Cancer Society units have undertaken serving cancer survivors.
The one social worker at our VA clinic provides support to all survivors in a weekly open get-together. Psychologists, pharmacists, and oncologists may attend these meetings. The focus is on allowing patients to express concerns and share personal issues, such as incontinence and sexual dysfunction, in a safe and understanding environment. Veterans do not easily share deep feelings or ask for help. But here they provide various interventions, learn of multiple community possibilities, discuss loneliness, share their unfulfilled social needs, and express the stress of possible recurrences.
The PCPs and oncologist/urologist identified in the Skolarus/Hawley article are needed for possibly correcting physical impairments, but there are others, such as social workers, American Cancer Society teams, psychologists, etc, who are better at helping patients adjust to their impairments.
Everett Shocket, MD, MSurg
Jennifer Feeney, LCSW
Bay Pines VAMC, Sarasota Florida
Editor's Note: For guidance on creating cancer survivorship plans, visit FedPrac.com/AVAHO.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
1. Skolarus TA, Hawley ST. Prostate cancer survivorship care. Fed Pract. 2014;31(8):10-17.
2. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2005.
Skolarus and Hawley alerted us to the large numbers of prostate cancer survivors in the VA.1 Prostate cancer is the most common male cancer. Many are cured, and those not cured generally have a long survival. There are adverse effects (AEs) to the curative procedures, including erectile dysfunction, urinary incontinence, and proctitis after radiation therapy. All those AEs require patients to seek professional attention over many years from their primary care providers (PCPs) and their oncologist/urologist. But fulfilling survivors' needs goes beyond those doctors who can effectively address physical impairments.
According to the Institute of Medicine, hospital discharge requires not only a warm goodbye, but also a written document that includes in lay terms the precise cancer and the precise treatment(s).2 This care plan must include a shared recognition of possible recurrence, how that might be detected early, and a list of recommended periodic tests (mammogram, PSA, etc). The plans should serve to lessen the anxiety and may suggest sources of support, of job finding, of retraining. It may also mention the remarkable collaborative role local American Cancer Society units have undertaken serving cancer survivors.
The one social worker at our VA clinic provides support to all survivors in a weekly open get-together. Psychologists, pharmacists, and oncologists may attend these meetings. The focus is on allowing patients to express concerns and share personal issues, such as incontinence and sexual dysfunction, in a safe and understanding environment. Veterans do not easily share deep feelings or ask for help. But here they provide various interventions, learn of multiple community possibilities, discuss loneliness, share their unfulfilled social needs, and express the stress of possible recurrences.
The PCPs and oncologist/urologist identified in the Skolarus/Hawley article are needed for possibly correcting physical impairments, but there are others, such as social workers, American Cancer Society teams, psychologists, etc, who are better at helping patients adjust to their impairments.
Everett Shocket, MD, MSurg
Jennifer Feeney, LCSW
Bay Pines VAMC, Sarasota Florida
Editor's Note: For guidance on creating cancer survivorship plans, visit FedPrac.com/AVAHO.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Skolarus and Hawley alerted us to the large numbers of prostate cancer survivors in the VA.1 Prostate cancer is the most common male cancer. Many are cured, and those not cured generally have a long survival. There are adverse effects (AEs) to the curative procedures, including erectile dysfunction, urinary incontinence, and proctitis after radiation therapy. All those AEs require patients to seek professional attention over many years from their primary care providers (PCPs) and their oncologist/urologist. But fulfilling survivors' needs goes beyond those doctors who can effectively address physical impairments.
According to the Institute of Medicine, hospital discharge requires not only a warm goodbye, but also a written document that includes in lay terms the precise cancer and the precise treatment(s).2 This care plan must include a shared recognition of possible recurrence, how that might be detected early, and a list of recommended periodic tests (mammogram, PSA, etc). The plans should serve to lessen the anxiety and may suggest sources of support, of job finding, of retraining. It may also mention the remarkable collaborative role local American Cancer Society units have undertaken serving cancer survivors.
The one social worker at our VA clinic provides support to all survivors in a weekly open get-together. Psychologists, pharmacists, and oncologists may attend these meetings. The focus is on allowing patients to express concerns and share personal issues, such as incontinence and sexual dysfunction, in a safe and understanding environment. Veterans do not easily share deep feelings or ask for help. But here they provide various interventions, learn of multiple community possibilities, discuss loneliness, share their unfulfilled social needs, and express the stress of possible recurrences.
The PCPs and oncologist/urologist identified in the Skolarus/Hawley article are needed for possibly correcting physical impairments, but there are others, such as social workers, American Cancer Society teams, psychologists, etc, who are better at helping patients adjust to their impairments.
Everett Shocket, MD, MSurg
Jennifer Feeney, LCSW
Bay Pines VAMC, Sarasota Florida
Editor's Note: For guidance on creating cancer survivorship plans, visit FedPrac.com/AVAHO.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
1. Skolarus TA, Hawley ST. Prostate cancer survivorship care. Fed Pract. 2014;31(8):10-17.
2. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2005.
1. Skolarus TA, Hawley ST. Prostate cancer survivorship care. Fed Pract. 2014;31(8):10-17.
2. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2005.
Last night I had a nightmare
In the dream I had an asymptomatic 5.7-cm juxtarenal abdominal aortic aneurysm. Like most of my patients I also had a 70% left internal carotid stenosis and nondisabling right leg claudication due to a superficial femoral artery stenosis. Having stood at the operating table for most of my life, my varicose veins were ugly but fortunately did not hurt.
In this dream I decided to first visit my family physician. He insisted that I stop smoking, but I had already quit 30 years ago. He was unaware of this as he had not updated his new electronic medical record system. He said “Jim, you have to take a statin. I would like to treat you with Crestor but your insurance carrier won’t pay for it. Try some red rice yeast.” I forgave him for not knowing that my name was Russell. After all, he was seeing 150 patients that day just to make ends meet and seemed rushed.
Unhappy with this consultation, I sought out one of the new concierge doctors in town. He gave me professional courtesy and charged me only a retainer of $7,000 a year. He ordered a stress test, CTA, MRI, bone scan, hypercoagulable and lipid blood analysis, and full metabolic profile. A vascular lab tech who came to his office once a week repeated my aortic, venous, carotid, and lower-extremity arterial vascular studies.
The doctor informed me that a radiologist in some other country would be reading the test, but he was sure it would be reliable. When the results came back I now had “Critical 95% carotid stenoses bilaterally,” and my AAA had “inexplicably” grown to 8.5 cm. I also had “limb-threatening severe PAD.” He recommended that I see his favorite cardiologist whom he felt could easily treat all these conditions and my aneurysm. Then, as a favor, he drove me to that appointment in his new Ferrari.
The cardiologist’s eyes gleamed when he saw me. He was an older gentleman wearing a tight-fitting all-in-one red satin suit and constantly plucked at his pointy beard. He had breath that smelled of sulfur. He seemed distracted by something pointed that appeared to be coming out of the back of his pants. His sharp ears tilted forward as he listened to me. He tried to convince me that no matter how I elected to have my aneurysm treated he should stent my carotid first, followed by an atherectomy and stent to open up my superficial femoral artery to prevent an amputation.
Furthermore, he was quite certain that I would get a DVT if I did not let him laser my great saphenous veins. After he had performed these procedures he would treat my AAA with a percutaneous endograft which he was planning to do in his outpatient cath lab. As this was early in my dream, my subconscious still had some control, and so, wisely, I declined to consent. He told me that “One way or another I will eventually get to take care of you!” I must say I was disconcerted by his words since I had a feeling he implied something entirely different.
Terrified, I sought someone competent to take care of my aneurysm. Clearly, as a practicing vascular surgeon myself, I had a pretty good idea as to who would be best, but I could not decide between the young, hotshot endovascular surgeon or the older vascular surgeon who had performed hundreds of open procedures and also performed many endovascular aneurysm repairs. I decided to visit the young surgeon first. After all, even though I was in a dream, I didn’t want to suffer the pain and recovery of an open procedure. He was confident he could help me by was using a new self-constructed fenestrated graft that he had made from scratch in his research lab at the university. Recently he had presented his series of two patients at Vascular Interventional Advances. Both patients had done “very well.” The first patient was still in the intensive care unit 4 weeks after the implant but he expected she would be off the respirator and dialysis soon. The second patient was thrilled that he was getting back some function in his toes after developing spinal paresis.
The older surgeon was also not reassuring. Although he had done hundreds of open AAAs in the past, with the advent of endovascular therapies, over the last few years he felt compelled to use this new less invasive technology. Furthermore, he was quite sure that virtually every aneurysm in his community had already been treated by a gamut of different specialists. The result was that he was performing only a handful of open aneurysms a year. Like many other surgeons of his era he had become less certain of his open surgical skills. He told me that, whereas when he was younger he would sleep soundly the night before a major complex aortic procedure, he now spent the night worrying. Perhaps it was the bags around his eyes, the drooping shoulders, and the slight tremor in his hands that suggested that he might not be the best surgeon for my aneurysm.
So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.
On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.
The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.
“Who is going to be able to fix my aneurysm?” I said, waking myself.
“Calm down,” she said. “It’s only a dream.”
But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.
In the dream I had an asymptomatic 5.7-cm juxtarenal abdominal aortic aneurysm. Like most of my patients I also had a 70% left internal carotid stenosis and nondisabling right leg claudication due to a superficial femoral artery stenosis. Having stood at the operating table for most of my life, my varicose veins were ugly but fortunately did not hurt.
In this dream I decided to first visit my family physician. He insisted that I stop smoking, but I had already quit 30 years ago. He was unaware of this as he had not updated his new electronic medical record system. He said “Jim, you have to take a statin. I would like to treat you with Crestor but your insurance carrier won’t pay for it. Try some red rice yeast.” I forgave him for not knowing that my name was Russell. After all, he was seeing 150 patients that day just to make ends meet and seemed rushed.
Unhappy with this consultation, I sought out one of the new concierge doctors in town. He gave me professional courtesy and charged me only a retainer of $7,000 a year. He ordered a stress test, CTA, MRI, bone scan, hypercoagulable and lipid blood analysis, and full metabolic profile. A vascular lab tech who came to his office once a week repeated my aortic, venous, carotid, and lower-extremity arterial vascular studies.
The doctor informed me that a radiologist in some other country would be reading the test, but he was sure it would be reliable. When the results came back I now had “Critical 95% carotid stenoses bilaterally,” and my AAA had “inexplicably” grown to 8.5 cm. I also had “limb-threatening severe PAD.” He recommended that I see his favorite cardiologist whom he felt could easily treat all these conditions and my aneurysm. Then, as a favor, he drove me to that appointment in his new Ferrari.
The cardiologist’s eyes gleamed when he saw me. He was an older gentleman wearing a tight-fitting all-in-one red satin suit and constantly plucked at his pointy beard. He had breath that smelled of sulfur. He seemed distracted by something pointed that appeared to be coming out of the back of his pants. His sharp ears tilted forward as he listened to me. He tried to convince me that no matter how I elected to have my aneurysm treated he should stent my carotid first, followed by an atherectomy and stent to open up my superficial femoral artery to prevent an amputation.
Furthermore, he was quite certain that I would get a DVT if I did not let him laser my great saphenous veins. After he had performed these procedures he would treat my AAA with a percutaneous endograft which he was planning to do in his outpatient cath lab. As this was early in my dream, my subconscious still had some control, and so, wisely, I declined to consent. He told me that “One way or another I will eventually get to take care of you!” I must say I was disconcerted by his words since I had a feeling he implied something entirely different.
Terrified, I sought someone competent to take care of my aneurysm. Clearly, as a practicing vascular surgeon myself, I had a pretty good idea as to who would be best, but I could not decide between the young, hotshot endovascular surgeon or the older vascular surgeon who had performed hundreds of open procedures and also performed many endovascular aneurysm repairs. I decided to visit the young surgeon first. After all, even though I was in a dream, I didn’t want to suffer the pain and recovery of an open procedure. He was confident he could help me by was using a new self-constructed fenestrated graft that he had made from scratch in his research lab at the university. Recently he had presented his series of two patients at Vascular Interventional Advances. Both patients had done “very well.” The first patient was still in the intensive care unit 4 weeks after the implant but he expected she would be off the respirator and dialysis soon. The second patient was thrilled that he was getting back some function in his toes after developing spinal paresis.
The older surgeon was also not reassuring. Although he had done hundreds of open AAAs in the past, with the advent of endovascular therapies, over the last few years he felt compelled to use this new less invasive technology. Furthermore, he was quite sure that virtually every aneurysm in his community had already been treated by a gamut of different specialists. The result was that he was performing only a handful of open aneurysms a year. Like many other surgeons of his era he had become less certain of his open surgical skills. He told me that, whereas when he was younger he would sleep soundly the night before a major complex aortic procedure, he now spent the night worrying. Perhaps it was the bags around his eyes, the drooping shoulders, and the slight tremor in his hands that suggested that he might not be the best surgeon for my aneurysm.
So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.
On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.
The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.
“Who is going to be able to fix my aneurysm?” I said, waking myself.
“Calm down,” she said. “It’s only a dream.”
But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.
In the dream I had an asymptomatic 5.7-cm juxtarenal abdominal aortic aneurysm. Like most of my patients I also had a 70% left internal carotid stenosis and nondisabling right leg claudication due to a superficial femoral artery stenosis. Having stood at the operating table for most of my life, my varicose veins were ugly but fortunately did not hurt.
In this dream I decided to first visit my family physician. He insisted that I stop smoking, but I had already quit 30 years ago. He was unaware of this as he had not updated his new electronic medical record system. He said “Jim, you have to take a statin. I would like to treat you with Crestor but your insurance carrier won’t pay for it. Try some red rice yeast.” I forgave him for not knowing that my name was Russell. After all, he was seeing 150 patients that day just to make ends meet and seemed rushed.
Unhappy with this consultation, I sought out one of the new concierge doctors in town. He gave me professional courtesy and charged me only a retainer of $7,000 a year. He ordered a stress test, CTA, MRI, bone scan, hypercoagulable and lipid blood analysis, and full metabolic profile. A vascular lab tech who came to his office once a week repeated my aortic, venous, carotid, and lower-extremity arterial vascular studies.
The doctor informed me that a radiologist in some other country would be reading the test, but he was sure it would be reliable. When the results came back I now had “Critical 95% carotid stenoses bilaterally,” and my AAA had “inexplicably” grown to 8.5 cm. I also had “limb-threatening severe PAD.” He recommended that I see his favorite cardiologist whom he felt could easily treat all these conditions and my aneurysm. Then, as a favor, he drove me to that appointment in his new Ferrari.
The cardiologist’s eyes gleamed when he saw me. He was an older gentleman wearing a tight-fitting all-in-one red satin suit and constantly plucked at his pointy beard. He had breath that smelled of sulfur. He seemed distracted by something pointed that appeared to be coming out of the back of his pants. His sharp ears tilted forward as he listened to me. He tried to convince me that no matter how I elected to have my aneurysm treated he should stent my carotid first, followed by an atherectomy and stent to open up my superficial femoral artery to prevent an amputation.
Furthermore, he was quite certain that I would get a DVT if I did not let him laser my great saphenous veins. After he had performed these procedures he would treat my AAA with a percutaneous endograft which he was planning to do in his outpatient cath lab. As this was early in my dream, my subconscious still had some control, and so, wisely, I declined to consent. He told me that “One way or another I will eventually get to take care of you!” I must say I was disconcerted by his words since I had a feeling he implied something entirely different.
Terrified, I sought someone competent to take care of my aneurysm. Clearly, as a practicing vascular surgeon myself, I had a pretty good idea as to who would be best, but I could not decide between the young, hotshot endovascular surgeon or the older vascular surgeon who had performed hundreds of open procedures and also performed many endovascular aneurysm repairs. I decided to visit the young surgeon first. After all, even though I was in a dream, I didn’t want to suffer the pain and recovery of an open procedure. He was confident he could help me by was using a new self-constructed fenestrated graft that he had made from scratch in his research lab at the university. Recently he had presented his series of two patients at Vascular Interventional Advances. Both patients had done “very well.” The first patient was still in the intensive care unit 4 weeks after the implant but he expected she would be off the respirator and dialysis soon. The second patient was thrilled that he was getting back some function in his toes after developing spinal paresis.
The older surgeon was also not reassuring. Although he had done hundreds of open AAAs in the past, with the advent of endovascular therapies, over the last few years he felt compelled to use this new less invasive technology. Furthermore, he was quite sure that virtually every aneurysm in his community had already been treated by a gamut of different specialists. The result was that he was performing only a handful of open aneurysms a year. Like many other surgeons of his era he had become less certain of his open surgical skills. He told me that, whereas when he was younger he would sleep soundly the night before a major complex aortic procedure, he now spent the night worrying. Perhaps it was the bags around his eyes, the drooping shoulders, and the slight tremor in his hands that suggested that he might not be the best surgeon for my aneurysm.
So I went back to the young surgeon and asked him if he could do an open operation. He shrugged his shoulders, and with some chagrin he explained he had done only one in his vascular residency. This was not only because there were so few aneurysms treated open, but because his OR time was reduced as a result of a mandate that residents could not work more than 40 hours a week and had to have at least 8 hours of sleep every night.
On the other hand, he had won the “Top Gun” competition at the Society for Clinical Vascular Surgery where he had successfully completed an aortic aneurysm surgery on a plastic mannequin. However, now in his first 3 years in practice he employed only endovascular techniques. He assured me, though, that he would read a textbook before the operation. Walking out of his office I noticed a framed picture in which he was surrounded by his beaming mother and grandmother as he was delivering the valedictorian speech at his grade school graduation.
The sheets were drenched with perspiration, and I cried out in my sleep, waking my wife.
“Who is going to be able to fix my aneurysm?” I said, waking myself.
“Calm down,” she said. “It’s only a dream.”
But was it? Are we training enough young surgeons in open surgery to maintain the surgical skills necessary to safely perform complex aneurysm surgery? Are our older surgeons maintaining proficiency as more and more procedures are performed percutaneously? Are the inroads from other specialties reducing overall aneurysm experience? Is the improvement in medical management slowing aneurysm growth and prevalence? Time will tell, but I believe training programs should be developing shared opportunities where programs strong in open procedures exchange their fellows with programs incorporating high-volume endovascular approaches. Further, older surgeons may need to refresh their skills in both open and endovascular procedures. Otherwise we may have to concede that Centers of Excellence may be the only way that patients can receive optimal care.
Adnexal masses in pregnancy
With the increasing use of ultrasound in the first trimester, asymptomatic adnexal masses are being diagnosed earlier in pregnancy, leaving providers with an often difficult clinical scenario. The reported incidence of adnexal masses ranges from 1 in 81 to 1 in 8,000 pregnancies, and 0.93%-6% of these are malignant (Gynecol. Oncol. 2006;101:315-21; Am. J. Obstet. Gynecol. 1999;181:19-24). In light of this, the importance of recognizing adnexal masses and knowledge of their management are crucial for any practicing obstetrician gynecologist.
Differential diagnosis
In pregnancy, the majority of adnexal masses are benign simple cysts less than 5 cm (BJOG 2003;110:578-83). As such, the majority of masses (probable corpus luteum cysts) detected in the first trimester (70% in one study) will resolve by the early part of the second trimester (Clin. Obstet. Gynecol. 2006;49:492-505). Adnexal masses are commonly physiologic or functional cysts. Benign masses with complex features can include corpus luteum, mature teratomas, hydrosalpinx, theca lutein cysts, or endometriomas. Complex adnexal masses greater than 5 cm are most likely mature teratomas (Am. J. Obstet. Gynecol. 2001;184:1504-12). Degenerating or pedunculated fibroids can mimic an adnexal mass and may cause pain, clouding the diagnosis.
Of the rare malignant lesions that occur in pregnancy, approximately half are epithelial tumors and one-third are germ cell tumors. Of the epithelial neoplasms, up to 50% may be low-malignant-potential tumors.
Diagnostic evaluation
Imaging: Transvaginal ultrasound is regarded as the modality of choice when evaluating adnexal pathology. Abdominal ultrasound may be especially helpful when the ovaries are outside of the pelvis, especially later in gestation. MRI without contrast may aid in distinguishing leiomyoma and ovarian pathology, which is vital when planning surgery. However, MRI with gadolinium is not recommended as its safety in pregnancy has not been established.
Tumor markers: None of the available tumor markers may be reliably used to diagnose ovarian cancer in pregnancy. CA-125 is elevated in epithelial ovarian cancer, but it is also elevated in pregnancy. However, significant elevations (greater than 1,000 U/mL) are more likely to be associated with cancer.
Markers for germ cell tumors include alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG). Maternal serum levels of AFP (MSAFP) normally rise in pregnancy, although extreme values (less than 500 ng/mL) are associated with neural tube defects while levels greater than 1,000 ng/mL may be associated with an ovarian germ cell tumor (especially when greater than 10,000 ng/mL). LDH is elevated in women with ovarian dysgerminomas and is reliable in pregnancy outside of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Of course, hCG is elevated in pregnancy, negating its value as a germ cell tumor marker. Inhibin B may be elevated in association with granulosa cell tumors; however, it is also elevated in early gestation.
Management
Because most corpus luteum will resolve, it is recommended to electively resect adnexal masses in the second trimester when they meet the following criteria: lesions are greater than 10 cm in diameter; they are complex lesions (Fertil. Steril. 2009;91:1895-902; Obstet. Gynecol. 1999;93:585-9).
Benign-appearing but persistent simple cysts in the second trimester may be managed conservatively, as approximately 70% will resolve. Thus, routine removal of persistent cysts is not recommended (BJOG 2003;110:578-83). Risk factors for persistent lesions include size greater than 5 cm and complex morphology (Obstet. Gynecol. 1999;93:585-9).Providers may consider serial ultrasounds of ovarian cysts to detect an increase in size or change in character that may warrant further investigation.
Surgery is considered in asymptomatic women meeting the above criteria, to diagnose malignancy or reduce the risk of torsion or rupture. Torsion has been found to be more likely in the late first and early second trimester, with only 6% occurring after 20 weeks. Corpus luteum cysts may on occasion persist into the second trimester and can account for up to 17% of all cystic adnexal masses (Am. J. Obstet. Gynecol. 1999;181:19-24). It is important to remember that if a corpus luteum is surgically resected in the first trimester, progesterone needs to be replaced to avoid pregnancy loss. Of those complex lesions diagnosed in the first trimester that persist into the second trimester, up to 10% may be malignant.
Providers who feel comfortable with laparoscopic techniques can proceed with minimally invasive surgery, with optimal timing in the early second trimester (J. Minim. Invasive Gynecol. 2011;18:720-5). Care should be taken to consider fundal height when choosing trocar placement. If there is a high suspicion for malignancy, providers may want to proceed via laparotomy, which should be via a vertical midline incision. Tocolytic therapy given prophylactically at the time of surgery has no proven benefit and should not be routinely administered.
Washings should be obtained and providers should perform a thorough inspection of the abdomen, contralateral ovary, omentum, and peritoneal surfaces. Any suspicious lesions should be biopsied. A simple cystectomy is reasonable with benign lesions; however, a unilateral salpingo-oophorectomy should be performed with frozen confirmation if there are any concerning findings for malignancy. If a malignancy is confirmed, a gynecologic oncologist should be consulted, and surgical staging should be considered.
Dr. Sullivan is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Sullivan, Dr. Gehrig, and Dr. Clarke-Pearson said they had no relevant financial disclosures.
With the increasing use of ultrasound in the first trimester, asymptomatic adnexal masses are being diagnosed earlier in pregnancy, leaving providers with an often difficult clinical scenario. The reported incidence of adnexal masses ranges from 1 in 81 to 1 in 8,000 pregnancies, and 0.93%-6% of these are malignant (Gynecol. Oncol. 2006;101:315-21; Am. J. Obstet. Gynecol. 1999;181:19-24). In light of this, the importance of recognizing adnexal masses and knowledge of their management are crucial for any practicing obstetrician gynecologist.
Differential diagnosis
In pregnancy, the majority of adnexal masses are benign simple cysts less than 5 cm (BJOG 2003;110:578-83). As such, the majority of masses (probable corpus luteum cysts) detected in the first trimester (70% in one study) will resolve by the early part of the second trimester (Clin. Obstet. Gynecol. 2006;49:492-505). Adnexal masses are commonly physiologic or functional cysts. Benign masses with complex features can include corpus luteum, mature teratomas, hydrosalpinx, theca lutein cysts, or endometriomas. Complex adnexal masses greater than 5 cm are most likely mature teratomas (Am. J. Obstet. Gynecol. 2001;184:1504-12). Degenerating or pedunculated fibroids can mimic an adnexal mass and may cause pain, clouding the diagnosis.
Of the rare malignant lesions that occur in pregnancy, approximately half are epithelial tumors and one-third are germ cell tumors. Of the epithelial neoplasms, up to 50% may be low-malignant-potential tumors.
Diagnostic evaluation
Imaging: Transvaginal ultrasound is regarded as the modality of choice when evaluating adnexal pathology. Abdominal ultrasound may be especially helpful when the ovaries are outside of the pelvis, especially later in gestation. MRI without contrast may aid in distinguishing leiomyoma and ovarian pathology, which is vital when planning surgery. However, MRI with gadolinium is not recommended as its safety in pregnancy has not been established.
Tumor markers: None of the available tumor markers may be reliably used to diagnose ovarian cancer in pregnancy. CA-125 is elevated in epithelial ovarian cancer, but it is also elevated in pregnancy. However, significant elevations (greater than 1,000 U/mL) are more likely to be associated with cancer.
Markers for germ cell tumors include alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG). Maternal serum levels of AFP (MSAFP) normally rise in pregnancy, although extreme values (less than 500 ng/mL) are associated with neural tube defects while levels greater than 1,000 ng/mL may be associated with an ovarian germ cell tumor (especially when greater than 10,000 ng/mL). LDH is elevated in women with ovarian dysgerminomas and is reliable in pregnancy outside of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Of course, hCG is elevated in pregnancy, negating its value as a germ cell tumor marker. Inhibin B may be elevated in association with granulosa cell tumors; however, it is also elevated in early gestation.
Management
Because most corpus luteum will resolve, it is recommended to electively resect adnexal masses in the second trimester when they meet the following criteria: lesions are greater than 10 cm in diameter; they are complex lesions (Fertil. Steril. 2009;91:1895-902; Obstet. Gynecol. 1999;93:585-9).
Benign-appearing but persistent simple cysts in the second trimester may be managed conservatively, as approximately 70% will resolve. Thus, routine removal of persistent cysts is not recommended (BJOG 2003;110:578-83). Risk factors for persistent lesions include size greater than 5 cm and complex morphology (Obstet. Gynecol. 1999;93:585-9).Providers may consider serial ultrasounds of ovarian cysts to detect an increase in size or change in character that may warrant further investigation.
Surgery is considered in asymptomatic women meeting the above criteria, to diagnose malignancy or reduce the risk of torsion or rupture. Torsion has been found to be more likely in the late first and early second trimester, with only 6% occurring after 20 weeks. Corpus luteum cysts may on occasion persist into the second trimester and can account for up to 17% of all cystic adnexal masses (Am. J. Obstet. Gynecol. 1999;181:19-24). It is important to remember that if a corpus luteum is surgically resected in the first trimester, progesterone needs to be replaced to avoid pregnancy loss. Of those complex lesions diagnosed in the first trimester that persist into the second trimester, up to 10% may be malignant.
Providers who feel comfortable with laparoscopic techniques can proceed with minimally invasive surgery, with optimal timing in the early second trimester (J. Minim. Invasive Gynecol. 2011;18:720-5). Care should be taken to consider fundal height when choosing trocar placement. If there is a high suspicion for malignancy, providers may want to proceed via laparotomy, which should be via a vertical midline incision. Tocolytic therapy given prophylactically at the time of surgery has no proven benefit and should not be routinely administered.
Washings should be obtained and providers should perform a thorough inspection of the abdomen, contralateral ovary, omentum, and peritoneal surfaces. Any suspicious lesions should be biopsied. A simple cystectomy is reasonable with benign lesions; however, a unilateral salpingo-oophorectomy should be performed with frozen confirmation if there are any concerning findings for malignancy. If a malignancy is confirmed, a gynecologic oncologist should be consulted, and surgical staging should be considered.
Dr. Sullivan is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Sullivan, Dr. Gehrig, and Dr. Clarke-Pearson said they had no relevant financial disclosures.
With the increasing use of ultrasound in the first trimester, asymptomatic adnexal masses are being diagnosed earlier in pregnancy, leaving providers with an often difficult clinical scenario. The reported incidence of adnexal masses ranges from 1 in 81 to 1 in 8,000 pregnancies, and 0.93%-6% of these are malignant (Gynecol. Oncol. 2006;101:315-21; Am. J. Obstet. Gynecol. 1999;181:19-24). In light of this, the importance of recognizing adnexal masses and knowledge of their management are crucial for any practicing obstetrician gynecologist.
Differential diagnosis
In pregnancy, the majority of adnexal masses are benign simple cysts less than 5 cm (BJOG 2003;110:578-83). As such, the majority of masses (probable corpus luteum cysts) detected in the first trimester (70% in one study) will resolve by the early part of the second trimester (Clin. Obstet. Gynecol. 2006;49:492-505). Adnexal masses are commonly physiologic or functional cysts. Benign masses with complex features can include corpus luteum, mature teratomas, hydrosalpinx, theca lutein cysts, or endometriomas. Complex adnexal masses greater than 5 cm are most likely mature teratomas (Am. J. Obstet. Gynecol. 2001;184:1504-12). Degenerating or pedunculated fibroids can mimic an adnexal mass and may cause pain, clouding the diagnosis.
Of the rare malignant lesions that occur in pregnancy, approximately half are epithelial tumors and one-third are germ cell tumors. Of the epithelial neoplasms, up to 50% may be low-malignant-potential tumors.
Diagnostic evaluation
Imaging: Transvaginal ultrasound is regarded as the modality of choice when evaluating adnexal pathology. Abdominal ultrasound may be especially helpful when the ovaries are outside of the pelvis, especially later in gestation. MRI without contrast may aid in distinguishing leiomyoma and ovarian pathology, which is vital when planning surgery. However, MRI with gadolinium is not recommended as its safety in pregnancy has not been established.
Tumor markers: None of the available tumor markers may be reliably used to diagnose ovarian cancer in pregnancy. CA-125 is elevated in epithelial ovarian cancer, but it is also elevated in pregnancy. However, significant elevations (greater than 1,000 U/mL) are more likely to be associated with cancer.
Markers for germ cell tumors include alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG). Maternal serum levels of AFP (MSAFP) normally rise in pregnancy, although extreme values (less than 500 ng/mL) are associated with neural tube defects while levels greater than 1,000 ng/mL may be associated with an ovarian germ cell tumor (especially when greater than 10,000 ng/mL). LDH is elevated in women with ovarian dysgerminomas and is reliable in pregnancy outside of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Of course, hCG is elevated in pregnancy, negating its value as a germ cell tumor marker. Inhibin B may be elevated in association with granulosa cell tumors; however, it is also elevated in early gestation.
Management
Because most corpus luteum will resolve, it is recommended to electively resect adnexal masses in the second trimester when they meet the following criteria: lesions are greater than 10 cm in diameter; they are complex lesions (Fertil. Steril. 2009;91:1895-902; Obstet. Gynecol. 1999;93:585-9).
Benign-appearing but persistent simple cysts in the second trimester may be managed conservatively, as approximately 70% will resolve. Thus, routine removal of persistent cysts is not recommended (BJOG 2003;110:578-83). Risk factors for persistent lesions include size greater than 5 cm and complex morphology (Obstet. Gynecol. 1999;93:585-9).Providers may consider serial ultrasounds of ovarian cysts to detect an increase in size or change in character that may warrant further investigation.
Surgery is considered in asymptomatic women meeting the above criteria, to diagnose malignancy or reduce the risk of torsion or rupture. Torsion has been found to be more likely in the late first and early second trimester, with only 6% occurring after 20 weeks. Corpus luteum cysts may on occasion persist into the second trimester and can account for up to 17% of all cystic adnexal masses (Am. J. Obstet. Gynecol. 1999;181:19-24). It is important to remember that if a corpus luteum is surgically resected in the first trimester, progesterone needs to be replaced to avoid pregnancy loss. Of those complex lesions diagnosed in the first trimester that persist into the second trimester, up to 10% may be malignant.
Providers who feel comfortable with laparoscopic techniques can proceed with minimally invasive surgery, with optimal timing in the early second trimester (J. Minim. Invasive Gynecol. 2011;18:720-5). Care should be taken to consider fundal height when choosing trocar placement. If there is a high suspicion for malignancy, providers may want to proceed via laparotomy, which should be via a vertical midline incision. Tocolytic therapy given prophylactically at the time of surgery has no proven benefit and should not be routinely administered.
Washings should be obtained and providers should perform a thorough inspection of the abdomen, contralateral ovary, omentum, and peritoneal surfaces. Any suspicious lesions should be biopsied. A simple cystectomy is reasonable with benign lesions; however, a unilateral salpingo-oophorectomy should be performed with frozen confirmation if there are any concerning findings for malignancy. If a malignancy is confirmed, a gynecologic oncologist should be consulted, and surgical staging should be considered.
Dr. Sullivan is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Sullivan, Dr. Gehrig, and Dr. Clarke-Pearson said they had no relevant financial disclosures.
Too little time and no money for meet-and-greet interviews
I don’t do meet-and-greets.
It is not that we get a huge number of calls for them. Maybe once a week a new patient will call, asking to “interview” me to see if we’re a good match and to review my credentials.
I’m not playing this game. My credentials are on my office website, as well as many rate-a-doc sites that I have no affiliation with. I’m not running a concierge practice where I ask you to pay up front.
My time is valuable. If you need a neurologist, I’m happy to see you and try to help. But your insurance doesn’t pay me to do “interviews.” And when we’ve quoted people a fee for the time, they get indignant and hang up. They tell my secretary they’ll take their business elsewhere, which is fine with me.
I have to wonder how many other neurologists they go through with this routine. I don’t know any who do this, at least in my area of town. By the time they call my office, they’ve likely already tried five other neurologists.
I suppose some will argue in favor of it, maybe as a way of weeding out people who you really don’t want in your practice or with whom you are genuinely a bad personality match. To me, it’s not worth it.
Unfortunately, modern medicine is trying to squeeze as many dollars out of the limited office time you have. I already work through lunch. I’m not going to take unpaid visits just so that people can decide if my dress habits, hygiene, or personality are up to their standards.
I see patients as they come. If they don’t like me, nobody is forcing them to stay. But I’m not going to do a complimentary meet-and-greet so they can judge me or try to get free medical advice.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t do meet-and-greets.
It is not that we get a huge number of calls for them. Maybe once a week a new patient will call, asking to “interview” me to see if we’re a good match and to review my credentials.
I’m not playing this game. My credentials are on my office website, as well as many rate-a-doc sites that I have no affiliation with. I’m not running a concierge practice where I ask you to pay up front.
My time is valuable. If you need a neurologist, I’m happy to see you and try to help. But your insurance doesn’t pay me to do “interviews.” And when we’ve quoted people a fee for the time, they get indignant and hang up. They tell my secretary they’ll take their business elsewhere, which is fine with me.
I have to wonder how many other neurologists they go through with this routine. I don’t know any who do this, at least in my area of town. By the time they call my office, they’ve likely already tried five other neurologists.
I suppose some will argue in favor of it, maybe as a way of weeding out people who you really don’t want in your practice or with whom you are genuinely a bad personality match. To me, it’s not worth it.
Unfortunately, modern medicine is trying to squeeze as many dollars out of the limited office time you have. I already work through lunch. I’m not going to take unpaid visits just so that people can decide if my dress habits, hygiene, or personality are up to their standards.
I see patients as they come. If they don’t like me, nobody is forcing them to stay. But I’m not going to do a complimentary meet-and-greet so they can judge me or try to get free medical advice.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t do meet-and-greets.
It is not that we get a huge number of calls for them. Maybe once a week a new patient will call, asking to “interview” me to see if we’re a good match and to review my credentials.
I’m not playing this game. My credentials are on my office website, as well as many rate-a-doc sites that I have no affiliation with. I’m not running a concierge practice where I ask you to pay up front.
My time is valuable. If you need a neurologist, I’m happy to see you and try to help. But your insurance doesn’t pay me to do “interviews.” And when we’ve quoted people a fee for the time, they get indignant and hang up. They tell my secretary they’ll take their business elsewhere, which is fine with me.
I have to wonder how many other neurologists they go through with this routine. I don’t know any who do this, at least in my area of town. By the time they call my office, they’ve likely already tried five other neurologists.
I suppose some will argue in favor of it, maybe as a way of weeding out people who you really don’t want in your practice or with whom you are genuinely a bad personality match. To me, it’s not worth it.
Unfortunately, modern medicine is trying to squeeze as many dollars out of the limited office time you have. I already work through lunch. I’m not going to take unpaid visits just so that people can decide if my dress habits, hygiene, or personality are up to their standards.
I see patients as they come. If they don’t like me, nobody is forcing them to stay. But I’m not going to do a complimentary meet-and-greet so they can judge me or try to get free medical advice.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
COMMENTARIES: The mixed health risk communication for Ebola
Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.
From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.
Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.
We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.
On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.
On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.
More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.
Here in the United States, people from Africa report stigma and discrimination.
What is the middle ground?
• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.
• Acknowledge that this is a major issue, not only for West Africa but for the world.
• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.
• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.
• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.
• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.
• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.
• Encourage social distancing from people who might have been exposed to Ebola in community settings.
Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.
Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.
From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.
Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.
We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.
On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.
On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.
More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.
Here in the United States, people from Africa report stigma and discrimination.
What is the middle ground?
• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.
• Acknowledge that this is a major issue, not only for West Africa but for the world.
• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.
• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.
• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.
• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.
• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.
• Encourage social distancing from people who might have been exposed to Ebola in community settings.
Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.
Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
Bushmeat. Bodily fluids. The homeless man, exposed to Ebola via Thomas Eric Duncan, who could not be found for 4 days in Dallas. Parents pulling their children from Dallas schools. Endless media stories.
From public officials: First, the chances of Ebola reaching our shores deemed an “unlikely event.” Then, the message that “we will stop it in its track.” Later, we get the message that officials are safeguarding all the contacts in Dallas.
Except for the homeless man, who allegedly rode in the same ambulance that was used to transport Mr. Duncan to a Dallas hospital. And now we have a health care worker who has apparently tested preliminarily positive.
We seem to be divided into two polarized opposites on communicating risk, and we need to find an accurate middle ground.
On one side, many of our colleagues say, “What is all the fuss about? Many more people will die of flu this year than Ebola.” Or at least they did, a week ago.
On the other side, the media, meanwhile, continue to highlight every known possible case of Ebola outside of West Africa. Reports of dead and dying are legion in Guinea, Liberia, and Sierra Leone. Those three countries are in crisis, and their health care workers are dying in droves.
More recently, the nurse who developed Ebola in Spain is fanning concerns among health care workers in developed countries. Health authorities euthanized her dog, although there is not a clear reason as to why.
Here in the United States, people from Africa report stigma and discrimination.
What is the middle ground?
• Do not belittle concerns. Recognize that this is both a medical and psychological crisis.
• Acknowledge that this is a major issue, not only for West Africa but for the world.
• Emphasize the importance of supporting the public health infrastructure, not only for Ebola but for flu, SARS, rhinovirus, AIDS, and other infectious diseases.
• Stress basic infection control procedures, such as good old hand washing, of course. Ensure that masks and gloves are widely available and that people wear them.
• Develop widely visible protocols in every single clinic and emergency room – including psychiatric clinics and ERs. The protocols would emphasize that individuals who present with fever should be screened for a travel history in themselves or their families. Those with potential exposure to Ebola need to get to the hospital.
• Develop Ebola capacity, which we are calling Ebola Epidemic Management Initiatives, for each jurisdiction. Local workgroups with representatives from physical and mental health and safety officials could initiate the process.
• Do not assume that all fevers from West Africa are Ebola. Such fevers could be indicative of malaria or any number of other diseases.
• Encourage social distancing from people who might have been exposed to Ebola in community settings.
Many practitioners and jurisdictions are following the recommendations listed above, but not enough, and not on a systematic basis. The above are basic principles of health risk communication and public health measures. We have learned them over the last 30 years; let us use them.
Michael D. McDonald, Dr.PH., coordinator of the Global Health Response and Resilience Alliance and chairman of Oviar Global Resilience Systems, Washington, contributed to this commentary.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.
SPRINTing Toward a Systolic Answer
Faithful readers may recall from previous editorials that I’m not particularly happy with the new hypertension guidelines issued recently by the JNC 8 authors. I am especially concerned that the new recommendations of a blood pressure goal of < 150/90 mm Hg for people aged > 60 years, like myself, could lead to a real deterioration in blood pressure control. We know that adherence to the previous goal of < 140/90 mm Hg for this age group has hardly been optimal, so why in the world would we want to relax our targets even further? I have confronted several of the JNC 8 writers with my concerns, and they have reluctantly acknowledged that I am hardly alone in my worries.
But one thing I never saw coming was that the new guidelines would confound one of the important clinical trials I’ve been participating in over the past 4 years. I’m referring to the National Institutes of Health-funded Systolic Blood Pressure Intervention Trial (SPRINT), which was designed to compare 2 systolic blood pressure goals, the traditional 140 mm Hg goal and a more aggressive 120 mm Hg goal.
One thing that is particularly confounding in the context of the new guidelines for those aged > 60 years is that we SPRINT investigators were instructed specifically to recruit as many patients as possible aged > 75 years, so that we could get a clear sense of what the systolic goal should be in this particularly high-risk population. The study architects didn’t even consider testing a goal of 150 mm Hg systolic. In a similar vein, we also worked very hard to over-recruit 2 other groups of high-risk patients, those who had already had a cardiovascular event and those with mild renal insufficiency.
The new guidelines wound up impacting my conduct of the SPRINT trial. An intellectually curious trial subject in his late 70s took a keen interest in the question: What is the optimal systolic blood pressure goal? As it turns out, he was among those who had been randomized to the more aggressive systolic goal of 120 mm Hg. At his most recent visit, he caught me off guard by asking why we were testing a blood pressure goal of 120 mm Hg in someone of his age. He had read that people aged > 60 years needed a blood pressure goal of only 150 mm Hg,according to the latest expert recommendations.
Initially I was flummoxed by his question. Perhaps I should have anticipated that some of our subjects might have questions, but I have to admit that the thought had not occurred to me. I was pleased to see that he was not at all agitated at the apparent disconnect. He was merely curious as to how there could be such a discrepancy between guidelines intended for the general public and the study goal of 120 mm Hg. This proved to be an important teachable moment. After gathering my wits, I was able to explain the difference between guidelines and hypotheses that are carefully tested in clinical trials. I was especially eager to let him know that the true science of a clinical trial trumps the value of clinical guidelines, which are based on the best clinical judgments and guesstimates of leaders in the field.
The key to understanding the role of clinical guidelines is to recognize that they simply represent the most informed opinions available, given the sum total of clinical information that is available at that time. Clinical guidelines are based on evidence as much as is humanly possible, but there are often gaps in what we have learned from published clinical trials. Such trials are inherently limited with respect to the insights they can provide, because funding limitations invariably dictate that hard choices must be made in terms of the hypotheses that can be tested and the populations that can be studied. So the total amount of available data from clinical trials is almost invariably insufficient to answer a significant number of clinical questions definitively.
And that’s why a well-designed clinical trial trumps whatever expert guidelines may seem pertinent to the clinical question at stake. Yes, the JNC 8 authors may have determined (albeit with a significant contrarian minority report) that their best reading of the available literature was that there was no definitive evidence supporting a blood pressure goal of < 150/90 mm Hg in those aged > 60 years. But it must be recognized that the absence of such definitive evidence to date does not at all mean that a lower goal might one day be shown to be superior to the JNC 8 recommendations. And that’s where the SPRINT trial comes in: It’s specifically designed to test the hypothesis that a lower systolic goal of 120 mm Hg might be superior in terms of clinical outcomes to the higher goal of 140 mm Hg. Well-designed clinical trials are the mechanism through which meaningful clinical data are accrued; those data can then inform clinical guidelines.
I am happy to report that my alert SPRINT subject grasped the point rather quickly. As a retired engineer, he understood the importance of obtaining definitive data rather than relying forevermore upon the best guesses of well-meaning experts in the field. Clinical guidelines are useful as far as they go, but they are heavily dependent upon the generation of clinically valid data from randomized clinical trials. My SPRINT subject left the clinic with a renewed commitment to getting his systolic blood pressure down to the assigned goal of 120 mm Hg. All of us should follow his example and try mightily to keep in mind the distinction between clinical guidelines and actual data generated from randomized clinical trials.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Faithful readers may recall from previous editorials that I’m not particularly happy with the new hypertension guidelines issued recently by the JNC 8 authors. I am especially concerned that the new recommendations of a blood pressure goal of < 150/90 mm Hg for people aged > 60 years, like myself, could lead to a real deterioration in blood pressure control. We know that adherence to the previous goal of < 140/90 mm Hg for this age group has hardly been optimal, so why in the world would we want to relax our targets even further? I have confronted several of the JNC 8 writers with my concerns, and they have reluctantly acknowledged that I am hardly alone in my worries.
But one thing I never saw coming was that the new guidelines would confound one of the important clinical trials I’ve been participating in over the past 4 years. I’m referring to the National Institutes of Health-funded Systolic Blood Pressure Intervention Trial (SPRINT), which was designed to compare 2 systolic blood pressure goals, the traditional 140 mm Hg goal and a more aggressive 120 mm Hg goal.
One thing that is particularly confounding in the context of the new guidelines for those aged > 60 years is that we SPRINT investigators were instructed specifically to recruit as many patients as possible aged > 75 years, so that we could get a clear sense of what the systolic goal should be in this particularly high-risk population. The study architects didn’t even consider testing a goal of 150 mm Hg systolic. In a similar vein, we also worked very hard to over-recruit 2 other groups of high-risk patients, those who had already had a cardiovascular event and those with mild renal insufficiency.
The new guidelines wound up impacting my conduct of the SPRINT trial. An intellectually curious trial subject in his late 70s took a keen interest in the question: What is the optimal systolic blood pressure goal? As it turns out, he was among those who had been randomized to the more aggressive systolic goal of 120 mm Hg. At his most recent visit, he caught me off guard by asking why we were testing a blood pressure goal of 120 mm Hg in someone of his age. He had read that people aged > 60 years needed a blood pressure goal of only 150 mm Hg,according to the latest expert recommendations.
Initially I was flummoxed by his question. Perhaps I should have anticipated that some of our subjects might have questions, but I have to admit that the thought had not occurred to me. I was pleased to see that he was not at all agitated at the apparent disconnect. He was merely curious as to how there could be such a discrepancy between guidelines intended for the general public and the study goal of 120 mm Hg. This proved to be an important teachable moment. After gathering my wits, I was able to explain the difference between guidelines and hypotheses that are carefully tested in clinical trials. I was especially eager to let him know that the true science of a clinical trial trumps the value of clinical guidelines, which are based on the best clinical judgments and guesstimates of leaders in the field.
The key to understanding the role of clinical guidelines is to recognize that they simply represent the most informed opinions available, given the sum total of clinical information that is available at that time. Clinical guidelines are based on evidence as much as is humanly possible, but there are often gaps in what we have learned from published clinical trials. Such trials are inherently limited with respect to the insights they can provide, because funding limitations invariably dictate that hard choices must be made in terms of the hypotheses that can be tested and the populations that can be studied. So the total amount of available data from clinical trials is almost invariably insufficient to answer a significant number of clinical questions definitively.
And that’s why a well-designed clinical trial trumps whatever expert guidelines may seem pertinent to the clinical question at stake. Yes, the JNC 8 authors may have determined (albeit with a significant contrarian minority report) that their best reading of the available literature was that there was no definitive evidence supporting a blood pressure goal of < 150/90 mm Hg in those aged > 60 years. But it must be recognized that the absence of such definitive evidence to date does not at all mean that a lower goal might one day be shown to be superior to the JNC 8 recommendations. And that’s where the SPRINT trial comes in: It’s specifically designed to test the hypothesis that a lower systolic goal of 120 mm Hg might be superior in terms of clinical outcomes to the higher goal of 140 mm Hg. Well-designed clinical trials are the mechanism through which meaningful clinical data are accrued; those data can then inform clinical guidelines.
I am happy to report that my alert SPRINT subject grasped the point rather quickly. As a retired engineer, he understood the importance of obtaining definitive data rather than relying forevermore upon the best guesses of well-meaning experts in the field. Clinical guidelines are useful as far as they go, but they are heavily dependent upon the generation of clinically valid data from randomized clinical trials. My SPRINT subject left the clinic with a renewed commitment to getting his systolic blood pressure down to the assigned goal of 120 mm Hg. All of us should follow his example and try mightily to keep in mind the distinction between clinical guidelines and actual data generated from randomized clinical trials.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Faithful readers may recall from previous editorials that I’m not particularly happy with the new hypertension guidelines issued recently by the JNC 8 authors. I am especially concerned that the new recommendations of a blood pressure goal of < 150/90 mm Hg for people aged > 60 years, like myself, could lead to a real deterioration in blood pressure control. We know that adherence to the previous goal of < 140/90 mm Hg for this age group has hardly been optimal, so why in the world would we want to relax our targets even further? I have confronted several of the JNC 8 writers with my concerns, and they have reluctantly acknowledged that I am hardly alone in my worries.
But one thing I never saw coming was that the new guidelines would confound one of the important clinical trials I’ve been participating in over the past 4 years. I’m referring to the National Institutes of Health-funded Systolic Blood Pressure Intervention Trial (SPRINT), which was designed to compare 2 systolic blood pressure goals, the traditional 140 mm Hg goal and a more aggressive 120 mm Hg goal.
One thing that is particularly confounding in the context of the new guidelines for those aged > 60 years is that we SPRINT investigators were instructed specifically to recruit as many patients as possible aged > 75 years, so that we could get a clear sense of what the systolic goal should be in this particularly high-risk population. The study architects didn’t even consider testing a goal of 150 mm Hg systolic. In a similar vein, we also worked very hard to over-recruit 2 other groups of high-risk patients, those who had already had a cardiovascular event and those with mild renal insufficiency.
The new guidelines wound up impacting my conduct of the SPRINT trial. An intellectually curious trial subject in his late 70s took a keen interest in the question: What is the optimal systolic blood pressure goal? As it turns out, he was among those who had been randomized to the more aggressive systolic goal of 120 mm Hg. At his most recent visit, he caught me off guard by asking why we were testing a blood pressure goal of 120 mm Hg in someone of his age. He had read that people aged > 60 years needed a blood pressure goal of only 150 mm Hg,according to the latest expert recommendations.
Initially I was flummoxed by his question. Perhaps I should have anticipated that some of our subjects might have questions, but I have to admit that the thought had not occurred to me. I was pleased to see that he was not at all agitated at the apparent disconnect. He was merely curious as to how there could be such a discrepancy between guidelines intended for the general public and the study goal of 120 mm Hg. This proved to be an important teachable moment. After gathering my wits, I was able to explain the difference between guidelines and hypotheses that are carefully tested in clinical trials. I was especially eager to let him know that the true science of a clinical trial trumps the value of clinical guidelines, which are based on the best clinical judgments and guesstimates of leaders in the field.
The key to understanding the role of clinical guidelines is to recognize that they simply represent the most informed opinions available, given the sum total of clinical information that is available at that time. Clinical guidelines are based on evidence as much as is humanly possible, but there are often gaps in what we have learned from published clinical trials. Such trials are inherently limited with respect to the insights they can provide, because funding limitations invariably dictate that hard choices must be made in terms of the hypotheses that can be tested and the populations that can be studied. So the total amount of available data from clinical trials is almost invariably insufficient to answer a significant number of clinical questions definitively.
And that’s why a well-designed clinical trial trumps whatever expert guidelines may seem pertinent to the clinical question at stake. Yes, the JNC 8 authors may have determined (albeit with a significant contrarian minority report) that their best reading of the available literature was that there was no definitive evidence supporting a blood pressure goal of < 150/90 mm Hg in those aged > 60 years. But it must be recognized that the absence of such definitive evidence to date does not at all mean that a lower goal might one day be shown to be superior to the JNC 8 recommendations. And that’s where the SPRINT trial comes in: It’s specifically designed to test the hypothesis that a lower systolic goal of 120 mm Hg might be superior in terms of clinical outcomes to the higher goal of 140 mm Hg. Well-designed clinical trials are the mechanism through which meaningful clinical data are accrued; those data can then inform clinical guidelines.
I am happy to report that my alert SPRINT subject grasped the point rather quickly. As a retired engineer, he understood the importance of obtaining definitive data rather than relying forevermore upon the best guesses of well-meaning experts in the field. Clinical guidelines are useful as far as they go, but they are heavily dependent upon the generation of clinically valid data from randomized clinical trials. My SPRINT subject left the clinic with a renewed commitment to getting his systolic blood pressure down to the assigned goal of 120 mm Hg. All of us should follow his example and try mightily to keep in mind the distinction between clinical guidelines and actual data generated from randomized clinical trials.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Careers: Your job search and the interview questions doctors forget to ask
You must ask these questions if you are going to avoid the top three reasons employed physicians quit down the road. Let me give you a big list of queries and a method you can use in your interview to make a quality decision about your contract.
(Note: If you are not searching for a job at the moment ... This is a very interesting set of questions to ask about your current job. The answers may surprise you and give you some ideas on how to improve the quality of your work day.)
Let’s set the stage
I assume you have avoided the physician job search No. 1 mistake and have actually created an Ideal Job Description ... Yes? You will dramatically increase the odds of finding a great position when you compare your Ideal Job Description to any offers you get.
In your interview, I am sure you will ask the usual questions ... things like:
• How do I get paid?
• What is the call schedule?
• What are my benefits, and how much time off do I get?
These questions are important, and they give you no idea of what your day-to-day work experience will be with this group, in this facility, in this larger organization. Remember that the top three reasons employed physicians quit are culture, the way the group makes decisions, and the quality of your immediate supervisor.
This question list is designed to help you understand these important issues.
How to ask your interview questions
1) Take the questions below as a written list.
Yep, take a clipboard and this list so you make sure to ask all the questions. There is a piece of you that is hesitant to do this and will want to memorize the questions. But you are working too hard and that is just a piece of your physician programming. Honest. Take the list with you and take notes about the answers.
2) Channel Columbo.
The people interviewing you will have never heard questions like this. They might say something like, “Wow, never heard that question before.” It helps to have a way to ask these questions in a very nonthreatening manner. The key is to channel Columbo.
You remember the detective in the TV series with the baggy coat and half-chewed cigar? When you channel Columbo ... you start your questions with ...
• I’m curious .....
• I’m confused here, maybe you can help me out ...
Be “curious” and “confused.” Ask them to help you understand. You will be surprised at the candor of their answers when you adopt this attitude.
The questions
These questions are intended to give you specific information about the three main reasons you might eventually quit this position ... up front where you need it the most. I suggest you use these questions as raw materials to craft specific questions you would be comfortable asking in your interview. Then put them on a written list, take them with you to the interview, and channel your best Columbo.
1) Group culture:
• How long has this group existed?
• Please tell me a little about its history.
• Is there a group mission statement?
• If so, do the doctors and staff and the quality of their lives appear in it?
• How would you describe the culture of this group?
• If there were one thing you could change about the group’s culture, what would that be?
• How well do you feel the group members like each other?
• Do group members hang out together when not in the office?
• How much do you feel your partners “have your back”?
• Please tell me about the compensation formula.
• What physician behaviors is this compensation formula intended to motivate?
•If I worked here and wanted to maximize my compensation ... what is the simplest way for me to do that?
• Which do you feel the group values more as a whole ... making money or the quality of the care you provide?
• How much does the group believe that having a balanced life outside of your medical practice is important?
• What is the process you use to bring a new physician on board? What training, mentoring, and coaching would I receive, from whom and for how long?
• Who are the physicians in the group currently in this onboarding process? May I speak with one of them?
2) How the group makes decisions:
• How does this group make decisions?
• How often does the group meet to discuss the practice and the systems used to deliver care?
• Has the group ever had a strategic planning retreat?
• If so, how long ago was the last one?
• Who are the leaders of the group and how are they selected/elected?
• What were the last three significant decisions the group made?
• What happens if one or more physicians disagree with a decision the group has made?
• What is the relationship between the physicians and the administration?
• What happens if the physicians have made a decision and the administration (CEO, board of directors, executive committee) disagrees?
• Who were the last three physicians to leave the group and why did they leave?
• May I have their contact information so I can ask them a few questions?
3) Your immediate supervisor:
• Who would be my immediate supervisor or “boss” or the person in this group / organization that I report directly to? May I speak with him or her, too?
• Are you a physician?
• Do you still see patients?
• How long have you been in this position?
• How would you describe your leadership style?
• Does the group pay you for your leadership activities?
• If yes, do you feel it is a fair payment when compared with what you make seeing patients?
• What training have you had in physician leadership?
• Assuming I were to accept this position, how often would you and I meet?
• How would you like me to communicate with you if I have a question or concern?
• How would you communicate back with me and in what time frame?
• What happens if you and I were ever to disagree about a decision/project/action step ... what would we do then and how would we resolve our disagreement?
• What do you feel is the most stressful part of your job when you are serving as a physician leader?
• What is currently the biggest challenge to this group?
• What do you see as the biggest challenge to the group in the next 5 years?
Now it’s your turn
If you have an interview coming up ... make your list and take it with you.
If you are in a position now and not looking to change, I still suggest you answer these questions about your current group just to make sure you recognize these potential seeds of future discontent early. In my work as an executive coach with hundreds of overstressed doctors, it is not uncommon for them to quit a job and realize these issues only in hindsight.
Don’t let that happen to you.
Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention MATRIX Free Report with over 117 different ways physicians and organizations can lower stress and prevent burnout. He provides stress management, burnout prevention, and physician wellness and engagement coaching and consulting through his website, The Happy MD.
You must ask these questions if you are going to avoid the top three reasons employed physicians quit down the road. Let me give you a big list of queries and a method you can use in your interview to make a quality decision about your contract.
(Note: If you are not searching for a job at the moment ... This is a very interesting set of questions to ask about your current job. The answers may surprise you and give you some ideas on how to improve the quality of your work day.)
Let’s set the stage
I assume you have avoided the physician job search No. 1 mistake and have actually created an Ideal Job Description ... Yes? You will dramatically increase the odds of finding a great position when you compare your Ideal Job Description to any offers you get.
In your interview, I am sure you will ask the usual questions ... things like:
• How do I get paid?
• What is the call schedule?
• What are my benefits, and how much time off do I get?
These questions are important, and they give you no idea of what your day-to-day work experience will be with this group, in this facility, in this larger organization. Remember that the top three reasons employed physicians quit are culture, the way the group makes decisions, and the quality of your immediate supervisor.
This question list is designed to help you understand these important issues.
How to ask your interview questions
1) Take the questions below as a written list.
Yep, take a clipboard and this list so you make sure to ask all the questions. There is a piece of you that is hesitant to do this and will want to memorize the questions. But you are working too hard and that is just a piece of your physician programming. Honest. Take the list with you and take notes about the answers.
2) Channel Columbo.
The people interviewing you will have never heard questions like this. They might say something like, “Wow, never heard that question before.” It helps to have a way to ask these questions in a very nonthreatening manner. The key is to channel Columbo.
You remember the detective in the TV series with the baggy coat and half-chewed cigar? When you channel Columbo ... you start your questions with ...
• I’m curious .....
• I’m confused here, maybe you can help me out ...
Be “curious” and “confused.” Ask them to help you understand. You will be surprised at the candor of their answers when you adopt this attitude.
The questions
These questions are intended to give you specific information about the three main reasons you might eventually quit this position ... up front where you need it the most. I suggest you use these questions as raw materials to craft specific questions you would be comfortable asking in your interview. Then put them on a written list, take them with you to the interview, and channel your best Columbo.
1) Group culture:
• How long has this group existed?
• Please tell me a little about its history.
• Is there a group mission statement?
• If so, do the doctors and staff and the quality of their lives appear in it?
• How would you describe the culture of this group?
• If there were one thing you could change about the group’s culture, what would that be?
• How well do you feel the group members like each other?
• Do group members hang out together when not in the office?
• How much do you feel your partners “have your back”?
• Please tell me about the compensation formula.
• What physician behaviors is this compensation formula intended to motivate?
•If I worked here and wanted to maximize my compensation ... what is the simplest way for me to do that?
• Which do you feel the group values more as a whole ... making money or the quality of the care you provide?
• How much does the group believe that having a balanced life outside of your medical practice is important?
• What is the process you use to bring a new physician on board? What training, mentoring, and coaching would I receive, from whom and for how long?
• Who are the physicians in the group currently in this onboarding process? May I speak with one of them?
2) How the group makes decisions:
• How does this group make decisions?
• How often does the group meet to discuss the practice and the systems used to deliver care?
• Has the group ever had a strategic planning retreat?
• If so, how long ago was the last one?
• Who are the leaders of the group and how are they selected/elected?
• What were the last three significant decisions the group made?
• What happens if one or more physicians disagree with a decision the group has made?
• What is the relationship between the physicians and the administration?
• What happens if the physicians have made a decision and the administration (CEO, board of directors, executive committee) disagrees?
• Who were the last three physicians to leave the group and why did they leave?
• May I have their contact information so I can ask them a few questions?
3) Your immediate supervisor:
• Who would be my immediate supervisor or “boss” or the person in this group / organization that I report directly to? May I speak with him or her, too?
• Are you a physician?
• Do you still see patients?
• How long have you been in this position?
• How would you describe your leadership style?
• Does the group pay you for your leadership activities?
• If yes, do you feel it is a fair payment when compared with what you make seeing patients?
• What training have you had in physician leadership?
• Assuming I were to accept this position, how often would you and I meet?
• How would you like me to communicate with you if I have a question or concern?
• How would you communicate back with me and in what time frame?
• What happens if you and I were ever to disagree about a decision/project/action step ... what would we do then and how would we resolve our disagreement?
• What do you feel is the most stressful part of your job when you are serving as a physician leader?
• What is currently the biggest challenge to this group?
• What do you see as the biggest challenge to the group in the next 5 years?
Now it’s your turn
If you have an interview coming up ... make your list and take it with you.
If you are in a position now and not looking to change, I still suggest you answer these questions about your current group just to make sure you recognize these potential seeds of future discontent early. In my work as an executive coach with hundreds of overstressed doctors, it is not uncommon for them to quit a job and realize these issues only in hindsight.
Don’t let that happen to you.
Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention MATRIX Free Report with over 117 different ways physicians and organizations can lower stress and prevent burnout. He provides stress management, burnout prevention, and physician wellness and engagement coaching and consulting through his website, The Happy MD.
You must ask these questions if you are going to avoid the top three reasons employed physicians quit down the road. Let me give you a big list of queries and a method you can use in your interview to make a quality decision about your contract.
(Note: If you are not searching for a job at the moment ... This is a very interesting set of questions to ask about your current job. The answers may surprise you and give you some ideas on how to improve the quality of your work day.)
Let’s set the stage
I assume you have avoided the physician job search No. 1 mistake and have actually created an Ideal Job Description ... Yes? You will dramatically increase the odds of finding a great position when you compare your Ideal Job Description to any offers you get.
In your interview, I am sure you will ask the usual questions ... things like:
• How do I get paid?
• What is the call schedule?
• What are my benefits, and how much time off do I get?
These questions are important, and they give you no idea of what your day-to-day work experience will be with this group, in this facility, in this larger organization. Remember that the top three reasons employed physicians quit are culture, the way the group makes decisions, and the quality of your immediate supervisor.
This question list is designed to help you understand these important issues.
How to ask your interview questions
1) Take the questions below as a written list.
Yep, take a clipboard and this list so you make sure to ask all the questions. There is a piece of you that is hesitant to do this and will want to memorize the questions. But you are working too hard and that is just a piece of your physician programming. Honest. Take the list with you and take notes about the answers.
2) Channel Columbo.
The people interviewing you will have never heard questions like this. They might say something like, “Wow, never heard that question before.” It helps to have a way to ask these questions in a very nonthreatening manner. The key is to channel Columbo.
You remember the detective in the TV series with the baggy coat and half-chewed cigar? When you channel Columbo ... you start your questions with ...
• I’m curious .....
• I’m confused here, maybe you can help me out ...
Be “curious” and “confused.” Ask them to help you understand. You will be surprised at the candor of their answers when you adopt this attitude.
The questions
These questions are intended to give you specific information about the three main reasons you might eventually quit this position ... up front where you need it the most. I suggest you use these questions as raw materials to craft specific questions you would be comfortable asking in your interview. Then put them on a written list, take them with you to the interview, and channel your best Columbo.
1) Group culture:
• How long has this group existed?
• Please tell me a little about its history.
• Is there a group mission statement?
• If so, do the doctors and staff and the quality of their lives appear in it?
• How would you describe the culture of this group?
• If there were one thing you could change about the group’s culture, what would that be?
• How well do you feel the group members like each other?
• Do group members hang out together when not in the office?
• How much do you feel your partners “have your back”?
• Please tell me about the compensation formula.
• What physician behaviors is this compensation formula intended to motivate?
•If I worked here and wanted to maximize my compensation ... what is the simplest way for me to do that?
• Which do you feel the group values more as a whole ... making money or the quality of the care you provide?
• How much does the group believe that having a balanced life outside of your medical practice is important?
• What is the process you use to bring a new physician on board? What training, mentoring, and coaching would I receive, from whom and for how long?
• Who are the physicians in the group currently in this onboarding process? May I speak with one of them?
2) How the group makes decisions:
• How does this group make decisions?
• How often does the group meet to discuss the practice and the systems used to deliver care?
• Has the group ever had a strategic planning retreat?
• If so, how long ago was the last one?
• Who are the leaders of the group and how are they selected/elected?
• What were the last three significant decisions the group made?
• What happens if one or more physicians disagree with a decision the group has made?
• What is the relationship between the physicians and the administration?
• What happens if the physicians have made a decision and the administration (CEO, board of directors, executive committee) disagrees?
• Who were the last three physicians to leave the group and why did they leave?
• May I have their contact information so I can ask them a few questions?
3) Your immediate supervisor:
• Who would be my immediate supervisor or “boss” or the person in this group / organization that I report directly to? May I speak with him or her, too?
• Are you a physician?
• Do you still see patients?
• How long have you been in this position?
• How would you describe your leadership style?
• Does the group pay you for your leadership activities?
• If yes, do you feel it is a fair payment when compared with what you make seeing patients?
• What training have you had in physician leadership?
• Assuming I were to accept this position, how often would you and I meet?
• How would you like me to communicate with you if I have a question or concern?
• How would you communicate back with me and in what time frame?
• What happens if you and I were ever to disagree about a decision/project/action step ... what would we do then and how would we resolve our disagreement?
• What do you feel is the most stressful part of your job when you are serving as a physician leader?
• What is currently the biggest challenge to this group?
• What do you see as the biggest challenge to the group in the next 5 years?
Now it’s your turn
If you have an interview coming up ... make your list and take it with you.
If you are in a position now and not looking to change, I still suggest you answer these questions about your current group just to make sure you recognize these potential seeds of future discontent early. In my work as an executive coach with hundreds of overstressed doctors, it is not uncommon for them to quit a job and realize these issues only in hindsight.
Don’t let that happen to you.
Dike Drummond, M.D., is a family physician, executive coach, and creator of the Burnout Prevention MATRIX Free Report with over 117 different ways physicians and organizations can lower stress and prevent burnout. He provides stress management, burnout prevention, and physician wellness and engagement coaching and consulting through his website, The Happy MD.
Challenges Facing Our Specialty
The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.
Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.
Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.
It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.
Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.
We are privileged to practice a specialty that can provide patients with dramatic improvements in health and quality of life. We give back in so many ways, such as volunteering to help underserved populations overseas or at home. We have raised public awareness of the threat of melanoma. The Canadian Dermatology Association turned Niagara Falls orange on Melanoma Monday this year to raise skin cancer awareness; well done! Every one of us who helps support our patient advocacy efforts or the continued success of Camp Discovery (http://www.aad.org/dermatology-a-to-z/for-kids/camp-discovery) enhances the image of our specialty. Each time you see a hospital consultation, volunteer in the community, or squeeze in a patient who cannot pay at the end of a long day, you do more than help an individual; you help ensure the very future of our specialty.
To face the challenges ahead, we must stick together and project a unified voice. Stay informed! If you do not regularly read Dermatology World and the AAD’s member-to-member alerts, you are missing a lot. Our future depends on each one of us working together for our patients and our specialty.
The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.
Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.
Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.
It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.
Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.
We are privileged to practice a specialty that can provide patients with dramatic improvements in health and quality of life. We give back in so many ways, such as volunteering to help underserved populations overseas or at home. We have raised public awareness of the threat of melanoma. The Canadian Dermatology Association turned Niagara Falls orange on Melanoma Monday this year to raise skin cancer awareness; well done! Every one of us who helps support our patient advocacy efforts or the continued success of Camp Discovery (http://www.aad.org/dermatology-a-to-z/for-kids/camp-discovery) enhances the image of our specialty. Each time you see a hospital consultation, volunteer in the community, or squeeze in a patient who cannot pay at the end of a long day, you do more than help an individual; you help ensure the very future of our specialty.
To face the challenges ahead, we must stick together and project a unified voice. Stay informed! If you do not regularly read Dermatology World and the AAD’s member-to-member alerts, you are missing a lot. Our future depends on each one of us working together for our patients and our specialty.
The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.
Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.
Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.
It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.
Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.
We are privileged to practice a specialty that can provide patients with dramatic improvements in health and quality of life. We give back in so many ways, such as volunteering to help underserved populations overseas or at home. We have raised public awareness of the threat of melanoma. The Canadian Dermatology Association turned Niagara Falls orange on Melanoma Monday this year to raise skin cancer awareness; well done! Every one of us who helps support our patient advocacy efforts or the continued success of Camp Discovery (http://www.aad.org/dermatology-a-to-z/for-kids/camp-discovery) enhances the image of our specialty. Each time you see a hospital consultation, volunteer in the community, or squeeze in a patient who cannot pay at the end of a long day, you do more than help an individual; you help ensure the very future of our specialty.
To face the challenges ahead, we must stick together and project a unified voice. Stay informed! If you do not regularly read Dermatology World and the AAD’s member-to-member alerts, you are missing a lot. Our future depends on each one of us working together for our patients and our specialty.