Commentary

"In the latest report from the WHI, the data contradict the conclusions"
Holly Thacker, MD (Commentary, March 2014)

Enigmatic inconsistencies between WHI data and conclusions
The issue of the inconsistencies between the Women’s Health Initiative (WHI) data and conclusions is enigmatic because the integrity and judgment of researchers has in the past and should remain above reproach.

For those of us in the private sector of obstetrics and gynecology, the feeling that there must be information that intentionally or unintentionally has been omitted from our view remains the most comfortable and convenient explanation for the discrepancies.

The vindication of observational studies predating WHI by the reanalysis of WHI data seems to be continually suppressed in the literature, and the unreasoning exclusion of the critical issue of timing in the initiation and continued administration of estrogen therapy (ET) and hormone therapy (HT) is inexplicable. One is repeatedly tempted to consider some underlying agenda.

Elimination of sampling by Wyeth, and now exclusion from drug formularies with the attendant exorbitant increases in cost have, in addition to the absence of a defense by researchers or manufacturers, discouraged continuing use of this valuable medication, even among those in whom the safety and benefits of Premarin and Prempro have been established over years of experience and scores of studies. 

It is much like the children’s story, “The Emperor’s New Clothes.” It seems incredible that so many know­ledgeable authorities seem unable to recognize a 60% reduction in coronary artery plaque in recently menopausal women (ages 50–59 years) after 5.2 years of HT, which underscores the importance of patient selection and timing of administration.¹ Wyeth’s explanation, when I inquired, was that this involved “off-label” use, although the data are from reanalysis of WHI data. I would think that a 60% reduction of arterial plaque deserves front-page coverage.

When articles about the discontinuation of WHI began to appear in 2001, stated reasons included the overwhelming predominance of new breast cancer cases in estrogen-administered subjects, but no one seems to appreciate the 47% decrease in breast cancer mortality discovered in the reanalysis, due to the chronologically earlier appearance of disease at earlier clinical stages. In my practice, we are finding in situ disease in HT and ET patients after 4 to 5 years of use.

Consequently, I am appreciative of Dr. Thacker’s mention of the ­Sarrel data² and her expansion into the “so often” overlooked issues. I think that it’s overdue—integrity must be restored to the interpretation of NIH’s $780,000,000 expenditure of taxpayer dollars. After all, WHI was to be the statistically unimpeachable clarification of estrogen and hormone replacement.

Glenn N. Hayashi, MD
Honolulu, Hawaii

Exaggerated or intentionally fabricated data?
Thank you for publishing Dr. Holly Thacker’s commentary regarding the travesty that was and is WHI. I enthusiastically support her admonition to “look at the totality of the data on menopausal HT, evaluate our patients individually, treat those who are truly hormonally deficient and suffering, and counsel them that many of the harms linked to HT have been exaggerated.”

My only disagreement is Dr. Thacker’s choice of the word “exaggerated” when describing the harms linked to HT. I would have chosen instead the words “intentionally fabricated.” How? By taking data out of context, by releasing data selectively, by withholding data—all for the purpose of achieving and then protecting their frighteningly negative and destructive initial conclusions.

I wish it were the case that an independent commission might right these wrongs. Unfortunately, that cannot happen in today’s intellectual context. The fundamental error that made WHI’s multitude of errors possible was the notion that we can dispense with the difficult work of considering “the totality of the data” by placing our faith in “statistical significance” derived from a single “randomized controlled trial.” That fundamental error is too deeply entrenched, too highly remunerative, and too propitiously useful to those seeking a world concordant with their fantasies.

Reality demands that we account for every fact and will in time put an end to this deadly conceit. 

Geoffrey C. Kincaid, MD
Knoxville, Tennessee

TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!

"In the latest report from the WHI, the data contradict the conclusions"
Holly Thacker, MD (Commentary, March 2014)

Enigmatic inconsistencies between WHI data and conclusions
The issue of the inconsistencies between the Women’s Health Initiative (WHI) data and conclusions is enigmatic because the integrity and judgment of researchers has in the past and should remain above reproach.

For those of us in the private sector of obstetrics and gynecology, the feeling that there must be information that intentionally or unintentionally has been omitted from our view remains the most comfortable and convenient explanation for the discrepancies.

The vindication of observational studies predating WHI by the reanalysis of WHI data seems to be continually suppressed in the literature, and the unreasoning exclusion of the critical issue of timing in the initiation and continued administration of estrogen therapy (ET) and hormone therapy (HT) is inexplicable. One is repeatedly tempted to consider some underlying agenda.

Elimination of sampling by Wyeth, and now exclusion from drug formularies with the attendant exorbitant increases in cost have, in addition to the absence of a defense by researchers or manufacturers, discouraged continuing use of this valuable medication, even among those in whom the safety and benefits of Premarin and Prempro have been established over years of experience and scores of studies. 

It is much like the children’s story, “The Emperor’s New Clothes.” It seems incredible that so many know­ledgeable authorities seem unable to recognize a 60% reduction in coronary artery plaque in recently menopausal women (ages 50–59 years) after 5.2 years of HT, which underscores the importance of patient selection and timing of administration.¹ Wyeth’s explanation, when I inquired, was that this involved “off-label” use, although the data are from reanalysis of WHI data. I would think that a 60% reduction of arterial plaque deserves front-page coverage.

When articles about the discontinuation of WHI began to appear in 2001, stated reasons included the overwhelming predominance of new breast cancer cases in estrogen-administered subjects, but no one seems to appreciate the 47% decrease in breast cancer mortality discovered in the reanalysis, due to the chronologically earlier appearance of disease at earlier clinical stages. In my practice, we are finding in situ disease in HT and ET patients after 4 to 5 years of use.

Consequently, I am appreciative of Dr. Thacker’s mention of the ­Sarrel data² and her expansion into the “so often” overlooked issues. I think that it’s overdue—integrity must be restored to the interpretation of NIH’s $780,000,000 expenditure of taxpayer dollars. After all, WHI was to be the statistically unimpeachable clarification of estrogen and hormone replacement.

Glenn N. Hayashi, MD
Honolulu, Hawaii

Exaggerated or intentionally fabricated data?
Thank you for publishing Dr. Holly Thacker’s commentary regarding the travesty that was and is WHI. I enthusiastically support her admonition to “look at the totality of the data on menopausal HT, evaluate our patients individually, treat those who are truly hormonally deficient and suffering, and counsel them that many of the harms linked to HT have been exaggerated.”

My only disagreement is Dr. Thacker’s choice of the word “exaggerated” when describing the harms linked to HT. I would have chosen instead the words “intentionally fabricated.” How? By taking data out of context, by releasing data selectively, by withholding data—all for the purpose of achieving and then protecting their frighteningly negative and destructive initial conclusions.

I wish it were the case that an independent commission might right these wrongs. Unfortunately, that cannot happen in today’s intellectual context. The fundamental error that made WHI’s multitude of errors possible was the notion that we can dispense with the difficult work of considering “the totality of the data” by placing our faith in “statistical significance” derived from a single “randomized controlled trial.” That fundamental error is too deeply entrenched, too highly remunerative, and too propitiously useful to those seeking a world concordant with their fantasies.

Reality demands that we account for every fact and will in time put an end to this deadly conceit. 

Geoffrey C. Kincaid, MD
Knoxville, Tennessee

TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!

"In the latest report from the WHI, the data contradict the conclusions"
Holly Thacker, MD (Commentary, March 2014)

Enigmatic inconsistencies between WHI data and conclusions
The issue of the inconsistencies between the Women’s Health Initiative (WHI) data and conclusions is enigmatic because the integrity and judgment of researchers has in the past and should remain above reproach.

For those of us in the private sector of obstetrics and gynecology, the feeling that there must be information that intentionally or unintentionally has been omitted from our view remains the most comfortable and convenient explanation for the discrepancies.

The vindication of observational studies predating WHI by the reanalysis of WHI data seems to be continually suppressed in the literature, and the unreasoning exclusion of the critical issue of timing in the initiation and continued administration of estrogen therapy (ET) and hormone therapy (HT) is inexplicable. One is repeatedly tempted to consider some underlying agenda.

Elimination of sampling by Wyeth, and now exclusion from drug formularies with the attendant exorbitant increases in cost have, in addition to the absence of a defense by researchers or manufacturers, discouraged continuing use of this valuable medication, even among those in whom the safety and benefits of Premarin and Prempro have been established over years of experience and scores of studies. 

It is much like the children’s story, “The Emperor’s New Clothes.” It seems incredible that so many know­ledgeable authorities seem unable to recognize a 60% reduction in coronary artery plaque in recently menopausal women (ages 50–59 years) after 5.2 years of HT, which underscores the importance of patient selection and timing of administration.¹ Wyeth’s explanation, when I inquired, was that this involved “off-label” use, although the data are from reanalysis of WHI data. I would think that a 60% reduction of arterial plaque deserves front-page coverage.

When articles about the discontinuation of WHI began to appear in 2001, stated reasons included the overwhelming predominance of new breast cancer cases in estrogen-administered subjects, but no one seems to appreciate the 47% decrease in breast cancer mortality discovered in the reanalysis, due to the chronologically earlier appearance of disease at earlier clinical stages. In my practice, we are finding in situ disease in HT and ET patients after 4 to 5 years of use.

Consequently, I am appreciative of Dr. Thacker’s mention of the ­Sarrel data² and her expansion into the “so often” overlooked issues. I think that it’s overdue—integrity must be restored to the interpretation of NIH’s $780,000,000 expenditure of taxpayer dollars. After all, WHI was to be the statistically unimpeachable clarification of estrogen and hormone replacement.

Glenn N. Hayashi, MD
Honolulu, Hawaii

Exaggerated or intentionally fabricated data?
Thank you for publishing Dr. Holly Thacker’s commentary regarding the travesty that was and is WHI. I enthusiastically support her admonition to “look at the totality of the data on menopausal HT, evaluate our patients individually, treat those who are truly hormonally deficient and suffering, and counsel them that many of the harms linked to HT have been exaggerated.”

My only disagreement is Dr. Thacker’s choice of the word “exaggerated” when describing the harms linked to HT. I would have chosen instead the words “intentionally fabricated.” How? By taking data out of context, by releasing data selectively, by withholding data—all for the purpose of achieving and then protecting their frighteningly negative and destructive initial conclusions.

I wish it were the case that an independent commission might right these wrongs. Unfortunately, that cannot happen in today’s intellectual context. The fundamental error that made WHI’s multitude of errors possible was the notion that we can dispense with the difficult work of considering “the totality of the data” by placing our faith in “statistical significance” derived from a single “randomized controlled trial.” That fundamental error is too deeply entrenched, too highly remunerative, and too propitiously useful to those seeking a world concordant with their fantasies.

Reality demands that we account for every fact and will in time put an end to this deadly conceit. 

Geoffrey C. Kincaid, MD
Knoxville, Tennessee

TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!

Mobile app interventions for people with diabetes improved glycemic control in separate studies reported at the annual scientific sessions of the American Diabetes Association, San Francisco.

Interim results from a prospective randomized controlled study of 106 patients from a medically underserved Hispanic population with poorly controlled type 2 diabetes found that hemoglobin A_1c (HbA_1c) levels decreased by an average of a relative 12% after 6 months in those who used a text-messaging intervention called Dulce Digital on their mobile phones in addition to receiving usual care, compared with a 2% relative decrease in the control patients who received usual care alone.

Mean HbA_1c levels decreased from 9.4% at baseline in the Dulce Digital group to 8.4% after 3 months and at 6 months. In the control group, mean HbA_1c levels started at 9.5%, decreased to 9.2% at 3 months, and increased to 9.3% at 6 months. The differences between groups were statistically significant, nurse practitioner Maria Isabel Garcia reported.

Changes in other measures, including weight, blood pressure, or lipids, did not differ significantly between groups, said Ms. Garcia of Scripps Health, San Diego.

Patients in the Dulce Digital group who had no cell phone or had limited text-messaging service, received a phone with unlimited messaging. They then received two or three texts per day initially, with the frequency tapering over a 6-month period. Three kinds of texts were sent. Educational messages included a reminder to "Use small plates! Portions will look larger, and you may feel more satisfied after eating." Medication reminders might say, "Tick, tock. Take your medication at the same time every day!" Blood glucose prompts reminded patients, "Time to check your blood sugar! Text back your results."

Nurses monitored blood glucose responses and called the patient if they saw one reported value greater than 250 mg/L or less than 70 mg/dL, three values in the 181- to 250-mg/dL range within 1 month, or no texts back for 1 week.

"Ninety-one percent of the U.S. population already has a cell phone. So let’s use that as a way to circumvent these barriers to access to care," Ms. Garcia said. She and her associates are pursuing funding for further study of Dulce Digital with longer follow-up.

In a separate randomized, controlled French study of 190 adults with type 2 diabetes who were starting insulin, the Telediab2 software system loaded onto patients’ phones nearly doubled the likelihood that patients would achieve HbA_1c levels of less than 7% by 13 months (31%), compared with patients in a control group or a third group who used a simplified software intervention for only the first 4 months (19%), Dr. Sylvia Franc reported in a poster presentation.

The TeleDiab2 system provides automatic basal insulin titration based on blood glucose targets and rules devised by the treating physician, as well as automatic personalized coaching for blood glucose monitoring, diet, and physical activity based on pre- and postprandial blood glucose values. The app enables remote telemonitoring and short teleconsultations, said Dr. Franc of Sud-Francilien Hospital, Corbeil Essones, France.

Physicians initiated and titrated basal insulin at baseline. Patients in the control group then received face-to-face consultations every 3 months. The simplified intervention group received phone consultations through the app for the first 4 months (and had significantly improved HbA_1c levels, compared with the control group, in that period), then had face-to-face visits every 3 months. Patients in the Telediab2 group had no face-to-face visits; they had phone consultations every 2 weeks until month 4, then monthly phone consultations.

Mobile technology also impressed attendees at the meeting in four small studies showing progress in early attempts to develop an "artificial pancreas." In two 5-day crossover studies, 52 U.S. adults and adolescents with type 1 diabetes using a bionic insulin-glucagon pancreas achieved better glycemic control than did patients using insulin pump therapy (N. Engl. J. Med. 2014 June 15 [doi:10.1056/NEJMoa1314474]). The FlorenceD2 closed-loop insulin delivery system seemed to improve glucose control when used by patients at home in two small European randomized crossover studies.

Dr. Garcia and Dr. Franc reported having no financial disclosures. Lifescan, which sells glucose monitoring products, supported Dr. Garcia’s study.

[email protected]

On Twitter @SherryBoschert

Mobile app interventions for people with diabetes improved glycemic control in separate studies reported at the annual scientific sessions of the American Diabetes Association, San Francisco.

Interim results from a prospective randomized controlled study of 106 patients from a medically underserved Hispanic population with poorly controlled type 2 diabetes found that hemoglobin A_1c (HbA_1c) levels decreased by an average of a relative 12% after 6 months in those who used a text-messaging intervention called Dulce Digital on their mobile phones in addition to receiving usual care, compared with a 2% relative decrease in the control patients who received usual care alone.

Mean HbA_1c levels decreased from 9.4% at baseline in the Dulce Digital group to 8.4% after 3 months and at 6 months. In the control group, mean HbA_1c levels started at 9.5%, decreased to 9.2% at 3 months, and increased to 9.3% at 6 months. The differences between groups were statistically significant, nurse practitioner Maria Isabel Garcia reported.

Changes in other measures, including weight, blood pressure, or lipids, did not differ significantly between groups, said Ms. Garcia of Scripps Health, San Diego.

Patients in the Dulce Digital group who had no cell phone or had limited text-messaging service, received a phone with unlimited messaging. They then received two or three texts per day initially, with the frequency tapering over a 6-month period. Three kinds of texts were sent. Educational messages included a reminder to "Use small plates! Portions will look larger, and you may feel more satisfied after eating." Medication reminders might say, "Tick, tock. Take your medication at the same time every day!" Blood glucose prompts reminded patients, "Time to check your blood sugar! Text back your results."

Nurses monitored blood glucose responses and called the patient if they saw one reported value greater than 250 mg/L or less than 70 mg/dL, three values in the 181- to 250-mg/dL range within 1 month, or no texts back for 1 week.

"Ninety-one percent of the U.S. population already has a cell phone. So let’s use that as a way to circumvent these barriers to access to care," Ms. Garcia said. She and her associates are pursuing funding for further study of Dulce Digital with longer follow-up.

In a separate randomized, controlled French study of 190 adults with type 2 diabetes who were starting insulin, the Telediab2 software system loaded onto patients’ phones nearly doubled the likelihood that patients would achieve HbA_1c levels of less than 7% by 13 months (31%), compared with patients in a control group or a third group who used a simplified software intervention for only the first 4 months (19%), Dr. Sylvia Franc reported in a poster presentation.

The TeleDiab2 system provides automatic basal insulin titration based on blood glucose targets and rules devised by the treating physician, as well as automatic personalized coaching for blood glucose monitoring, diet, and physical activity based on pre- and postprandial blood glucose values. The app enables remote telemonitoring and short teleconsultations, said Dr. Franc of Sud-Francilien Hospital, Corbeil Essones, France.

Physicians initiated and titrated basal insulin at baseline. Patients in the control group then received face-to-face consultations every 3 months. The simplified intervention group received phone consultations through the app for the first 4 months (and had significantly improved HbA_1c levels, compared with the control group, in that period), then had face-to-face visits every 3 months. Patients in the Telediab2 group had no face-to-face visits; they had phone consultations every 2 weeks until month 4, then monthly phone consultations.

Mobile technology also impressed attendees at the meeting in four small studies showing progress in early attempts to develop an "artificial pancreas." In two 5-day crossover studies, 52 U.S. adults and adolescents with type 1 diabetes using a bionic insulin-glucagon pancreas achieved better glycemic control than did patients using insulin pump therapy (N. Engl. J. Med. 2014 June 15 [doi:10.1056/NEJMoa1314474]). The FlorenceD2 closed-loop insulin delivery system seemed to improve glucose control when used by patients at home in two small European randomized crossover studies.

Dr. Garcia and Dr. Franc reported having no financial disclosures. Lifescan, which sells glucose monitoring products, supported Dr. Garcia’s study.

[email protected]

On Twitter @SherryBoschert

Mobile app interventions for people with diabetes improved glycemic control in separate studies reported at the annual scientific sessions of the American Diabetes Association, San Francisco.

Interim results from a prospective randomized controlled study of 106 patients from a medically underserved Hispanic population with poorly controlled type 2 diabetes found that hemoglobin A_1c (HbA_1c) levels decreased by an average of a relative 12% after 6 months in those who used a text-messaging intervention called Dulce Digital on their mobile phones in addition to receiving usual care, compared with a 2% relative decrease in the control patients who received usual care alone.

Mean HbA_1c levels decreased from 9.4% at baseline in the Dulce Digital group to 8.4% after 3 months and at 6 months. In the control group, mean HbA_1c levels started at 9.5%, decreased to 9.2% at 3 months, and increased to 9.3% at 6 months. The differences between groups were statistically significant, nurse practitioner Maria Isabel Garcia reported.

Changes in other measures, including weight, blood pressure, or lipids, did not differ significantly between groups, said Ms. Garcia of Scripps Health, San Diego.

Patients in the Dulce Digital group who had no cell phone or had limited text-messaging service, received a phone with unlimited messaging. They then received two or three texts per day initially, with the frequency tapering over a 6-month period. Three kinds of texts were sent. Educational messages included a reminder to "Use small plates! Portions will look larger, and you may feel more satisfied after eating." Medication reminders might say, "Tick, tock. Take your medication at the same time every day!" Blood glucose prompts reminded patients, "Time to check your blood sugar! Text back your results."

Nurses monitored blood glucose responses and called the patient if they saw one reported value greater than 250 mg/L or less than 70 mg/dL, three values in the 181- to 250-mg/dL range within 1 month, or no texts back for 1 week.

"Ninety-one percent of the U.S. population already has a cell phone. So let’s use that as a way to circumvent these barriers to access to care," Ms. Garcia said. She and her associates are pursuing funding for further study of Dulce Digital with longer follow-up.

In a separate randomized, controlled French study of 190 adults with type 2 diabetes who were starting insulin, the Telediab2 software system loaded onto patients’ phones nearly doubled the likelihood that patients would achieve HbA_1c levels of less than 7% by 13 months (31%), compared with patients in a control group or a third group who used a simplified software intervention for only the first 4 months (19%), Dr. Sylvia Franc reported in a poster presentation.

The TeleDiab2 system provides automatic basal insulin titration based on blood glucose targets and rules devised by the treating physician, as well as automatic personalized coaching for blood glucose monitoring, diet, and physical activity based on pre- and postprandial blood glucose values. The app enables remote telemonitoring and short teleconsultations, said Dr. Franc of Sud-Francilien Hospital, Corbeil Essones, France.

Physicians initiated and titrated basal insulin at baseline. Patients in the control group then received face-to-face consultations every 3 months. The simplified intervention group received phone consultations through the app for the first 4 months (and had significantly improved HbA_1c levels, compared with the control group, in that period), then had face-to-face visits every 3 months. Patients in the Telediab2 group had no face-to-face visits; they had phone consultations every 2 weeks until month 4, then monthly phone consultations.

Mobile technology also impressed attendees at the meeting in four small studies showing progress in early attempts to develop an "artificial pancreas." In two 5-day crossover studies, 52 U.S. adults and adolescents with type 1 diabetes using a bionic insulin-glucagon pancreas achieved better glycemic control than did patients using insulin pump therapy (N. Engl. J. Med. 2014 June 15 [doi:10.1056/NEJMoa1314474]). The FlorenceD2 closed-loop insulin delivery system seemed to improve glucose control when used by patients at home in two small European randomized crossover studies.

Dr. Garcia and Dr. Franc reported having no financial disclosures. Lifescan, which sells glucose monitoring products, supported Dr. Garcia’s study.

[email protected]

On Twitter @SherryBoschert

Summer is here, and with it comes an increase in swimming and other aquatic activities. To me, there is nothing more relaxing than floating in the ocean or a pool. (Personally, I’ve never been a lake girl.)

I cannot remember not knowing how to swim. My mother, who in her youth was a swimming instructor, taught all my siblings and me. Mom instructed us not only on how to swim but also on understanding that every “body” of water has the potential to be dangerous.

Moreover, we all knew “the rules” to follow when near the water. The key ones: Pay attention in the water; wait an hour after eating before going in; and never swim alone. If we were in a boat, regardless of our swimming ability, we were required to wear a life jacket. Failure to adhere to even one of these would result in being “dry docked”—in other words, having to sit on the beach or poolside and not being allowed to go into the water. This was something none of us ever wanted.       

Because of my childhood experience, swimming and water safety are second nature to me, along with playing a role in water safety activities through high school and college. I was a lifeguard at local pools and taught swimming and lifesaving at a YMCA. Just as I learned, I taught others to be ever vigilant around the water. I was, and taught others to be, cautious about never swimming alone—always have a buddy—and when in the ocean, to heed the warning signs of dangerous waves or riptides. 

I taught people of all ages to swim. The youngest was an 8-month-old girl and the oldest, a 62-year-old man. While I never expected either of them to become a competitive swimmer, what I wanted was for them to be able to keep safe around the water. That is the goal of teaching someone to swim: to give that person the tools to save himself or herself when in danger in the water. Sadly, every season (not just summer), people drown. 

According to the CDC’s National Center for Injury Prevention and Control, the leading factors that affect the risk for drowning—the ones over which we have control—are

Lack of Swimming Ability: Many people—adults and children alike—report that they cannot swim. Research indicates that formal swimming lessons can reduce the risk for drowning among children ages 1 to 4.

Lack of Barriers: Barriers such as fencing can prevent young ­children from gaining access to a pool without caregivers’ awareness. (Some municipalities have zoning ordinances for private pool owners, requiring barriers for safety.)

Lack of Supervision: Drowning can happen quickly and quietly anywhere there is water (eg, bathtub, swimming pool, bucket) and even in the presence of lifeguards.

Location: People of different ages drown in different locations. For example, home swimming pools are the site of most drownings among children ages 1 to 4. Drownings in natural settings (eg, lakes, rivers, oceans) increase with age; more than half of fatal and nonfatal drownings among those ages 15 and older occur in these settings.

Failure to Wear Life Jackets: The US Coast Guard (USCG) received reports of 4,604 boating incidents in 2010; a total of 3,153 boaters were injured, and 672 died. Most boating deaths were by drowning, with 88% of victims not wearing life jackets at the time of the incident.

Alcohol Use: Among adolescents and adults, alcohol use is involved in up to 70% of deaths associated with water recreation, almost a quarter of emergency department visits for drowning, and about one in five reported boating deaths.¹

Since 2010, I have read multiple news stories about people drowning unintentionally. The causes have ranged from being swept away in raging floodwaters; grounding, capsizing, or sinking a vessel; and water-skiing or similar mishaps.² In fact, each day about 10 people die from unintentional drowning; what is surprising is that only two of them are children younger than 14. This statistic tells me that we need to include water safety warnings in our “anticipatory guidance” for all patients. We must raise awareness of the need to be cautious around water, even if the person knows how to swim.

The National Drowning Prevention Alliance, the USCG, the CDC, and the World Health Organization provide information about water safety and drowning prevention. The vital message is that no single device or solution can prevent drowning.

That said, we must remind our patients and families to be attentive while near, in, or on the water. Caution them to be alert to potential dangers in all environments—even the most innocent-looking or most familiar body of water can be a threat. All adults and children should wear life jackets or personal flotation devices (PFD) approved by the USCG when boating (even if the boat is only a canoe)!  

Recent events among my circle of friends and family have made me revisit one of the rules of my childhood and consider extending it. In discussions with colleagues, I have suggested that we recommend everyone older than 40 seriously consider wearing some type of PFD when near or in the water, even if they are not in a boat. Some rebuffed this idea as an unnecessary nuisance. But I consider it a minor inconvenience that could mean the difference between a fatal and nonfatal aquatic incident. I cannot help but wonder if it would have made a difference in some cases.

How strictly do you enforce “the rules” for yourself and your family? Share your feedback at [email protected].

REFERENCES
1. CDC. Unintentional drowning: get the facts. www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. Accessed June 16, 2014.

2. US Department of Homeland Security and US Coast Guard. 2013 Recreational Boating Statistics. COMDTPUB P16754.27. www.uscgboating.org/assets/1/AssetManager/2013RecBoatingStats.pdf. Accessed June 16, 2014. 

Summer is here, and with it comes an increase in swimming and other aquatic activities. To me, there is nothing more relaxing than floating in the ocean or a pool. (Personally, I’ve never been a lake girl.)

I cannot remember not knowing how to swim. My mother, who in her youth was a swimming instructor, taught all my siblings and me. Mom instructed us not only on how to swim but also on understanding that every “body” of water has the potential to be dangerous.

Moreover, we all knew “the rules” to follow when near the water. The key ones: Pay attention in the water; wait an hour after eating before going in; and never swim alone. If we were in a boat, regardless of our swimming ability, we were required to wear a life jacket. Failure to adhere to even one of these would result in being “dry docked”—in other words, having to sit on the beach or poolside and not being allowed to go into the water. This was something none of us ever wanted.       

Because of my childhood experience, swimming and water safety are second nature to me, along with playing a role in water safety activities through high school and college. I was a lifeguard at local pools and taught swimming and lifesaving at a YMCA. Just as I learned, I taught others to be ever vigilant around the water. I was, and taught others to be, cautious about never swimming alone—always have a buddy—and when in the ocean, to heed the warning signs of dangerous waves or riptides. 

I taught people of all ages to swim. The youngest was an 8-month-old girl and the oldest, a 62-year-old man. While I never expected either of them to become a competitive swimmer, what I wanted was for them to be able to keep safe around the water. That is the goal of teaching someone to swim: to give that person the tools to save himself or herself when in danger in the water. Sadly, every season (not just summer), people drown. 

According to the CDC’s National Center for Injury Prevention and Control, the leading factors that affect the risk for drowning—the ones over which we have control—are

Lack of Swimming Ability: Many people—adults and children alike—report that they cannot swim. Research indicates that formal swimming lessons can reduce the risk for drowning among children ages 1 to 4.

Lack of Barriers: Barriers such as fencing can prevent young ­children from gaining access to a pool without caregivers’ awareness. (Some municipalities have zoning ordinances for private pool owners, requiring barriers for safety.)

Lack of Supervision: Drowning can happen quickly and quietly anywhere there is water (eg, bathtub, swimming pool, bucket) and even in the presence of lifeguards.

Location: People of different ages drown in different locations. For example, home swimming pools are the site of most drownings among children ages 1 to 4. Drownings in natural settings (eg, lakes, rivers, oceans) increase with age; more than half of fatal and nonfatal drownings among those ages 15 and older occur in these settings.

Failure to Wear Life Jackets: The US Coast Guard (USCG) received reports of 4,604 boating incidents in 2010; a total of 3,153 boaters were injured, and 672 died. Most boating deaths were by drowning, with 88% of victims not wearing life jackets at the time of the incident.

Alcohol Use: Among adolescents and adults, alcohol use is involved in up to 70% of deaths associated with water recreation, almost a quarter of emergency department visits for drowning, and about one in five reported boating deaths.¹

Since 2010, I have read multiple news stories about people drowning unintentionally. The causes have ranged from being swept away in raging floodwaters; grounding, capsizing, or sinking a vessel; and water-skiing or similar mishaps.² In fact, each day about 10 people die from unintentional drowning; what is surprising is that only two of them are children younger than 14. This statistic tells me that we need to include water safety warnings in our “anticipatory guidance” for all patients. We must raise awareness of the need to be cautious around water, even if the person knows how to swim.

The National Drowning Prevention Alliance, the USCG, the CDC, and the World Health Organization provide information about water safety and drowning prevention. The vital message is that no single device or solution can prevent drowning.

That said, we must remind our patients and families to be attentive while near, in, or on the water. Caution them to be alert to potential dangers in all environments—even the most innocent-looking or most familiar body of water can be a threat. All adults and children should wear life jackets or personal flotation devices (PFD) approved by the USCG when boating (even if the boat is only a canoe)!  

Recent events among my circle of friends and family have made me revisit one of the rules of my childhood and consider extending it. In discussions with colleagues, I have suggested that we recommend everyone older than 40 seriously consider wearing some type of PFD when near or in the water, even if they are not in a boat. Some rebuffed this idea as an unnecessary nuisance. But I consider it a minor inconvenience that could mean the difference between a fatal and nonfatal aquatic incident. I cannot help but wonder if it would have made a difference in some cases.

How strictly do you enforce “the rules” for yourself and your family? Share your feedback at [email protected].

REFERENCES
1. CDC. Unintentional drowning: get the facts. www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. Accessed June 16, 2014.

2. US Department of Homeland Security and US Coast Guard. 2013 Recreational Boating Statistics. COMDTPUB P16754.27. www.uscgboating.org/assets/1/AssetManager/2013RecBoatingStats.pdf. Accessed June 16, 2014. 

Summer is here, and with it comes an increase in swimming and other aquatic activities. To me, there is nothing more relaxing than floating in the ocean or a pool. (Personally, I’ve never been a lake girl.)

I cannot remember not knowing how to swim. My mother, who in her youth was a swimming instructor, taught all my siblings and me. Mom instructed us not only on how to swim but also on understanding that every “body” of water has the potential to be dangerous.

Moreover, we all knew “the rules” to follow when near the water. The key ones: Pay attention in the water; wait an hour after eating before going in; and never swim alone. If we were in a boat, regardless of our swimming ability, we were required to wear a life jacket. Failure to adhere to even one of these would result in being “dry docked”—in other words, having to sit on the beach or poolside and not being allowed to go into the water. This was something none of us ever wanted.       

Because of my childhood experience, swimming and water safety are second nature to me, along with playing a role in water safety activities through high school and college. I was a lifeguard at local pools and taught swimming and lifesaving at a YMCA. Just as I learned, I taught others to be ever vigilant around the water. I was, and taught others to be, cautious about never swimming alone—always have a buddy—and when in the ocean, to heed the warning signs of dangerous waves or riptides. 

I taught people of all ages to swim. The youngest was an 8-month-old girl and the oldest, a 62-year-old man. While I never expected either of them to become a competitive swimmer, what I wanted was for them to be able to keep safe around the water. That is the goal of teaching someone to swim: to give that person the tools to save himself or herself when in danger in the water. Sadly, every season (not just summer), people drown. 

According to the CDC’s National Center for Injury Prevention and Control, the leading factors that affect the risk for drowning—the ones over which we have control—are

Lack of Swimming Ability: Many people—adults and children alike—report that they cannot swim. Research indicates that formal swimming lessons can reduce the risk for drowning among children ages 1 to 4.

Lack of Barriers: Barriers such as fencing can prevent young ­children from gaining access to a pool without caregivers’ awareness. (Some municipalities have zoning ordinances for private pool owners, requiring barriers for safety.)

Lack of Supervision: Drowning can happen quickly and quietly anywhere there is water (eg, bathtub, swimming pool, bucket) and even in the presence of lifeguards.

Location: People of different ages drown in different locations. For example, home swimming pools are the site of most drownings among children ages 1 to 4. Drownings in natural settings (eg, lakes, rivers, oceans) increase with age; more than half of fatal and nonfatal drownings among those ages 15 and older occur in these settings.

Failure to Wear Life Jackets: The US Coast Guard (USCG) received reports of 4,604 boating incidents in 2010; a total of 3,153 boaters were injured, and 672 died. Most boating deaths were by drowning, with 88% of victims not wearing life jackets at the time of the incident.

Alcohol Use: Among adolescents and adults, alcohol use is involved in up to 70% of deaths associated with water recreation, almost a quarter of emergency department visits for drowning, and about one in five reported boating deaths.¹

Since 2010, I have read multiple news stories about people drowning unintentionally. The causes have ranged from being swept away in raging floodwaters; grounding, capsizing, or sinking a vessel; and water-skiing or similar mishaps.² In fact, each day about 10 people die from unintentional drowning; what is surprising is that only two of them are children younger than 14. This statistic tells me that we need to include water safety warnings in our “anticipatory guidance” for all patients. We must raise awareness of the need to be cautious around water, even if the person knows how to swim.

The National Drowning Prevention Alliance, the USCG, the CDC, and the World Health Organization provide information about water safety and drowning prevention. The vital message is that no single device or solution can prevent drowning.

That said, we must remind our patients and families to be attentive while near, in, or on the water. Caution them to be alert to potential dangers in all environments—even the most innocent-looking or most familiar body of water can be a threat. All adults and children should wear life jackets or personal flotation devices (PFD) approved by the USCG when boating (even if the boat is only a canoe)!  

Recent events among my circle of friends and family have made me revisit one of the rules of my childhood and consider extending it. In discussions with colleagues, I have suggested that we recommend everyone older than 40 seriously consider wearing some type of PFD when near or in the water, even if they are not in a boat. Some rebuffed this idea as an unnecessary nuisance. But I consider it a minor inconvenience that could mean the difference between a fatal and nonfatal aquatic incident. I cannot help but wonder if it would have made a difference in some cases.

How strictly do you enforce “the rules” for yourself and your family? Share your feedback at [email protected].

REFERENCES
1. CDC. Unintentional drowning: get the facts. www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. Accessed June 16, 2014.

2. US Department of Homeland Security and US Coast Guard. 2013 Recreational Boating Statistics. COMDTPUB P16754.27. www.uscgboating.org/assets/1/AssetManager/2013RecBoatingStats.pdf. Accessed June 16, 2014. 

As I reflect on my 1 year of writing for this newspaper and my first year as an attending, some things stand out as being, for me, consistently challenging and others, consistently rewarding. Time has seemed to go by much faster than during residency. So, without further ado, here is a list of those things that I have, continue to, and may always either struggle with or find joy in.

The checkout e-mail

What I feared the most about becoming an attending – managing a team day to day and teaching students and residents – has come easier than I thought. What has brought me the most angst, however, is passing my team off to my partners. As I write my "checkout e-mail," I am often plagued by doubt and worry that I have overlooked something. I worry I have ordered too many/not enough studies, consulted too often/not enough, or discharged too early/not early enough.

For the first half, and most emotionally pathologic part, of the year, I would log in each day after coming off-service, to see how my partners had changed things, to see what I had missed, and to see how the patients were progressing. I would even text my partners and residents to "see how Mr. X is doing" or to ask "How is the team doing?" This would often result in me second-guessing myself and ruining my day off. I don’t do this anymore.

Now I give myself several healthy days of "no team contact" before I log in to finish notes and inevitably check in on patients. I know that there must be a balance of educational follow-up, feedback, and a healthy forgiving mind, but I still struggle to find it.

Placement

Though there are some scoring systems that help the clinician know which patients need to be hospitalized, who needs the ICU, and who can go home, a lot of this falls in evidence-based medicine’s gray zone. One of the learning curves for me was to know which patients I should insist go to the unit, insist be evaluated by the unit, or who, though sick, can be managed on the floor. In the end, I have found that my gut feeling and the first 15 seconds of my encounter with the patient help me more with placement than any scoring system or guideline.

The consult

It has been a bit painful learning to juggle the nuances of consultant services preferences (who always wants to be involved vs. who rarely does), attending preferences (some want to know when any of their patients are in-house), and what is my own comfort level. I think, for the most part, I have erred on the overconsult side this year, and though I have felt embarrassed a couple of times, it has been the safer route as I become comfortable as a hospitalist.

Discharge

As with The Placement, there is virtually no evidence to help The Discharge. As a resident, an earlier discharge usually was better, but as an attending, The Discharge is where the complex intertwinement of disease, social situation, physical therapy, and unfortunately, day of the week manifests (see previous column: "Closed on weekends?" Hospitalist News, May 2014). Also, like The Placement, this often ends up being a gut feeling supported by close follow-up, a good conversation with the patient and family, and some hopeful finger-crossing.

Being a people pleaser

This personality trait has helped me to be a good student, a responsive employee, and sometimes a good doctor. But it has also caused me a good amount of suffering. Thus, when despite my best efforts a patient or family continues to be upset with how quickly or slowly things are being done, which services are or are not involved, etc., I feel bad. Maybe this will change in the coming years. Maybe not.

Teaching

I have always liked teaching, but as a resident this often played second fiddle to grunt work and "res-interning." As an attending, however, I have finally been able to make this a significant part of every day. I enjoy it, and I think my residents and medical students enjoy that I enjoy it. This has been one of the true pleasures of my first year as an attending.

Connection

As an attending I now benefit from much more time to enjoy my patient connections. Less tired and harried, I have longer conversations and enjoy actively practicing communication. I have the ability to have more in-depth conversations about goals of care, and have found that often these conversations end with a decrease in anxiety and a sense of peace.

I now also have a business card with an e-mail address that receives occasional thank-you notes. Yesterday, I received an e-mail that said simply, "Thank you for your great service." How incredibly fulfilling. Talk about unexpected joy.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

As I reflect on my 1 year of writing for this newspaper and my first year as an attending, some things stand out as being, for me, consistently challenging and others, consistently rewarding. Time has seemed to go by much faster than during residency. So, without further ado, here is a list of those things that I have, continue to, and may always either struggle with or find joy in.

The checkout e-mail

What I feared the most about becoming an attending – managing a team day to day and teaching students and residents – has come easier than I thought. What has brought me the most angst, however, is passing my team off to my partners. As I write my "checkout e-mail," I am often plagued by doubt and worry that I have overlooked something. I worry I have ordered too many/not enough studies, consulted too often/not enough, or discharged too early/not early enough.

For the first half, and most emotionally pathologic part, of the year, I would log in each day after coming off-service, to see how my partners had changed things, to see what I had missed, and to see how the patients were progressing. I would even text my partners and residents to "see how Mr. X is doing" or to ask "How is the team doing?" This would often result in me second-guessing myself and ruining my day off. I don’t do this anymore.

Now I give myself several healthy days of "no team contact" before I log in to finish notes and inevitably check in on patients. I know that there must be a balance of educational follow-up, feedback, and a healthy forgiving mind, but I still struggle to find it.

Placement

Though there are some scoring systems that help the clinician know which patients need to be hospitalized, who needs the ICU, and who can go home, a lot of this falls in evidence-based medicine’s gray zone. One of the learning curves for me was to know which patients I should insist go to the unit, insist be evaluated by the unit, or who, though sick, can be managed on the floor. In the end, I have found that my gut feeling and the first 15 seconds of my encounter with the patient help me more with placement than any scoring system or guideline.

The consult

It has been a bit painful learning to juggle the nuances of consultant services preferences (who always wants to be involved vs. who rarely does), attending preferences (some want to know when any of their patients are in-house), and what is my own comfort level. I think, for the most part, I have erred on the overconsult side this year, and though I have felt embarrassed a couple of times, it has been the safer route as I become comfortable as a hospitalist.

Discharge

As with The Placement, there is virtually no evidence to help The Discharge. As a resident, an earlier discharge usually was better, but as an attending, The Discharge is where the complex intertwinement of disease, social situation, physical therapy, and unfortunately, day of the week manifests (see previous column: "Closed on weekends?" Hospitalist News, May 2014). Also, like The Placement, this often ends up being a gut feeling supported by close follow-up, a good conversation with the patient and family, and some hopeful finger-crossing.

Being a people pleaser

This personality trait has helped me to be a good student, a responsive employee, and sometimes a good doctor. But it has also caused me a good amount of suffering. Thus, when despite my best efforts a patient or family continues to be upset with how quickly or slowly things are being done, which services are or are not involved, etc., I feel bad. Maybe this will change in the coming years. Maybe not.

Teaching

I have always liked teaching, but as a resident this often played second fiddle to grunt work and "res-interning." As an attending, however, I have finally been able to make this a significant part of every day. I enjoy it, and I think my residents and medical students enjoy that I enjoy it. This has been one of the true pleasures of my first year as an attending.

Connection

As an attending I now benefit from much more time to enjoy my patient connections. Less tired and harried, I have longer conversations and enjoy actively practicing communication. I have the ability to have more in-depth conversations about goals of care, and have found that often these conversations end with a decrease in anxiety and a sense of peace.

I now also have a business card with an e-mail address that receives occasional thank-you notes. Yesterday, I received an e-mail that said simply, "Thank you for your great service." How incredibly fulfilling. Talk about unexpected joy.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

As I reflect on my 1 year of writing for this newspaper and my first year as an attending, some things stand out as being, for me, consistently challenging and others, consistently rewarding. Time has seemed to go by much faster than during residency. So, without further ado, here is a list of those things that I have, continue to, and may always either struggle with or find joy in.

The checkout e-mail

What I feared the most about becoming an attending – managing a team day to day and teaching students and residents – has come easier than I thought. What has brought me the most angst, however, is passing my team off to my partners. As I write my "checkout e-mail," I am often plagued by doubt and worry that I have overlooked something. I worry I have ordered too many/not enough studies, consulted too often/not enough, or discharged too early/not early enough.

For the first half, and most emotionally pathologic part, of the year, I would log in each day after coming off-service, to see how my partners had changed things, to see what I had missed, and to see how the patients were progressing. I would even text my partners and residents to "see how Mr. X is doing" or to ask "How is the team doing?" This would often result in me second-guessing myself and ruining my day off. I don’t do this anymore.

Now I give myself several healthy days of "no team contact" before I log in to finish notes and inevitably check in on patients. I know that there must be a balance of educational follow-up, feedback, and a healthy forgiving mind, but I still struggle to find it.

Placement

Though there are some scoring systems that help the clinician know which patients need to be hospitalized, who needs the ICU, and who can go home, a lot of this falls in evidence-based medicine’s gray zone. One of the learning curves for me was to know which patients I should insist go to the unit, insist be evaluated by the unit, or who, though sick, can be managed on the floor. In the end, I have found that my gut feeling and the first 15 seconds of my encounter with the patient help me more with placement than any scoring system or guideline.

The consult

It has been a bit painful learning to juggle the nuances of consultant services preferences (who always wants to be involved vs. who rarely does), attending preferences (some want to know when any of their patients are in-house), and what is my own comfort level. I think, for the most part, I have erred on the overconsult side this year, and though I have felt embarrassed a couple of times, it has been the safer route as I become comfortable as a hospitalist.

Discharge

As with The Placement, there is virtually no evidence to help The Discharge. As a resident, an earlier discharge usually was better, but as an attending, The Discharge is where the complex intertwinement of disease, social situation, physical therapy, and unfortunately, day of the week manifests (see previous column: "Closed on weekends?" Hospitalist News, May 2014). Also, like The Placement, this often ends up being a gut feeling supported by close follow-up, a good conversation with the patient and family, and some hopeful finger-crossing.

Being a people pleaser

This personality trait has helped me to be a good student, a responsive employee, and sometimes a good doctor. But it has also caused me a good amount of suffering. Thus, when despite my best efforts a patient or family continues to be upset with how quickly or slowly things are being done, which services are or are not involved, etc., I feel bad. Maybe this will change in the coming years. Maybe not.

Teaching

I have always liked teaching, but as a resident this often played second fiddle to grunt work and "res-interning." As an attending, however, I have finally been able to make this a significant part of every day. I enjoy it, and I think my residents and medical students enjoy that I enjoy it. This has been one of the true pleasures of my first year as an attending.

Connection

As an attending I now benefit from much more time to enjoy my patient connections. Less tired and harried, I have longer conversations and enjoy actively practicing communication. I have the ability to have more in-depth conversations about goals of care, and have found that often these conversations end with a decrease in anxiety and a sense of peace.

I now also have a business card with an e-mail address that receives occasional thank-you notes. Yesterday, I received an e-mail that said simply, "Thank you for your great service." How incredibly fulfilling. Talk about unexpected joy.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

In my area, there are several internists who run cash-pay practices. Only one of them refers to me, and that’s just when he can’t get them to see the Mayo Clinic folks fast enough.

I’m not a cash-only concierge neurologist for a number of reasons I’ve previously mentioned. I don’t really try to cultivate these referrals, and the concierge physicians don’t really want me to see their patients.

Why would I not be bending over backward to get more patients? I take Medicare (and other insurances), so whether you want to pay cash or not, if you’re on Medicare, I can’t accept it. It’s a crime. I can only take what Washington says I can. Maybe that law will change someday, but I doubt it.

So the patient who’s paying $3,000 per year to see Dr. Concierge down the street and cash for every visit after that isn’t financially any more special to me than the guy who’s living on a fixed income and only has Medicare. I get paid the same for both.

About a year ago, a representative from a cash-only practice came by, asking me to be the "designated neurologist" for them. In return, I’d have to agree to the following conditions:

• All patients from them would be seen within 24 hours of calling my office.

• I’d have to give my cell and home phone numbers to all of their patients, so I’d be available. ("Our patients want a lot of hand-holding" is what he said.)

• If needed, I’d meet them on weekends, either at my office or by making house calls, at the patient’s request.

There were a few other requests. I politely said, "No, thank you" and handed his "designated specialist" paperwork back to him.

My practice right now is pretty egalitarian. Uncle Sam pays me the same for your visit regardless of how much money you have or what your social standing is. I also value my privacy and home life. My patients know how to reach the doc on call in an emergency, and know it may not be me.

So, if you’re a concierge physician and don’t feel I’m going the extra mile to get your patients in at the drop of a hat, or to make sure a double-soy latte is ready for them on arrival, I’m sorry. They may be paying you a lot for these perks, but not me. The only thing I have to offer at my practice is the best patient care I can – to all equally.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In my area, there are several internists who run cash-pay practices. Only one of them refers to me, and that’s just when he can’t get them to see the Mayo Clinic folks fast enough.

I’m not a cash-only concierge neurologist for a number of reasons I’ve previously mentioned. I don’t really try to cultivate these referrals, and the concierge physicians don’t really want me to see their patients.

Why would I not be bending over backward to get more patients? I take Medicare (and other insurances), so whether you want to pay cash or not, if you’re on Medicare, I can’t accept it. It’s a crime. I can only take what Washington says I can. Maybe that law will change someday, but I doubt it.

So the patient who’s paying $3,000 per year to see Dr. Concierge down the street and cash for every visit after that isn’t financially any more special to me than the guy who’s living on a fixed income and only has Medicare. I get paid the same for both.

About a year ago, a representative from a cash-only practice came by, asking me to be the "designated neurologist" for them. In return, I’d have to agree to the following conditions:

• All patients from them would be seen within 24 hours of calling my office.

• I’d have to give my cell and home phone numbers to all of their patients, so I’d be available. ("Our patients want a lot of hand-holding" is what he said.)

• If needed, I’d meet them on weekends, either at my office or by making house calls, at the patient’s request.

There were a few other requests. I politely said, "No, thank you" and handed his "designated specialist" paperwork back to him.

My practice right now is pretty egalitarian. Uncle Sam pays me the same for your visit regardless of how much money you have or what your social standing is. I also value my privacy and home life. My patients know how to reach the doc on call in an emergency, and know it may not be me.

So, if you’re a concierge physician and don’t feel I’m going the extra mile to get your patients in at the drop of a hat, or to make sure a double-soy latte is ready for them on arrival, I’m sorry. They may be paying you a lot for these perks, but not me. The only thing I have to offer at my practice is the best patient care I can – to all equally.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In my area, there are several internists who run cash-pay practices. Only one of them refers to me, and that’s just when he can’t get them to see the Mayo Clinic folks fast enough.

I’m not a cash-only concierge neurologist for a number of reasons I’ve previously mentioned. I don’t really try to cultivate these referrals, and the concierge physicians don’t really want me to see their patients.

Why would I not be bending over backward to get more patients? I take Medicare (and other insurances), so whether you want to pay cash or not, if you’re on Medicare, I can’t accept it. It’s a crime. I can only take what Washington says I can. Maybe that law will change someday, but I doubt it.

So the patient who’s paying $3,000 per year to see Dr. Concierge down the street and cash for every visit after that isn’t financially any more special to me than the guy who’s living on a fixed income and only has Medicare. I get paid the same for both.

About a year ago, a representative from a cash-only practice came by, asking me to be the "designated neurologist" for them. In return, I’d have to agree to the following conditions:

• All patients from them would be seen within 24 hours of calling my office.

• I’d have to give my cell and home phone numbers to all of their patients, so I’d be available. ("Our patients want a lot of hand-holding" is what he said.)

• If needed, I’d meet them on weekends, either at my office or by making house calls, at the patient’s request.

There were a few other requests. I politely said, "No, thank you" and handed his "designated specialist" paperwork back to him.

My practice right now is pretty egalitarian. Uncle Sam pays me the same for your visit regardless of how much money you have or what your social standing is. I also value my privacy and home life. My patients know how to reach the doc on call in an emergency, and know it may not be me.

So, if you’re a concierge physician and don’t feel I’m going the extra mile to get your patients in at the drop of a hat, or to make sure a double-soy latte is ready for them on arrival, I’m sorry. They may be paying you a lot for these perks, but not me. The only thing I have to offer at my practice is the best patient care I can – to all equally.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.

Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.

With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.

Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.

It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.

Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.

Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.

Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).

As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.

Dr. Clark 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 of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.

As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.

Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.

With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.

Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.

It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.

Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.

Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.

Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).

As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.

Dr. Clark 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 of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.

As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.

Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.

With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.

Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.

It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.

Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.

Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.

Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).

As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.

Dr. Clark 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 of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.