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Treatment includes surgery
Treatment includes surgery
Thank you for the great article about hidradenitis suppurativa. It was very informative as usual, but a little shortsighted. As ObGyns we tend not to focus so much on these dermatologic conditions. However, I think something very important is missing in the article. I do not see it mentioned that hidradenitis suppurativa is a type of acne, also called acne inversa. As such, it should be treated like acne, with special attention to diet with zero dairy products as a prevention measure. Also, metformin is very important, as noted in the article. Retinoids are also needed, maybe for years.
According to experts, the primary approach to this condition is surgical, with punch biopsies and unroofing of the lesions, with medical therapies as prevention strategies. Fortunately, special task forces are now tackling this condition, especially in Europe. I strongly recommend the book, Acne: Causes and Practical Management, by F. William Danby.
Ivan Valencia, MD
Quito, Ecuador
Dr. Barbieri responds
Dr. Valencia provides an important perspective on the surgical treatment of hidradenitis suppurativa (HS). I agree that surgery is an important treatment for Stage III HS, but nonsurgical approaches are preferred and often effective for Stage I HS, a stage most likely to be treated by a gynecologist.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Treatment includes surgery
Thank you for the great article about hidradenitis suppurativa. It was very informative as usual, but a little shortsighted. As ObGyns we tend not to focus so much on these dermatologic conditions. However, I think something very important is missing in the article. I do not see it mentioned that hidradenitis suppurativa is a type of acne, also called acne inversa. As such, it should be treated like acne, with special attention to diet with zero dairy products as a prevention measure. Also, metformin is very important, as noted in the article. Retinoids are also needed, maybe for years.
According to experts, the primary approach to this condition is surgical, with punch biopsies and unroofing of the lesions, with medical therapies as prevention strategies. Fortunately, special task forces are now tackling this condition, especially in Europe. I strongly recommend the book, Acne: Causes and Practical Management, by F. William Danby.
Ivan Valencia, MD
Quito, Ecuador
Dr. Barbieri responds
Dr. Valencia provides an important perspective on the surgical treatment of hidradenitis suppurativa (HS). I agree that surgery is an important treatment for Stage III HS, but nonsurgical approaches are preferred and often effective for Stage I HS, a stage most likely to be treated by a gynecologist.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Treatment includes surgery
Thank you for the great article about hidradenitis suppurativa. It was very informative as usual, but a little shortsighted. As ObGyns we tend not to focus so much on these dermatologic conditions. However, I think something very important is missing in the article. I do not see it mentioned that hidradenitis suppurativa is a type of acne, also called acne inversa. As such, it should be treated like acne, with special attention to diet with zero dairy products as a prevention measure. Also, metformin is very important, as noted in the article. Retinoids are also needed, maybe for years.
According to experts, the primary approach to this condition is surgical, with punch biopsies and unroofing of the lesions, with medical therapies as prevention strategies. Fortunately, special task forces are now tackling this condition, especially in Europe. I strongly recommend the book, Acne: Causes and Practical Management, by F. William Danby.
Ivan Valencia, MD
Quito, Ecuador
Dr. Barbieri responds
Dr. Valencia provides an important perspective on the surgical treatment of hidradenitis suppurativa (HS). I agree that surgery is an important treatment for Stage III HS, but nonsurgical approaches are preferred and often effective for Stage I HS, a stage most likely to be treated by a gynecologist.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Incision site for cesarean delivery is important in infection prevention
Incision site for cesarean delivery is important in infection prevention
Dr. Barbieri’s editorial very nicely explained strategies to reduce the risk of post–cesarean delivery surgical site infection (SSI). However, what was not mentioned, in my opinion, is the most important preventive strategy. Selecting the site for the initial skin incision plays a great role in whether or not the patient will develop an infection postoperatively.
Pfannenstiel incisions are popular because of their obvious cosmetic benefit. In nonemergent cesarean deliveries, most ObGyns try to use this incision. However, exactly where the incision is placed plays a large role in the genesis of a postoperative wound infection. The worst place for such incisions is in the crease above the pubis and below the panniculus. Invariably, this area remains moist and macerated, especially in obese patients, thus providing a fertile breeding ground for bacteria. This problem can be avoided by incising the skin approximately 2 cm cranial to and parallel to the aforementioned crease, provided that the panniculus is not too large. The point is that the incision should be placed in an area where it has a chance to stay dry.
Sometimes patients who are hugely obese require great creativity in the placement of their transverse skin incision. I recall one patient, pregnant with triplets, whose abdomen was so large that her umbilicus was over the region of the lower uterine segment when she was supine on the operating room table. Some would have lifted up her immense panniculus and placed the incision in the usual crease site. This would be problematic for obtaining adequate exposure to deliver the babies, and the risk of developing an incisional infection would be very high. Therefore, a transverse incision was made just below her umbilicus. The panniculus was a nonissue regarding gaining adequate exposure and, when closed, the incision remained completely dry and uninfected. The patient did extremely well postoperatively and had no infectious sequelae.
David L. Zisow, MD
Baltimore, Maryland
Extraperitoneal approach should be considered
I enjoyed the editorial on reducing surgical site infection, especially the references to the historical Halsted principles of surgery. “He was the first in this country to promulgate the philosophy of ‘safe’ surgery.”1 Regarding surgical principles of cesarean delivery, the pioneering German obstetricians in the 1930s were keenly aware that avoiding the peritoneal cavity was instrumental in reducing morbidity and mortality. They championed the safety of the extraperitoneal approach as the fundamental principle of cesarean delivery for maternal safety.2
I learned to embrace the principles of Kaboth while learning the technique in 1968–1972. Thus, for more than 30 years, I used the extraperitoneal approach to access the lower uterine segment, avoiding entrance into the abdominal cavity. My patients seemed to benefit. As the surgeon, I also benefited: with short operative delivery times, less postoperative pain and minor morbidities, fewer phone calls from nursing staff, and less difficulty for my patients. I had not contaminated the peritoneal cavity and avoided all those inherent problems. The decision to open the peritoneal cavity has not been subjected to the rigors of critical analysis.3 I think that Kaboth’s principles remain worthy of consideration even today.
Contemporary experiences in large populations such as in India and China that use the extraperitoneal cesarean approach seem to implicitly support Kaboth’s principles. However, in the milieu of evidence-based medicine, extraperitoneal cesarean delivery has not been adequately studied.4 Just maybe the extraperitoneal approach should be considered and understood as a primary surgical technique for cesarean deliveries; just maybe it deserves a historical asterisk alongside the Halsted dicta.
Hedric Hanson, MD
Anchorage, Alaska
Dr. Barbieri responds
I thank Drs. Zisow and Hanson for their great recommendations and clinical pearls. I agree with Dr. Zisow that I should have mentioned the importance of optimal placement of the transverse skin incision. Incision in a skin crease that is perpetually moist increases the risk for a postoperative complication. When the abdomen is prepped for surgery, the skin crease above the pubis appears to be very inviting for placement of the skin incision. Dr. Hanson highlights the important option of an extraperitoneal approach to cesarean delivery. I have not thought about using this approach since the mid-1980s. Dr. Hanson’s recommendation that a randomized trial be performed comparing the SSI rate and other outcomes for extraperitoneal and intraperitoneal cesarean delivery is a great idea.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Cameron JL. William Steward Halsted: our surgical heritage. Ann Surg. 1997;225(5):445–458.
- Kaboth G. Die Technik des extraperitonealen Entibindungschnittes. Zentralblatt fur Gynakologie.1934;58(6):310–311.
- Berghella V, Baxter JK Chauhan SP. Evidence-based surgery for cesarean section. Am J Obstet Gynecol. 2005;193(5):1607–1617.
- Hofmeyr GJ, Mathai M, Shah AN, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008; CD004662.
Incision site for cesarean delivery is important in infection prevention
Dr. Barbieri’s editorial very nicely explained strategies to reduce the risk of post–cesarean delivery surgical site infection (SSI). However, what was not mentioned, in my opinion, is the most important preventive strategy. Selecting the site for the initial skin incision plays a great role in whether or not the patient will develop an infection postoperatively.
Pfannenstiel incisions are popular because of their obvious cosmetic benefit. In nonemergent cesarean deliveries, most ObGyns try to use this incision. However, exactly where the incision is placed plays a large role in the genesis of a postoperative wound infection. The worst place for such incisions is in the crease above the pubis and below the panniculus. Invariably, this area remains moist and macerated, especially in obese patients, thus providing a fertile breeding ground for bacteria. This problem can be avoided by incising the skin approximately 2 cm cranial to and parallel to the aforementioned crease, provided that the panniculus is not too large. The point is that the incision should be placed in an area where it has a chance to stay dry.
Sometimes patients who are hugely obese require great creativity in the placement of their transverse skin incision. I recall one patient, pregnant with triplets, whose abdomen was so large that her umbilicus was over the region of the lower uterine segment when she was supine on the operating room table. Some would have lifted up her immense panniculus and placed the incision in the usual crease site. This would be problematic for obtaining adequate exposure to deliver the babies, and the risk of developing an incisional infection would be very high. Therefore, a transverse incision was made just below her umbilicus. The panniculus was a nonissue regarding gaining adequate exposure and, when closed, the incision remained completely dry and uninfected. The patient did extremely well postoperatively and had no infectious sequelae.
David L. Zisow, MD
Baltimore, Maryland
Extraperitoneal approach should be considered
I enjoyed the editorial on reducing surgical site infection, especially the references to the historical Halsted principles of surgery. “He was the first in this country to promulgate the philosophy of ‘safe’ surgery.”1 Regarding surgical principles of cesarean delivery, the pioneering German obstetricians in the 1930s were keenly aware that avoiding the peritoneal cavity was instrumental in reducing morbidity and mortality. They championed the safety of the extraperitoneal approach as the fundamental principle of cesarean delivery for maternal safety.2
I learned to embrace the principles of Kaboth while learning the technique in 1968–1972. Thus, for more than 30 years, I used the extraperitoneal approach to access the lower uterine segment, avoiding entrance into the abdominal cavity. My patients seemed to benefit. As the surgeon, I also benefited: with short operative delivery times, less postoperative pain and minor morbidities, fewer phone calls from nursing staff, and less difficulty for my patients. I had not contaminated the peritoneal cavity and avoided all those inherent problems. The decision to open the peritoneal cavity has not been subjected to the rigors of critical analysis.3 I think that Kaboth’s principles remain worthy of consideration even today.
Contemporary experiences in large populations such as in India and China that use the extraperitoneal cesarean approach seem to implicitly support Kaboth’s principles. However, in the milieu of evidence-based medicine, extraperitoneal cesarean delivery has not been adequately studied.4 Just maybe the extraperitoneal approach should be considered and understood as a primary surgical technique for cesarean deliveries; just maybe it deserves a historical asterisk alongside the Halsted dicta.
Hedric Hanson, MD
Anchorage, Alaska
Dr. Barbieri responds
I thank Drs. Zisow and Hanson for their great recommendations and clinical pearls. I agree with Dr. Zisow that I should have mentioned the importance of optimal placement of the transverse skin incision. Incision in a skin crease that is perpetually moist increases the risk for a postoperative complication. When the abdomen is prepped for surgery, the skin crease above the pubis appears to be very inviting for placement of the skin incision. Dr. Hanson highlights the important option of an extraperitoneal approach to cesarean delivery. I have not thought about using this approach since the mid-1980s. Dr. Hanson’s recommendation that a randomized trial be performed comparing the SSI rate and other outcomes for extraperitoneal and intraperitoneal cesarean delivery is a great idea.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Incision site for cesarean delivery is important in infection prevention
Dr. Barbieri’s editorial very nicely explained strategies to reduce the risk of post–cesarean delivery surgical site infection (SSI). However, what was not mentioned, in my opinion, is the most important preventive strategy. Selecting the site for the initial skin incision plays a great role in whether or not the patient will develop an infection postoperatively.
Pfannenstiel incisions are popular because of their obvious cosmetic benefit. In nonemergent cesarean deliveries, most ObGyns try to use this incision. However, exactly where the incision is placed plays a large role in the genesis of a postoperative wound infection. The worst place for such incisions is in the crease above the pubis and below the panniculus. Invariably, this area remains moist and macerated, especially in obese patients, thus providing a fertile breeding ground for bacteria. This problem can be avoided by incising the skin approximately 2 cm cranial to and parallel to the aforementioned crease, provided that the panniculus is not too large. The point is that the incision should be placed in an area where it has a chance to stay dry.
Sometimes patients who are hugely obese require great creativity in the placement of their transverse skin incision. I recall one patient, pregnant with triplets, whose abdomen was so large that her umbilicus was over the region of the lower uterine segment when she was supine on the operating room table. Some would have lifted up her immense panniculus and placed the incision in the usual crease site. This would be problematic for obtaining adequate exposure to deliver the babies, and the risk of developing an incisional infection would be very high. Therefore, a transverse incision was made just below her umbilicus. The panniculus was a nonissue regarding gaining adequate exposure and, when closed, the incision remained completely dry and uninfected. The patient did extremely well postoperatively and had no infectious sequelae.
David L. Zisow, MD
Baltimore, Maryland
Extraperitoneal approach should be considered
I enjoyed the editorial on reducing surgical site infection, especially the references to the historical Halsted principles of surgery. “He was the first in this country to promulgate the philosophy of ‘safe’ surgery.”1 Regarding surgical principles of cesarean delivery, the pioneering German obstetricians in the 1930s were keenly aware that avoiding the peritoneal cavity was instrumental in reducing morbidity and mortality. They championed the safety of the extraperitoneal approach as the fundamental principle of cesarean delivery for maternal safety.2
I learned to embrace the principles of Kaboth while learning the technique in 1968–1972. Thus, for more than 30 years, I used the extraperitoneal approach to access the lower uterine segment, avoiding entrance into the abdominal cavity. My patients seemed to benefit. As the surgeon, I also benefited: with short operative delivery times, less postoperative pain and minor morbidities, fewer phone calls from nursing staff, and less difficulty for my patients. I had not contaminated the peritoneal cavity and avoided all those inherent problems. The decision to open the peritoneal cavity has not been subjected to the rigors of critical analysis.3 I think that Kaboth’s principles remain worthy of consideration even today.
Contemporary experiences in large populations such as in India and China that use the extraperitoneal cesarean approach seem to implicitly support Kaboth’s principles. However, in the milieu of evidence-based medicine, extraperitoneal cesarean delivery has not been adequately studied.4 Just maybe the extraperitoneal approach should be considered and understood as a primary surgical technique for cesarean deliveries; just maybe it deserves a historical asterisk alongside the Halsted dicta.
Hedric Hanson, MD
Anchorage, Alaska
Dr. Barbieri responds
I thank Drs. Zisow and Hanson for their great recommendations and clinical pearls. I agree with Dr. Zisow that I should have mentioned the importance of optimal placement of the transverse skin incision. Incision in a skin crease that is perpetually moist increases the risk for a postoperative complication. When the abdomen is prepped for surgery, the skin crease above the pubis appears to be very inviting for placement of the skin incision. Dr. Hanson highlights the important option of an extraperitoneal approach to cesarean delivery. I have not thought about using this approach since the mid-1980s. Dr. Hanson’s recommendation that a randomized trial be performed comparing the SSI rate and other outcomes for extraperitoneal and intraperitoneal cesarean delivery is a great idea.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Cameron JL. William Steward Halsted: our surgical heritage. Ann Surg. 1997;225(5):445–458.
- Kaboth G. Die Technik des extraperitonealen Entibindungschnittes. Zentralblatt fur Gynakologie.1934;58(6):310–311.
- Berghella V, Baxter JK Chauhan SP. Evidence-based surgery for cesarean section. Am J Obstet Gynecol. 2005;193(5):1607–1617.
- Hofmeyr GJ, Mathai M, Shah AN, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008; CD004662.
- Cameron JL. William Steward Halsted: our surgical heritage. Ann Surg. 1997;225(5):445–458.
- Kaboth G. Die Technik des extraperitonealen Entibindungschnittes. Zentralblatt fur Gynakologie.1934;58(6):310–311.
- Berghella V, Baxter JK Chauhan SP. Evidence-based surgery for cesarean section. Am J Obstet Gynecol. 2005;193(5):1607–1617.
- Hofmeyr GJ, Mathai M, Shah AN, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008; CD004662.
Eleven on a scale of 1 to 10
I literally rode into the sunset recently as I finished my tour of duty as one of the Director examiners for the American Board of Surgery. I was heading out of St. Louis westward toward my home in Kansas. It was a 9-hour drive, which gave me plenty of time to reflect on the 6 years I shared the responsibility of administering the certifying exam known by most surgeons as “the oral exam.”
Over the last dozen years, Directors V. Suzanne Klimberg and Karen J. Brasel, along with former Executive Director Frank Lewis, a team of psychometricians at the Board, and members of the certification committee of the Board, worked tirelessly to create a testing instrument as fair and statistically sound as possible given the inherently qualitative exam. I believe they did a magnificent job. Gone are the legends of yesteryear where candidates were subjected to the whims of whatever crossed the mind of the examiners, including their prejudices about the “right” answer. The oral exam now represents a well-constructed survey of surgical judgment issues that have been thoroughly vetted.
Being an examiner for the orals means you arrive Sunday afternoon before the exams that are given over the next two and a half days. Each examiner undergoes an overview briefing on Sunday afternoon and then studies “the book” for that test’s content usually until late into the night. This book is an impressive document.
We arise around 0530 to attend a breakfast meeting, which includes breaking into our six-person teams and going over each question that will be given that day. At 0800, the first candidates for the first session walk into a room and meet the two surgeons who will make some of the most important decisions affecting that candidate’s career. If you rate the intensity of this moment on a scale of 1 to 10, this is an 11 for both candidates and examiners. No one in the room knows how it will turn out because every session has its own twists and turns. Everyone there wants to see a passing score, but the two examiners know that they must make a decision that is safe for the public and fair for the candidate.
Twelve exams are given per team per day except for the final day which has only six. So, each team examines 30 candidates over 3 days. I’ve opened a door and shaken the moist hand of 438 candidates. I’ve seen every sort of emotion during those sessions. I’ve had moments of great joy and times of profound sadness as candidates respond to the questions. I’ve always tried to be friendly, but just like surgery, it is a serious business and decisions have to be made. That means ignoring one’s hopes and acting on the best facts available at the moment. Most surgeons remember their oral examiners and what they were asked for a lifetime. I know I do.
I could write a book on this experience (I won’t, though). But as I reflect on my time as a Director, what stands out in my mind are the associate examiners with whom I’ve worked. These surgeons are invited to participate and receive no compensation. It’s 3 days out of their lives, and because they don’t give the exam as frequently as the Directors do, the amount of study and effort is greater for them. Each is selected because he or she is considered to be a thoughtful surgeon with high standards. These surgeons do this job because they care about quality in our profession.
Most of the associates I have worked with are far more accomplished than I. I was once paired with a renowned breast surgeon (okay, it was Kelly K. Hunt). My ego was at great risk because I knew how accomplished she was. But like all the other associates, she was gracious and hard working. We rarely work with another Director, but Anne G. Rizzo, who later became a Director, and I did an exam together. She was a dazzling questioner with very high standards. In other words, she was typical of the people I met. My first associate (also later a Director) was Reid Adams. He was great; I was nervous. My last associate was Marc L. Melcher, a transplant surgeon who asked penetrating questions in a calm manner. I wish I could name each of my associates and thank them for making my work so much better, for teaching me things I didn’t know, for deepening my own knowledge, and serving in a hard job with grace. This column can’t be that long, but you all know who you are. Thank you.
At the end of the day, I believe the oral exam to be a great thing for our profession. When you think about the number of patients potentially affected throughout a surgeon’s career, the impact of decisions made on the day of the exam can be enormous. Given that, over a 20-year career, a surgeon may operate on 25,000 patients, a summative check on a surgeon’s judgment and knowledge is important. Each year, the ABS adjudicates on some 1,100 surgeons. A single year’s set of surgeons over the following 20-year period translates into 27.5 million patients. I hope we never stop doing the orals because of cost, time, or convenience. The exam is just too important to our profession to risk forgoing this last, big step before a surgeon is presented to the world as “certified.”
I literally rode into the sunset recently as I finished my tour of duty as one of the Director examiners for the American Board of Surgery. I was heading out of St. Louis westward toward my home in Kansas. It was a 9-hour drive, which gave me plenty of time to reflect on the 6 years I shared the responsibility of administering the certifying exam known by most surgeons as “the oral exam.”
Over the last dozen years, Directors V. Suzanne Klimberg and Karen J. Brasel, along with former Executive Director Frank Lewis, a team of psychometricians at the Board, and members of the certification committee of the Board, worked tirelessly to create a testing instrument as fair and statistically sound as possible given the inherently qualitative exam. I believe they did a magnificent job. Gone are the legends of yesteryear where candidates were subjected to the whims of whatever crossed the mind of the examiners, including their prejudices about the “right” answer. The oral exam now represents a well-constructed survey of surgical judgment issues that have been thoroughly vetted.
Being an examiner for the orals means you arrive Sunday afternoon before the exams that are given over the next two and a half days. Each examiner undergoes an overview briefing on Sunday afternoon and then studies “the book” for that test’s content usually until late into the night. This book is an impressive document.
We arise around 0530 to attend a breakfast meeting, which includes breaking into our six-person teams and going over each question that will be given that day. At 0800, the first candidates for the first session walk into a room and meet the two surgeons who will make some of the most important decisions affecting that candidate’s career. If you rate the intensity of this moment on a scale of 1 to 10, this is an 11 for both candidates and examiners. No one in the room knows how it will turn out because every session has its own twists and turns. Everyone there wants to see a passing score, but the two examiners know that they must make a decision that is safe for the public and fair for the candidate.
Twelve exams are given per team per day except for the final day which has only six. So, each team examines 30 candidates over 3 days. I’ve opened a door and shaken the moist hand of 438 candidates. I’ve seen every sort of emotion during those sessions. I’ve had moments of great joy and times of profound sadness as candidates respond to the questions. I’ve always tried to be friendly, but just like surgery, it is a serious business and decisions have to be made. That means ignoring one’s hopes and acting on the best facts available at the moment. Most surgeons remember their oral examiners and what they were asked for a lifetime. I know I do.
I could write a book on this experience (I won’t, though). But as I reflect on my time as a Director, what stands out in my mind are the associate examiners with whom I’ve worked. These surgeons are invited to participate and receive no compensation. It’s 3 days out of their lives, and because they don’t give the exam as frequently as the Directors do, the amount of study and effort is greater for them. Each is selected because he or she is considered to be a thoughtful surgeon with high standards. These surgeons do this job because they care about quality in our profession.
Most of the associates I have worked with are far more accomplished than I. I was once paired with a renowned breast surgeon (okay, it was Kelly K. Hunt). My ego was at great risk because I knew how accomplished she was. But like all the other associates, she was gracious and hard working. We rarely work with another Director, but Anne G. Rizzo, who later became a Director, and I did an exam together. She was a dazzling questioner with very high standards. In other words, she was typical of the people I met. My first associate (also later a Director) was Reid Adams. He was great; I was nervous. My last associate was Marc L. Melcher, a transplant surgeon who asked penetrating questions in a calm manner. I wish I could name each of my associates and thank them for making my work so much better, for teaching me things I didn’t know, for deepening my own knowledge, and serving in a hard job with grace. This column can’t be that long, but you all know who you are. Thank you.
At the end of the day, I believe the oral exam to be a great thing for our profession. When you think about the number of patients potentially affected throughout a surgeon’s career, the impact of decisions made on the day of the exam can be enormous. Given that, over a 20-year career, a surgeon may operate on 25,000 patients, a summative check on a surgeon’s judgment and knowledge is important. Each year, the ABS adjudicates on some 1,100 surgeons. A single year’s set of surgeons over the following 20-year period translates into 27.5 million patients. I hope we never stop doing the orals because of cost, time, or convenience. The exam is just too important to our profession to risk forgoing this last, big step before a surgeon is presented to the world as “certified.”
I literally rode into the sunset recently as I finished my tour of duty as one of the Director examiners for the American Board of Surgery. I was heading out of St. Louis westward toward my home in Kansas. It was a 9-hour drive, which gave me plenty of time to reflect on the 6 years I shared the responsibility of administering the certifying exam known by most surgeons as “the oral exam.”
Over the last dozen years, Directors V. Suzanne Klimberg and Karen J. Brasel, along with former Executive Director Frank Lewis, a team of psychometricians at the Board, and members of the certification committee of the Board, worked tirelessly to create a testing instrument as fair and statistically sound as possible given the inherently qualitative exam. I believe they did a magnificent job. Gone are the legends of yesteryear where candidates were subjected to the whims of whatever crossed the mind of the examiners, including their prejudices about the “right” answer. The oral exam now represents a well-constructed survey of surgical judgment issues that have been thoroughly vetted.
Being an examiner for the orals means you arrive Sunday afternoon before the exams that are given over the next two and a half days. Each examiner undergoes an overview briefing on Sunday afternoon and then studies “the book” for that test’s content usually until late into the night. This book is an impressive document.
We arise around 0530 to attend a breakfast meeting, which includes breaking into our six-person teams and going over each question that will be given that day. At 0800, the first candidates for the first session walk into a room and meet the two surgeons who will make some of the most important decisions affecting that candidate’s career. If you rate the intensity of this moment on a scale of 1 to 10, this is an 11 for both candidates and examiners. No one in the room knows how it will turn out because every session has its own twists and turns. Everyone there wants to see a passing score, but the two examiners know that they must make a decision that is safe for the public and fair for the candidate.
Twelve exams are given per team per day except for the final day which has only six. So, each team examines 30 candidates over 3 days. I’ve opened a door and shaken the moist hand of 438 candidates. I’ve seen every sort of emotion during those sessions. I’ve had moments of great joy and times of profound sadness as candidates respond to the questions. I’ve always tried to be friendly, but just like surgery, it is a serious business and decisions have to be made. That means ignoring one’s hopes and acting on the best facts available at the moment. Most surgeons remember their oral examiners and what they were asked for a lifetime. I know I do.
I could write a book on this experience (I won’t, though). But as I reflect on my time as a Director, what stands out in my mind are the associate examiners with whom I’ve worked. These surgeons are invited to participate and receive no compensation. It’s 3 days out of their lives, and because they don’t give the exam as frequently as the Directors do, the amount of study and effort is greater for them. Each is selected because he or she is considered to be a thoughtful surgeon with high standards. These surgeons do this job because they care about quality in our profession.
Most of the associates I have worked with are far more accomplished than I. I was once paired with a renowned breast surgeon (okay, it was Kelly K. Hunt). My ego was at great risk because I knew how accomplished she was. But like all the other associates, she was gracious and hard working. We rarely work with another Director, but Anne G. Rizzo, who later became a Director, and I did an exam together. She was a dazzling questioner with very high standards. In other words, she was typical of the people I met. My first associate (also later a Director) was Reid Adams. He was great; I was nervous. My last associate was Marc L. Melcher, a transplant surgeon who asked penetrating questions in a calm manner. I wish I could name each of my associates and thank them for making my work so much better, for teaching me things I didn’t know, for deepening my own knowledge, and serving in a hard job with grace. This column can’t be that long, but you all know who you are. Thank you.
At the end of the day, I believe the oral exam to be a great thing for our profession. When you think about the number of patients potentially affected throughout a surgeon’s career, the impact of decisions made on the day of the exam can be enormous. Given that, over a 20-year career, a surgeon may operate on 25,000 patients, a summative check on a surgeon’s judgment and knowledge is important. Each year, the ABS adjudicates on some 1,100 surgeons. A single year’s set of surgeons over the following 20-year period translates into 27.5 million patients. I hope we never stop doing the orals because of cost, time, or convenience. The exam is just too important to our profession to risk forgoing this last, big step before a surgeon is presented to the world as “certified.”
June 2018 Question 2
Correct answer: C
Rationale
This patient has long-standing diabetes with associated complications from prolonged hyperglycemia, with symptoms of delayed gastric emptying. The next best step would be to perform a gastric-emptying study or scintigraphy to confirm the diagnosis of diabetic gastroparesis. A dietitian consult will be necessary once gastroparesis is confirmed, since dietary modifications are the mainstay of treatment. Strict blood glucose control is necessary to prevent worsening gastrointestinal symptoms, and an evaluation by an endocrinologist is reasonable if gastroparesis is confirmed. A trial of metoclopramide may be necessary if gastroparesis symptoms are not controlled with dietary modifications, but it would not be first-line treatment in diabetic gastroparesis.
References
1. Camilleri M. Advances in diabetic gastroparesis. Rev Gastroenterol Disord. 2002;2:47-56.
2. Camilleri M, Vazquez-Roque MI. Gastric dysmotility at the organ level in gastroparesis. In: Parkman H, McCallum R. Gastroparesis: Pathophysiology, presentation, diagnosis, and treatment. New York: Springer; 2011. p. 37-46.
Correct answer: C
Rationale
This patient has long-standing diabetes with associated complications from prolonged hyperglycemia, with symptoms of delayed gastric emptying. The next best step would be to perform a gastric-emptying study or scintigraphy to confirm the diagnosis of diabetic gastroparesis. A dietitian consult will be necessary once gastroparesis is confirmed, since dietary modifications are the mainstay of treatment. Strict blood glucose control is necessary to prevent worsening gastrointestinal symptoms, and an evaluation by an endocrinologist is reasonable if gastroparesis is confirmed. A trial of metoclopramide may be necessary if gastroparesis symptoms are not controlled with dietary modifications, but it would not be first-line treatment in diabetic gastroparesis.
References
1. Camilleri M. Advances in diabetic gastroparesis. Rev Gastroenterol Disord. 2002;2:47-56.
2. Camilleri M, Vazquez-Roque MI. Gastric dysmotility at the organ level in gastroparesis. In: Parkman H, McCallum R. Gastroparesis: Pathophysiology, presentation, diagnosis, and treatment. New York: Springer; 2011. p. 37-46.
Correct answer: C
Rationale
This patient has long-standing diabetes with associated complications from prolonged hyperglycemia, with symptoms of delayed gastric emptying. The next best step would be to perform a gastric-emptying study or scintigraphy to confirm the diagnosis of diabetic gastroparesis. A dietitian consult will be necessary once gastroparesis is confirmed, since dietary modifications are the mainstay of treatment. Strict blood glucose control is necessary to prevent worsening gastrointestinal symptoms, and an evaluation by an endocrinologist is reasonable if gastroparesis is confirmed. A trial of metoclopramide may be necessary if gastroparesis symptoms are not controlled with dietary modifications, but it would not be first-line treatment in diabetic gastroparesis.
References
1. Camilleri M. Advances in diabetic gastroparesis. Rev Gastroenterol Disord. 2002;2:47-56.
2. Camilleri M, Vazquez-Roque MI. Gastric dysmotility at the organ level in gastroparesis. In: Parkman H, McCallum R. Gastroparesis: Pathophysiology, presentation, diagnosis, and treatment. New York: Springer; 2011. p. 37-46.
A 55-year-old obese man with long-standing type 2 diabetes mellitus complains of nausea and early satiety for over a year. His medical history is significant for retinopathy, neuropathy, and nephropathy. His diabetes is treated with subcutaneous insulin and an oral hypoglycemic agent, but his recent glycosylated hemoglobin was 11.2%. Since the onset of symptoms, he has lost approximately 30 pounds. Recent upper endoscopy was normal.
June 2018 Question 1
Correct answer: C
Rationale
This patient is presenting early post-liver transplant with severe hepatic dysfunction. This severity of enzyme elevation is concerning for an underlying hepatic artery thrombosis. The next appropriate diagnostic test for this patient is a hepatic ultrasound with Dopplers to assess hepatic artery patency. CMV infection does not typically occur within the first month post-liver transplant and would not be expected to cause this degree of elevation in the liver enzymes. Performance of liver biopsy, MRCP, or ERCP would not reveal the underlying etiology and may result in delay in diagnosis.
Reference
1. Stange BJ, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transplantation 2003;9:612-20.
Correct answer: C
Rationale
This patient is presenting early post-liver transplant with severe hepatic dysfunction. This severity of enzyme elevation is concerning for an underlying hepatic artery thrombosis. The next appropriate diagnostic test for this patient is a hepatic ultrasound with Dopplers to assess hepatic artery patency. CMV infection does not typically occur within the first month post-liver transplant and would not be expected to cause this degree of elevation in the liver enzymes. Performance of liver biopsy, MRCP, or ERCP would not reveal the underlying etiology and may result in delay in diagnosis.
Reference
1. Stange BJ, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transplantation 2003;9:612-20.
Correct answer: C
Rationale
This patient is presenting early post-liver transplant with severe hepatic dysfunction. This severity of enzyme elevation is concerning for an underlying hepatic artery thrombosis. The next appropriate diagnostic test for this patient is a hepatic ultrasound with Dopplers to assess hepatic artery patency. CMV infection does not typically occur within the first month post-liver transplant and would not be expected to cause this degree of elevation in the liver enzymes. Performance of liver biopsy, MRCP, or ERCP would not reveal the underlying etiology and may result in delay in diagnosis.
Reference
1. Stange BJ, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transplantation 2003;9:612-20.
A 62-year-old man underwent deceased-donor liver transplant 36 hours ago for decompensated chronic hepatitis C cirrhosis. He did well initially posttransplant with a steady decline in his transaminases and improvement in hepatic synthetic function. But he has had a rapidly progressive decline in his clinical status over the past 12 hours. On physical exam, his mental status is notable for new confusion. His temperature is 38.9 ºC. Laboratory data reveal the following:
AST 10,300 U/L
ALT 14,550 U/L
total bilirubin 9.6 mg/dL
alkaline phosphatase 693 IU/L
INR 3.6
creatinine 4.6 mg/dL with oliguria.
I’M NOT A PROVIDER
I am not sure when it occurred. I don’t know how it happened. I don’t think anyone took a vote on it. It happened gradually over the last decade. I think it happened when the administrative staff became larger than the medical staff. In order to include everyone under the same umbrella, everyone became a provider.
All those patients in our waiting room suddenly became consumers or clients. My grandfather ran a grocery store and had a lot of customers, and my father was a lawyer and had a lot of clients. None of those customers or clients would come to see me as their doctor with their illnesses today if I were a provider. The use of the terminology of “providers” and “customers” lowers all health care staff to the lowest common denominator and demeans the concerns of my patients.
I do not mean to diminish the role of the auto mechanic and salesperson, but they know and I know that our roles and are different and we are not just providers of a medical commodity. They do not expect me to deal with them as though they were coming to buy a car. They understand that we are actually trying to cure and treat worried patients and not to sell to customers in a show room.
This change in nomenclature that has permeated health care has had significant effects on how medical care is provided. Hospital care has been depersonalized in order to expedite hospital stays and maximize reimbursement. Gone is the hospital visit of your doctors when you need them the most.
Part of it is the complexity of contemporary care that requires the input from varying levels of expertise. Patients are often shuttled from one doctor to another. Communication is carried out through the web and rarely doctor to doctor. Often doctors are dealt with both at the patient level and the administrative level as commodities off the shelf, like buying a pair of shoes. And doctors in the hospital and in the clinic can be replaced by another one as the shift changes or the schedule dictates with little regard to the patient’s – or customer’s – choice.
Can we return to the days of yore? Probably not. All we can do now is try to inject some level of humanity and empathy as we see our patients in today’s world of mechanized medicine.
Dr. Goldstein, medical editor of Cardiology News, is a professor of medicine at Wayne State University and the division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
I am not sure when it occurred. I don’t know how it happened. I don’t think anyone took a vote on it. It happened gradually over the last decade. I think it happened when the administrative staff became larger than the medical staff. In order to include everyone under the same umbrella, everyone became a provider.
All those patients in our waiting room suddenly became consumers or clients. My grandfather ran a grocery store and had a lot of customers, and my father was a lawyer and had a lot of clients. None of those customers or clients would come to see me as their doctor with their illnesses today if I were a provider. The use of the terminology of “providers” and “customers” lowers all health care staff to the lowest common denominator and demeans the concerns of my patients.
I do not mean to diminish the role of the auto mechanic and salesperson, but they know and I know that our roles and are different and we are not just providers of a medical commodity. They do not expect me to deal with them as though they were coming to buy a car. They understand that we are actually trying to cure and treat worried patients and not to sell to customers in a show room.
This change in nomenclature that has permeated health care has had significant effects on how medical care is provided. Hospital care has been depersonalized in order to expedite hospital stays and maximize reimbursement. Gone is the hospital visit of your doctors when you need them the most.
Part of it is the complexity of contemporary care that requires the input from varying levels of expertise. Patients are often shuttled from one doctor to another. Communication is carried out through the web and rarely doctor to doctor. Often doctors are dealt with both at the patient level and the administrative level as commodities off the shelf, like buying a pair of shoes. And doctors in the hospital and in the clinic can be replaced by another one as the shift changes or the schedule dictates with little regard to the patient’s – or customer’s – choice.
Can we return to the days of yore? Probably not. All we can do now is try to inject some level of humanity and empathy as we see our patients in today’s world of mechanized medicine.
Dr. Goldstein, medical editor of Cardiology News, is a professor of medicine at Wayne State University and the division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
I am not sure when it occurred. I don’t know how it happened. I don’t think anyone took a vote on it. It happened gradually over the last decade. I think it happened when the administrative staff became larger than the medical staff. In order to include everyone under the same umbrella, everyone became a provider.
All those patients in our waiting room suddenly became consumers or clients. My grandfather ran a grocery store and had a lot of customers, and my father was a lawyer and had a lot of clients. None of those customers or clients would come to see me as their doctor with their illnesses today if I were a provider. The use of the terminology of “providers” and “customers” lowers all health care staff to the lowest common denominator and demeans the concerns of my patients.
I do not mean to diminish the role of the auto mechanic and salesperson, but they know and I know that our roles and are different and we are not just providers of a medical commodity. They do not expect me to deal with them as though they were coming to buy a car. They understand that we are actually trying to cure and treat worried patients and not to sell to customers in a show room.
This change in nomenclature that has permeated health care has had significant effects on how medical care is provided. Hospital care has been depersonalized in order to expedite hospital stays and maximize reimbursement. Gone is the hospital visit of your doctors when you need them the most.
Part of it is the complexity of contemporary care that requires the input from varying levels of expertise. Patients are often shuttled from one doctor to another. Communication is carried out through the web and rarely doctor to doctor. Often doctors are dealt with both at the patient level and the administrative level as commodities off the shelf, like buying a pair of shoes. And doctors in the hospital and in the clinic can be replaced by another one as the shift changes or the schedule dictates with little regard to the patient’s – or customer’s – choice.
Can we return to the days of yore? Probably not. All we can do now is try to inject some level of humanity and empathy as we see our patients in today’s world of mechanized medicine.
Dr. Goldstein, medical editor of Cardiology News, is a professor of medicine at Wayne State University and the division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
Fake medical news: The black salve and the black arts
Jake clearly needed a biopsy.
When I suggested that we find out what that new growth on his cheek was, he responded with fear. “Do you really need to test it?” he asked. Then he proposed an alternative.
“I had another spot last year,” he said. “This European doctor I saw in somebody’s home put a special black salve on it, and it went away.”
“Who was this doctor?” I asked.
“At the time, I was a raw vegan,” he said. “One of our group members gave me the doctor’s name. He has a big reputation in Europe. He treated people locally in people’s living rooms.”
“Do you recall his name?” I asked him.
Jake didn’t. But I did.
Three years ago, a frightened, middle-aged woman named Josie came to see me with ugly scarring all over her face.
Josie’s story was similar to Jake’s: A famous European doctor. Somebody’s living room.
“He had me lie on the floor,” she recalled, “and he put on some kind of salve. It burned horribly. I was screaming in pain. He washed it off, but it still burned for a long time. This is what it left,” she said, pointing to denting and discoloration on her cheeks and upper lip. She remembered the man’s name.
It took just a few clicks to find him. He wasn’t a licensed doctor and had fled his home country ahead of fraud charges for illegal and harmful practice.
I couldn’t offer Josie much, beyond advising her to avoid getting treated on living room floors by strange practitioners with painful salves.
If you don’t know about the treatment Josie and Jake underwent – it’s called “escharotic treatment” – you can look it up on Wikipedia. It’s also the topic of a case study in the May issue of JAMA Dermatology (2018;154[5]:618-9).
Escharotic treatment has been around a long time. It is used for cancers of the skin and cervix, among others. The principle behind The idea behind both is to apply something that blisters the skin and raises a scab. The eschar is supposed to draw the evil out of the body and bring cure.
Smile if you want, but this idea has been around forever and will likely outlast many treatments we now use. Fake news is old news, and does not need social media to spread (though Facebook helps).
Apparently ordinary people believe strange, irrational, harmful things. Why? Why on earth would Jake and Josie let somebody they don’t know put black goop that hurts like hell on their faces as they lie on a stranger’s carpet? Some thoughts:
- Fear. They think they have cancer and are afraid to find out.
- Suspicion. They don’t trust doctors.
- People they hang with tell them to. Some groups harbor a suspicious, even hostile stance toward conventional medicine, convinced that its principles are unnatural and its practitioners are more concerned with profit and prestige than with the good of their patients.
Those who hold such beliefs, like various conspiracy theorists, span the political and social spectrum, from left to right, and they’ve been around forever.
I don’t plan to try convincing them otherwise. No one can convince them. Citing facts and authority gets you nowhere. As Jonathan Swift said, “You cannot reason someone out of something they did not reason themselves into.”
Fake political news is a problem for society. Fake medical news can be a problem for doctors. A pediatrician confronting an antivaxer family must decide whether to try negotiating (giving their kid vaccines a little at a time) or to give up and send them elsewhere.
It takes effort for physicians to have patience with people who let unscrupulous strangers etch and mutilate their faces. As professionals, however, we doctors are obligated to care even for people we don’t like or agree with. We should therefore try to understand why people who undertake dangerous and irrational treatments think the way they do.
Often, what such patients mainly are is afraid. Still, the ones who actually show up in our offices are willing to at least consider medical opinion. Those who aren’t would never show up.
Jake had enough faith in me to let me calm him down enough to do the biopsy.
It was benign.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Jake clearly needed a biopsy.
When I suggested that we find out what that new growth on his cheek was, he responded with fear. “Do you really need to test it?” he asked. Then he proposed an alternative.
“I had another spot last year,” he said. “This European doctor I saw in somebody’s home put a special black salve on it, and it went away.”
“Who was this doctor?” I asked.
“At the time, I was a raw vegan,” he said. “One of our group members gave me the doctor’s name. He has a big reputation in Europe. He treated people locally in people’s living rooms.”
“Do you recall his name?” I asked him.
Jake didn’t. But I did.
Three years ago, a frightened, middle-aged woman named Josie came to see me with ugly scarring all over her face.
Josie’s story was similar to Jake’s: A famous European doctor. Somebody’s living room.
“He had me lie on the floor,” she recalled, “and he put on some kind of salve. It burned horribly. I was screaming in pain. He washed it off, but it still burned for a long time. This is what it left,” she said, pointing to denting and discoloration on her cheeks and upper lip. She remembered the man’s name.
It took just a few clicks to find him. He wasn’t a licensed doctor and had fled his home country ahead of fraud charges for illegal and harmful practice.
I couldn’t offer Josie much, beyond advising her to avoid getting treated on living room floors by strange practitioners with painful salves.
If you don’t know about the treatment Josie and Jake underwent – it’s called “escharotic treatment” – you can look it up on Wikipedia. It’s also the topic of a case study in the May issue of JAMA Dermatology (2018;154[5]:618-9).
Escharotic treatment has been around a long time. It is used for cancers of the skin and cervix, among others. The principle behind The idea behind both is to apply something that blisters the skin and raises a scab. The eschar is supposed to draw the evil out of the body and bring cure.
Smile if you want, but this idea has been around forever and will likely outlast many treatments we now use. Fake news is old news, and does not need social media to spread (though Facebook helps).
Apparently ordinary people believe strange, irrational, harmful things. Why? Why on earth would Jake and Josie let somebody they don’t know put black goop that hurts like hell on their faces as they lie on a stranger’s carpet? Some thoughts:
- Fear. They think they have cancer and are afraid to find out.
- Suspicion. They don’t trust doctors.
- People they hang with tell them to. Some groups harbor a suspicious, even hostile stance toward conventional medicine, convinced that its principles are unnatural and its practitioners are more concerned with profit and prestige than with the good of their patients.
Those who hold such beliefs, like various conspiracy theorists, span the political and social spectrum, from left to right, and they’ve been around forever.
I don’t plan to try convincing them otherwise. No one can convince them. Citing facts and authority gets you nowhere. As Jonathan Swift said, “You cannot reason someone out of something they did not reason themselves into.”
Fake political news is a problem for society. Fake medical news can be a problem for doctors. A pediatrician confronting an antivaxer family must decide whether to try negotiating (giving their kid vaccines a little at a time) or to give up and send them elsewhere.
It takes effort for physicians to have patience with people who let unscrupulous strangers etch and mutilate their faces. As professionals, however, we doctors are obligated to care even for people we don’t like or agree with. We should therefore try to understand why people who undertake dangerous and irrational treatments think the way they do.
Often, what such patients mainly are is afraid. Still, the ones who actually show up in our offices are willing to at least consider medical opinion. Those who aren’t would never show up.
Jake had enough faith in me to let me calm him down enough to do the biopsy.
It was benign.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Jake clearly needed a biopsy.
When I suggested that we find out what that new growth on his cheek was, he responded with fear. “Do you really need to test it?” he asked. Then he proposed an alternative.
“I had another spot last year,” he said. “This European doctor I saw in somebody’s home put a special black salve on it, and it went away.”
“Who was this doctor?” I asked.
“At the time, I was a raw vegan,” he said. “One of our group members gave me the doctor’s name. He has a big reputation in Europe. He treated people locally in people’s living rooms.”
“Do you recall his name?” I asked him.
Jake didn’t. But I did.
Three years ago, a frightened, middle-aged woman named Josie came to see me with ugly scarring all over her face.
Josie’s story was similar to Jake’s: A famous European doctor. Somebody’s living room.
“He had me lie on the floor,” she recalled, “and he put on some kind of salve. It burned horribly. I was screaming in pain. He washed it off, but it still burned for a long time. This is what it left,” she said, pointing to denting and discoloration on her cheeks and upper lip. She remembered the man’s name.
It took just a few clicks to find him. He wasn’t a licensed doctor and had fled his home country ahead of fraud charges for illegal and harmful practice.
I couldn’t offer Josie much, beyond advising her to avoid getting treated on living room floors by strange practitioners with painful salves.
If you don’t know about the treatment Josie and Jake underwent – it’s called “escharotic treatment” – you can look it up on Wikipedia. It’s also the topic of a case study in the May issue of JAMA Dermatology (2018;154[5]:618-9).
Escharotic treatment has been around a long time. It is used for cancers of the skin and cervix, among others. The principle behind The idea behind both is to apply something that blisters the skin and raises a scab. The eschar is supposed to draw the evil out of the body and bring cure.
Smile if you want, but this idea has been around forever and will likely outlast many treatments we now use. Fake news is old news, and does not need social media to spread (though Facebook helps).
Apparently ordinary people believe strange, irrational, harmful things. Why? Why on earth would Jake and Josie let somebody they don’t know put black goop that hurts like hell on their faces as they lie on a stranger’s carpet? Some thoughts:
- Fear. They think they have cancer and are afraid to find out.
- Suspicion. They don’t trust doctors.
- People they hang with tell them to. Some groups harbor a suspicious, even hostile stance toward conventional medicine, convinced that its principles are unnatural and its practitioners are more concerned with profit and prestige than with the good of their patients.
Those who hold such beliefs, like various conspiracy theorists, span the political and social spectrum, from left to right, and they’ve been around forever.
I don’t plan to try convincing them otherwise. No one can convince them. Citing facts and authority gets you nowhere. As Jonathan Swift said, “You cannot reason someone out of something they did not reason themselves into.”
Fake political news is a problem for society. Fake medical news can be a problem for doctors. A pediatrician confronting an antivaxer family must decide whether to try negotiating (giving their kid vaccines a little at a time) or to give up and send them elsewhere.
It takes effort for physicians to have patience with people who let unscrupulous strangers etch and mutilate their faces. As professionals, however, we doctors are obligated to care even for people we don’t like or agree with. We should therefore try to understand why people who undertake dangerous and irrational treatments think the way they do.
Often, what such patients mainly are is afraid. Still, the ones who actually show up in our offices are willing to at least consider medical opinion. Those who aren’t would never show up.
Jake had enough faith in me to let me calm him down enough to do the biopsy.
It was benign.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
The diagnosis and treatment of ureteral injury
A gynecologic surgeon learns very early in his/her career to respect the ureter. Whether from the procedure being performed (endometriosis surgery, hysterectomy, myomectomy for ligamentous fibroids, salpingo-oophorectomy, excision of ovarian remnants, adhesiolysis), blood loss that obscures visualization and must be controlled, or use of energy for cutting, desiccation, and coagulation leading to potential lateral tissue damage, ureteral injury is a well-known complication. Even normal anatomic variations may put some women at greater risk; according to Hurd et al. (Am J Obstet Gynecol. 2001;184:336-9). In a small subset of women, the distance between the cervix and the ureter may be less than 0.5 cm.
As a practicing minimally invasive gynecologic surgeon for the past 30 years, and an early adapter to laparoscopic hysterectomy, I remember quite well the recommendation to always dissect out ureters at time of the procedure. At present, most will agree that selective dissection is safe and thus, more desirable, as bleeding, damage secondary to desiccation, and ureter devascularization with subsequent necrosis are all increased with ureterolysis.
I agree with Dr. Kenton and Dr. Mueller that ureteral stenting has not been shown to significantly decrease ureteral injury rates. Often times, with loss of peristalsis secondary to stent placement, locating the ureter may be even more difficult. Recent advances using lighted stents or indocyanine green, which fluoresces in response to near-infrared laser and can be injected into the ureter via the ureteral catheter tip, are still in the feasibility phase of evaluation and can be costly.
As most urogenital fistulae are secondary to unrecognized injuries at time of surgery, and due to the fact that intraoperative recognition of the injury allows for primary repair, thus, decreasing the rate of secondary surgery and the associated increased morbidity, I recommend cystoscopy to check for ureteral jets (ureteral efflux) be performed when there is concern regarding ureter compromise.
Currently, I utilize a 70° cystoscope to visualize the ureters. While in the past, I have used intravenous indigo carmine, methylene blue, or fluorescein sodium, I currently use Pyridium (phenazopyridine) 200 mg taken by mouth 1 hour prior to the procedure.
Unfortunately, ureteral jetting still may be noted despite partial ligation, laceration, or desiccation of the ureter.
If ureteral injury is not recognized at time of surgery, it can lead to various postoperative symptoms. If there is a ureteral defect, the patient may note profuse wound leakage, increased abdominal fluid, or a urinoma, ileus, fever, peritonitis, or hematuria. With ureteral obstruction, flank or abdominal pain or anuria can be noted; while, with fistula formation, the patient will likely present with urinary incontinence or watery vaginal discharge.
Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.
A gynecologic surgeon learns very early in his/her career to respect the ureter. Whether from the procedure being performed (endometriosis surgery, hysterectomy, myomectomy for ligamentous fibroids, salpingo-oophorectomy, excision of ovarian remnants, adhesiolysis), blood loss that obscures visualization and must be controlled, or use of energy for cutting, desiccation, and coagulation leading to potential lateral tissue damage, ureteral injury is a well-known complication. Even normal anatomic variations may put some women at greater risk; according to Hurd et al. (Am J Obstet Gynecol. 2001;184:336-9). In a small subset of women, the distance between the cervix and the ureter may be less than 0.5 cm.
As a practicing minimally invasive gynecologic surgeon for the past 30 years, and an early adapter to laparoscopic hysterectomy, I remember quite well the recommendation to always dissect out ureters at time of the procedure. At present, most will agree that selective dissection is safe and thus, more desirable, as bleeding, damage secondary to desiccation, and ureter devascularization with subsequent necrosis are all increased with ureterolysis.
I agree with Dr. Kenton and Dr. Mueller that ureteral stenting has not been shown to significantly decrease ureteral injury rates. Often times, with loss of peristalsis secondary to stent placement, locating the ureter may be even more difficult. Recent advances using lighted stents or indocyanine green, which fluoresces in response to near-infrared laser and can be injected into the ureter via the ureteral catheter tip, are still in the feasibility phase of evaluation and can be costly.
As most urogenital fistulae are secondary to unrecognized injuries at time of surgery, and due to the fact that intraoperative recognition of the injury allows for primary repair, thus, decreasing the rate of secondary surgery and the associated increased morbidity, I recommend cystoscopy to check for ureteral jets (ureteral efflux) be performed when there is concern regarding ureter compromise.
Currently, I utilize a 70° cystoscope to visualize the ureters. While in the past, I have used intravenous indigo carmine, methylene blue, or fluorescein sodium, I currently use Pyridium (phenazopyridine) 200 mg taken by mouth 1 hour prior to the procedure.
Unfortunately, ureteral jetting still may be noted despite partial ligation, laceration, or desiccation of the ureter.
If ureteral injury is not recognized at time of surgery, it can lead to various postoperative symptoms. If there is a ureteral defect, the patient may note profuse wound leakage, increased abdominal fluid, or a urinoma, ileus, fever, peritonitis, or hematuria. With ureteral obstruction, flank or abdominal pain or anuria can be noted; while, with fistula formation, the patient will likely present with urinary incontinence or watery vaginal discharge.
Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.
A gynecologic surgeon learns very early in his/her career to respect the ureter. Whether from the procedure being performed (endometriosis surgery, hysterectomy, myomectomy for ligamentous fibroids, salpingo-oophorectomy, excision of ovarian remnants, adhesiolysis), blood loss that obscures visualization and must be controlled, or use of energy for cutting, desiccation, and coagulation leading to potential lateral tissue damage, ureteral injury is a well-known complication. Even normal anatomic variations may put some women at greater risk; according to Hurd et al. (Am J Obstet Gynecol. 2001;184:336-9). In a small subset of women, the distance between the cervix and the ureter may be less than 0.5 cm.
As a practicing minimally invasive gynecologic surgeon for the past 30 years, and an early adapter to laparoscopic hysterectomy, I remember quite well the recommendation to always dissect out ureters at time of the procedure. At present, most will agree that selective dissection is safe and thus, more desirable, as bleeding, damage secondary to desiccation, and ureter devascularization with subsequent necrosis are all increased with ureterolysis.
I agree with Dr. Kenton and Dr. Mueller that ureteral stenting has not been shown to significantly decrease ureteral injury rates. Often times, with loss of peristalsis secondary to stent placement, locating the ureter may be even more difficult. Recent advances using lighted stents or indocyanine green, which fluoresces in response to near-infrared laser and can be injected into the ureter via the ureteral catheter tip, are still in the feasibility phase of evaluation and can be costly.
As most urogenital fistulae are secondary to unrecognized injuries at time of surgery, and due to the fact that intraoperative recognition of the injury allows for primary repair, thus, decreasing the rate of secondary surgery and the associated increased morbidity, I recommend cystoscopy to check for ureteral jets (ureteral efflux) be performed when there is concern regarding ureter compromise.
Currently, I utilize a 70° cystoscope to visualize the ureters. While in the past, I have used intravenous indigo carmine, methylene blue, or fluorescein sodium, I currently use Pyridium (phenazopyridine) 200 mg taken by mouth 1 hour prior to the procedure.
Unfortunately, ureteral jetting still may be noted despite partial ligation, laceration, or desiccation of the ureter.
If ureteral injury is not recognized at time of surgery, it can lead to various postoperative symptoms. If there is a ureteral defect, the patient may note profuse wound leakage, increased abdominal fluid, or a urinoma, ileus, fever, peritonitis, or hematuria. With ureteral obstruction, flank or abdominal pain or anuria can be noted; while, with fistula formation, the patient will likely present with urinary incontinence or watery vaginal discharge.
Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.
USPSTF: Fall prevention in the elderly? Think exercise
The United States Preventive Services Task Force (USPSTF) commissioned a systematic evidence review of 62 randomized clinical trials with a total of 35,058 patients to gather evidence on the effectiveness and harms of primary care–relevant interventions to prevent falls in community-dwelling adults 65 years or older.1 It thereby has updated its 2012 statement, in which exercise or physical therapy and vitamin D supplementation were recommended to prevent falls.
Importance
Scope of review
Out of the 62 randomized clinical trials, 65% of intervention studies targeted patients at high risk of falls; they were most commonly identified by history of prior falls, but mobility, gait, and balance impairment were often also considered. Specific medical diagnoses that could affect fall-related outcomes (osteoporosis, visual impairment, neurocognitive disorders) were excluded. This review did not look at the outcome of studies in populations who were vitamin D deficient because, in this population, vitamin D supplementation would be considered treatment rather than prevention. Of note, women constituted the majority in most studies.
Exercise interventions
USPSTF found five good-quality and 16 fair-quality studies, which altogether included a total of 7,297 patients, that reported on various exercise interventions to prevent falls; altogether, these studies included a total of 7,297 patients. Of the studies, 57% recruited populations at high risk for falls with a mean age ranging from 68 to 88 years. Exercise interventions included supervised individual classes, group classes, and physical therapy. The most common exercise component was gait, balance, and functional training; other common components included, in order of frequency, were resistance training, flexibility training, and endurance training. Most common frequency and duration were three sessions per week for 12 months. Exercise interventions reduced the number of persons experiencing a fall (relative risk 0.89; 95% confidence interval, 0.81-0.97), reduced the number of injurious falls (incidence rate ratio, 0.81; 95% CI, 0.73-0.90), and revealed a statistically insignificant reduction in the number of falls. Reported adverse events were minor and most commonly included pain or bruising related to exercise.
Multifactorial interventions
USPSTF found seven good-quality and 19 fair-quality studies that reported on multifactorial interventions; altogether, these studies included a total of 15,506 patients. Of the studies, 73% recruited populations at high risk for falls, and the mean age ranged from 71.9 to 85 years. Multifactorial interventions had two components:
- Initial assessment to screen for modifiable risk factors for falls (multidisciplinary comprehensive geriatric assessment or specific assessment that evaluated various factors, such as balance, gait, vision, cardiovascular health, medication, environment, cognition, and psychological health).
- Subsequent customized interventions (group or individual exercise, cognitive-behavioral therapy, nutrition, environmental modification, physical or occupational therapy, social or community services, and referral to specialists).
While studies found that multifactorial interventions reduced the number of falls (IRR, 0.79; 95% CI, 0.68-0.91), they did not reduce the number of people who experienced a fall (RR, 0.95; 95% CI, 0.89-1.01) or an injurious fall (RR, 0.94; 95% CI, 0.85-1.03). Four studies reported minor harm, mostly bruising, from exercise. Therefore, USPSTF has recommended that clinicians take into consideration patient’s medical history (including prior falls and comorbidities) to selectively offer multifactorial interventions.
Vitamin D supplementation
USPSTF found four good-quality and three fair-quality studies that reported on the effect of vitamin D supplementation on the prevention of falls; altogether, these studies included a total of 7,531 patients. Of the studies, 43% recruited populations at high risk for falls. The mean age ranged from 71 to 76.8 years, and mean serum 25-OH vitamin D levels ranged from 26.4 to 31.8 ng/mL. Vitamin D formulations and dosages varied among trials from 700 IU/day to 150,000 IU/3 months to 500,000 IU/year. Pooled analyses did not show a significant reduction in falls (IRR, 0.97; 95% CI, 0.79-1.20) or the number of persons experiencing a fall (RR, 0.97; 95% CI, 0.88-1.08). Only two trials reported on injurious falls; one reported an increase and the other reported no statistically significant difference. One study using high doses of Vitamin D supplementation (500,000 IU per year) showed statistically significant increase in all three endpoints.
Recommendation of others for fall prevention
The National Institution of Aging has emphasized exercise for strength and balance, monitoring for environmental hazards, and hearing and vision care, as well as medication management. The American Geriatric Society (AGS) has recommended asking about prior falls annually and assessing gait and balance on those who have experienced a fall. The AGS also has recommended strength and gait training, environmental modification, medication management, and vitamin D supplementation of at least 800 IU/day for those vitamin D deficient or at increased risk of falls. The Center for Disease Control and Prevention recommends STEADI (Stopping Elderly Accidents, Deaths & Injuries), a coordinated approach to implement the AGS’s clinical practice guidelines. The American Academy of Family Physicians recommends exercise or physical therapy and vitamin D supplementation.
The bottom line
Regarding reduction of falls, the USPSTF found adequate evidence that exercise interventions confer a moderate net benefit, multifactorial interventions have a small net benefit, and vitamin D supplementation offers no net benefit in preventing falls.
References
1. Guirquis-Blake JM et al. JAMA. 2018 Apr 24;319(16):1705-16.
2. U.S. Preventive Services Task Force et al. JAMA. 2018 Apr 24;319(16):1696-1704.
Dr. Shrestha is a first-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
.
The United States Preventive Services Task Force (USPSTF) commissioned a systematic evidence review of 62 randomized clinical trials with a total of 35,058 patients to gather evidence on the effectiveness and harms of primary care–relevant interventions to prevent falls in community-dwelling adults 65 years or older.1 It thereby has updated its 2012 statement, in which exercise or physical therapy and vitamin D supplementation were recommended to prevent falls.
Importance
Scope of review
Out of the 62 randomized clinical trials, 65% of intervention studies targeted patients at high risk of falls; they were most commonly identified by history of prior falls, but mobility, gait, and balance impairment were often also considered. Specific medical diagnoses that could affect fall-related outcomes (osteoporosis, visual impairment, neurocognitive disorders) were excluded. This review did not look at the outcome of studies in populations who were vitamin D deficient because, in this population, vitamin D supplementation would be considered treatment rather than prevention. Of note, women constituted the majority in most studies.
Exercise interventions
USPSTF found five good-quality and 16 fair-quality studies, which altogether included a total of 7,297 patients, that reported on various exercise interventions to prevent falls; altogether, these studies included a total of 7,297 patients. Of the studies, 57% recruited populations at high risk for falls with a mean age ranging from 68 to 88 years. Exercise interventions included supervised individual classes, group classes, and physical therapy. The most common exercise component was gait, balance, and functional training; other common components included, in order of frequency, were resistance training, flexibility training, and endurance training. Most common frequency and duration were three sessions per week for 12 months. Exercise interventions reduced the number of persons experiencing a fall (relative risk 0.89; 95% confidence interval, 0.81-0.97), reduced the number of injurious falls (incidence rate ratio, 0.81; 95% CI, 0.73-0.90), and revealed a statistically insignificant reduction in the number of falls. Reported adverse events were minor and most commonly included pain or bruising related to exercise.
Multifactorial interventions
USPSTF found seven good-quality and 19 fair-quality studies that reported on multifactorial interventions; altogether, these studies included a total of 15,506 patients. Of the studies, 73% recruited populations at high risk for falls, and the mean age ranged from 71.9 to 85 years. Multifactorial interventions had two components:
- Initial assessment to screen for modifiable risk factors for falls (multidisciplinary comprehensive geriatric assessment or specific assessment that evaluated various factors, such as balance, gait, vision, cardiovascular health, medication, environment, cognition, and psychological health).
- Subsequent customized interventions (group or individual exercise, cognitive-behavioral therapy, nutrition, environmental modification, physical or occupational therapy, social or community services, and referral to specialists).
While studies found that multifactorial interventions reduced the number of falls (IRR, 0.79; 95% CI, 0.68-0.91), they did not reduce the number of people who experienced a fall (RR, 0.95; 95% CI, 0.89-1.01) or an injurious fall (RR, 0.94; 95% CI, 0.85-1.03). Four studies reported minor harm, mostly bruising, from exercise. Therefore, USPSTF has recommended that clinicians take into consideration patient’s medical history (including prior falls and comorbidities) to selectively offer multifactorial interventions.
Vitamin D supplementation
USPSTF found four good-quality and three fair-quality studies that reported on the effect of vitamin D supplementation on the prevention of falls; altogether, these studies included a total of 7,531 patients. Of the studies, 43% recruited populations at high risk for falls. The mean age ranged from 71 to 76.8 years, and mean serum 25-OH vitamin D levels ranged from 26.4 to 31.8 ng/mL. Vitamin D formulations and dosages varied among trials from 700 IU/day to 150,000 IU/3 months to 500,000 IU/year. Pooled analyses did not show a significant reduction in falls (IRR, 0.97; 95% CI, 0.79-1.20) or the number of persons experiencing a fall (RR, 0.97; 95% CI, 0.88-1.08). Only two trials reported on injurious falls; one reported an increase and the other reported no statistically significant difference. One study using high doses of Vitamin D supplementation (500,000 IU per year) showed statistically significant increase in all three endpoints.
Recommendation of others for fall prevention
The National Institution of Aging has emphasized exercise for strength and balance, monitoring for environmental hazards, and hearing and vision care, as well as medication management. The American Geriatric Society (AGS) has recommended asking about prior falls annually and assessing gait and balance on those who have experienced a fall. The AGS also has recommended strength and gait training, environmental modification, medication management, and vitamin D supplementation of at least 800 IU/day for those vitamin D deficient or at increased risk of falls. The Center for Disease Control and Prevention recommends STEADI (Stopping Elderly Accidents, Deaths & Injuries), a coordinated approach to implement the AGS’s clinical practice guidelines. The American Academy of Family Physicians recommends exercise or physical therapy and vitamin D supplementation.
The bottom line
Regarding reduction of falls, the USPSTF found adequate evidence that exercise interventions confer a moderate net benefit, multifactorial interventions have a small net benefit, and vitamin D supplementation offers no net benefit in preventing falls.
References
1. Guirquis-Blake JM et al. JAMA. 2018 Apr 24;319(16):1705-16.
2. U.S. Preventive Services Task Force et al. JAMA. 2018 Apr 24;319(16):1696-1704.
Dr. Shrestha is a first-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
.
The United States Preventive Services Task Force (USPSTF) commissioned a systematic evidence review of 62 randomized clinical trials with a total of 35,058 patients to gather evidence on the effectiveness and harms of primary care–relevant interventions to prevent falls in community-dwelling adults 65 years or older.1 It thereby has updated its 2012 statement, in which exercise or physical therapy and vitamin D supplementation were recommended to prevent falls.
Importance
Scope of review
Out of the 62 randomized clinical trials, 65% of intervention studies targeted patients at high risk of falls; they were most commonly identified by history of prior falls, but mobility, gait, and balance impairment were often also considered. Specific medical diagnoses that could affect fall-related outcomes (osteoporosis, visual impairment, neurocognitive disorders) were excluded. This review did not look at the outcome of studies in populations who were vitamin D deficient because, in this population, vitamin D supplementation would be considered treatment rather than prevention. Of note, women constituted the majority in most studies.
Exercise interventions
USPSTF found five good-quality and 16 fair-quality studies, which altogether included a total of 7,297 patients, that reported on various exercise interventions to prevent falls; altogether, these studies included a total of 7,297 patients. Of the studies, 57% recruited populations at high risk for falls with a mean age ranging from 68 to 88 years. Exercise interventions included supervised individual classes, group classes, and physical therapy. The most common exercise component was gait, balance, and functional training; other common components included, in order of frequency, were resistance training, flexibility training, and endurance training. Most common frequency and duration were three sessions per week for 12 months. Exercise interventions reduced the number of persons experiencing a fall (relative risk 0.89; 95% confidence interval, 0.81-0.97), reduced the number of injurious falls (incidence rate ratio, 0.81; 95% CI, 0.73-0.90), and revealed a statistically insignificant reduction in the number of falls. Reported adverse events were minor and most commonly included pain or bruising related to exercise.
Multifactorial interventions
USPSTF found seven good-quality and 19 fair-quality studies that reported on multifactorial interventions; altogether, these studies included a total of 15,506 patients. Of the studies, 73% recruited populations at high risk for falls, and the mean age ranged from 71.9 to 85 years. Multifactorial interventions had two components:
- Initial assessment to screen for modifiable risk factors for falls (multidisciplinary comprehensive geriatric assessment or specific assessment that evaluated various factors, such as balance, gait, vision, cardiovascular health, medication, environment, cognition, and psychological health).
- Subsequent customized interventions (group or individual exercise, cognitive-behavioral therapy, nutrition, environmental modification, physical or occupational therapy, social or community services, and referral to specialists).
While studies found that multifactorial interventions reduced the number of falls (IRR, 0.79; 95% CI, 0.68-0.91), they did not reduce the number of people who experienced a fall (RR, 0.95; 95% CI, 0.89-1.01) or an injurious fall (RR, 0.94; 95% CI, 0.85-1.03). Four studies reported minor harm, mostly bruising, from exercise. Therefore, USPSTF has recommended that clinicians take into consideration patient’s medical history (including prior falls and comorbidities) to selectively offer multifactorial interventions.
Vitamin D supplementation
USPSTF found four good-quality and three fair-quality studies that reported on the effect of vitamin D supplementation on the prevention of falls; altogether, these studies included a total of 7,531 patients. Of the studies, 43% recruited populations at high risk for falls. The mean age ranged from 71 to 76.8 years, and mean serum 25-OH vitamin D levels ranged from 26.4 to 31.8 ng/mL. Vitamin D formulations and dosages varied among trials from 700 IU/day to 150,000 IU/3 months to 500,000 IU/year. Pooled analyses did not show a significant reduction in falls (IRR, 0.97; 95% CI, 0.79-1.20) or the number of persons experiencing a fall (RR, 0.97; 95% CI, 0.88-1.08). Only two trials reported on injurious falls; one reported an increase and the other reported no statistically significant difference. One study using high doses of Vitamin D supplementation (500,000 IU per year) showed statistically significant increase in all three endpoints.
Recommendation of others for fall prevention
The National Institution of Aging has emphasized exercise for strength and balance, monitoring for environmental hazards, and hearing and vision care, as well as medication management. The American Geriatric Society (AGS) has recommended asking about prior falls annually and assessing gait and balance on those who have experienced a fall. The AGS also has recommended strength and gait training, environmental modification, medication management, and vitamin D supplementation of at least 800 IU/day for those vitamin D deficient or at increased risk of falls. The Center for Disease Control and Prevention recommends STEADI (Stopping Elderly Accidents, Deaths & Injuries), a coordinated approach to implement the AGS’s clinical practice guidelines. The American Academy of Family Physicians recommends exercise or physical therapy and vitamin D supplementation.
The bottom line
Regarding reduction of falls, the USPSTF found adequate evidence that exercise interventions confer a moderate net benefit, multifactorial interventions have a small net benefit, and vitamin D supplementation offers no net benefit in preventing falls.
References
1. Guirquis-Blake JM et al. JAMA. 2018 Apr 24;319(16):1705-16.
2. U.S. Preventive Services Task Force et al. JAMA. 2018 Apr 24;319(16):1696-1704.
Dr. Shrestha is a first-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
.
Doctors’ pay involves a lot of unseen work
“Doctors make a lot of money.” We hear that a lot, always from people who aren’t part of the profession.
Last month, I had to do my tax forms. Not my annual forms, but the quarterly withholding ones for the IRS, and for the state, along with the Arizona Department of Economic Security forms.
The whole thing takes me about 2 hours every 3 months. I suppose I could hire an accountant or office manager to deal with that stuff, but in solo practice, you do everything you can to keep the overhead low. So I do it myself.
Eight hours a year doesn’t sound too bad, but it got me thinking about all the other ways that work creeps into my home time.
I’m usually at the office around 5:00 a.m., when I start with reviewing charts, doing paperwork, and catching up on dictations until patients start at 8:00 a.m. From then on, they’re a steady stream until 4:00 p.m., when we close up and head home.
I get home and then have 1-2 hours of time paying bills, sorting mail, and catching up on phone calls and other unresolved issues.
On weekends, there’s always other stuff. Payroll for the coming weeks, office bills, and credit card statements I didn’t get to during the week, CME, forms, licensing paperwork, etc.
I’d guess about 15 hours/week goes into nonpatient-related stuff. Each year that’s more than 700 hours (or a little over a month) of extra time. Tack that on to the roughly 60 hours that I spend seeing patients between the office and hospital.
People say we make “a lot” (whatever that is), but they don’t see everything behind it. The 7-12 years of post-college training. The student loans of $200,000 and dating back to when I was 26 years old. The rising costs of overhead and dropping rates of reimbursement. The denied payments in disputes over claims. And, as mentioned above, the huge amount of time this job takes for stuff beyond just seeing patients.
We don’t get paid by the hour, but if we did, the rate would probably be a lot lower than what most would expect.
I suppose I could become employed, and let someone else worry about those things. But the financial impact doesn’t go away. Someone else still has to be doing those things, and since doctors are the ones who generate income in the majority of medical practices, the salaries for everyone else come out of ours. Plus, as I’ve previously written about, I’ve been employed before and got sick of the meetings and memos about cost-sharing, productivity numbers, and dollars earned per square foot.
But whenever I hear the refrain about our field being overpaid, I think about the actual hours the public doesn’t see (or care about). This isn’t a job for slackers, and
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“Doctors make a lot of money.” We hear that a lot, always from people who aren’t part of the profession.
Last month, I had to do my tax forms. Not my annual forms, but the quarterly withholding ones for the IRS, and for the state, along with the Arizona Department of Economic Security forms.
The whole thing takes me about 2 hours every 3 months. I suppose I could hire an accountant or office manager to deal with that stuff, but in solo practice, you do everything you can to keep the overhead low. So I do it myself.
Eight hours a year doesn’t sound too bad, but it got me thinking about all the other ways that work creeps into my home time.
I’m usually at the office around 5:00 a.m., when I start with reviewing charts, doing paperwork, and catching up on dictations until patients start at 8:00 a.m. From then on, they’re a steady stream until 4:00 p.m., when we close up and head home.
I get home and then have 1-2 hours of time paying bills, sorting mail, and catching up on phone calls and other unresolved issues.
On weekends, there’s always other stuff. Payroll for the coming weeks, office bills, and credit card statements I didn’t get to during the week, CME, forms, licensing paperwork, etc.
I’d guess about 15 hours/week goes into nonpatient-related stuff. Each year that’s more than 700 hours (or a little over a month) of extra time. Tack that on to the roughly 60 hours that I spend seeing patients between the office and hospital.
People say we make “a lot” (whatever that is), but they don’t see everything behind it. The 7-12 years of post-college training. The student loans of $200,000 and dating back to when I was 26 years old. The rising costs of overhead and dropping rates of reimbursement. The denied payments in disputes over claims. And, as mentioned above, the huge amount of time this job takes for stuff beyond just seeing patients.
We don’t get paid by the hour, but if we did, the rate would probably be a lot lower than what most would expect.
I suppose I could become employed, and let someone else worry about those things. But the financial impact doesn’t go away. Someone else still has to be doing those things, and since doctors are the ones who generate income in the majority of medical practices, the salaries for everyone else come out of ours. Plus, as I’ve previously written about, I’ve been employed before and got sick of the meetings and memos about cost-sharing, productivity numbers, and dollars earned per square foot.
But whenever I hear the refrain about our field being overpaid, I think about the actual hours the public doesn’t see (or care about). This isn’t a job for slackers, and
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
“Doctors make a lot of money.” We hear that a lot, always from people who aren’t part of the profession.
Last month, I had to do my tax forms. Not my annual forms, but the quarterly withholding ones for the IRS, and for the state, along with the Arizona Department of Economic Security forms.
The whole thing takes me about 2 hours every 3 months. I suppose I could hire an accountant or office manager to deal with that stuff, but in solo practice, you do everything you can to keep the overhead low. So I do it myself.
Eight hours a year doesn’t sound too bad, but it got me thinking about all the other ways that work creeps into my home time.
I’m usually at the office around 5:00 a.m., when I start with reviewing charts, doing paperwork, and catching up on dictations until patients start at 8:00 a.m. From then on, they’re a steady stream until 4:00 p.m., when we close up and head home.
I get home and then have 1-2 hours of time paying bills, sorting mail, and catching up on phone calls and other unresolved issues.
On weekends, there’s always other stuff. Payroll for the coming weeks, office bills, and credit card statements I didn’t get to during the week, CME, forms, licensing paperwork, etc.
I’d guess about 15 hours/week goes into nonpatient-related stuff. Each year that’s more than 700 hours (or a little over a month) of extra time. Tack that on to the roughly 60 hours that I spend seeing patients between the office and hospital.
People say we make “a lot” (whatever that is), but they don’t see everything behind it. The 7-12 years of post-college training. The student loans of $200,000 and dating back to when I was 26 years old. The rising costs of overhead and dropping rates of reimbursement. The denied payments in disputes over claims. And, as mentioned above, the huge amount of time this job takes for stuff beyond just seeing patients.
We don’t get paid by the hour, but if we did, the rate would probably be a lot lower than what most would expect.
I suppose I could become employed, and let someone else worry about those things. But the financial impact doesn’t go away. Someone else still has to be doing those things, and since doctors are the ones who generate income in the majority of medical practices, the salaries for everyone else come out of ours. Plus, as I’ve previously written about, I’ve been employed before and got sick of the meetings and memos about cost-sharing, productivity numbers, and dollars earned per square foot.
But whenever I hear the refrain about our field being overpaid, I think about the actual hours the public doesn’t see (or care about). This isn’t a job for slackers, and
Dr. Block has a solo neurology practice in Scottsdale, Ariz.