Opinion

The United States Preventive Services Task Force (USPSTF) has issued recommendations on screening for idiopathic scoliosis in asymptomatic children and adolescents aged 10-18 years.¹ This recommendation concluded that the current evidence on the benefits and harms of screening is insufficient (I statement) and updated its 2004 recommendation against routine screening, in which it had concluded that the harms of screening exceeded the potential benefits (D recommendation).

Importance

Wavebreakmedia/Thinkstock

Screening methods

The USPSTF concluded that currently available screening tests can accurately detect adolescent idiopathic scoliosis. Screening methods include visual inspection using the forward bend test, use of scoliometer measurement of the angle of trunk rotation during forward bend test with a rotation of 5 degrees–7 degrees recommended to be referred for radiography, and Moiré topography that enumerates asymmetric contour lines on the back (values greater than 2 are referred to radiography).

The USPSTF reviewed seven fair-quality observational studies (n = 447,243) and concluded that screening with a combination of forward bend test, scoliometer measurement and that Moiré topography had the highest sensitivity (93.8%) and specificity (99.2%), a low false-negative rate (6.2%), the lowest false-positive rate (0.8%), and the highest positive predictive value (81%). Sensitivity was lower when screening programs used only one or two screening tests, and single screening tests were associated with highest false-positive rates.

In general, the potential harms associated with false-positive results include psychological harm, chest radiation exposure, and other unnecessary treatment, but the USPSTF did not find evidence on the direct harms of screening.
 

Effectiveness of intervention or treatment

Bracing: The USPSTF found five studies (n = 651) that evaluated the effectiveness of treatment with three different types of braces. The average ages of participants ranged from 12 to 13 years, and their curvature severity varied from Cobb angle of 20 degrees to 30 degrees. The largest study (n = 242) was a good-quality, international, controlled clinical trial known as the Bracing in Adolescent Idiopathic Scoliosis Trial; it demonstrated significant benefit and quality-of-life outcomes associated with bracing for 18 hours/day. In this study, the rate of treatment success in the as-treated analysis was 72% in the intervention group and 48% in the control group. The rate of treatment success in the intention-to-treat analysis was 75% in the intervention group and 42% in the control group. The number needed to treat was three to prevent one case of curvature progression past 50%.

Exercise: The USPSTF found just two trials (n = 184) that evaluated the effectiveness of tailored physiotherapeutic, scoliosis-specific exercise treatments. The participants were older than 10 years and had Cobb angles ranging from 10 degrees to 25 degrees. At the 12-month follow-up, the studies showed significant improvement, including those in quality-of-life measures. In one of the trials, the intervention group had a Cobb angle reduction of 4.9 degrees while the control group had an increase of 2.8 degrees.

Harms: Only one good-quality study (n = 242) reported harms of bracing, which include skin problems, body pain, physical limitations, anxiety, and depression. The USPSTF did not find any studies that assessed the harms of treatment with exercise or surgery.

Association between spinal curvature severity and adult health outcomes

The USPSTF did not find any studies that directly addressed whether changes in the severity of spinal curvature in adolescence resulted in changes in adult health outcomes. The USPSTF did review two fair-quality retrospective, observational, long-term, follow-up analyses (n = 339) of adults diagnosed with idiopathic scoliosis in adolescence and treated with either bracing or surgery. Quality of life measurements, pulmonary consequences, and pregnancy outcomes were not significantly different between the two treatment groups or between those treated and those simply observed. However, those treated with bracing did report more negative treatment experience and body distortion.

Recommendation of others

The Scoliosis Research Society, American Academy of Orthopedic Surgeons, Pediatric Orthopedic Society of North America, and American Academy of Pediatrics issued a joint position statement in September 2015 recommending that screening examinations for scoliosis should be performed for females at ages 10 and 12 years and for males at either 13 or 14 years.²

Their rationale, articulated in the statement and in an editorial in JAMA accompanying the publication of the USPSTF statement, is primarily based on findings in the Bracing in Adolescent Idiopathic Scoliosis Trial that showed a 56% decrease in the rate of progression of moderate curves to greater than 50 degrees. The evidence that intervention works – along with concerns about costs, family burden, loss of school time, risks of surgical complications, and the 22% need for long-term revision surgery – makes avoidance of progression of curves in scoliosis a high-value issue. In addition, they reasoned, the screening trials from which the false-positive values were derived were primarily school-based screening and not done in physician offices.
 

The Bottom Line

Dr. Aarisha 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 associate director of the family medicine residency program at Abington Jefferson Health.

References

1. US Preventive Services Task Force. JAMA. 2018;319(2):165–72.

2. HreskoMT et al. SRS/POSNA/AAOS/AAP position statement: Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Accessed December 8, 2017.
 

The United States Preventive Services Task Force (USPSTF) has issued recommendations on screening for idiopathic scoliosis in asymptomatic children and adolescents aged 10-18 years.¹ This recommendation concluded that the current evidence on the benefits and harms of screening is insufficient (I statement) and updated its 2004 recommendation against routine screening, in which it had concluded that the harms of screening exceeded the potential benefits (D recommendation).

Importance

Wavebreakmedia/Thinkstock

Screening methods

The USPSTF concluded that currently available screening tests can accurately detect adolescent idiopathic scoliosis. Screening methods include visual inspection using the forward bend test, use of scoliometer measurement of the angle of trunk rotation during forward bend test with a rotation of 5 degrees–7 degrees recommended to be referred for radiography, and Moiré topography that enumerates asymmetric contour lines on the back (values greater than 2 are referred to radiography).

The USPSTF reviewed seven fair-quality observational studies (n = 447,243) and concluded that screening with a combination of forward bend test, scoliometer measurement and that Moiré topography had the highest sensitivity (93.8%) and specificity (99.2%), a low false-negative rate (6.2%), the lowest false-positive rate (0.8%), and the highest positive predictive value (81%). Sensitivity was lower when screening programs used only one or two screening tests, and single screening tests were associated with highest false-positive rates.

In general, the potential harms associated with false-positive results include psychological harm, chest radiation exposure, and other unnecessary treatment, but the USPSTF did not find evidence on the direct harms of screening.
 

Effectiveness of intervention or treatment

Bracing: The USPSTF found five studies (n = 651) that evaluated the effectiveness of treatment with three different types of braces. The average ages of participants ranged from 12 to 13 years, and their curvature severity varied from Cobb angle of 20 degrees to 30 degrees. The largest study (n = 242) was a good-quality, international, controlled clinical trial known as the Bracing in Adolescent Idiopathic Scoliosis Trial; it demonstrated significant benefit and quality-of-life outcomes associated with bracing for 18 hours/day. In this study, the rate of treatment success in the as-treated analysis was 72% in the intervention group and 48% in the control group. The rate of treatment success in the intention-to-treat analysis was 75% in the intervention group and 42% in the control group. The number needed to treat was three to prevent one case of curvature progression past 50%.

Exercise: The USPSTF found just two trials (n = 184) that evaluated the effectiveness of tailored physiotherapeutic, scoliosis-specific exercise treatments. The participants were older than 10 years and had Cobb angles ranging from 10 degrees to 25 degrees. At the 12-month follow-up, the studies showed significant improvement, including those in quality-of-life measures. In one of the trials, the intervention group had a Cobb angle reduction of 4.9 degrees while the control group had an increase of 2.8 degrees.

Harms: Only one good-quality study (n = 242) reported harms of bracing, which include skin problems, body pain, physical limitations, anxiety, and depression. The USPSTF did not find any studies that assessed the harms of treatment with exercise or surgery.

Association between spinal curvature severity and adult health outcomes

The USPSTF did not find any studies that directly addressed whether changes in the severity of spinal curvature in adolescence resulted in changes in adult health outcomes. The USPSTF did review two fair-quality retrospective, observational, long-term, follow-up analyses (n = 339) of adults diagnosed with idiopathic scoliosis in adolescence and treated with either bracing or surgery. Quality of life measurements, pulmonary consequences, and pregnancy outcomes were not significantly different between the two treatment groups or between those treated and those simply observed. However, those treated with bracing did report more negative treatment experience and body distortion.

Recommendation of others

The Scoliosis Research Society, American Academy of Orthopedic Surgeons, Pediatric Orthopedic Society of North America, and American Academy of Pediatrics issued a joint position statement in September 2015 recommending that screening examinations for scoliosis should be performed for females at ages 10 and 12 years and for males at either 13 or 14 years.²

Their rationale, articulated in the statement and in an editorial in JAMA accompanying the publication of the USPSTF statement, is primarily based on findings in the Bracing in Adolescent Idiopathic Scoliosis Trial that showed a 56% decrease in the rate of progression of moderate curves to greater than 50 degrees. The evidence that intervention works – along with concerns about costs, family burden, loss of school time, risks of surgical complications, and the 22% need for long-term revision surgery – makes avoidance of progression of curves in scoliosis a high-value issue. In addition, they reasoned, the screening trials from which the false-positive values were derived were primarily school-based screening and not done in physician offices.
 

The Bottom Line

Dr. Aarisha 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 associate director of the family medicine residency program at Abington Jefferson Health.

References

1. US Preventive Services Task Force. JAMA. 2018;319(2):165–72.

2. HreskoMT et al. SRS/POSNA/AAOS/AAP position statement: Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Accessed December 8, 2017.
 

The United States Preventive Services Task Force (USPSTF) has issued recommendations on screening for idiopathic scoliosis in asymptomatic children and adolescents aged 10-18 years.¹ This recommendation concluded that the current evidence on the benefits and harms of screening is insufficient (I statement) and updated its 2004 recommendation against routine screening, in which it had concluded that the harms of screening exceeded the potential benefits (D recommendation).

Importance

Wavebreakmedia/Thinkstock

Screening methods

The USPSTF concluded that currently available screening tests can accurately detect adolescent idiopathic scoliosis. Screening methods include visual inspection using the forward bend test, use of scoliometer measurement of the angle of trunk rotation during forward bend test with a rotation of 5 degrees–7 degrees recommended to be referred for radiography, and Moiré topography that enumerates asymmetric contour lines on the back (values greater than 2 are referred to radiography).

The USPSTF reviewed seven fair-quality observational studies (n = 447,243) and concluded that screening with a combination of forward bend test, scoliometer measurement and that Moiré topography had the highest sensitivity (93.8%) and specificity (99.2%), a low false-negative rate (6.2%), the lowest false-positive rate (0.8%), and the highest positive predictive value (81%). Sensitivity was lower when screening programs used only one or two screening tests, and single screening tests were associated with highest false-positive rates.

In general, the potential harms associated with false-positive results include psychological harm, chest radiation exposure, and other unnecessary treatment, but the USPSTF did not find evidence on the direct harms of screening.
 

Effectiveness of intervention or treatment

Bracing: The USPSTF found five studies (n = 651) that evaluated the effectiveness of treatment with three different types of braces. The average ages of participants ranged from 12 to 13 years, and their curvature severity varied from Cobb angle of 20 degrees to 30 degrees. The largest study (n = 242) was a good-quality, international, controlled clinical trial known as the Bracing in Adolescent Idiopathic Scoliosis Trial; it demonstrated significant benefit and quality-of-life outcomes associated with bracing for 18 hours/day. In this study, the rate of treatment success in the as-treated analysis was 72% in the intervention group and 48% in the control group. The rate of treatment success in the intention-to-treat analysis was 75% in the intervention group and 42% in the control group. The number needed to treat was three to prevent one case of curvature progression past 50%.

Exercise: The USPSTF found just two trials (n = 184) that evaluated the effectiveness of tailored physiotherapeutic, scoliosis-specific exercise treatments. The participants were older than 10 years and had Cobb angles ranging from 10 degrees to 25 degrees. At the 12-month follow-up, the studies showed significant improvement, including those in quality-of-life measures. In one of the trials, the intervention group had a Cobb angle reduction of 4.9 degrees while the control group had an increase of 2.8 degrees.

Harms: Only one good-quality study (n = 242) reported harms of bracing, which include skin problems, body pain, physical limitations, anxiety, and depression. The USPSTF did not find any studies that assessed the harms of treatment with exercise or surgery.

Association between spinal curvature severity and adult health outcomes

The USPSTF did not find any studies that directly addressed whether changes in the severity of spinal curvature in adolescence resulted in changes in adult health outcomes. The USPSTF did review two fair-quality retrospective, observational, long-term, follow-up analyses (n = 339) of adults diagnosed with idiopathic scoliosis in adolescence and treated with either bracing or surgery. Quality of life measurements, pulmonary consequences, and pregnancy outcomes were not significantly different between the two treatment groups or between those treated and those simply observed. However, those treated with bracing did report more negative treatment experience and body distortion.

Recommendation of others

The Scoliosis Research Society, American Academy of Orthopedic Surgeons, Pediatric Orthopedic Society of North America, and American Academy of Pediatrics issued a joint position statement in September 2015 recommending that screening examinations for scoliosis should be performed for females at ages 10 and 12 years and for males at either 13 or 14 years.²

Their rationale, articulated in the statement and in an editorial in JAMA accompanying the publication of the USPSTF statement, is primarily based on findings in the Bracing in Adolescent Idiopathic Scoliosis Trial that showed a 56% decrease in the rate of progression of moderate curves to greater than 50 degrees. The evidence that intervention works – along with concerns about costs, family burden, loss of school time, risks of surgical complications, and the 22% need for long-term revision surgery – makes avoidance of progression of curves in scoliosis a high-value issue. In addition, they reasoned, the screening trials from which the false-positive values were derived were primarily school-based screening and not done in physician offices.
 

The Bottom Line

Dr. Aarisha 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 associate director of the family medicine residency program at Abington Jefferson Health.

References

1. US Preventive Services Task Force. JAMA. 2018;319(2):165–72.

2. HreskoMT et al. SRS/POSNA/AAOS/AAP position statement: Screening for the early detection for idiopathic scoliosis in adolescents. 2015. Accessed December 8, 2017.
 

I recently attended a local Charleston (S.C.) Medical Society meeting, the theme of which was the opioid crisis. Although at the time I did not see a perfect relevance of this crisis to hospital medicine, I attended anyway, hoping to gain some pearls of wisdom regarding what my role in this epidemic could be.

I was already certainly aware of the extent of the opioid epidemic, including some startling statistics. For example, the burden of the crisis totaled $95 billion in the United States in 2016 from lost productivity and health care and criminal justice system expenses.¹ But I was still not certain what my specific role could be in doing something about it.

The main speaker at the meeting was Nanci Steadman Shipman, the mother of a 19-year-old college student who had accidentally overdosed on heroin the year prior. She told the story of his upbringing, which was in an upper-middle-class suburban neighborhood, full of family, friends, and loving support. When her son was 15 years old, he suffered a leg injury during his lacrosse season, which led to a hospital stay, a surgery, and a prolonged recovery. It was during this period of time that, unbeknownst to his family, he became addicted to opioids.

Over the years, Nanci’s son found ever more creative mechanisms to procure various opioids, eventually resorting to heroin, which was remarkably cheap and easy to find. All the while in high school, he maintained good grades, remained active in sports, and had a normal social circle of friends. It was not until his first year of college that his mother started to worry that something might be wrong. In less than a year, her son quit sports, and his grades spiraled. Despite ongoing family support and extensive rehab, he suffered more than one setback and accidentally overdosed.

After her son’s death, Nanci started a nonprofit organization, Wake Up Carolina.² Its mission is to fight drug abuse among adolescents and young adults. They use a combination of education, awareness, prevention, and recovery tactics to achieve their task. In the meantime, they try to diminish the shame and secrecy among families suffering from opioid addiction. During Nanci’s presentation at the medical society meeting, the message she conveyed to us – an audience full of physicians – was simple: We can either be part of the problem or part of the solution; we all have a duty to help and a role to play in this crisis. Whether a patient is exposed first inside the hospital or outside of it, for a short period of time or for a long one, every opioid exposure comes with a risk. Nanci’s story was incredibly affecting and made me rethink my personal role in this epidemic; how might I have contributed to this, and what could I do differently?

Shortly after her son died, her younger son suffered a femur fracture during a football game. You can imagine the horror her family felt knowing that he would need some pain medication for his acute injury. Nanci and her family were able to work with the medical and surgical teams, and through multimodal pain regimens, her son received little to no opioids during the hospital stay and was able to recover from the fracture with reasonable pain levels. She expressed gratitude that the hospital teams were willing to listen to her and her family’s concerns and offer both pharmacological and nonpharmacological therapies for her son’s recovery, which allayed their fears about opioids.

From this incredibly powerful and moving story of one family’s experience, I was able to gather some very meaningful, evidence-based, and tangible practices that I could implement in my own organization. These might even help other hospitalists take an active role in stemming this sadly growing epidemic.



As hospitalists, we should work on the following:

• Improve our personal knowledge of and skills in utilizing multimodal pain therapies regardless of the etiology of the pain. These should include both pharmacologic and nonpharmacologic interventions.
• Use consultants to assist us with difficult cases. Depending on our practice setting, we should utilize consultants who can give us good advice on nonopioid pain management regimens, such as palliative care.
• Try to influence the practice of surgeons and other specialties that consult us, to help shape prescribing patterns that include nonopioid medical regimens, and to get doctors used to entertaining nonpharmacologic pain-reducing interventions.
• Limit the volume of prescription opioids written to our patients at the time of hospital discharge. There is mounting literature that suggests leftover prescriptions can be the start of an opioid addiction for a family member.
• Educate ourselves and our patients about any local “take back” programs that allow for safe, secure, and anonymous drops of prescription medications. This may reduce opioids getting into the hands of someone who might later become addicted.
• Find out whether our hospitals or health systems have a pain or opioid oversight group or team, and if not, see whether there is interest in starting one.
• Look into local community activist programs to partner with for education, awareness, prevention, or treatment options (such as Wake Up Carolina).
• Work with local resources (for example, case management, social workers, psychiatrists) to learn about and utilize local options for rehabilitation. We should actively and openly discuss these options with any patients known or suspected to be addicted.
• Make a valiant attempt to remove any unconscious bias against people who have become addicted to opioids. Continuing the social stigma of addiction only spurs the shame and secrecy.

Please share other ideas or suggestions you may have regarding the role hospitalists can have in curbing this growing epidemic.
 

References

1. “Burden of opioid crisis reached $95 billion in 2016; private sector hit hardest.” Altarum press release. Nov 16, 2017.

2. Wake Up Carolina website.








 

I recently attended a local Charleston (S.C.) Medical Society meeting, the theme of which was the opioid crisis. Although at the time I did not see a perfect relevance of this crisis to hospital medicine, I attended anyway, hoping to gain some pearls of wisdom regarding what my role in this epidemic could be.

I was already certainly aware of the extent of the opioid epidemic, including some startling statistics. For example, the burden of the crisis totaled $95 billion in the United States in 2016 from lost productivity and health care and criminal justice system expenses.¹ But I was still not certain what my specific role could be in doing something about it.

The main speaker at the meeting was Nanci Steadman Shipman, the mother of a 19-year-old college student who had accidentally overdosed on heroin the year prior. She told the story of his upbringing, which was in an upper-middle-class suburban neighborhood, full of family, friends, and loving support. When her son was 15 years old, he suffered a leg injury during his lacrosse season, which led to a hospital stay, a surgery, and a prolonged recovery. It was during this period of time that, unbeknownst to his family, he became addicted to opioids.

Over the years, Nanci’s son found ever more creative mechanisms to procure various opioids, eventually resorting to heroin, which was remarkably cheap and easy to find. All the while in high school, he maintained good grades, remained active in sports, and had a normal social circle of friends. It was not until his first year of college that his mother started to worry that something might be wrong. In less than a year, her son quit sports, and his grades spiraled. Despite ongoing family support and extensive rehab, he suffered more than one setback and accidentally overdosed.

After her son’s death, Nanci started a nonprofit organization, Wake Up Carolina.² Its mission is to fight drug abuse among adolescents and young adults. They use a combination of education, awareness, prevention, and recovery tactics to achieve their task. In the meantime, they try to diminish the shame and secrecy among families suffering from opioid addiction. During Nanci’s presentation at the medical society meeting, the message she conveyed to us – an audience full of physicians – was simple: We can either be part of the problem or part of the solution; we all have a duty to help and a role to play in this crisis. Whether a patient is exposed first inside the hospital or outside of it, for a short period of time or for a long one, every opioid exposure comes with a risk. Nanci’s story was incredibly affecting and made me rethink my personal role in this epidemic; how might I have contributed to this, and what could I do differently?

Shortly after her son died, her younger son suffered a femur fracture during a football game. You can imagine the horror her family felt knowing that he would need some pain medication for his acute injury. Nanci and her family were able to work with the medical and surgical teams, and through multimodal pain regimens, her son received little to no opioids during the hospital stay and was able to recover from the fracture with reasonable pain levels. She expressed gratitude that the hospital teams were willing to listen to her and her family’s concerns and offer both pharmacological and nonpharmacological therapies for her son’s recovery, which allayed their fears about opioids.

From this incredibly powerful and moving story of one family’s experience, I was able to gather some very meaningful, evidence-based, and tangible practices that I could implement in my own organization. These might even help other hospitalists take an active role in stemming this sadly growing epidemic.



As hospitalists, we should work on the following:

• Improve our personal knowledge of and skills in utilizing multimodal pain therapies regardless of the etiology of the pain. These should include both pharmacologic and nonpharmacologic interventions.
• Use consultants to assist us with difficult cases. Depending on our practice setting, we should utilize consultants who can give us good advice on nonopioid pain management regimens, such as palliative care.
• Try to influence the practice of surgeons and other specialties that consult us, to help shape prescribing patterns that include nonopioid medical regimens, and to get doctors used to entertaining nonpharmacologic pain-reducing interventions.
• Limit the volume of prescription opioids written to our patients at the time of hospital discharge. There is mounting literature that suggests leftover prescriptions can be the start of an opioid addiction for a family member.
• Educate ourselves and our patients about any local “take back” programs that allow for safe, secure, and anonymous drops of prescription medications. This may reduce opioids getting into the hands of someone who might later become addicted.
• Find out whether our hospitals or health systems have a pain or opioid oversight group or team, and if not, see whether there is interest in starting one.
• Look into local community activist programs to partner with for education, awareness, prevention, or treatment options (such as Wake Up Carolina).
• Work with local resources (for example, case management, social workers, psychiatrists) to learn about and utilize local options for rehabilitation. We should actively and openly discuss these options with any patients known or suspected to be addicted.
• Make a valiant attempt to remove any unconscious bias against people who have become addicted to opioids. Continuing the social stigma of addiction only spurs the shame and secrecy.

Please share other ideas or suggestions you may have regarding the role hospitalists can have in curbing this growing epidemic.
 

References

1. “Burden of opioid crisis reached $95 billion in 2016; private sector hit hardest.” Altarum press release. Nov 16, 2017.

2. Wake Up Carolina website.








 

I recently attended a local Charleston (S.C.) Medical Society meeting, the theme of which was the opioid crisis. Although at the time I did not see a perfect relevance of this crisis to hospital medicine, I attended anyway, hoping to gain some pearls of wisdom regarding what my role in this epidemic could be.

I was already certainly aware of the extent of the opioid epidemic, including some startling statistics. For example, the burden of the crisis totaled $95 billion in the United States in 2016 from lost productivity and health care and criminal justice system expenses.¹ But I was still not certain what my specific role could be in doing something about it.

The main speaker at the meeting was Nanci Steadman Shipman, the mother of a 19-year-old college student who had accidentally overdosed on heroin the year prior. She told the story of his upbringing, which was in an upper-middle-class suburban neighborhood, full of family, friends, and loving support. When her son was 15 years old, he suffered a leg injury during his lacrosse season, which led to a hospital stay, a surgery, and a prolonged recovery. It was during this period of time that, unbeknownst to his family, he became addicted to opioids.

Over the years, Nanci’s son found ever more creative mechanisms to procure various opioids, eventually resorting to heroin, which was remarkably cheap and easy to find. All the while in high school, he maintained good grades, remained active in sports, and had a normal social circle of friends. It was not until his first year of college that his mother started to worry that something might be wrong. In less than a year, her son quit sports, and his grades spiraled. Despite ongoing family support and extensive rehab, he suffered more than one setback and accidentally overdosed.

After her son’s death, Nanci started a nonprofit organization, Wake Up Carolina.² Its mission is to fight drug abuse among adolescents and young adults. They use a combination of education, awareness, prevention, and recovery tactics to achieve their task. In the meantime, they try to diminish the shame and secrecy among families suffering from opioid addiction. During Nanci’s presentation at the medical society meeting, the message she conveyed to us – an audience full of physicians – was simple: We can either be part of the problem or part of the solution; we all have a duty to help and a role to play in this crisis. Whether a patient is exposed first inside the hospital or outside of it, for a short period of time or for a long one, every opioid exposure comes with a risk. Nanci’s story was incredibly affecting and made me rethink my personal role in this epidemic; how might I have contributed to this, and what could I do differently?

Shortly after her son died, her younger son suffered a femur fracture during a football game. You can imagine the horror her family felt knowing that he would need some pain medication for his acute injury. Nanci and her family were able to work with the medical and surgical teams, and through multimodal pain regimens, her son received little to no opioids during the hospital stay and was able to recover from the fracture with reasonable pain levels. She expressed gratitude that the hospital teams were willing to listen to her and her family’s concerns and offer both pharmacological and nonpharmacological therapies for her son’s recovery, which allayed their fears about opioids.

From this incredibly powerful and moving story of one family’s experience, I was able to gather some very meaningful, evidence-based, and tangible practices that I could implement in my own organization. These might even help other hospitalists take an active role in stemming this sadly growing epidemic.



As hospitalists, we should work on the following:

• Improve our personal knowledge of and skills in utilizing multimodal pain therapies regardless of the etiology of the pain. These should include both pharmacologic and nonpharmacologic interventions.
• Use consultants to assist us with difficult cases. Depending on our practice setting, we should utilize consultants who can give us good advice on nonopioid pain management regimens, such as palliative care.
• Try to influence the practice of surgeons and other specialties that consult us, to help shape prescribing patterns that include nonopioid medical regimens, and to get doctors used to entertaining nonpharmacologic pain-reducing interventions.
• Limit the volume of prescription opioids written to our patients at the time of hospital discharge. There is mounting literature that suggests leftover prescriptions can be the start of an opioid addiction for a family member.
• Educate ourselves and our patients about any local “take back” programs that allow for safe, secure, and anonymous drops of prescription medications. This may reduce opioids getting into the hands of someone who might later become addicted.
• Find out whether our hospitals or health systems have a pain or opioid oversight group or team, and if not, see whether there is interest in starting one.
• Look into local community activist programs to partner with for education, awareness, prevention, or treatment options (such as Wake Up Carolina).
• Work with local resources (for example, case management, social workers, psychiatrists) to learn about and utilize local options for rehabilitation. We should actively and openly discuss these options with any patients known or suspected to be addicted.
• Make a valiant attempt to remove any unconscious bias against people who have become addicted to opioids. Continuing the social stigma of addiction only spurs the shame and secrecy.

Please share other ideas or suggestions you may have regarding the role hospitalists can have in curbing this growing epidemic.
 

References

1. “Burden of opioid crisis reached $95 billion in 2016; private sector hit hardest.” Altarum press release. Nov 16, 2017.

2. Wake Up Carolina website.








 

Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.

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

Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.

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

Surgeons’ practice situations vary. Therefore, for various reasons, surgeons may not be required to participate in MIPS, or they may not be eligible to do so. For 2018, the Centers for Medicare & Medicaid Services (CMS) estimates that approximately 40 percent of eligible clinicians will be required to submit data under MIPS. Furthermore, many providers (particularly those who are employed or are in large group practices) will have data submitted on their behalf by their groups, institutions, or employers. It is thus imperative that surgeons determine whether they are exempt from participating in the MIPS program. If not exempt, they should then determine if their practice situation necessitates that they report their own individual MIPS data for 2018 or, alternatively, if data will be reported for their groups, institutions, or employers.

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

How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.

To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.

Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.

Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.

Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.

Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.

How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?

Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.

Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?

While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.

In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.

Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.

It’s worth it. It’s our health.
 

Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
 

How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.

To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.

Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.

Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.

Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.

Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.

How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?

Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.

Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?

While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.

In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.

Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.

It’s worth it. It’s our health.
 

Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
 

How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.

To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.

Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.

Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.

Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.

Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.

How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?

Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.

Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?

While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.

In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.

Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.

It’s worth it. It’s our health.
 

Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
 

Why are you bothering to read this? What could I offer that could possibly be useful to you? In fact, I was invited to write this column simply because I happened to be at the right conference at the right time. Soon, if not already, you’ll discover I’m actually not that clever. I’m an impostor.

I’ve thought this while staring at the blank page that is to be my article for the month. Reflecting on it, I realize you’ve probably had the same feelings of fraud at one time or another. Impostor syndrome is common. It is the experience of believing you don’t deserve a role or success despite evidence to the contrary. It often occurs at moments of transition, such as when you were accepted into medical school or matched into a competitive specialty. Looking at your peers, watching how your colleagues perform, you feel you just aren’t smart enough to be there; either someone made a mistake or you just got lucky.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Why are you bothering to read this? What could I offer that could possibly be useful to you? In fact, I was invited to write this column simply because I happened to be at the right conference at the right time. Soon, if not already, you’ll discover I’m actually not that clever. I’m an impostor.

I’ve thought this while staring at the blank page that is to be my article for the month. Reflecting on it, I realize you’ve probably had the same feelings of fraud at one time or another. Impostor syndrome is common. It is the experience of believing you don’t deserve a role or success despite evidence to the contrary. It often occurs at moments of transition, such as when you were accepted into medical school or matched into a competitive specialty. Looking at your peers, watching how your colleagues perform, you feel you just aren’t smart enough to be there; either someone made a mistake or you just got lucky.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Why are you bothering to read this? What could I offer that could possibly be useful to you? In fact, I was invited to write this column simply because I happened to be at the right conference at the right time. Soon, if not already, you’ll discover I’m actually not that clever. I’m an impostor.

I’ve thought this while staring at the blank page that is to be my article for the month. Reflecting on it, I realize you’ve probably had the same feelings of fraud at one time or another. Impostor syndrome is common. It is the experience of believing you don’t deserve a role or success despite evidence to the contrary. It often occurs at moments of transition, such as when you were accepted into medical school or matched into a competitive specialty. Looking at your peers, watching how your colleagues perform, you feel you just aren’t smart enough to be there; either someone made a mistake or you just got lucky.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Recently, there was a lot of hoopla in the popular press caused by the report by Philip A. May, PhD, and his team showing that the rates of fetal alcohol spectrum disorder (FASD) ran between 1.1 to 5.0% in first graders in four U.S. communities (JAMA. 2018;319[5]:474-82). This publication and the press it received made my heart sing because the findings made national news – meaning the issue would be in the public’s consciousness for a day or two. That is progress.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; a clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago; a former president/CEO of Community Mental Health Council; and a former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Recently, there was a lot of hoopla in the popular press caused by the report by Philip A. May, PhD, and his team showing that the rates of fetal alcohol spectrum disorder (FASD) ran between 1.1 to 5.0% in first graders in four U.S. communities (JAMA. 2018;319[5]:474-82). This publication and the press it received made my heart sing because the findings made national news – meaning the issue would be in the public’s consciousness for a day or two. That is progress.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; a clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago; a former president/CEO of Community Mental Health Council; and a former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Recently, there was a lot of hoopla in the popular press caused by the report by Philip A. May, PhD, and his team showing that the rates of fetal alcohol spectrum disorder (FASD) ran between 1.1 to 5.0% in first graders in four U.S. communities (JAMA. 2018;319[5]:474-82). This publication and the press it received made my heart sing because the findings made national news – meaning the issue would be in the public’s consciousness for a day or two. That is progress.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; a clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago; a former president/CEO of Community Mental Health Council; and a former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Few movies have universal appeal these days, but one that comes close is Bill Murray’s 1993 classic, “Groundhog Day,” in which Murray’s character is trapped in a time loop, living the same day over and over until he finally “gets it right.”

One reason that this film resonates with so many, I think, is that we are all, in essence, similarly trapped. Not in a same-day loop, of course; but each week seems eerily similar to the last, as does each month, each year – on and on, ad infinitum. That’s why it is so important, every so often, to step out of the “loop” and reassess the bigger picture.

I write this reminder every couple of years because it’s so easy to lose sight of the overall landscape among the pressures of our daily routines. Sooner or later, no matter how dedicated we are, the grind gets to all of us, leading to fatigue, irritability, and a progressive decline in motivation. And we are too busy to sit down and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.

There are many ways to maintain your intellectual and emotional health, but here’s how I do it: I take individual days off (average of 1 a month) to catch up on journals or taking a CME course; or to try something new – something I’ve been thinking about doing “someday, when there is time” – such as a guitar, bass, or sailing lesson, or a long weekend away with my wife. And we take longer vacations, without fail, each year.

I know how some of you feel about “wasting” a day – or, God forbid, a week. Patients might go elsewhere while you’re gone, and every day the office is idle you “lose money.” That whole paradigm is wrong. You bring in a given amount of revenue per year – more on some days, less on other days, none on weekends and vacations. It all averages out in the end.

Besides, this is much more important than money: This is breaking the routine, clearing the cobwebs, living your life. And trust me, your practice will still be there when you return.

Dr. Joseph S. Eastern

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Few movies have universal appeal these days, but one that comes close is Bill Murray’s 1993 classic, “Groundhog Day,” in which Murray’s character is trapped in a time loop, living the same day over and over until he finally “gets it right.”

One reason that this film resonates with so many, I think, is that we are all, in essence, similarly trapped. Not in a same-day loop, of course; but each week seems eerily similar to the last, as does each month, each year – on and on, ad infinitum. That’s why it is so important, every so often, to step out of the “loop” and reassess the bigger picture.

I write this reminder every couple of years because it’s so easy to lose sight of the overall landscape among the pressures of our daily routines. Sooner or later, no matter how dedicated we are, the grind gets to all of us, leading to fatigue, irritability, and a progressive decline in motivation. And we are too busy to sit down and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.

There are many ways to maintain your intellectual and emotional health, but here’s how I do it: I take individual days off (average of 1 a month) to catch up on journals or taking a CME course; or to try something new – something I’ve been thinking about doing “someday, when there is time” – such as a guitar, bass, or sailing lesson, or a long weekend away with my wife. And we take longer vacations, without fail, each year.

I know how some of you feel about “wasting” a day – or, God forbid, a week. Patients might go elsewhere while you’re gone, and every day the office is idle you “lose money.” That whole paradigm is wrong. You bring in a given amount of revenue per year – more on some days, less on other days, none on weekends and vacations. It all averages out in the end.

Besides, this is much more important than money: This is breaking the routine, clearing the cobwebs, living your life. And trust me, your practice will still be there when you return.

Dr. Joseph S. Eastern

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Few movies have universal appeal these days, but one that comes close is Bill Murray’s 1993 classic, “Groundhog Day,” in which Murray’s character is trapped in a time loop, living the same day over and over until he finally “gets it right.”

One reason that this film resonates with so many, I think, is that we are all, in essence, similarly trapped. Not in a same-day loop, of course; but each week seems eerily similar to the last, as does each month, each year – on and on, ad infinitum. That’s why it is so important, every so often, to step out of the “loop” and reassess the bigger picture.

I write this reminder every couple of years because it’s so easy to lose sight of the overall landscape among the pressures of our daily routines. Sooner or later, no matter how dedicated we are, the grind gets to all of us, leading to fatigue, irritability, and a progressive decline in motivation. And we are too busy to sit down and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.

There are many ways to maintain your intellectual and emotional health, but here’s how I do it: I take individual days off (average of 1 a month) to catch up on journals or taking a CME course; or to try something new – something I’ve been thinking about doing “someday, when there is time” – such as a guitar, bass, or sailing lesson, or a long weekend away with my wife. And we take longer vacations, without fail, each year.

I know how some of you feel about “wasting” a day – or, God forbid, a week. Patients might go elsewhere while you’re gone, and every day the office is idle you “lose money.” That whole paradigm is wrong. You bring in a given amount of revenue per year – more on some days, less on other days, none on weekends and vacations. It all averages out in the end.

Besides, this is much more important than money: This is breaking the routine, clearing the cobwebs, living your life. And trust me, your practice will still be there when you return.

Dr. Joseph S. Eastern

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

I was one of about 600 dermatologists sitting in a lecture hall during a meeting in Maui when our muted smartphones suddenly started howling in unison. A text message popped up stating, “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” We all assumed a nuclear weapon from North Korea was headed our way.

The lecture was interrupted. The confused and concerned attendees milled around. The immediate response was largely “this can’t be real.” Meanwhile, the text alarm went off again transmitting the same message. The hotel intercom repeated the message and warned us to get inside the ballroom.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I was one of about 600 dermatologists sitting in a lecture hall during a meeting in Maui when our muted smartphones suddenly started howling in unison. A text message popped up stating, “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” We all assumed a nuclear weapon from North Korea was headed our way.

The lecture was interrupted. The confused and concerned attendees milled around. The immediate response was largely “this can’t be real.” Meanwhile, the text alarm went off again transmitting the same message. The hotel intercom repeated the message and warned us to get inside the ballroom.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I was one of about 600 dermatologists sitting in a lecture hall during a meeting in Maui when our muted smartphones suddenly started howling in unison. A text message popped up stating, “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” We all assumed a nuclear weapon from North Korea was headed our way.

The lecture was interrupted. The confused and concerned attendees milled around. The immediate response was largely “this can’t be real.” Meanwhile, the text alarm went off again transmitting the same message. The hotel intercom repeated the message and warned us to get inside the ballroom.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Our first daughter was born during my last year in medical school, and our second was born as I was finishing my second year in residency. Seeing those two little darlings grow and develop was a critical supplement to my pediatric training. And, watching my wife initially struggle and then succeed with breastfeeding provided a very personal experience and education about lactation that my interactions in the hospital and outpatient clinics didn’t offer.

We considered ourselves lucky because my wife wasn’t facing the additional challenge of returning to an out-of-the-home job. However, our good fortune did not confer immunity against the anxiety, insecurity, discomfort, and sleep deprivation–induced frustrations of breastfeeding. Watching my wife navigate the choppy waters of lactation certainly influenced my approach to counseling new mothers over my subsequent 4 decades of practice. I think I was a more sympathetic and realistic adviser based on my first-hand observations.

©Lev Olkha/iStockphoto.com

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

When we were invited to a family gathering to celebrate a 60th birthday, we expected to hear an abundance of news about grandchildren. They are natural, and seldom controversial, topics of discussion. If there is a child still waiting in utero and destined to be the first grandchild on one or both sides of the family, the impending adventure in parenthood will dominate the conversation.

To our great surprise, despite the presence of one very pregnant young woman, who in 6 weeks would be giving birth to the first grandchild in my nephew’s family, my wife and I can recall only one brief dialogue in which I was asked about how one might go about selecting a pediatrician.

Stockbyte/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”