The European Commission (EC) has approved cemiplimab (Libtayo) for the treatment of adults with locally advanced or metastatic basal cell carcinoma (BCC) who progressed on – or could not tolerate – treatment with a hedgehog pathway inhibitor (HHI).

The programmed death-1 (PD-1) inhibitor, which is being jointly developed by Regeneron and Sanofi under a global collaboration agreement, was approved by the Food and Drug Administration for this indication in the United States in February; the FDA granted full approval for its use in patients with locally advanced BCC and accelerated approval for use in patients with metastatic BCC.

The EC’s thumbs-up for cemiplimab as a treatment for BCC marks the third such approval for an advanced cancer in the European Union: The immunotherapy was concurrently approved by the EC for the first-line treatment of adults with advanced non–small cell lung cancer (NSCLC) whose tumor cells have ≥ 50% PD-L1 expression and no EGFR, ALK or ROS1 aberrations, and was approved in 2019 for the treatment of adults with metastatic or locally advanced cutaneous squamous cell carcinoma (CSCC) who are not candidates for curative surgery or curative radiation.

The FDA granted approval of cemiplimab for NSCLC in February, and for CSCC in 2018.

The latest BCC approval is based on data from an ongoing, open-label, prospective phase 2 clinical trial of 119 patients with advanced BCC who were previously treated with an HHI. The objective response rates in cemiplimab-treated patients were 32% (partial responses in 25%; complete responses in 7%) in those with locally advanced BCC, and 29% (partial responses in 26%; complete responses in 3%) in those with metastatic BCC.

About 90% of all patients had a duration of response (DOR) of 6 months or longer. Median DOR was not reached in either group at median follow-up of 16 months for locally advanced BCC and 9 months for metastatic BCC.

The safety profile of cemiplimab has been generally consistent across approved indications. Serious adverse events have been reported in 30% of 816 patients from all four cemiplimab monotherapy pivotal trials, and these led to permanent discontinuation of treatment in 8% of patients.

Immune-related adverse reactions occurred in 22% of patients, and led to permanent discontinuation in 4%. The most common such reactions were hypothyroidism (8%), hyperthyroidism (3%), pneumonitis (3%), hepatitis (2%), colitis (2%) and immune-related skin adverse reactions (2%).

Cemiplimab is administered by intravenous infusion over 30 minutes every 3 weeks until disease progression or unacceptable toxicity. The recommended dose is 350 mg.

A press release from Regeneron notes that research efforts with respect to cemiplimab – both as monotherapy and in combination with other agents – are focused on difficult-to-treat cancers, including advanced NSCLC, cervical cancer, and other solid tumors and blood cancers.

The European Commission (EC) has approved cemiplimab (Libtayo) for the treatment of adults with locally advanced or metastatic basal cell carcinoma (BCC) who progressed on – or could not tolerate – treatment with a hedgehog pathway inhibitor (HHI).

The programmed death-1 (PD-1) inhibitor, which is being jointly developed by Regeneron and Sanofi under a global collaboration agreement, was approved by the Food and Drug Administration for this indication in the United States in February; the FDA granted full approval for its use in patients with locally advanced BCC and accelerated approval for use in patients with metastatic BCC.

The EC’s thumbs-up for cemiplimab as a treatment for BCC marks the third such approval for an advanced cancer in the European Union: The immunotherapy was concurrently approved by the EC for the first-line treatment of adults with advanced non–small cell lung cancer (NSCLC) whose tumor cells have ≥ 50% PD-L1 expression and no EGFR, ALK or ROS1 aberrations, and was approved in 2019 for the treatment of adults with metastatic or locally advanced cutaneous squamous cell carcinoma (CSCC) who are not candidates for curative surgery or curative radiation.

The FDA granted approval of cemiplimab for NSCLC in February, and for CSCC in 2018.

The latest BCC approval is based on data from an ongoing, open-label, prospective phase 2 clinical trial of 119 patients with advanced BCC who were previously treated with an HHI. The objective response rates in cemiplimab-treated patients were 32% (partial responses in 25%; complete responses in 7%) in those with locally advanced BCC, and 29% (partial responses in 26%; complete responses in 3%) in those with metastatic BCC.

About 90% of all patients had a duration of response (DOR) of 6 months or longer. Median DOR was not reached in either group at median follow-up of 16 months for locally advanced BCC and 9 months for metastatic BCC.

The safety profile of cemiplimab has been generally consistent across approved indications. Serious adverse events have been reported in 30% of 816 patients from all four cemiplimab monotherapy pivotal trials, and these led to permanent discontinuation of treatment in 8% of patients.

Immune-related adverse reactions occurred in 22% of patients, and led to permanent discontinuation in 4%. The most common such reactions were hypothyroidism (8%), hyperthyroidism (3%), pneumonitis (3%), hepatitis (2%), colitis (2%) and immune-related skin adverse reactions (2%).

Cemiplimab is administered by intravenous infusion over 30 minutes every 3 weeks until disease progression or unacceptable toxicity. The recommended dose is 350 mg.

A press release from Regeneron notes that research efforts with respect to cemiplimab – both as monotherapy and in combination with other agents – are focused on difficult-to-treat cancers, including advanced NSCLC, cervical cancer, and other solid tumors and blood cancers.

The European Commission (EC) has approved cemiplimab (Libtayo) for the treatment of adults with locally advanced or metastatic basal cell carcinoma (BCC) who progressed on – or could not tolerate – treatment with a hedgehog pathway inhibitor (HHI).

The programmed death-1 (PD-1) inhibitor, which is being jointly developed by Regeneron and Sanofi under a global collaboration agreement, was approved by the Food and Drug Administration for this indication in the United States in February; the FDA granted full approval for its use in patients with locally advanced BCC and accelerated approval for use in patients with metastatic BCC.

The EC’s thumbs-up for cemiplimab as a treatment for BCC marks the third such approval for an advanced cancer in the European Union: The immunotherapy was concurrently approved by the EC for the first-line treatment of adults with advanced non–small cell lung cancer (NSCLC) whose tumor cells have ≥ 50% PD-L1 expression and no EGFR, ALK or ROS1 aberrations, and was approved in 2019 for the treatment of adults with metastatic or locally advanced cutaneous squamous cell carcinoma (CSCC) who are not candidates for curative surgery or curative radiation.

The FDA granted approval of cemiplimab for NSCLC in February, and for CSCC in 2018.

The latest BCC approval is based on data from an ongoing, open-label, prospective phase 2 clinical trial of 119 patients with advanced BCC who were previously treated with an HHI. The objective response rates in cemiplimab-treated patients were 32% (partial responses in 25%; complete responses in 7%) in those with locally advanced BCC, and 29% (partial responses in 26%; complete responses in 3%) in those with metastatic BCC.

About 90% of all patients had a duration of response (DOR) of 6 months or longer. Median DOR was not reached in either group at median follow-up of 16 months for locally advanced BCC and 9 months for metastatic BCC.

The safety profile of cemiplimab has been generally consistent across approved indications. Serious adverse events have been reported in 30% of 816 patients from all four cemiplimab monotherapy pivotal trials, and these led to permanent discontinuation of treatment in 8% of patients.

Immune-related adverse reactions occurred in 22% of patients, and led to permanent discontinuation in 4%. The most common such reactions were hypothyroidism (8%), hyperthyroidism (3%), pneumonitis (3%), hepatitis (2%), colitis (2%) and immune-related skin adverse reactions (2%).

Cemiplimab is administered by intravenous infusion over 30 minutes every 3 weeks until disease progression or unacceptable toxicity. The recommended dose is 350 mg.

A press release from Regeneron notes that research efforts with respect to cemiplimab – both as monotherapy and in combination with other agents – are focused on difficult-to-treat cancers, including advanced NSCLC, cervical cancer, and other solid tumors and blood cancers.

TUESDAY, 6/29/21. DAY 3 AT SGS

The third day of the annual SGS meeting started with several academic roundtables hosted by experts in the field. These authorities shared their knowledge on a range of topics including endometriosis, building an academic career, diversity and equity in the workplace, and scientific publishing. The general session got underway with additional oral and video presentations highlighting advancements in our field. This year’s SGS President Dr. Miles Murphy gave the annual presidential address. He spoke genuinely and humbly about our field. Whitney Ross, MD, (@WRossMD), referred to his speech on Twitter as “Best. Presidential. Address. Ever.” –a sentiment felt by many in the crowd!

This year’s Telinde Lecture was given by Janet Dombrowski, the first ever non-physician to present this lecture. She spoke on resiliency in a lecture titled, “Cultivating Resilience: The Power in Connection & Collaboration.” It was an insightful and wise presentation on the power of connection and how connection bolsters our resiliency. She challenged us to all break down “thinking habits” that isolate us into silos and get in the way of powerful connection and collaboration. She reminded us of the African greeting “Sawubona” (I see you) and “Sikhona” (Because you see me, I am here). A gentle reminder that we feel our existence most tangibly when we are seen by others—an idea consistent with other important themes of this conference, focused on diversity, equity, and inclusion of all.  The morning session was rounded out with a panel discussion on “Novel GYN Office Procedure,” featuring Drs. Cecile Ferrando (@CFerrandoMD), Abbas Shobeiri (@ShobeiriAbbas), Andrea Pezzela, and Eric Sokol.

The afternoon was filled with leisure activities in beautiful Palm Springs, including the SGS Golf Tournament, mountain biking, aerial tramway tour, and hike. The weather even cooperated with slightly cooler temperatures (think 100℉ instead of 120℉)! The evening was filled with food, drinks, and the excitement around the annual “SGS’ Got Talent” show! Everyone was able to let down, show off their dance moves, and enjoy some of that much needed connection time!

Tomorrow is the last day of #SGS2021! Excited to round out the conference with continued learning.

MONDAY, 6/28/21. DAY 2 AT SGS 

 The sun is up and working hard here in Palm Springs, and so are we!  
 
Welcome and introduction of new members 
 
The general session started with a warm welcome to the 12 new SGS members. A special shout out to Dr. Kelly Wright who is a new SGS Member and won the #SGS2021 tweetup! She ranked as a top influencer, prolific tweeter, and made more than 250K impressions leading up to SGS! Way to represent @MigsRunner.  
 
General scientific sessions 
 
There were several excellent oral and video presentations throughout the morning session. A range of topics were discussed, including postoperative pain management, strategies for cost-effective surgery, and how racial and ethnic disparities play into our medical education and patient outcomes. Dr. Eva Welch gave a stellar video presentation on straight-stick sacrocolpopexy techniques for the savvy surgeon. I personally will be incorporating some of her needle management tricks!  
 
After a brief break with some refreshments and a stroll around the exhibit hall, the second scientific session initiated with a transformative lecture. Dr. Mark Walters presented "Insights on Surgical Education: How Can I Help You Get Better" in the inaugural Mark D. Walters Lectureship. Dr. Walters shared his experience and insights on how to transform oneself from a good surgeon to an expert and from a teacher to a coach in the operating room. His dedication to our field, years of experience, and wisdom earned him a standing ovation! Additional oral and video presentations followed. Dr. J. Wong shared correlations between surgeon gender and ergonomic strain with laparoscopic devices. Female surgeons more often reported inappropriate fit and expressed physical discomfort compared with male surgeons. Injuries and ergonomic strain lead to less operating and even disability for some surgeons. It is past time for us to have better--we need instruments that fit our hands!  
 
The afternoon session started with a panel on "Perspectives on Race in GYN Surgery." It was another insightful discussion with thought- and action-provoking knowledge. The afternoon session included the SGS Prize Video by Dr. Angela DiCarlo-Meacham on excision of a vulvar cyst.  
 
Fellows' Pelvic Research Network 
 
After adjourning of the scientific sessions, the fellow-ran, multicenter research network (FPRN) met to give updates. This diverse group of both AUGS-SGS and FMIGS-SGS offers mentorship and relationships that are important for future careers and research. The collaboration allows the study of rare outcomes that may not be feasible at single sites. Dr. Amanda Yunker, fellowship director at Vanderbilt University, gave an amazing history lesson on the fields of OB and GYN, and the evolution of gynecologic surgery. We then had fun assigning a "report card grade" on how MIGS is doing comparatively with other subspecialties in the realms of academics and research.  
 
VideoFest 
 
The late afternoon was concluded with a surgical video session. What an amazing and talented group we are here at SGS!  
 
President's awards ceremony and reception 
The scientific focused day was rounded out with an evening of honors, awards, and social time as we celebrated all the achievements of our peers and colleagues. The president's reception was filled with food, laughter, networking, and reconnecting with friends and colleagues. We are looking forward to another day of education tomorrow! 
 
Follow @JennaRehmerMD, @GynSurgery, and #SGS2021 on Twitter for updates. 

SUNDAY, 6/27/21. DAY 1 AT SGS

Hello live from sunny Palm Spring, CA, and the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS)! This year’s conference balances the long-awaited return to in-person events while simultaneously embracing virtual learning with their hybrid meeting format. You can follow me, @JennaRehmerMD, and #SGS2021 in real-time on Twitter. 

Dismantling racism

We were incredibly fortunate to take a deep dive into dismantling racism in our personal and professional spheres. The postgraduate course was well researched and presented by Drs. Oluwateniola “Teni” Brown, Cassandra Carberry, Olivia Cardenas-Trowers (@otrowers_md), Annetta Madsen, Moiuri Siddique, and Blair Washington (@Dr_B_Washington). Each presentation provided a succinct and cohesive flow, taking us through what racism is, the historical and active structural racism in medicine, and the actions and steps of becoming anti-racist. 

Dr. Brown discussed critical race theory. We learned that the engineered system of oppression is so advanced that it is often hidden in plain sight, and that one’s conscious awareness is not necessary in order to uphold the system of oppression. It is reinforced and supported with minimal effort. This is why not being racist is not enough; active anti-racism is needed to bring about change. 

Fibroid management

Across the hall, Drs. Linda Bradley (@BradlelMD), Kimberly Kho (@KimberlyKho1), Cara King (@drcaraking), and Kelly Wright (@MigsRunner) broadened our armamentarium for uterine conservation in fibroid management. Dr. Bradley reviewed medical therapies, including novel treatments, as first-line or adjunct treatment options. Next, the course focused on surgical techniques for hysteroscopic myomectomies, optimization of minilaparotomy for myomectomy, and tissue extraction. Dr. King displayed true grit when giving her lecture from the airport after flight delays prevented her from being in person with us. 

Multidisciplinary care within gyn surgery

In this virtual only postgraduate course, Drs. Risal Djohan (@DjohanMD), Cecile Ferrando (@CFerrandoMD), Marie Fidela Paraiso, Sandip Vasavada (@SandipVasavada), and Sarah Vogler showed us the importance of multidisciplinary care within gynecologic surgery practices. They explored how to streamline the approach so it complements your practice, how to co-bill for shared patient care, and tips and tricks for optimizing the surgical experience for the patient. 

Industry presentations

Over lunch, Dr. Opoku-Akane presented on using ERAS (enhanced recovery after surgery) protocols for endometriosis and chronic pelvic pain and how to optimize the use of alternative surgical modalities for endometriosis. Following this, Drs. Albert Huany and Craig McCoy taught about a new technology using electrical stimulation to optimize visualization of the ureter. 

Harnessing the power of social media

This workshop, organized by SGS Social Media Committee Chair Dr. Amy Park (@dramypark) showed us the importance of having an online identity for the sharing of ideas, networking, professional development, and education. We learned how to optimize our online bios, proper use of GYN ontology for hashtags, and how to maintain professionalism on social media. We reviewed the data on how sharing publications on social media improves altmetric scores and discussed how our social media influence may be tied to performance in the future. 

Lessons in leadership

We rounded out the day with after-dinner dessert and drinks at the evening SGS Women’s Council presentation. We had the great honor of hearing from Lori Ryerker, CEO of Celanese Corporation, a Fortune 500 global company. She provided much wisdom on being a leader. She shared several keys to creating a successful work environment:

• being a leader that “provides an environment where people feel like they can bring their best selves every day” (and that being your best self is being your whole self, without reservations)
• allowing all genders, sexual orientations, races, ethnicities, and ages to show up together without reservations (because only then can people feel safe to be their best, because their best self is their true self). 

It was a wonderful and successful kick-off to the meeting. I look forward to a full day tomorrow! Follow along as this year’s Fellow Scholars, Drs. Tara Brah (@TaraBrah), Amr El Haraki (@drharaki), Sheena Galhotra (@SheenaGalhotra), Meenal Misal (@meenalmisalMD), and yours truly, post live updates daily.

TUESDAY, 6/29/21. DAY 3 AT SGS

The third day of the annual SGS meeting started with several academic roundtables hosted by experts in the field. These authorities shared their knowledge on a range of topics including endometriosis, building an academic career, diversity and equity in the workplace, and scientific publishing. The general session got underway with additional oral and video presentations highlighting advancements in our field. This year’s SGS President Dr. Miles Murphy gave the annual presidential address. He spoke genuinely and humbly about our field. Whitney Ross, MD, (@WRossMD), referred to his speech on Twitter as “Best. Presidential. Address. Ever.” –a sentiment felt by many in the crowd!

This year’s Telinde Lecture was given by Janet Dombrowski, the first ever non-physician to present this lecture. She spoke on resiliency in a lecture titled, “Cultivating Resilience: The Power in Connection & Collaboration.” It was an insightful and wise presentation on the power of connection and how connection bolsters our resiliency. She challenged us to all break down “thinking habits” that isolate us into silos and get in the way of powerful connection and collaboration. She reminded us of the African greeting “Sawubona” (I see you) and “Sikhona” (Because you see me, I am here). A gentle reminder that we feel our existence most tangibly when we are seen by others—an idea consistent with other important themes of this conference, focused on diversity, equity, and inclusion of all.  The morning session was rounded out with a panel discussion on “Novel GYN Office Procedure,” featuring Drs. Cecile Ferrando (@CFerrandoMD), Abbas Shobeiri (@ShobeiriAbbas), Andrea Pezzela, and Eric Sokol.

The afternoon was filled with leisure activities in beautiful Palm Springs, including the SGS Golf Tournament, mountain biking, aerial tramway tour, and hike. The weather even cooperated with slightly cooler temperatures (think 100℉ instead of 120℉)! The evening was filled with food, drinks, and the excitement around the annual “SGS’ Got Talent” show! Everyone was able to let down, show off their dance moves, and enjoy some of that much needed connection time!

Tomorrow is the last day of #SGS2021! Excited to round out the conference with continued learning.

MONDAY, 6/28/21. DAY 2 AT SGS 

 The sun is up and working hard here in Palm Springs, and so are we!  
 
Welcome and introduction of new members 
 
The general session started with a warm welcome to the 12 new SGS members. A special shout out to Dr. Kelly Wright who is a new SGS Member and won the #SGS2021 tweetup! She ranked as a top influencer, prolific tweeter, and made more than 250K impressions leading up to SGS! Way to represent @MigsRunner.  
 
General scientific sessions 
 
There were several excellent oral and video presentations throughout the morning session. A range of topics were discussed, including postoperative pain management, strategies for cost-effective surgery, and how racial and ethnic disparities play into our medical education and patient outcomes. Dr. Eva Welch gave a stellar video presentation on straight-stick sacrocolpopexy techniques for the savvy surgeon. I personally will be incorporating some of her needle management tricks!  
 
After a brief break with some refreshments and a stroll around the exhibit hall, the second scientific session initiated with a transformative lecture. Dr. Mark Walters presented "Insights on Surgical Education: How Can I Help You Get Better" in the inaugural Mark D. Walters Lectureship. Dr. Walters shared his experience and insights on how to transform oneself from a good surgeon to an expert and from a teacher to a coach in the operating room. His dedication to our field, years of experience, and wisdom earned him a standing ovation! Additional oral and video presentations followed. Dr. J. Wong shared correlations between surgeon gender and ergonomic strain with laparoscopic devices. Female surgeons more often reported inappropriate fit and expressed physical discomfort compared with male surgeons. Injuries and ergonomic strain lead to less operating and even disability for some surgeons. It is past time for us to have better--we need instruments that fit our hands!  
 
The afternoon session started with a panel on "Perspectives on Race in GYN Surgery." It was another insightful discussion with thought- and action-provoking knowledge. The afternoon session included the SGS Prize Video by Dr. Angela DiCarlo-Meacham on excision of a vulvar cyst.  
 
Fellows' Pelvic Research Network 
 
After adjourning of the scientific sessions, the fellow-ran, multicenter research network (FPRN) met to give updates. This diverse group of both AUGS-SGS and FMIGS-SGS offers mentorship and relationships that are important for future careers and research. The collaboration allows the study of rare outcomes that may not be feasible at single sites. Dr. Amanda Yunker, fellowship director at Vanderbilt University, gave an amazing history lesson on the fields of OB and GYN, and the evolution of gynecologic surgery. We then had fun assigning a "report card grade" on how MIGS is doing comparatively with other subspecialties in the realms of academics and research.  
 
VideoFest 
 
The late afternoon was concluded with a surgical video session. What an amazing and talented group we are here at SGS!  
 
President's awards ceremony and reception 
The scientific focused day was rounded out with an evening of honors, awards, and social time as we celebrated all the achievements of our peers and colleagues. The president's reception was filled with food, laughter, networking, and reconnecting with friends and colleagues. We are looking forward to another day of education tomorrow! 
 
Follow @JennaRehmerMD, @GynSurgery, and #SGS2021 on Twitter for updates. 

SUNDAY, 6/27/21. DAY 1 AT SGS

Hello live from sunny Palm Spring, CA, and the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS)! This year’s conference balances the long-awaited return to in-person events while simultaneously embracing virtual learning with their hybrid meeting format. You can follow me, @JennaRehmerMD, and #SGS2021 in real-time on Twitter. 

Dismantling racism

We were incredibly fortunate to take a deep dive into dismantling racism in our personal and professional spheres. The postgraduate course was well researched and presented by Drs. Oluwateniola “Teni” Brown, Cassandra Carberry, Olivia Cardenas-Trowers (@otrowers_md), Annetta Madsen, Moiuri Siddique, and Blair Washington (@Dr_B_Washington). Each presentation provided a succinct and cohesive flow, taking us through what racism is, the historical and active structural racism in medicine, and the actions and steps of becoming anti-racist. 

Dr. Brown discussed critical race theory. We learned that the engineered system of oppression is so advanced that it is often hidden in plain sight, and that one’s conscious awareness is not necessary in order to uphold the system of oppression. It is reinforced and supported with minimal effort. This is why not being racist is not enough; active anti-racism is needed to bring about change. 

Fibroid management

Across the hall, Drs. Linda Bradley (@BradlelMD), Kimberly Kho (@KimberlyKho1), Cara King (@drcaraking), and Kelly Wright (@MigsRunner) broadened our armamentarium for uterine conservation in fibroid management. Dr. Bradley reviewed medical therapies, including novel treatments, as first-line or adjunct treatment options. Next, the course focused on surgical techniques for hysteroscopic myomectomies, optimization of minilaparotomy for myomectomy, and tissue extraction. Dr. King displayed true grit when giving her lecture from the airport after flight delays prevented her from being in person with us. 

Multidisciplinary care within gyn surgery

In this virtual only postgraduate course, Drs. Risal Djohan (@DjohanMD), Cecile Ferrando (@CFerrandoMD), Marie Fidela Paraiso, Sandip Vasavada (@SandipVasavada), and Sarah Vogler showed us the importance of multidisciplinary care within gynecologic surgery practices. They explored how to streamline the approach so it complements your practice, how to co-bill for shared patient care, and tips and tricks for optimizing the surgical experience for the patient. 

Industry presentations

Over lunch, Dr. Opoku-Akane presented on using ERAS (enhanced recovery after surgery) protocols for endometriosis and chronic pelvic pain and how to optimize the use of alternative surgical modalities for endometriosis. Following this, Drs. Albert Huany and Craig McCoy taught about a new technology using electrical stimulation to optimize visualization of the ureter. 

Harnessing the power of social media

This workshop, organized by SGS Social Media Committee Chair Dr. Amy Park (@dramypark) showed us the importance of having an online identity for the sharing of ideas, networking, professional development, and education. We learned how to optimize our online bios, proper use of GYN ontology for hashtags, and how to maintain professionalism on social media. We reviewed the data on how sharing publications on social media improves altmetric scores and discussed how our social media influence may be tied to performance in the future. 

Lessons in leadership

We rounded out the day with after-dinner dessert and drinks at the evening SGS Women’s Council presentation. We had the great honor of hearing from Lori Ryerker, CEO of Celanese Corporation, a Fortune 500 global company. She provided much wisdom on being a leader. She shared several keys to creating a successful work environment:

• being a leader that “provides an environment where people feel like they can bring their best selves every day” (and that being your best self is being your whole self, without reservations)
• allowing all genders, sexual orientations, races, ethnicities, and ages to show up together without reservations (because only then can people feel safe to be their best, because their best self is their true self). 

It was a wonderful and successful kick-off to the meeting. I look forward to a full day tomorrow! Follow along as this year’s Fellow Scholars, Drs. Tara Brah (@TaraBrah), Amr El Haraki (@drharaki), Sheena Galhotra (@SheenaGalhotra), Meenal Misal (@meenalmisalMD), and yours truly, post live updates daily.

TUESDAY, 6/29/21. DAY 3 AT SGS

The third day of the annual SGS meeting started with several academic roundtables hosted by experts in the field. These authorities shared their knowledge on a range of topics including endometriosis, building an academic career, diversity and equity in the workplace, and scientific publishing. The general session got underway with additional oral and video presentations highlighting advancements in our field. This year’s SGS President Dr. Miles Murphy gave the annual presidential address. He spoke genuinely and humbly about our field. Whitney Ross, MD, (@WRossMD), referred to his speech on Twitter as “Best. Presidential. Address. Ever.” –a sentiment felt by many in the crowd!

This year’s Telinde Lecture was given by Janet Dombrowski, the first ever non-physician to present this lecture. She spoke on resiliency in a lecture titled, “Cultivating Resilience: The Power in Connection & Collaboration.” It was an insightful and wise presentation on the power of connection and how connection bolsters our resiliency. She challenged us to all break down “thinking habits” that isolate us into silos and get in the way of powerful connection and collaboration. She reminded us of the African greeting “Sawubona” (I see you) and “Sikhona” (Because you see me, I am here). A gentle reminder that we feel our existence most tangibly when we are seen by others—an idea consistent with other important themes of this conference, focused on diversity, equity, and inclusion of all.  The morning session was rounded out with a panel discussion on “Novel GYN Office Procedure,” featuring Drs. Cecile Ferrando (@CFerrandoMD), Abbas Shobeiri (@ShobeiriAbbas), Andrea Pezzela, and Eric Sokol.

The afternoon was filled with leisure activities in beautiful Palm Springs, including the SGS Golf Tournament, mountain biking, aerial tramway tour, and hike. The weather even cooperated with slightly cooler temperatures (think 100℉ instead of 120℉)! The evening was filled with food, drinks, and the excitement around the annual “SGS’ Got Talent” show! Everyone was able to let down, show off their dance moves, and enjoy some of that much needed connection time!

Tomorrow is the last day of #SGS2021! Excited to round out the conference with continued learning.

MONDAY, 6/28/21. DAY 2 AT SGS 

 The sun is up and working hard here in Palm Springs, and so are we!  
 
Welcome and introduction of new members 
 
The general session started with a warm welcome to the 12 new SGS members. A special shout out to Dr. Kelly Wright who is a new SGS Member and won the #SGS2021 tweetup! She ranked as a top influencer, prolific tweeter, and made more than 250K impressions leading up to SGS! Way to represent @MigsRunner.  
 
General scientific sessions 
 
There were several excellent oral and video presentations throughout the morning session. A range of topics were discussed, including postoperative pain management, strategies for cost-effective surgery, and how racial and ethnic disparities play into our medical education and patient outcomes. Dr. Eva Welch gave a stellar video presentation on straight-stick sacrocolpopexy techniques for the savvy surgeon. I personally will be incorporating some of her needle management tricks!  
 
After a brief break with some refreshments and a stroll around the exhibit hall, the second scientific session initiated with a transformative lecture. Dr. Mark Walters presented "Insights on Surgical Education: How Can I Help You Get Better" in the inaugural Mark D. Walters Lectureship. Dr. Walters shared his experience and insights on how to transform oneself from a good surgeon to an expert and from a teacher to a coach in the operating room. His dedication to our field, years of experience, and wisdom earned him a standing ovation! Additional oral and video presentations followed. Dr. J. Wong shared correlations between surgeon gender and ergonomic strain with laparoscopic devices. Female surgeons more often reported inappropriate fit and expressed physical discomfort compared with male surgeons. Injuries and ergonomic strain lead to less operating and even disability for some surgeons. It is past time for us to have better--we need instruments that fit our hands!  
 
The afternoon session started with a panel on "Perspectives on Race in GYN Surgery." It was another insightful discussion with thought- and action-provoking knowledge. The afternoon session included the SGS Prize Video by Dr. Angela DiCarlo-Meacham on excision of a vulvar cyst.  
 
Fellows' Pelvic Research Network 
 
After adjourning of the scientific sessions, the fellow-ran, multicenter research network (FPRN) met to give updates. This diverse group of both AUGS-SGS and FMIGS-SGS offers mentorship and relationships that are important for future careers and research. The collaboration allows the study of rare outcomes that may not be feasible at single sites. Dr. Amanda Yunker, fellowship director at Vanderbilt University, gave an amazing history lesson on the fields of OB and GYN, and the evolution of gynecologic surgery. We then had fun assigning a "report card grade" on how MIGS is doing comparatively with other subspecialties in the realms of academics and research.  
 
VideoFest 
 
The late afternoon was concluded with a surgical video session. What an amazing and talented group we are here at SGS!  
 
President's awards ceremony and reception 
The scientific focused day was rounded out with an evening of honors, awards, and social time as we celebrated all the achievements of our peers and colleagues. The president's reception was filled with food, laughter, networking, and reconnecting with friends and colleagues. We are looking forward to another day of education tomorrow! 
 
Follow @JennaRehmerMD, @GynSurgery, and #SGS2021 on Twitter for updates. 

SUNDAY, 6/27/21. DAY 1 AT SGS

Hello live from sunny Palm Spring, CA, and the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS)! This year’s conference balances the long-awaited return to in-person events while simultaneously embracing virtual learning with their hybrid meeting format. You can follow me, @JennaRehmerMD, and #SGS2021 in real-time on Twitter. 

Dismantling racism

We were incredibly fortunate to take a deep dive into dismantling racism in our personal and professional spheres. The postgraduate course was well researched and presented by Drs. Oluwateniola “Teni” Brown, Cassandra Carberry, Olivia Cardenas-Trowers (@otrowers_md), Annetta Madsen, Moiuri Siddique, and Blair Washington (@Dr_B_Washington). Each presentation provided a succinct and cohesive flow, taking us through what racism is, the historical and active structural racism in medicine, and the actions and steps of becoming anti-racist. 

Dr. Brown discussed critical race theory. We learned that the engineered system of oppression is so advanced that it is often hidden in plain sight, and that one’s conscious awareness is not necessary in order to uphold the system of oppression. It is reinforced and supported with minimal effort. This is why not being racist is not enough; active anti-racism is needed to bring about change. 

Fibroid management

Across the hall, Drs. Linda Bradley (@BradlelMD), Kimberly Kho (@KimberlyKho1), Cara King (@drcaraking), and Kelly Wright (@MigsRunner) broadened our armamentarium for uterine conservation in fibroid management. Dr. Bradley reviewed medical therapies, including novel treatments, as first-line or adjunct treatment options. Next, the course focused on surgical techniques for hysteroscopic myomectomies, optimization of minilaparotomy for myomectomy, and tissue extraction. Dr. King displayed true grit when giving her lecture from the airport after flight delays prevented her from being in person with us. 

Multidisciplinary care within gyn surgery

In this virtual only postgraduate course, Drs. Risal Djohan (@DjohanMD), Cecile Ferrando (@CFerrandoMD), Marie Fidela Paraiso, Sandip Vasavada (@SandipVasavada), and Sarah Vogler showed us the importance of multidisciplinary care within gynecologic surgery practices. They explored how to streamline the approach so it complements your practice, how to co-bill for shared patient care, and tips and tricks for optimizing the surgical experience for the patient. 

Industry presentations

Over lunch, Dr. Opoku-Akane presented on using ERAS (enhanced recovery after surgery) protocols for endometriosis and chronic pelvic pain and how to optimize the use of alternative surgical modalities for endometriosis. Following this, Drs. Albert Huany and Craig McCoy taught about a new technology using electrical stimulation to optimize visualization of the ureter. 

Harnessing the power of social media

This workshop, organized by SGS Social Media Committee Chair Dr. Amy Park (@dramypark) showed us the importance of having an online identity for the sharing of ideas, networking, professional development, and education. We learned how to optimize our online bios, proper use of GYN ontology for hashtags, and how to maintain professionalism on social media. We reviewed the data on how sharing publications on social media improves altmetric scores and discussed how our social media influence may be tied to performance in the future. 

Lessons in leadership

We rounded out the day with after-dinner dessert and drinks at the evening SGS Women’s Council presentation. We had the great honor of hearing from Lori Ryerker, CEO of Celanese Corporation, a Fortune 500 global company. She provided much wisdom on being a leader. She shared several keys to creating a successful work environment:

• being a leader that “provides an environment where people feel like they can bring their best selves every day” (and that being your best self is being your whole self, without reservations)
• allowing all genders, sexual orientations, races, ethnicities, and ages to show up together without reservations (because only then can people feel safe to be their best, because their best self is their true self). 

It was a wonderful and successful kick-off to the meeting. I look forward to a full day tomorrow! Follow along as this year’s Fellow Scholars, Drs. Tara Brah (@TaraBrah), Amr El Haraki (@drharaki), Sheena Galhotra (@SheenaGalhotra), Meenal Misal (@meenalmisalMD), and yours truly, post live updates daily.

As of today, I’m still wearing a mask. And I have no desire to stop.  I’ve been vaccinated. Everyone in my family and social circle has been vaccinated. But I’m still wearing one, at least inside (besides my house).

In my everyday life I see a fair number of patients. Because I’m in a medical office, not a grocery store, I still ask others to wear them.

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

As of today, I’m still wearing a mask. And I have no desire to stop.  I’ve been vaccinated. Everyone in my family and social circle has been vaccinated. But I’m still wearing one, at least inside (besides my house).

In my everyday life I see a fair number of patients. Because I’m in a medical office, not a grocery store, I still ask others to wear them.

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

As of today, I’m still wearing a mask. And I have no desire to stop.  I’ve been vaccinated. Everyone in my family and social circle has been vaccinated. But I’m still wearing one, at least inside (besides my house).

In my everyday life I see a fair number of patients. Because I’m in a medical office, not a grocery store, I still ask others to wear them.

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

Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.

Study design: Observational cohort study.

Setting: Duke University Medical Center, Durham, N.C.

Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).

Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.

Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.

Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.

Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.

Study design: Observational cohort study.

Setting: Duke University Medical Center, Durham, N.C.

Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).

Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.

Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.

Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.

Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.

Study design: Observational cohort study.

Setting: Duke University Medical Center, Durham, N.C.

Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).

Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.

Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.

Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

Dr. Michael Grunwald presents highlights in the latest studies involving several types of leukemia from the ASCO 2021 Virtual Congress.

In a dose-optimization study of ponatinib, patients with chronic-phase chronic myeloid leukemia were randomized 1:1:1 to receive 45, 30, or 15 mg daily, with dose reductions occurring once patients met the primary endpoint of ≤1% BCR-ABL1. At 12 months, response rate was highest with the 45 mg to 15 mg regimen, and 73.3% of patients in this cohort maintained response.

The phase 1/2 ZUMA-3 study evaluated KTE-X19 in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. The drug’s efficacy, speed of manufacture, and ease of safety management were found to be sufficient to provide long-term clinical benefit.

Another study focused on the efficacy and safety of aspacytarabine (BST-236) for patients with acute myeloid leukemia (AML) who were unfit for chemotherapy. The rate of complete remission was 39% among the AML population, and 63% of the population in complete remission had minimal residual disease.

Dr. Grunwald closes with a study of ponatinib and blinatumomab in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia. The combination of both drugs was proven to be a safe and effective chemotherapy-free regimen in both newly diagnosed patients and patients with relapsed/refractory disease.
 

--

Michael R. Grunwald, MD, Chief, Leukemia Division. Department of Hematologic Oncology and Blood Disorders. Levine Cancer Institute, Atrium Health. Charlotte, North Carolina.

Michael R. Grunwald, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Agios; Amgen; Astellas Pharma; Blueprint Medicines; Bristol Myers Squibb; Cardinal Health; Daiichi Sankyo; Gilead Sciences; Incyte; Karius; Pfizer; Premier Pharmaceuticals; Sierra Oncology; Stemline Therapeutics.
Received research grant from: Incyte; Janssen.
 

Dr. Michael Grunwald presents highlights in the latest studies involving several types of leukemia from the ASCO 2021 Virtual Congress.

In a dose-optimization study of ponatinib, patients with chronic-phase chronic myeloid leukemia were randomized 1:1:1 to receive 45, 30, or 15 mg daily, with dose reductions occurring once patients met the primary endpoint of ≤1% BCR-ABL1. At 12 months, response rate was highest with the 45 mg to 15 mg regimen, and 73.3% of patients in this cohort maintained response.

The phase 1/2 ZUMA-3 study evaluated KTE-X19 in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. The drug’s efficacy, speed of manufacture, and ease of safety management were found to be sufficient to provide long-term clinical benefit.

Another study focused on the efficacy and safety of aspacytarabine (BST-236) for patients with acute myeloid leukemia (AML) who were unfit for chemotherapy. The rate of complete remission was 39% among the AML population, and 63% of the population in complete remission had minimal residual disease.

Dr. Grunwald closes with a study of ponatinib and blinatumomab in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia. The combination of both drugs was proven to be a safe and effective chemotherapy-free regimen in both newly diagnosed patients and patients with relapsed/refractory disease.
 

--

Michael R. Grunwald, MD, Chief, Leukemia Division. Department of Hematologic Oncology and Blood Disorders. Levine Cancer Institute, Atrium Health. Charlotte, North Carolina.

Michael R. Grunwald, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Agios; Amgen; Astellas Pharma; Blueprint Medicines; Bristol Myers Squibb; Cardinal Health; Daiichi Sankyo; Gilead Sciences; Incyte; Karius; Pfizer; Premier Pharmaceuticals; Sierra Oncology; Stemline Therapeutics.
Received research grant from: Incyte; Janssen.
 

Dr. Michael Grunwald presents highlights in the latest studies involving several types of leukemia from the ASCO 2021 Virtual Congress.

In a dose-optimization study of ponatinib, patients with chronic-phase chronic myeloid leukemia were randomized 1:1:1 to receive 45, 30, or 15 mg daily, with dose reductions occurring once patients met the primary endpoint of ≤1% BCR-ABL1. At 12 months, response rate was highest with the 45 mg to 15 mg regimen, and 73.3% of patients in this cohort maintained response.

The phase 1/2 ZUMA-3 study evaluated KTE-X19 in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. The drug’s efficacy, speed of manufacture, and ease of safety management were found to be sufficient to provide long-term clinical benefit.

Another study focused on the efficacy and safety of aspacytarabine (BST-236) for patients with acute myeloid leukemia (AML) who were unfit for chemotherapy. The rate of complete remission was 39% among the AML population, and 63% of the population in complete remission had minimal residual disease.

Dr. Grunwald closes with a study of ponatinib and blinatumomab in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia. The combination of both drugs was proven to be a safe and effective chemotherapy-free regimen in both newly diagnosed patients and patients with relapsed/refractory disease.
 

--

Michael R. Grunwald, MD, Chief, Leukemia Division. Department of Hematologic Oncology and Blood Disorders. Levine Cancer Institute, Atrium Health. Charlotte, North Carolina.

Michael R. Grunwald, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Agios; Amgen; Astellas Pharma; Blueprint Medicines; Bristol Myers Squibb; Cardinal Health; Daiichi Sankyo; Gilead Sciences; Incyte; Karius; Pfizer; Premier Pharmaceuticals; Sierra Oncology; Stemline Therapeutics.
Received research grant from: Incyte; Janssen.
 

Centers for Medicare and Medicaid Services (CMS)–promulgated quality metrics continue to attract critics. Physicians decry that many metrics are outside their control, while patient groups are frustrated that metrics lack meaning for beneficiaries. The Hospital Readmissions Reduction Program (HRRP) reduces payments for “excess” 30-day risk-standardized readmissions for six conditions and procedures, and may be less effective in reducing readmissions than previously reported due to intentional and increasing use of hospital observation stays.¹

In this issue, Sheehy et al² report that nearly one in five rehospitalizations were unrecognized because either the index hospitalization or the rehospitalization was an observation stay, highlighting yet another challenge with the HRRP. Limitations of their study include the use of a single year of claims data and the exclusion of Medicare Advantage claims data, as one might expect lower readmission rates in this capitated program. Opportunities for improving the HRRP could consist of updating the HRRP metric to include observation stays and, for surgical hospitalizations, extended-stay surgical recovery, wherein patients may be observed for up to 2 days following a procedure. Unfortunately, despite the HRRP missing nearly one in five readmissions, CMS would likely need additional statutory authority from Congress in order to reinterpret the definition of readmission³ to include observation stays.

Challenges with the HRRP metrics raise broader concerns about the program. For decades, administrators viewed readmissions as a utilization metric, only to have the Affordable Care Act re-designate and define all-cause readmissions as a quality metric. Yet hospitals and health systems control only some factors driving readmission. Readmissions occur for a variety of reasons, including not only poor quality of initial hospital care and inadequate care coordination, but also factors that are beyond the hospital’s purview, such as lack of access to ambulatory services, multiple and severe chronic conditions that progress or remain unresponsive to intervention,⁴ and demographic and social factors such as housing instability, health literacy, or residence in a food desert. These non-hospital factors reside within the domain of other market participants or local, state, and federal government agencies.

Challenges to the utility, validity, and appropriateness of HRRP metrics should remind policymakers of the dangers of over-legislating the details of healthcare policy and the statutory inflexibility that can ensue. Clinical care evolves, and artificial constructs—including payment categories such as observation status—may age poorly over time, exemplified best by the challenges of accessing post-acute care due to the 3-day rule.⁵ Introduced as a statutory requirement in 1967, when the average length of stay was 13.8 days and observation care did not exist as a payment category, the 3-day rule requires Medicare beneficiaries to spend 3 days admitted to the hospital in order to qualify for coverage of post-acute care, creating care gaps for observation stay patients.

Observation care itself is an artificial construct of CMS payment policy. In the Medicare program, observation care falls under Part B, exposing patients to both greater financial responsibility and billing complexity through the engagement of their supplemental insurance, even though those receiving observation care experience the same care as if hospitalized— routine monitoring, nursing care, blood draws, imaging, and diagnostic tests. While CMS requires notification of observation status and explanation of the difference in patient financial responsibility, in clinical practice, patient understanding is limited. Policymakers can support both Medicare beneficiaries and hospitals by reexamining observation care as a payment category.

Sheehy and colleagues’ work simultaneously challenges the face validity of the HRRP and the reasonableness of categorizing some inpatient stays as outpatient care in the hospital—issues that policymakers can and should address.

Centers for Medicare and Medicaid Services (CMS)–promulgated quality metrics continue to attract critics. Physicians decry that many metrics are outside their control, while patient groups are frustrated that metrics lack meaning for beneficiaries. The Hospital Readmissions Reduction Program (HRRP) reduces payments for “excess” 30-day risk-standardized readmissions for six conditions and procedures, and may be less effective in reducing readmissions than previously reported due to intentional and increasing use of hospital observation stays.¹

In this issue, Sheehy et al² report that nearly one in five rehospitalizations were unrecognized because either the index hospitalization or the rehospitalization was an observation stay, highlighting yet another challenge with the HRRP. Limitations of their study include the use of a single year of claims data and the exclusion of Medicare Advantage claims data, as one might expect lower readmission rates in this capitated program. Opportunities for improving the HRRP could consist of updating the HRRP metric to include observation stays and, for surgical hospitalizations, extended-stay surgical recovery, wherein patients may be observed for up to 2 days following a procedure. Unfortunately, despite the HRRP missing nearly one in five readmissions, CMS would likely need additional statutory authority from Congress in order to reinterpret the definition of readmission³ to include observation stays.

Challenges with the HRRP metrics raise broader concerns about the program. For decades, administrators viewed readmissions as a utilization metric, only to have the Affordable Care Act re-designate and define all-cause readmissions as a quality metric. Yet hospitals and health systems control only some factors driving readmission. Readmissions occur for a variety of reasons, including not only poor quality of initial hospital care and inadequate care coordination, but also factors that are beyond the hospital’s purview, such as lack of access to ambulatory services, multiple and severe chronic conditions that progress or remain unresponsive to intervention,⁴ and demographic and social factors such as housing instability, health literacy, or residence in a food desert. These non-hospital factors reside within the domain of other market participants or local, state, and federal government agencies.

Challenges to the utility, validity, and appropriateness of HRRP metrics should remind policymakers of the dangers of over-legislating the details of healthcare policy and the statutory inflexibility that can ensue. Clinical care evolves, and artificial constructs—including payment categories such as observation status—may age poorly over time, exemplified best by the challenges of accessing post-acute care due to the 3-day rule.⁵ Introduced as a statutory requirement in 1967, when the average length of stay was 13.8 days and observation care did not exist as a payment category, the 3-day rule requires Medicare beneficiaries to spend 3 days admitted to the hospital in order to qualify for coverage of post-acute care, creating care gaps for observation stay patients.

Observation care itself is an artificial construct of CMS payment policy. In the Medicare program, observation care falls under Part B, exposing patients to both greater financial responsibility and billing complexity through the engagement of their supplemental insurance, even though those receiving observation care experience the same care as if hospitalized— routine monitoring, nursing care, blood draws, imaging, and diagnostic tests. While CMS requires notification of observation status and explanation of the difference in patient financial responsibility, in clinical practice, patient understanding is limited. Policymakers can support both Medicare beneficiaries and hospitals by reexamining observation care as a payment category.

Sheehy and colleagues’ work simultaneously challenges the face validity of the HRRP and the reasonableness of categorizing some inpatient stays as outpatient care in the hospital—issues that policymakers can and should address.

Centers for Medicare and Medicaid Services (CMS)–promulgated quality metrics continue to attract critics. Physicians decry that many metrics are outside their control, while patient groups are frustrated that metrics lack meaning for beneficiaries. The Hospital Readmissions Reduction Program (HRRP) reduces payments for “excess” 30-day risk-standardized readmissions for six conditions and procedures, and may be less effective in reducing readmissions than previously reported due to intentional and increasing use of hospital observation stays.¹

In this issue, Sheehy et al² report that nearly one in five rehospitalizations were unrecognized because either the index hospitalization or the rehospitalization was an observation stay, highlighting yet another challenge with the HRRP. Limitations of their study include the use of a single year of claims data and the exclusion of Medicare Advantage claims data, as one might expect lower readmission rates in this capitated program. Opportunities for improving the HRRP could consist of updating the HRRP metric to include observation stays and, for surgical hospitalizations, extended-stay surgical recovery, wherein patients may be observed for up to 2 days following a procedure. Unfortunately, despite the HRRP missing nearly one in five readmissions, CMS would likely need additional statutory authority from Congress in order to reinterpret the definition of readmission³ to include observation stays.

Challenges with the HRRP metrics raise broader concerns about the program. For decades, administrators viewed readmissions as a utilization metric, only to have the Affordable Care Act re-designate and define all-cause readmissions as a quality metric. Yet hospitals and health systems control only some factors driving readmission. Readmissions occur for a variety of reasons, including not only poor quality of initial hospital care and inadequate care coordination, but also factors that are beyond the hospital’s purview, such as lack of access to ambulatory services, multiple and severe chronic conditions that progress or remain unresponsive to intervention,⁴ and demographic and social factors such as housing instability, health literacy, or residence in a food desert. These non-hospital factors reside within the domain of other market participants or local, state, and federal government agencies.

Challenges to the utility, validity, and appropriateness of HRRP metrics should remind policymakers of the dangers of over-legislating the details of healthcare policy and the statutory inflexibility that can ensue. Clinical care evolves, and artificial constructs—including payment categories such as observation status—may age poorly over time, exemplified best by the challenges of accessing post-acute care due to the 3-day rule.⁵ Introduced as a statutory requirement in 1967, when the average length of stay was 13.8 days and observation care did not exist as a payment category, the 3-day rule requires Medicare beneficiaries to spend 3 days admitted to the hospital in order to qualify for coverage of post-acute care, creating care gaps for observation stay patients.

Observation care itself is an artificial construct of CMS payment policy. In the Medicare program, observation care falls under Part B, exposing patients to both greater financial responsibility and billing complexity through the engagement of their supplemental insurance, even though those receiving observation care experience the same care as if hospitalized— routine monitoring, nursing care, blood draws, imaging, and diagnostic tests. While CMS requires notification of observation status and explanation of the difference in patient financial responsibility, in clinical practice, patient understanding is limited. Policymakers can support both Medicare beneficiaries and hospitals by reexamining observation care as a payment category.

Sheehy and colleagues’ work simultaneously challenges the face validity of the HRRP and the reasonableness of categorizing some inpatient stays as outpatient care in the hospital—issues that policymakers can and should address.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

Although malpractice “crises” come and go, liability fears persist near top of mind for most physicians.¹ Liability insurance premiums have plateaued in recent years, but remain at high levels, and the prospect of being reported to the National Practitioner Data Bank (NPDB) or listed on a state medical board’s website for a paid liability claim is unsettling. The high-acuity setting and the absence of longitudinal patient relationships in hospital medicine may theoretically raise malpractice risk, yet hospitalists’ liability risk remains understudied.²

The contribution by Schaffer and colleagues³ in this issue of the Journal of Hospital Medicine is thus welcome and illuminating. The researchers examine the liability risk of hospitalists compared to that of other specialties by utilizing a large database of malpractice claims compiled from multiple insurers across a decade.³ In a field of research plagued by inadequate data, the Comparative Benchmarking System (CBS) built by CRICO/RMF is a treasure. Unlike the primary national database of malpractice claims, the NPDB, the CBS contains information on claims that did not result in a payment, as well as physicians’ specialty and detailed information on the allegations, injuries, and their causes. The CBS contains almost a third of all medical liability claims made in the United States during the study period, supporting generalizability.

Schaffer and colleagues¹ found that hospitalists had a lower claims rate than physicians in emergency medicine or neurosurgery. The rate was on par with that for non-hospital general internists, even though hospitalists often care for higher-acuity patients. Although claims rates dropped over the study period for physicians in neurosurgery, emergency medicine, psychiatry, and internal medicine subspecialties, the rate for hospitalists did not change significantly. Further, the median payout on claims against hospitalists was the highest of all the specialties examined, except neurosurgery. This reflects higher injury severity in hospitalist cases: half the claims against hospitalists involved death and three-quarters were high severity.

The study is not without limitations. Due to missing data, only a fraction of the claims (8.2% to 11%) in the full dataset are used in the claims rate analysis. Regression models predicting a payment are based on a small number of payments for hospitalists (n = 363). Further, the authors advance, as a potential explanation for hospitalists’ higher liability risk, that hospitalists are disproportionately young compared to other specialists, but the dataset lacks age data. These limitations suggest caution in the authors’ overall conclusion that “the malpractice environment for hospitalists is becoming less favorable.”

Nevertheless, several important insights emerge from their analysis. The very existence of claims demonstrates that patient harm continues. The contributing factors and judgment errors found in these claims demonstrate that much of this harm is potentially preventable and a risk to patient safety. Whether or not the authors’ young-hospitalist hypothesis is ultimately proven, it is difficult to argue with more mentorship as a means to improve safety. Also, preventing or intercepting judgment errors remains a vexing challenge in medicine that undoubtedly calls for creative clinical decision support solutions. Schaffer and colleagues¹ also note that hospitalists are increasingly co-managing patients with other specialties, such as orthopedic surgery. Whether this new practice model drives hospitalist liability risk because hospitalists are practicing in areas in which they have less experience (as the authors posit) or whether hospitalists are simply more likely to be named in a suit as part of a specialty team with higher liability risk remains unknown and merits further investigation.

Ultimately, regardless of whether the liability environment is worsening for hospitalists, the need to improve our liability system is clear. There is room to improve the system on a number of metrics, including properly compensating negligently harmed patients without unduly burdening providers. The system also induces defensive medicine and has not driven safety improvements as expected. The liability environment, as a result, remains challenging not just for hospitalists, but for all patients and physicians as well.

Although malpractice “crises” come and go, liability fears persist near top of mind for most physicians.¹ Liability insurance premiums have plateaued in recent years, but remain at high levels, and the prospect of being reported to the National Practitioner Data Bank (NPDB) or listed on a state medical board’s website for a paid liability claim is unsettling. The high-acuity setting and the absence of longitudinal patient relationships in hospital medicine may theoretically raise malpractice risk, yet hospitalists’ liability risk remains understudied.²

The contribution by Schaffer and colleagues³ in this issue of the Journal of Hospital Medicine is thus welcome and illuminating. The researchers examine the liability risk of hospitalists compared to that of other specialties by utilizing a large database of malpractice claims compiled from multiple insurers across a decade.³ In a field of research plagued by inadequate data, the Comparative Benchmarking System (CBS) built by CRICO/RMF is a treasure. Unlike the primary national database of malpractice claims, the NPDB, the CBS contains information on claims that did not result in a payment, as well as physicians’ specialty and detailed information on the allegations, injuries, and their causes. The CBS contains almost a third of all medical liability claims made in the United States during the study period, supporting generalizability.

Schaffer and colleagues¹ found that hospitalists had a lower claims rate than physicians in emergency medicine or neurosurgery. The rate was on par with that for non-hospital general internists, even though hospitalists often care for higher-acuity patients. Although claims rates dropped over the study period for physicians in neurosurgery, emergency medicine, psychiatry, and internal medicine subspecialties, the rate for hospitalists did not change significantly. Further, the median payout on claims against hospitalists was the highest of all the specialties examined, except neurosurgery. This reflects higher injury severity in hospitalist cases: half the claims against hospitalists involved death and three-quarters were high severity.

The study is not without limitations. Due to missing data, only a fraction of the claims (8.2% to 11%) in the full dataset are used in the claims rate analysis. Regression models predicting a payment are based on a small number of payments for hospitalists (n = 363). Further, the authors advance, as a potential explanation for hospitalists’ higher liability risk, that hospitalists are disproportionately young compared to other specialists, but the dataset lacks age data. These limitations suggest caution in the authors’ overall conclusion that “the malpractice environment for hospitalists is becoming less favorable.”

Nevertheless, several important insights emerge from their analysis. The very existence of claims demonstrates that patient harm continues. The contributing factors and judgment errors found in these claims demonstrate that much of this harm is potentially preventable and a risk to patient safety. Whether or not the authors’ young-hospitalist hypothesis is ultimately proven, it is difficult to argue with more mentorship as a means to improve safety. Also, preventing or intercepting judgment errors remains a vexing challenge in medicine that undoubtedly calls for creative clinical decision support solutions. Schaffer and colleagues¹ also note that hospitalists are increasingly co-managing patients with other specialties, such as orthopedic surgery. Whether this new practice model drives hospitalist liability risk because hospitalists are practicing in areas in which they have less experience (as the authors posit) or whether hospitalists are simply more likely to be named in a suit as part of a specialty team with higher liability risk remains unknown and merits further investigation.

Ultimately, regardless of whether the liability environment is worsening for hospitalists, the need to improve our liability system is clear. There is room to improve the system on a number of metrics, including properly compensating negligently harmed patients without unduly burdening providers. The system also induces defensive medicine and has not driven safety improvements as expected. The liability environment, as a result, remains challenging not just for hospitalists, but for all patients and physicians as well.

Although malpractice “crises” come and go, liability fears persist near top of mind for most physicians.¹ Liability insurance premiums have plateaued in recent years, but remain at high levels, and the prospect of being reported to the National Practitioner Data Bank (NPDB) or listed on a state medical board’s website for a paid liability claim is unsettling. The high-acuity setting and the absence of longitudinal patient relationships in hospital medicine may theoretically raise malpractice risk, yet hospitalists’ liability risk remains understudied.²

The contribution by Schaffer and colleagues³ in this issue of the Journal of Hospital Medicine is thus welcome and illuminating. The researchers examine the liability risk of hospitalists compared to that of other specialties by utilizing a large database of malpractice claims compiled from multiple insurers across a decade.³ In a field of research plagued by inadequate data, the Comparative Benchmarking System (CBS) built by CRICO/RMF is a treasure. Unlike the primary national database of malpractice claims, the NPDB, the CBS contains information on claims that did not result in a payment, as well as physicians’ specialty and detailed information on the allegations, injuries, and their causes. The CBS contains almost a third of all medical liability claims made in the United States during the study period, supporting generalizability.

Schaffer and colleagues¹ found that hospitalists had a lower claims rate than physicians in emergency medicine or neurosurgery. The rate was on par with that for non-hospital general internists, even though hospitalists often care for higher-acuity patients. Although claims rates dropped over the study period for physicians in neurosurgery, emergency medicine, psychiatry, and internal medicine subspecialties, the rate for hospitalists did not change significantly. Further, the median payout on claims against hospitalists was the highest of all the specialties examined, except neurosurgery. This reflects higher injury severity in hospitalist cases: half the claims against hospitalists involved death and three-quarters were high severity.

The study is not without limitations. Due to missing data, only a fraction of the claims (8.2% to 11%) in the full dataset are used in the claims rate analysis. Regression models predicting a payment are based on a small number of payments for hospitalists (n = 363). Further, the authors advance, as a potential explanation for hospitalists’ higher liability risk, that hospitalists are disproportionately young compared to other specialists, but the dataset lacks age data. These limitations suggest caution in the authors’ overall conclusion that “the malpractice environment for hospitalists is becoming less favorable.”

Nevertheless, several important insights emerge from their analysis. The very existence of claims demonstrates that patient harm continues. The contributing factors and judgment errors found in these claims demonstrate that much of this harm is potentially preventable and a risk to patient safety. Whether or not the authors’ young-hospitalist hypothesis is ultimately proven, it is difficult to argue with more mentorship as a means to improve safety. Also, preventing or intercepting judgment errors remains a vexing challenge in medicine that undoubtedly calls for creative clinical decision support solutions. Schaffer and colleagues¹ also note that hospitalists are increasingly co-managing patients with other specialties, such as orthopedic surgery. Whether this new practice model drives hospitalist liability risk because hospitalists are practicing in areas in which they have less experience (as the authors posit) or whether hospitalists are simply more likely to be named in a suit as part of a specialty team with higher liability risk remains unknown and merits further investigation.

Ultimately, regardless of whether the liability environment is worsening for hospitalists, the need to improve our liability system is clear. There is room to improve the system on a number of metrics, including properly compensating negligently harmed patients without unduly burdening providers. The system also induces defensive medicine and has not driven safety improvements as expected. The liability environment, as a result, remains challenging not just for hospitalists, but for all patients and physicians as well.

“As we work to create light for others, we naturally light our own way.”

– Mary Anne Radmacher

Perhaps unknowingly, hospitalists establish microcultures in their everyday work. Hospitalists’ interactions with colleagues often occur in the context of shared workspaces. The nature of these seemingly minor exchanges shapes the microculture, often described as the culture shared by a small group based on location within an organization. Hospitalists have an opportunity to cultivate well-being within these microcultures through gracious and thoughtful acknowledgments of their peers. Collegial support at the micro level influences wellness at the organizational level. A larger shared culture of wellness is necessary to nurture physicians’ personal fulfillment and professional development.¹

We propose the CARE framework for cultivating well-being within the microcultures of hospital medicine shared workspaces. CARE consists of Capitalization, Active listening, Recognition, and Empathy. This framework is based on positive psychology research and inspired by lessons from The Happiness Advantage by Shawn Achor.²

Capitalization. Capitalization is defined as sharing upbeat news and receiving a positive reaction. Emotional support during good times, more so than during bad times, strengthens relationships. When a peer shares good news, show enthusiasm and counter with an active, constructive response to maximize the validation she perceives.²

For example, Alex sits at her desk and says to Kristen: “

My workshop proposal was accepted for medical education day!” “

Congratulations, Alex! Tell me more about the workshop.”

Active listening. Active listening requires concentration and observation of body language. Show engagement by maintaining an open posture, using positive facial expressions, and providing occasional cues that you’re paying attention. Paraphrasing and asking targeted questions to dive deeper demonstrates genuine interest. 

“Katie, I could use your advice. Do you have a minute?”

Katie turns to face John and smiles. “Of course. How can I help?”

“My team seems drained after a code this morning. I planned a lecture for later, but I’m not sure this is the right time.”

Katie nods. “I think you’re right, John. How have you thought about handling the situation?”

Recognition. Acts of recognition and encouragement are catalysts for boosting morale. Even brief expressions of gratitude can have a significant emotional impact. Recognition is most meaningful when delivered deliberately and with warmth.

Kevin walks into the hospitalist workroom. “Diane, congratulations on your publication! I plan to make a medication interaction review part of my discharge workflow.”

Leah turns to Diane. “Diane, that’s great news! Can you send me the link to your article?”

Empathy. Burnout is prevalent in medicine, and our fellow hospitalists deserve empathy. Showing empathy reduces stress and promotes connectedness. Sense when your colleagues are in distress and take time to share in their feelings and emotions. Draw on your own clinical experience to find common ground and convey understanding.

“I transferred another patient with COVID-19 to the ICU. I spent the last hour talking to family.”

“Ashwin, you’ve had a tough week. I know how you must feel—I had to transfer a patient yesterday. Want to take a quick walk outside?”

Hospitalists are inherently busy while on service, but these four interventions are brief, requiring only several minutes. Each small investment of your time will pay significant emotional dividends. These practices will not only enhance your colleagues’ sense of well-being, but will also bolster your happiness and productivity. A positive mindset fosters creative thinking and enhances complex problem solving. Recharging the microcultures of hospitalist workspaces with positivity will spark a larger transformation at the organizational level. That’s because positive actions are contagious.² One hospitalist’s commitment to CARE will encourage other hospitalists to adopt these behaviors, establishing a virtuous cycle that sustains an organization’s culture of wellness.

“As we work to create light for others, we naturally light our own way.”

– Mary Anne Radmacher

Perhaps unknowingly, hospitalists establish microcultures in their everyday work. Hospitalists’ interactions with colleagues often occur in the context of shared workspaces. The nature of these seemingly minor exchanges shapes the microculture, often described as the culture shared by a small group based on location within an organization. Hospitalists have an opportunity to cultivate well-being within these microcultures through gracious and thoughtful acknowledgments of their peers. Collegial support at the micro level influences wellness at the organizational level. A larger shared culture of wellness is necessary to nurture physicians’ personal fulfillment and professional development.¹

We propose the CARE framework for cultivating well-being within the microcultures of hospital medicine shared workspaces. CARE consists of Capitalization, Active listening, Recognition, and Empathy. This framework is based on positive psychology research and inspired by lessons from The Happiness Advantage by Shawn Achor.²

Capitalization. Capitalization is defined as sharing upbeat news and receiving a positive reaction. Emotional support during good times, more so than during bad times, strengthens relationships. When a peer shares good news, show enthusiasm and counter with an active, constructive response to maximize the validation she perceives.²

For example, Alex sits at her desk and says to Kristen: “

My workshop proposal was accepted for medical education day!” “

Congratulations, Alex! Tell me more about the workshop.”

Active listening. Active listening requires concentration and observation of body language. Show engagement by maintaining an open posture, using positive facial expressions, and providing occasional cues that you’re paying attention. Paraphrasing and asking targeted questions to dive deeper demonstrates genuine interest. 

“Katie, I could use your advice. Do you have a minute?”

Katie turns to face John and smiles. “Of course. How can I help?”

“My team seems drained after a code this morning. I planned a lecture for later, but I’m not sure this is the right time.”

Katie nods. “I think you’re right, John. How have you thought about handling the situation?”

Recognition. Acts of recognition and encouragement are catalysts for boosting morale. Even brief expressions of gratitude can have a significant emotional impact. Recognition is most meaningful when delivered deliberately and with warmth.

Kevin walks into the hospitalist workroom. “Diane, congratulations on your publication! I plan to make a medication interaction review part of my discharge workflow.”

Leah turns to Diane. “Diane, that’s great news! Can you send me the link to your article?”

Empathy. Burnout is prevalent in medicine, and our fellow hospitalists deserve empathy. Showing empathy reduces stress and promotes connectedness. Sense when your colleagues are in distress and take time to share in their feelings and emotions. Draw on your own clinical experience to find common ground and convey understanding.

“I transferred another patient with COVID-19 to the ICU. I spent the last hour talking to family.”

“Ashwin, you’ve had a tough week. I know how you must feel—I had to transfer a patient yesterday. Want to take a quick walk outside?”

Hospitalists are inherently busy while on service, but these four interventions are brief, requiring only several minutes. Each small investment of your time will pay significant emotional dividends. These practices will not only enhance your colleagues’ sense of well-being, but will also bolster your happiness and productivity. A positive mindset fosters creative thinking and enhances complex problem solving. Recharging the microcultures of hospitalist workspaces with positivity will spark a larger transformation at the organizational level. That’s because positive actions are contagious.² One hospitalist’s commitment to CARE will encourage other hospitalists to adopt these behaviors, establishing a virtuous cycle that sustains an organization’s culture of wellness.

“As we work to create light for others, we naturally light our own way.”

– Mary Anne Radmacher

Perhaps unknowingly, hospitalists establish microcultures in their everyday work. Hospitalists’ interactions with colleagues often occur in the context of shared workspaces. The nature of these seemingly minor exchanges shapes the microculture, often described as the culture shared by a small group based on location within an organization. Hospitalists have an opportunity to cultivate well-being within these microcultures through gracious and thoughtful acknowledgments of their peers. Collegial support at the micro level influences wellness at the organizational level. A larger shared culture of wellness is necessary to nurture physicians’ personal fulfillment and professional development.¹

We propose the CARE framework for cultivating well-being within the microcultures of hospital medicine shared workspaces. CARE consists of Capitalization, Active listening, Recognition, and Empathy. This framework is based on positive psychology research and inspired by lessons from The Happiness Advantage by Shawn Achor.²

Capitalization. Capitalization is defined as sharing upbeat news and receiving a positive reaction. Emotional support during good times, more so than during bad times, strengthens relationships. When a peer shares good news, show enthusiasm and counter with an active, constructive response to maximize the validation she perceives.²

For example, Alex sits at her desk and says to Kristen: “

My workshop proposal was accepted for medical education day!” “

Congratulations, Alex! Tell me more about the workshop.”

Active listening. Active listening requires concentration and observation of body language. Show engagement by maintaining an open posture, using positive facial expressions, and providing occasional cues that you’re paying attention. Paraphrasing and asking targeted questions to dive deeper demonstrates genuine interest. 

“Katie, I could use your advice. Do you have a minute?”

Katie turns to face John and smiles. “Of course. How can I help?”

“My team seems drained after a code this morning. I planned a lecture for later, but I’m not sure this is the right time.”

Katie nods. “I think you’re right, John. How have you thought about handling the situation?”

Recognition. Acts of recognition and encouragement are catalysts for boosting morale. Even brief expressions of gratitude can have a significant emotional impact. Recognition is most meaningful when delivered deliberately and with warmth.

Kevin walks into the hospitalist workroom. “Diane, congratulations on your publication! I plan to make a medication interaction review part of my discharge workflow.”

Leah turns to Diane. “Diane, that’s great news! Can you send me the link to your article?”

Empathy. Burnout is prevalent in medicine, and our fellow hospitalists deserve empathy. Showing empathy reduces stress and promotes connectedness. Sense when your colleagues are in distress and take time to share in their feelings and emotions. Draw on your own clinical experience to find common ground and convey understanding.

“I transferred another patient with COVID-19 to the ICU. I spent the last hour talking to family.”

“Ashwin, you’ve had a tough week. I know how you must feel—I had to transfer a patient yesterday. Want to take a quick walk outside?”

Hospitalists are inherently busy while on service, but these four interventions are brief, requiring only several minutes. Each small investment of your time will pay significant emotional dividends. These practices will not only enhance your colleagues’ sense of well-being, but will also bolster your happiness and productivity. A positive mindset fosters creative thinking and enhances complex problem solving. Recharging the microcultures of hospitalist workspaces with positivity will spark a larger transformation at the organizational level. That’s because positive actions are contagious.² One hospitalist’s commitment to CARE will encourage other hospitalists to adopt these behaviors, establishing a virtuous cycle that sustains an organization’s culture of wellness.