CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; [email protected].

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; [email protected].

CASE

Dr. Peter D is a mid-career family physician in a group practice that recently adopted an electronic health record system. Although he realizes he is now competent at computerized medicine, he has far less of the one-on-one patient contact that he once found so gratifying about the field of medicine.

Others in the practice have similar concerns, but they suggest that everyone ought to “go along to get along.” To manage the increasing demands of his case load and the required documentation, Dr. D has begun staying late to finish charting, which is negatively impacting his family life.

Dr. D finds himself burdened by record keeping that is increasingly complicated and insurance company demands that are onerous. Pharmaceutical prior authorizations that previously had been mildly bothersome are now a full-on burden. More often than not, he finds himself becoming irritable over extra requests and administrative demands, impatient with some patients and staff, and extremely fatigued at the end of workdays. Simply put, he finds that practicing medicine is far less enjoyable than it once was. He takes the Maslach Burnout Inventory, and his score indicates that he has moderate burnout.

©Joe Gorman/Shutterstock

Physician burnout has been a growing concern in recent decades.¹ Characterized by varying degrees of job dissatisfaction, cynicism, emotional exhaustion, clinical inefficiency, and depression, physician burnout can impede effective patient care, cause significant health issues among physicians, diminish professional gratification and feelings of accomplishment, and financially burden society as a whole. Here we present the information you need to recognize burnout in yourself and colleagues and address the problem on personal, organizational, and legislative levels.

A problem that affects physicians of all ages

Physician burnout has been recognized to present anywhere on a spectrum, manifesting as ineffectiveness, overextension, disengagement, and/or an inability to practice.² Such features may lead to feelings of professional inadequacy among even the highest functioning physicians.

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.

Burnout occurs in all stages of medical life—as students, residents, and practicing physicians.^3-6 Due to pressures in excess of coping capacity, some physicians will suffer from alcohol or other drug abuse, depression, and/or suicidal thinking.⁷ Stress and burnout can also result in musculoskeletal disorders, immune system dysfunction, cardiac pathology, and a shorter lifespan.⁸

Not only do individual practitioners suffer consequences from burnout, but it also compromises health care delivery. In 2018, the Medscape National Physician Burnout and Depression Report surveyed 15,000 physicians from 29 specialties; 33% of the respondents said that they were more easily frustrated by patients, and 32% reported less personal engagement.⁹ Burnout adversely impacts care, patient satisfaction, productivity, physician retention, retirement, and income, as well.⁶ Safety during clinical practice deteriorates because of an increase in medical error rates.¹⁰ Resultant emotional distress for physicians creates a vicious cycle.¹⁰

[polldaddy:10427848]

Continue to: These issues negatively impact...

These issues negatively impact practice enthusiasm and may engender self-doubt.¹¹ They may lead to absenteeism or, worse, to abandoning the profession, further contributing to physician shortages.¹² The financial impact of physician burnout in lost revenue in 2018 was about $17 billion, according to the National Taskforce for Humanity in ­Medicine.¹³

How prevalent is physician burnout?

Between October 2012 and March 2013, the American Society of Clinical Oncology surveyed US oncologists and found that 45% had evidence of burnout.¹⁴ In another survey of US physicians from all specialties conducted in 2011, at least 1 symptom of burnout was documented in nearly 46% of respondents.¹⁵ By 2014, this percentage increased to 54%.¹⁶

In 2018, the Medscape National Physician Burnout and Depression Report indicated that 42% of physicians admitted to some burnout, while 12% said they were unhappy at work, and 3% reported being clinically depressed.⁹ About 48% of female practitioners reported burnout vs 38% of male peers.⁹ Work-related distress varies between specialties, with internists, family physicians, intensivists, neurologists, and gynecologists more affected than those from other specialties.⁹

Causes and contributing factors

Job stress generally increases with changes in the workplace. This can be heightened in the health care workplace, which demands perfection and leaves little room for emotional issues. Loss of autonomy, time constraints associated with clinical care, electronic health record (EHR) documentation, and disorganized workflow tend to contribute to provider dissatisfaction and stress, as do ethical disagreements about patient care between physicians and leadership.^10,17 Fear of reprisal for speaking up about such issues can further exacerbate the problem. Some older physicians may have difficulty with technology and computerized record keeping. Reduced patient contact due to increasing reliance on computers can diminish physicians’ job satisfaction. And managing recurrent or difficult-to-treat ailments can result in compassion fatigue, diminished empathy, and emotional disengagement.

Burnout in the health care workplace is inconsistently addressed, despite negative professional and personal ramifications. The reasons include denial, uncertainty about monetary implications, and lack of corrective programs by decision-making organizations and/or employers.⁶ American medicine has lacked the political and financial will to implement strategies to mitigate burnout. Improvement requires changes on the part of government, physician groups, and the population at large.

The answer?

A multipronged approach

Identifying burnout is the first step in management. The 22-item Maslach Burnout Inventory (MBI) is a self-reporting questionnaire, reliable at detecting and assessing burnout severity.¹⁸ It screens 3 main domains: emotional exhaustion, depersonalization, and diminished feelings of accomplishment. The American Medical Association recommends the 10-item Zero Burnout Program—the “Mini Z Survey”—as being quicker and more convenient.¹⁹

Once the problem is recognized, experts suggest adopting a multipronged approach to prevention and intervention by using personal, organizational, and legislative strategies.²⁰

Continue to: On a personal level...

On a personal level, it’s important to identify stressors and employ stress-reduction and coping skills, such as mindfulness and/or reflection.²¹ Mindfulness programs may help to minimize exhaustion, increase compassion, and improve understanding of other people’s feelings.²² Such programs are widely available and may be accessed through the Internet, mental health centers, or by contacting psychiatric or psychological services.

Other self-care methods include ensuring adequate sleep, nutrition, exercise, and enjoyable activities. If a physician who is suffering from burnout is taking any prescription or over-the-counter drugs or supplements, it is important to be self-aware of the potential for misuse of medications. Of course, one should never self-prescribe controlled drugs, such as opiates and sedatives. Consumption of alcohol must be well-controlled, without excesses, and drinking near bedtime is ill-advised. The use of illegal substances should be avoided.

Pursuing aspects of health care that are meaningful and that increase patient contact time can boost enthusiasm, as can focusing on the positives aspects of one’s career.²³ Continuing medical education can enhance self-esteem and promote a sense of purpose.²⁴

Peer support. Practice partners may assist their colleagues by alerting them to signs of burnout, offering timely intervention suggestions, and monitoring the effectiveness of strategies. Physicians should discuss stress and burnout with their peers; camaraderie within a practice group is helpful.

Professional coaches or counselors may be engaged to mitigate workplace distress. Coaching is best instituted collegially with pre-identified goals in order to minimize stigmatization.

Continue to: Professional societies and medical boards

Professional societies and medical boards. Reporting requirements by medical boards tend to stigmatize those seeking professional assistance. But that could change if all of us—through our participation in these organizations—pursue change.

Specifically, organizations and related societies could assist with better guidance and policy adjustment (see “Resources”). State medical boards could, for example, increase education of, and outreach to, physicians about mental health issues, while maintaining confidentiality.²⁵ Medical organizations could regularly survey their membership to identify burnout early and identify personal, social, and institutional shortcomings that contribute to physician burnout. In addition, hospital quality improvement committees that monitor health care delivery appropriateness could take steps toward change as well.

The American Medical Association (AMA) just recently announced that they are launching a new effort to fight the causes of physician burnout. The AMA’s Practice Transformation Inititative²⁶ seeks to fill the knowledge gaps regarding effective interventions to reduce burnout. AMA’s leadership indicates that the initiative will focus on “improving joy in medicine by using validated assessment tools to measure burnout; field-testing interventions that are designed to improve workflows, applying practice science research methodology to evaluate impact, and sharing best practices within an AMA-facilitated learning community.”²⁶

Stanford’s example. Stanford University instituted a ‘time bank’ program, to help their academic medical faculty balance work and life and reduce stress. They essentially offer services, such as home food delivery and house cleaning, in return for hours spent in the clinic.²⁷

Reorganizing and reprioritizing. Prioritizing physician wellness as a quality indicator and instituting a committee to advocate for wellness can help attenuate burnout.^28,29 Specific measures include minimizing rushed, overloaded scheduling and allowing more clinical contact time with patients. Using nursing and office staff to streamline workflow is also helpful.²⁹ The University of Colorado’s “Ambulatory Process Excellence Model” strives to assist doctors by increasing the medical assistant-to-clinician ratio, yielding better productivity.²³ Medical assistants are increasingly handling tasks such as data entry, medication reconciliation, and preventive care, to allow physicians more time to focus on medical decision-making.²³

Continue to: The role of the EHR

The role of the EHR. One important way to boost professional morale is to simplify and shorten the EHR. The complexity of and reduced patient contact caused by today’s record-keeping systems is the source of great frustration among many physicians. In addition, many patients dislike the disproportionate attention paid by physicians to the computer during office visits, further compromising physician-patient relationships. Improving documentation methodology and/or employing medical assistant scribes can be helpful.^30,31 (See “Advanced team-based care: How we made it work” at http://bit.ly/2lNaB5Q.)

Legislation with physician input can mandate policies for more appropriate work environments. A good way to initiate improvement and reform strategies is to contact local medical societies and political representatives. Federal and state collaboration to reduce physician shortages in selected specialties or geographic regions can improve work-related stress. This might be attained by expanding residency programs, using telemedicine in underserved regions, and employing more physician assistants.³²

Health insurance. Enhancing universal access to affordable medical care, including pharmaceutical coverage, would alleviate stress for physicians and patients alike.³³ Health insurance regulation to decrease paperwork and simplify coverage would decrease physician workload. Standardized policy requirements, fewer exclusionary rules, and simplified prescribing guidelines (including having less cumbersome prescription pre-authorizations and greater standardization of drug formularies by different payer sources or insurance plans) would facilitate better clinical management.

CASE

Dr. D begins by discussing his concerns with his colleagues in the group practice and finds he is not alone. Many of the concerns of the group center around brief, rushed appointments that diminish relationships with patients, a lack of autonomy, and the fear of medical malpractice. Several older physicians acknowledge that they just want to retire.

Stanford University instituted a "time bank" program that offers home food delivery and house cleaning in return for hours spent in the clinic.

To address the patient contact and documentation issues, the group decides to hire scribes. They also decide to bring their concerns to the next county medical society meeting. The end result: They petitioned their state medical association to host presentations about mitigating burnout, to hold roundtable discussions, and to establish panels focused on remedying the situation.

Continue to: With this accomplished...

With this accomplished, Dr. D’s anxieties lessened. He surveyed relevant literature and shared tips for improving professional time management with his partners. In a hopeful mood, he volunteered to address burnout prevention at the next statewide medical meeting. He felt it was a good start.

CORRESPONDENCE
Steven Lippmann, MD, 401 E. Chestnut Street, Suite 610, Louisville, KY 40202; [email protected].

The Diagnosis: Fracture Blisters 

The shave biopsy pathology demonstrated a subepidermal bulla with re-epithelialization that was clinically consistent with fracture blisters (also known as fracture bullae)(Figure). Fracture blisters are a complication of bone fractures, usually occurring 24 to 48 hours after the trauma but possibly up to 3 weeks later. The skin usually is edematous with tense bullae overlying the fracture (in this case it was distal to the fracture); most blisters contain clear fluid, but older blisters tend to be more flaccid with hemorrhagic fluid.¹ The cause is thought to be the result of skin strain during fracture formation.² Edema and hypoxia from injured vessels and lymphatics contribute to the formation of bullae, which are seen as a dermoepidermal junction split on histology.¹ 

The bullae are histologically indistinguishable from edema blisters. A clinical history can help to differentiate. Edema blisters occur in the setting of an acute exacerbation of chronic edema, usually on the lower extremities in the setting of fluid overload.³ Bullous cellulitis is associated with skin erythema, warmth, and systemic symptoms. Bullous pemphigoid can be localized to the lower legs at times; however, biopsy would show a subepidermal bulla with eosinophils along the dermoepidermal junction. Linear IgA bullous dermatosis can be drug induced from vancomycin; however, pathology would show a subepidermal blister with a neutrophil predominant infiltrate. Nonsteroidal anti-inflammatory medications such as naproxen are a common culprit for bullous drug eruptions, which can be localized or generalized and include diagnoses such as fixed drug eruption, toxic epidermal necrolysis, and drug-induced pseudoporphyria. Naproxen-induced pseudoporphyria more commonly presents with blisters, erosions, and scarring with a predilection for the dorsal hands. Histology also will demonstrate subepidermal bullae. Clues to differentiate pseudoporphyria from fracture blisters include festooning of the dermal papilla and caterpillar bodies consisting of basement membrane material and colloid bodies in the basal layer of the epidermis, though they are not always present.⁴ 

Fracture blisters can be localized to the injury site or extend beyond the fracture site. They usually are found where there is minimal subcutaneous tissue, such as the tibia, ankles, and elbows. Fractures treated within 24 hours are much less likely to have bullae formation.¹ The bullae are sterile but may lead to wound healing complications, such as infections or delay in surgical management. However, there are no major adverse effects of postoperative fracture blisters.¹ Fracture blisters are self-healing, though silver sulfadiazine has been shown to minimize soft-tissue complications by promoting re-epithelialization.⁵ 
 

The Diagnosis: Fracture Blisters 

The shave biopsy pathology demonstrated a subepidermal bulla with re-epithelialization that was clinically consistent with fracture blisters (also known as fracture bullae)(Figure). Fracture blisters are a complication of bone fractures, usually occurring 24 to 48 hours after the trauma but possibly up to 3 weeks later. The skin usually is edematous with tense bullae overlying the fracture (in this case it was distal to the fracture); most blisters contain clear fluid, but older blisters tend to be more flaccid with hemorrhagic fluid.¹ The cause is thought to be the result of skin strain during fracture formation.² Edema and hypoxia from injured vessels and lymphatics contribute to the formation of bullae, which are seen as a dermoepidermal junction split on histology.¹ 

The bullae are histologically indistinguishable from edema blisters. A clinical history can help to differentiate. Edema blisters occur in the setting of an acute exacerbation of chronic edema, usually on the lower extremities in the setting of fluid overload.³ Bullous cellulitis is associated with skin erythema, warmth, and systemic symptoms. Bullous pemphigoid can be localized to the lower legs at times; however, biopsy would show a subepidermal bulla with eosinophils along the dermoepidermal junction. Linear IgA bullous dermatosis can be drug induced from vancomycin; however, pathology would show a subepidermal blister with a neutrophil predominant infiltrate. Nonsteroidal anti-inflammatory medications such as naproxen are a common culprit for bullous drug eruptions, which can be localized or generalized and include diagnoses such as fixed drug eruption, toxic epidermal necrolysis, and drug-induced pseudoporphyria. Naproxen-induced pseudoporphyria more commonly presents with blisters, erosions, and scarring with a predilection for the dorsal hands. Histology also will demonstrate subepidermal bullae. Clues to differentiate pseudoporphyria from fracture blisters include festooning of the dermal papilla and caterpillar bodies consisting of basement membrane material and colloid bodies in the basal layer of the epidermis, though they are not always present.⁴ 

Fracture blisters can be localized to the injury site or extend beyond the fracture site. They usually are found where there is minimal subcutaneous tissue, such as the tibia, ankles, and elbows. Fractures treated within 24 hours are much less likely to have bullae formation.¹ The bullae are sterile but may lead to wound healing complications, such as infections or delay in surgical management. However, there are no major adverse effects of postoperative fracture blisters.¹ Fracture blisters are self-healing, though silver sulfadiazine has been shown to minimize soft-tissue complications by promoting re-epithelialization.⁵ 
 

The Diagnosis: Fracture Blisters 

The shave biopsy pathology demonstrated a subepidermal bulla with re-epithelialization that was clinically consistent with fracture blisters (also known as fracture bullae)(Figure). Fracture blisters are a complication of bone fractures, usually occurring 24 to 48 hours after the trauma but possibly up to 3 weeks later. The skin usually is edematous with tense bullae overlying the fracture (in this case it was distal to the fracture); most blisters contain clear fluid, but older blisters tend to be more flaccid with hemorrhagic fluid.¹ The cause is thought to be the result of skin strain during fracture formation.² Edema and hypoxia from injured vessels and lymphatics contribute to the formation of bullae, which are seen as a dermoepidermal junction split on histology.¹ 

The bullae are histologically indistinguishable from edema blisters. A clinical history can help to differentiate. Edema blisters occur in the setting of an acute exacerbation of chronic edema, usually on the lower extremities in the setting of fluid overload.³ Bullous cellulitis is associated with skin erythema, warmth, and systemic symptoms. Bullous pemphigoid can be localized to the lower legs at times; however, biopsy would show a subepidermal bulla with eosinophils along the dermoepidermal junction. Linear IgA bullous dermatosis can be drug induced from vancomycin; however, pathology would show a subepidermal blister with a neutrophil predominant infiltrate. Nonsteroidal anti-inflammatory medications such as naproxen are a common culprit for bullous drug eruptions, which can be localized or generalized and include diagnoses such as fixed drug eruption, toxic epidermal necrolysis, and drug-induced pseudoporphyria. Naproxen-induced pseudoporphyria more commonly presents with blisters, erosions, and scarring with a predilection for the dorsal hands. Histology also will demonstrate subepidermal bullae. Clues to differentiate pseudoporphyria from fracture blisters include festooning of the dermal papilla and caterpillar bodies consisting of basement membrane material and colloid bodies in the basal layer of the epidermis, though they are not always present.⁴ 

Fracture blisters can be localized to the injury site or extend beyond the fracture site. They usually are found where there is minimal subcutaneous tissue, such as the tibia, ankles, and elbows. Fractures treated within 24 hours are much less likely to have bullae formation.¹ The bullae are sterile but may lead to wound healing complications, such as infections or delay in surgical management. However, there are no major adverse effects of postoperative fracture blisters.¹ Fracture blisters are self-healing, though silver sulfadiazine has been shown to minimize soft-tissue complications by promoting re-epithelialization.⁵ 
 

Mark your calendars: the 2020 Vascular Annual Meeting will take place June 17-20 at the Toronto Convention Center in Toronto, Ontario, Canada. All U.S. residents entering Canada will be required to travel with a valid passport. Your passport expiration date may not be within six months of your travel dates. For additional information (including passport requirements for international travelers), please visit the Canada Border Services Agency’s website. Read all future VAM details here.

Mark your calendars: the 2020 Vascular Annual Meeting will take place June 17-20 at the Toronto Convention Center in Toronto, Ontario, Canada. All U.S. residents entering Canada will be required to travel with a valid passport. Your passport expiration date may not be within six months of your travel dates. For additional information (including passport requirements for international travelers), please visit the Canada Border Services Agency’s website. Read all future VAM details here.

Mark your calendars: the 2020 Vascular Annual Meeting will take place June 17-20 at the Toronto Convention Center in Toronto, Ontario, Canada. All U.S. residents entering Canada will be required to travel with a valid passport. Your passport expiration date may not be within six months of your travel dates. For additional information (including passport requirements for international travelers), please visit the Canada Border Services Agency’s website. Read all future VAM details here.

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

Our website contains many resources that SVS members can use for help with managing a practice, continuing education, patient education materials and much more. The patient resource pages on the site cover a variety of vascular conditions, tests and treatments. Most recently, we’ve added a page for Transcarotid Artery Revascularization (TCAR). This, and most of our pages, can give patients and/or their loved ones a better understanding of their vascular condition, as well as how it’s being tested and treated. Take a look at our pages and share with your patients today.

Our website contains many resources that SVS members can use for help with managing a practice, continuing education, patient education materials and much more. The patient resource pages on the site cover a variety of vascular conditions, tests and treatments. Most recently, we’ve added a page for Transcarotid Artery Revascularization (TCAR). This, and most of our pages, can give patients and/or their loved ones a better understanding of their vascular condition, as well as how it’s being tested and treated. Take a look at our pages and share with your patients today.

Our website contains many resources that SVS members can use for help with managing a practice, continuing education, patient education materials and much more. The patient resource pages on the site cover a variety of vascular conditions, tests and treatments. Most recently, we’ve added a page for Transcarotid Artery Revascularization (TCAR). This, and most of our pages, can give patients and/or their loved ones a better understanding of their vascular condition, as well as how it’s being tested and treated. Take a look at our pages and share with your patients today.

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

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

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

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

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

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

The practice of dermatology is rife with bedside tools: swabs, smears, and scoring systems. First popularized in specialties such as emergency medicine and internal medicine, clinical scoring systems are now emerging in dermatology. These evidence-based scores can be calculated quickly at the bedside—often through a free smartphone app—to help guide clinical decision-making regarding diagnosis, prognosis, and management. As with any medical tool, scoring systems have limitations and should be used as a supplement, not substitute, for one’s clinical judgement. This article reviews 4 clinical scoring systems practical for dermatology residents.

SCORTEN Prognosticates Cases of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Perhaps the best-known scoring system in dermatology, the SCORTEN is widely used to predict hospital mortality from Stevens-Johnson syndrome/toxic epidermal necrolysis. The SCORTEN includes 7 variables of equal weight—age of 40 years or older, heart rate of 120 beats per minute or more, cancer/hematologic malignancy, involved body surface area (BSA) greater than 10%, serum urea greater than 10 mmol/L, serum bicarbonate less than 20 mmol/L, and serum glucose greater than 14 mmol/L—each contributing 1 point to the overall score if present.¹ The involved BSA is defined as the sum of detached and detachable epidermis.¹

The SCORTEN was developed and prospectively validated to be calculated at the end of the first 24 hours of admission; for this calculation, use the BSA affected at that time, and use the most abnormal values during the first 24 hours of admission for the other variables.¹ In addition, a follow-up study including some of the original coauthors recommends recalculating the SCORTEN at the end of hospital day 3, having found that the score’s predictive value was better on this day than hospital days 1, 2, 4, or 5.² Based on the original study, a SCORTEN of 0 to 1 corresponds to a mortality rate of 3.2%, 2 to 12.1%, 3 to 35.3%, 4 to 58.3%, and 5 or greater to 90.0%.¹

Limitations of the SCORTEN include its ability to overestimate or underestimate mortality as demonstrated by 2 multi-institutional cohorts.^3,4 Recently, the ABCD-10 score was developed as an alternative to the SCORTEN and was found to predict mortality similarly when validated in an internal cohort.⁵

PEST Screens for Psoriatic Arthritis

Dermatologists play an important role in screening for psoriatic arthritis, as an estimated 1 in 5 patients with psoriasis have psoriatic arthritis.⁶ To this end, several screening tools have been developed to help differentiate psoriatic arthritis from other arthritides. Joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation acknowledge that “. . . these screening tools have tended to perform less well when tested in groups of people other than those for which they were originally developed. As such, their usefulness in routine clinical practice remains controversial.”⁷ Nevertheless, the guidelines state, “[b]ecause screening and early detection of inflammatory arthritis are essential to optimize patient [quality of life] and reduce morbidity, providers may consider using a formal screening tool of their choice.”⁷

With these limitations in mind, I have found the Psoriasis Epidemiology Screening Tool (PEST) to be the most useful psoriatic arthritis screening tool. One study determined that the PEST has the best trade-off between sensitivity and specificity compared to 2 other psoriatic arthritis screening tools, the Psoriatic Arthritis Screening and Evaluation (PASE) and the Early Arthritis for Psoriatic Patients (EARP).⁸

The PEST is comprised of 5 questions: (1) Have you ever had a swollen joint (or joints)? (2) Has a doctor ever told you that you have arthritis? (3) Do your fingernails or toenails have holes or pits? (4) Have you had pain in your heel? (5) Have you had a finger or toe that was completely swollen and painful for no apparent reason? According to the PEST, a referral to a rheumatologist should be considered for patients answering yes to 3 or more questions, which is 97% sensitive and 79% specific for psoriatic arthritis.⁹ Patients who answer yes to fewer than 3 questions should still be referred to a rheumatologist if there is a strong clinical suspicion of psoriatic arthritis.¹⁰

The PEST can be accessed for free in 13 languages via the GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) app as well as downloaded for free from the National Psoriasis Foundation’s website (https://www.psoriasis.org/psa-screening/providers).

ALT-70 Differentiates Cellulitis From Pseudocellulitis

Overdiagnosing cellulitis in the United States has been estimated to result in up to 130,000 unnecessary hospitalizations and up to $515 million in avoidable health care spending.¹¹ Dermatologists are in a unique position to help fix this issue. In one retrospective study of 1430 inpatient dermatology consultations, 74.32% of inpatients evaluated for presumed cellulitis by a dermatologist were instead diagnosed with a cellulitis mimicker (ie, pseudocellulitis), such as stasis dermatitis or contact dermatitis.¹²

The ALT-70 score was developed and prospectively validated to help differentiate lower extremity cellulitis from pseudocellulitis in adult patients in the emergency department (ED).¹³ In addition, the score has retrospectively been shown to function similarly in the inpatient setting when calculated at 24 and 48 hours after ED presentation.¹⁴ Although the ALT-70 score was designed for use by frontline clinicians prior to dermatology consultation, I also have found it helpful to calculate as a consultant, as it provides an objective measure of risk to communicate to the primary team in support of one diagnosis or another.

ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.¹⁵ If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.¹⁵

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.¹⁵ The ALT-70 score is available for free via the MDCalc app and website (https://www.mdcalc.com/alt-70-score-cellulitis).

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.¹⁶ Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.¹⁶

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS¹⁷ (which an AUC coauthor¹⁸ and others^19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),²¹ including counterintuitive scores,²² and omitting trials from Europe²³ (which AUC coauthors also have defended²⁴). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”¹⁶ The Mohs AUC app (https://www.aad.org/members/aad-apps/mohs-auc) is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.

The practice of dermatology is rife with bedside tools: swabs, smears, and scoring systems. First popularized in specialties such as emergency medicine and internal medicine, clinical scoring systems are now emerging in dermatology. These evidence-based scores can be calculated quickly at the bedside—often through a free smartphone app—to help guide clinical decision-making regarding diagnosis, prognosis, and management. As with any medical tool, scoring systems have limitations and should be used as a supplement, not substitute, for one’s clinical judgement. This article reviews 4 clinical scoring systems practical for dermatology residents.

SCORTEN Prognosticates Cases of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Perhaps the best-known scoring system in dermatology, the SCORTEN is widely used to predict hospital mortality from Stevens-Johnson syndrome/toxic epidermal necrolysis. The SCORTEN includes 7 variables of equal weight—age of 40 years or older, heart rate of 120 beats per minute or more, cancer/hematologic malignancy, involved body surface area (BSA) greater than 10%, serum urea greater than 10 mmol/L, serum bicarbonate less than 20 mmol/L, and serum glucose greater than 14 mmol/L—each contributing 1 point to the overall score if present.¹ The involved BSA is defined as the sum of detached and detachable epidermis.¹

The SCORTEN was developed and prospectively validated to be calculated at the end of the first 24 hours of admission; for this calculation, use the BSA affected at that time, and use the most abnormal values during the first 24 hours of admission for the other variables.¹ In addition, a follow-up study including some of the original coauthors recommends recalculating the SCORTEN at the end of hospital day 3, having found that the score’s predictive value was better on this day than hospital days 1, 2, 4, or 5.² Based on the original study, a SCORTEN of 0 to 1 corresponds to a mortality rate of 3.2%, 2 to 12.1%, 3 to 35.3%, 4 to 58.3%, and 5 or greater to 90.0%.¹

Limitations of the SCORTEN include its ability to overestimate or underestimate mortality as demonstrated by 2 multi-institutional cohorts.^3,4 Recently, the ABCD-10 score was developed as an alternative to the SCORTEN and was found to predict mortality similarly when validated in an internal cohort.⁵

PEST Screens for Psoriatic Arthritis

Dermatologists play an important role in screening for psoriatic arthritis, as an estimated 1 in 5 patients with psoriasis have psoriatic arthritis.⁶ To this end, several screening tools have been developed to help differentiate psoriatic arthritis from other arthritides. Joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation acknowledge that “. . . these screening tools have tended to perform less well when tested in groups of people other than those for which they were originally developed. As such, their usefulness in routine clinical practice remains controversial.”⁷ Nevertheless, the guidelines state, “[b]ecause screening and early detection of inflammatory arthritis are essential to optimize patient [quality of life] and reduce morbidity, providers may consider using a formal screening tool of their choice.”⁷

With these limitations in mind, I have found the Psoriasis Epidemiology Screening Tool (PEST) to be the most useful psoriatic arthritis screening tool. One study determined that the PEST has the best trade-off between sensitivity and specificity compared to 2 other psoriatic arthritis screening tools, the Psoriatic Arthritis Screening and Evaluation (PASE) and the Early Arthritis for Psoriatic Patients (EARP).⁸

The PEST is comprised of 5 questions: (1) Have you ever had a swollen joint (or joints)? (2) Has a doctor ever told you that you have arthritis? (3) Do your fingernails or toenails have holes or pits? (4) Have you had pain in your heel? (5) Have you had a finger or toe that was completely swollen and painful for no apparent reason? According to the PEST, a referral to a rheumatologist should be considered for patients answering yes to 3 or more questions, which is 97% sensitive and 79% specific for psoriatic arthritis.⁹ Patients who answer yes to fewer than 3 questions should still be referred to a rheumatologist if there is a strong clinical suspicion of psoriatic arthritis.¹⁰

The PEST can be accessed for free in 13 languages via the GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) app as well as downloaded for free from the National Psoriasis Foundation’s website (https://www.psoriasis.org/psa-screening/providers).

ALT-70 Differentiates Cellulitis From Pseudocellulitis

Overdiagnosing cellulitis in the United States has been estimated to result in up to 130,000 unnecessary hospitalizations and up to $515 million in avoidable health care spending.¹¹ Dermatologists are in a unique position to help fix this issue. In one retrospective study of 1430 inpatient dermatology consultations, 74.32% of inpatients evaluated for presumed cellulitis by a dermatologist were instead diagnosed with a cellulitis mimicker (ie, pseudocellulitis), such as stasis dermatitis or contact dermatitis.¹²

The ALT-70 score was developed and prospectively validated to help differentiate lower extremity cellulitis from pseudocellulitis in adult patients in the emergency department (ED).¹³ In addition, the score has retrospectively been shown to function similarly in the inpatient setting when calculated at 24 and 48 hours after ED presentation.¹⁴ Although the ALT-70 score was designed for use by frontline clinicians prior to dermatology consultation, I also have found it helpful to calculate as a consultant, as it provides an objective measure of risk to communicate to the primary team in support of one diagnosis or another.

ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.¹⁵ If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.¹⁵

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.¹⁵ The ALT-70 score is available for free via the MDCalc app and website (https://www.mdcalc.com/alt-70-score-cellulitis).

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.¹⁶ Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.¹⁶

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS¹⁷ (which an AUC coauthor¹⁸ and others^19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),²¹ including counterintuitive scores,²² and omitting trials from Europe²³ (which AUC coauthors also have defended²⁴). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”¹⁶ The Mohs AUC app (https://www.aad.org/members/aad-apps/mohs-auc) is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.

The practice of dermatology is rife with bedside tools: swabs, smears, and scoring systems. First popularized in specialties such as emergency medicine and internal medicine, clinical scoring systems are now emerging in dermatology. These evidence-based scores can be calculated quickly at the bedside—often through a free smartphone app—to help guide clinical decision-making regarding diagnosis, prognosis, and management. As with any medical tool, scoring systems have limitations and should be used as a supplement, not substitute, for one’s clinical judgement. This article reviews 4 clinical scoring systems practical for dermatology residents.

SCORTEN Prognosticates Cases of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Perhaps the best-known scoring system in dermatology, the SCORTEN is widely used to predict hospital mortality from Stevens-Johnson syndrome/toxic epidermal necrolysis. The SCORTEN includes 7 variables of equal weight—age of 40 years or older, heart rate of 120 beats per minute or more, cancer/hematologic malignancy, involved body surface area (BSA) greater than 10%, serum urea greater than 10 mmol/L, serum bicarbonate less than 20 mmol/L, and serum glucose greater than 14 mmol/L—each contributing 1 point to the overall score if present.¹ The involved BSA is defined as the sum of detached and detachable epidermis.¹

The SCORTEN was developed and prospectively validated to be calculated at the end of the first 24 hours of admission; for this calculation, use the BSA affected at that time, and use the most abnormal values during the first 24 hours of admission for the other variables.¹ In addition, a follow-up study including some of the original coauthors recommends recalculating the SCORTEN at the end of hospital day 3, having found that the score’s predictive value was better on this day than hospital days 1, 2, 4, or 5.² Based on the original study, a SCORTEN of 0 to 1 corresponds to a mortality rate of 3.2%, 2 to 12.1%, 3 to 35.3%, 4 to 58.3%, and 5 or greater to 90.0%.¹

Limitations of the SCORTEN include its ability to overestimate or underestimate mortality as demonstrated by 2 multi-institutional cohorts.^3,4 Recently, the ABCD-10 score was developed as an alternative to the SCORTEN and was found to predict mortality similarly when validated in an internal cohort.⁵

PEST Screens for Psoriatic Arthritis

Dermatologists play an important role in screening for psoriatic arthritis, as an estimated 1 in 5 patients with psoriasis have psoriatic arthritis.⁶ To this end, several screening tools have been developed to help differentiate psoriatic arthritis from other arthritides. Joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation acknowledge that “. . . these screening tools have tended to perform less well when tested in groups of people other than those for which they were originally developed. As such, their usefulness in routine clinical practice remains controversial.”⁷ Nevertheless, the guidelines state, “[b]ecause screening and early detection of inflammatory arthritis are essential to optimize patient [quality of life] and reduce morbidity, providers may consider using a formal screening tool of their choice.”⁷

With these limitations in mind, I have found the Psoriasis Epidemiology Screening Tool (PEST) to be the most useful psoriatic arthritis screening tool. One study determined that the PEST has the best trade-off between sensitivity and specificity compared to 2 other psoriatic arthritis screening tools, the Psoriatic Arthritis Screening and Evaluation (PASE) and the Early Arthritis for Psoriatic Patients (EARP).⁸

The PEST is comprised of 5 questions: (1) Have you ever had a swollen joint (or joints)? (2) Has a doctor ever told you that you have arthritis? (3) Do your fingernails or toenails have holes or pits? (4) Have you had pain in your heel? (5) Have you had a finger or toe that was completely swollen and painful for no apparent reason? According to the PEST, a referral to a rheumatologist should be considered for patients answering yes to 3 or more questions, which is 97% sensitive and 79% specific for psoriatic arthritis.⁹ Patients who answer yes to fewer than 3 questions should still be referred to a rheumatologist if there is a strong clinical suspicion of psoriatic arthritis.¹⁰

The PEST can be accessed for free in 13 languages via the GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) app as well as downloaded for free from the National Psoriasis Foundation’s website (https://www.psoriasis.org/psa-screening/providers).

ALT-70 Differentiates Cellulitis From Pseudocellulitis

Overdiagnosing cellulitis in the United States has been estimated to result in up to 130,000 unnecessary hospitalizations and up to $515 million in avoidable health care spending.¹¹ Dermatologists are in a unique position to help fix this issue. In one retrospective study of 1430 inpatient dermatology consultations, 74.32% of inpatients evaluated for presumed cellulitis by a dermatologist were instead diagnosed with a cellulitis mimicker (ie, pseudocellulitis), such as stasis dermatitis or contact dermatitis.¹²

The ALT-70 score was developed and prospectively validated to help differentiate lower extremity cellulitis from pseudocellulitis in adult patients in the emergency department (ED).¹³ In addition, the score has retrospectively been shown to function similarly in the inpatient setting when calculated at 24 and 48 hours after ED presentation.¹⁴ Although the ALT-70 score was designed for use by frontline clinicians prior to dermatology consultation, I also have found it helpful to calculate as a consultant, as it provides an objective measure of risk to communicate to the primary team in support of one diagnosis or another.

ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.¹⁵ If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.¹⁵

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.¹⁵ The ALT-70 score is available for free via the MDCalc app and website (https://www.mdcalc.com/alt-70-score-cellulitis).

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.¹⁶ Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.¹⁶

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS¹⁷ (which an AUC coauthor¹⁸ and others^19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),²¹ including counterintuitive scores,²² and omitting trials from Europe²³ (which AUC coauthors also have defended²⁴). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”¹⁶ The Mohs AUC app (https://www.aad.org/members/aad-apps/mohs-auc) is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.

Jame Abraham, MD, has been appointed chair of the hematology/medical oncology department at Cleveland Clinic in Ohio. In this new role, Dr. Abraham will “recruit and develop staff and guide the department’s focus on patient access and a multidisciplinary approach to care,” according to a statement.

Dr. Abraham is also director of the breast oncology program at Taussig Cancer Institute, codirector of the Cleveland Clinic comprehensive breast cancer program, and a professor of medicine at Cleveland Clinic Lerner College of Medicine. He takes the helm from hematologist Matt Kalaycio, MD. Dr. Kalaycio also serves as editor-in-chief of Hematology News.

In other news, Zhe Ying, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, has received a 5-year Pathway to Independence Award from the National Institute of Dental and Craniofacial Research.

With this award funding, Dr. Ying will investigate oncogene-induced differentiation in PI3K-mutant head and neck squamous cell carcinoma. Specifically, he aims to determine if genetic mutations and niche factors can overcome oncogene-induced differentiation to promote tumorigenesis.

Another grant winner is Gina Mantia-Smaldone, MD, of Fox Chase Cancer Center in Philadelphia. She will receive 3 years of funding from the Gynecologic Oncology Group Foundation and NRG Oncology to study gynecologic malignancies.

This award will also provide Dr. Mantia-Smaldone with research mentorship and opportunities to collaborate with other researchers. Her research is focused on developing targeted therapies for ovarian and endometrial cancers that will, ideally, improve patients’ quality of life.

Lastly, Edna (Eti) Cukierman, PhD, of Fox Chase Cancer Center, received a grant to conduct research with Ashani Weeraratna, PhD, of Johns Hopkins University in Baltimore, and Vivek Shenoy, PhD, and Arjun Raj, PhD, both of the University of Pennsylvania in Philadelphia.

The grant, from the National Cancer Institute, will be used to investigate the link between cell aging and melanoma. Dr. Cukierman, Dr. Weeraratna, Dr. Shenoy, and Dr. Raj will focus their research "on better understanding the deterioration of collagen integrity via cellular aging and its role in melanoma metastasis,” according to a statement.

[email protected]

Jame Abraham, MD, has been appointed chair of the hematology/medical oncology department at Cleveland Clinic in Ohio. In this new role, Dr. Abraham will “recruit and develop staff and guide the department’s focus on patient access and a multidisciplinary approach to care,” according to a statement.

Dr. Abraham is also director of the breast oncology program at Taussig Cancer Institute, codirector of the Cleveland Clinic comprehensive breast cancer program, and a professor of medicine at Cleveland Clinic Lerner College of Medicine. He takes the helm from hematologist Matt Kalaycio, MD. Dr. Kalaycio also serves as editor-in-chief of Hematology News.

In other news, Zhe Ying, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, has received a 5-year Pathway to Independence Award from the National Institute of Dental and Craniofacial Research.

With this award funding, Dr. Ying will investigate oncogene-induced differentiation in PI3K-mutant head and neck squamous cell carcinoma. Specifically, he aims to determine if genetic mutations and niche factors can overcome oncogene-induced differentiation to promote tumorigenesis.

Another grant winner is Gina Mantia-Smaldone, MD, of Fox Chase Cancer Center in Philadelphia. She will receive 3 years of funding from the Gynecologic Oncology Group Foundation and NRG Oncology to study gynecologic malignancies.

This award will also provide Dr. Mantia-Smaldone with research mentorship and opportunities to collaborate with other researchers. Her research is focused on developing targeted therapies for ovarian and endometrial cancers that will, ideally, improve patients’ quality of life.

Lastly, Edna (Eti) Cukierman, PhD, of Fox Chase Cancer Center, received a grant to conduct research with Ashani Weeraratna, PhD, of Johns Hopkins University in Baltimore, and Vivek Shenoy, PhD, and Arjun Raj, PhD, both of the University of Pennsylvania in Philadelphia.

The grant, from the National Cancer Institute, will be used to investigate the link between cell aging and melanoma. Dr. Cukierman, Dr. Weeraratna, Dr. Shenoy, and Dr. Raj will focus their research "on better understanding the deterioration of collagen integrity via cellular aging and its role in melanoma metastasis,” according to a statement.

[email protected]

Jame Abraham, MD, has been appointed chair of the hematology/medical oncology department at Cleveland Clinic in Ohio. In this new role, Dr. Abraham will “recruit and develop staff and guide the department’s focus on patient access and a multidisciplinary approach to care,” according to a statement.

Dr. Abraham is also director of the breast oncology program at Taussig Cancer Institute, codirector of the Cleveland Clinic comprehensive breast cancer program, and a professor of medicine at Cleveland Clinic Lerner College of Medicine. He takes the helm from hematologist Matt Kalaycio, MD. Dr. Kalaycio also serves as editor-in-chief of Hematology News.

In other news, Zhe Ying, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, has received a 5-year Pathway to Independence Award from the National Institute of Dental and Craniofacial Research.

With this award funding, Dr. Ying will investigate oncogene-induced differentiation in PI3K-mutant head and neck squamous cell carcinoma. Specifically, he aims to determine if genetic mutations and niche factors can overcome oncogene-induced differentiation to promote tumorigenesis.

Another grant winner is Gina Mantia-Smaldone, MD, of Fox Chase Cancer Center in Philadelphia. She will receive 3 years of funding from the Gynecologic Oncology Group Foundation and NRG Oncology to study gynecologic malignancies.

This award will also provide Dr. Mantia-Smaldone with research mentorship and opportunities to collaborate with other researchers. Her research is focused on developing targeted therapies for ovarian and endometrial cancers that will, ideally, improve patients’ quality of life.

Lastly, Edna (Eti) Cukierman, PhD, of Fox Chase Cancer Center, received a grant to conduct research with Ashani Weeraratna, PhD, of Johns Hopkins University in Baltimore, and Vivek Shenoy, PhD, and Arjun Raj, PhD, both of the University of Pennsylvania in Philadelphia.

The grant, from the National Cancer Institute, will be used to investigate the link between cell aging and melanoma. Dr. Cukierman, Dr. Weeraratna, Dr. Shenoy, and Dr. Raj will focus their research "on better understanding the deterioration of collagen integrity via cellular aging and its role in melanoma metastasis,” according to a statement.

[email protected]

A study of 305 cases of acute flaccid myelitis has found further evidence of a viral etiology but is yet to identify a single pathogen as the primary cause.

Writing in Pediatrics, researchers published an analysis of patients presenting with acute flaccid limb weakness from January 2015 to December 2017 across 43 states.

A total of 25 cases were judged as probable for acute flaccid myelitis (AFM) because they met clinical criteria and had a white blood cell count above 5 cells per mm³ in cerebrospinal fluid, while 193 were judged as confirmed cases based on the additional presence of spinal cord gray matter lesions on MRI.

Overall, 83% of patients had experienced fever, cough, runny nose, vomiting, and/or diarrhea for a median of 5 days before limb weakness began. Two-thirds of patients had experienced a respiratory illness, 62% had experienced a fever, and 29% had experienced gastrointestinal illness.

Overall, 47% of the 193 patients who had specimens tested at a Centers for Disease Control and Prevention or non-CDC laboratory had a pathogen found at any site, 10% had a pathogen detected from a sterile site such as cerebrospinal fluid or sera, and 42% had a pathogen detected from a nonsterile site.

Among 72 patients who had serum specimens tested at the CDC, 2 were positive for enteroviruses. Among the 90 patients who had upper respiratory specimens tested, 36% were positive for either enteroviruses or rhinoviruses.

A number of stool specimens were also tested; 15% were positive for enteroviruses or rhinoviruses and one was positive for parechovirus.

Cerebrospinal fluid was tested in 170 patients, of which 4 were positive for enteroviruses. The testing also found adenovirus, Epstein-Barr virus, human herpesvirus 6, and mycoplasma in six patients. Sera testing of 123 patients found 9 were positive for enteroviruses, West Nile virus, mycoplasma, and coxsackievirus B.

“In our summary of national AFM surveillance from 2015 to 2017, we demonstrate that cases were widely distributed across the United States, the majority of cases occurred in late summer or fall, children were predominantly affected, there is a spectrum of clinical severity, and no single pathogen was identified as the primary cause of AFM,” wrote Tracy Ayers, PhD, from the National Center for Immunization and Respiratory Diseases, and coauthors. “We conclude that symptoms of a viral syndrome within the week before limb weakness, detection of viral pathogens from sterile and nonsterile sites from almost half of patients, and seasonality of AFM incidence, particularly during the 2016 peak year, strongly suggest a viral etiology, including [enteroviruses].”

The authors of an accompanying editorial noted that the clinical syndrome of acute flaccid paralysis caused by myelitis in the gray matter of the spinal cord has previously been associated with a range of viruses, including poliovirus, enteroviruses, and flaviviruses, so a single etiology to explain all cases would not be expected.

“The central question remains: What is driving seasonal biennial nationwide outbreaks of AFM since 2014?” wrote Kevin Messaca, MD, and colleagues from the University of Colorado at Denver, Aurora.

Two authors declared consultancies, grants, and research contracts with the pharmaceutical sector. No other conflicts of interest were declared. One editorial author declared funding from the National Institute of Allergy and Infectious Diseases.

SOURCE: Ayers T et al. Pediatrics. 2019 Oct 7. doi: 10.1542/peds.2019-1619.

*Updated 10/14/2019.

A study of 305 cases of acute flaccid myelitis has found further evidence of a viral etiology but is yet to identify a single pathogen as the primary cause.

Writing in Pediatrics, researchers published an analysis of patients presenting with acute flaccid limb weakness from January 2015 to December 2017 across 43 states.

A total of 25 cases were judged as probable for acute flaccid myelitis (AFM) because they met clinical criteria and had a white blood cell count above 5 cells per mm³ in cerebrospinal fluid, while 193 were judged as confirmed cases based on the additional presence of spinal cord gray matter lesions on MRI.

Overall, 83% of patients had experienced fever, cough, runny nose, vomiting, and/or diarrhea for a median of 5 days before limb weakness began. Two-thirds of patients had experienced a respiratory illness, 62% had experienced a fever, and 29% had experienced gastrointestinal illness.

Overall, 47% of the 193 patients who had specimens tested at a Centers for Disease Control and Prevention or non-CDC laboratory had a pathogen found at any site, 10% had a pathogen detected from a sterile site such as cerebrospinal fluid or sera, and 42% had a pathogen detected from a nonsterile site.

Among 72 patients who had serum specimens tested at the CDC, 2 were positive for enteroviruses. Among the 90 patients who had upper respiratory specimens tested, 36% were positive for either enteroviruses or rhinoviruses.

A number of stool specimens were also tested; 15% were positive for enteroviruses or rhinoviruses and one was positive for parechovirus.

Cerebrospinal fluid was tested in 170 patients, of which 4 were positive for enteroviruses. The testing also found adenovirus, Epstein-Barr virus, human herpesvirus 6, and mycoplasma in six patients. Sera testing of 123 patients found 9 were positive for enteroviruses, West Nile virus, mycoplasma, and coxsackievirus B.

“In our summary of national AFM surveillance from 2015 to 2017, we demonstrate that cases were widely distributed across the United States, the majority of cases occurred in late summer or fall, children were predominantly affected, there is a spectrum of clinical severity, and no single pathogen was identified as the primary cause of AFM,” wrote Tracy Ayers, PhD, from the National Center for Immunization and Respiratory Diseases, and coauthors. “We conclude that symptoms of a viral syndrome within the week before limb weakness, detection of viral pathogens from sterile and nonsterile sites from almost half of patients, and seasonality of AFM incidence, particularly during the 2016 peak year, strongly suggest a viral etiology, including [enteroviruses].”

The authors of an accompanying editorial noted that the clinical syndrome of acute flaccid paralysis caused by myelitis in the gray matter of the spinal cord has previously been associated with a range of viruses, including poliovirus, enteroviruses, and flaviviruses, so a single etiology to explain all cases would not be expected.

“The central question remains: What is driving seasonal biennial nationwide outbreaks of AFM since 2014?” wrote Kevin Messaca, MD, and colleagues from the University of Colorado at Denver, Aurora.

Two authors declared consultancies, grants, and research contracts with the pharmaceutical sector. No other conflicts of interest were declared. One editorial author declared funding from the National Institute of Allergy and Infectious Diseases.

SOURCE: Ayers T et al. Pediatrics. 2019 Oct 7. doi: 10.1542/peds.2019-1619.

*Updated 10/14/2019.

A study of 305 cases of acute flaccid myelitis has found further evidence of a viral etiology but is yet to identify a single pathogen as the primary cause.

Writing in Pediatrics, researchers published an analysis of patients presenting with acute flaccid limb weakness from January 2015 to December 2017 across 43 states.

A total of 25 cases were judged as probable for acute flaccid myelitis (AFM) because they met clinical criteria and had a white blood cell count above 5 cells per mm³ in cerebrospinal fluid, while 193 were judged as confirmed cases based on the additional presence of spinal cord gray matter lesions on MRI.

Overall, 83% of patients had experienced fever, cough, runny nose, vomiting, and/or diarrhea for a median of 5 days before limb weakness began. Two-thirds of patients had experienced a respiratory illness, 62% had experienced a fever, and 29% had experienced gastrointestinal illness.

Overall, 47% of the 193 patients who had specimens tested at a Centers for Disease Control and Prevention or non-CDC laboratory had a pathogen found at any site, 10% had a pathogen detected from a sterile site such as cerebrospinal fluid or sera, and 42% had a pathogen detected from a nonsterile site.

Among 72 patients who had serum specimens tested at the CDC, 2 were positive for enteroviruses. Among the 90 patients who had upper respiratory specimens tested, 36% were positive for either enteroviruses or rhinoviruses.

A number of stool specimens were also tested; 15% were positive for enteroviruses or rhinoviruses and one was positive for parechovirus.

Cerebrospinal fluid was tested in 170 patients, of which 4 were positive for enteroviruses. The testing also found adenovirus, Epstein-Barr virus, human herpesvirus 6, and mycoplasma in six patients. Sera testing of 123 patients found 9 were positive for enteroviruses, West Nile virus, mycoplasma, and coxsackievirus B.

“In our summary of national AFM surveillance from 2015 to 2017, we demonstrate that cases were widely distributed across the United States, the majority of cases occurred in late summer or fall, children were predominantly affected, there is a spectrum of clinical severity, and no single pathogen was identified as the primary cause of AFM,” wrote Tracy Ayers, PhD, from the National Center for Immunization and Respiratory Diseases, and coauthors. “We conclude that symptoms of a viral syndrome within the week before limb weakness, detection of viral pathogens from sterile and nonsterile sites from almost half of patients, and seasonality of AFM incidence, particularly during the 2016 peak year, strongly suggest a viral etiology, including [enteroviruses].”

The authors of an accompanying editorial noted that the clinical syndrome of acute flaccid paralysis caused by myelitis in the gray matter of the spinal cord has previously been associated with a range of viruses, including poliovirus, enteroviruses, and flaviviruses, so a single etiology to explain all cases would not be expected.

“The central question remains: What is driving seasonal biennial nationwide outbreaks of AFM since 2014?” wrote Kevin Messaca, MD, and colleagues from the University of Colorado at Denver, Aurora.

Two authors declared consultancies, grants, and research contracts with the pharmaceutical sector. No other conflicts of interest were declared. One editorial author declared funding from the National Institute of Allergy and Infectious Diseases.

SOURCE: Ayers T et al. Pediatrics. 2019 Oct 7. doi: 10.1542/peds.2019-1619.

*Updated 10/14/2019.