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From the Editors: Hanging up the scalpel
The decision to stop practicing surgery is a monumental one when you have been a surgeon for almost 40 years, have loved operating, and have defined yourself by the word “surgeon.”
The decision to cease operating should at best be a personal one that the surgeon makes, rather than one imposed by others. The “others” could be an institutional policy mandating retirement at a given age, the results of a series of psychomotor examinations, or even a kind department chair’s suggestion that you should stop operating because your complications have increased and it is in your patients’ best interests. As we approach “a certain age,” I suspect that most surgeons would prefer to decide their own fate and, especially, to avoid the last of the three above options.
Literature is emerging about the aging physician and how best the decisions should be made about ceasing practice. A recent such article published online by some dear and respected colleagues (JAMA Surg. 2017 July 19;doi:10.1001/jamasurg.2017.2342) proposes that institutions and professional organizations develop policies to address the aging physician that leave “flexibility to customize the approach” lest regulators and legislators impose “more draconian measures.” Their suggestions include mandatory cognitive evaluation, voluntary annual physical examinations, and confidential peer evaluations of wellness and competence as physicians reach a certain (unspecified) age.
I most certainly concur with the authors’ well-reasoned arguments. As they relate, only a handful of institutions to date have developed policies that require assessments of physician wellness and competence at a given age. Most institutions still rely on physicians’ voluntary submission to physical examinations, cognitive testing, or peer referral of a colleague if declining function is observed. Yet we all know that individuals tend to overlook signs of declining physical and cognitive function both in themselves and in colleagues. Moreover, we all know that even the most carefully designed and implemented tests have shortcomings and may fail to identify the exact nature of an individual’s malady or fail to identify a remediable issue early. And just as individuals’ physical and cognitive abilities decline at different chronological ages, problems with burnout, mental illness, and substance abuse have no reliable age threshold and may be difficult to diagnose accurately.
Whatever the age of the individual, it is critical that a decline in function of a practitioner be addressed promptly and effectively, for the benefit of the affected individual, his or her patients, and the institution. It is therefore most appropriate for every institution to develop a firm policy to deal with concerns of competency of all staff members, regardless of age.
It is also appropriate for peers to pay attention to a colleague’s stumbles and have the courage to first initiate a dialogue directly with that person, referring the issue to an individual in authority if the direct approach fails. A culture that promotes responsible self-policing protects patients and the reputations of both the affected individual and the institution.
Most of us with “seniority” will recall situations during our training when surgeons with diminished physical or cognitive capacity continued operating well beyond their prime. In those days, it was not unusual for a chief resident to be told, “Your job is to scrub with Dr. X and keep him out of trouble.” As inappropriate as that was, we complied, all the while vowing that we would never let ourselves be in the same position when we aged.
It therefore became my habit as I aged to “listen to my body” and pay attention to evidence that my skills might be declining and perhaps it was time to hang up the scalpel. As an almost lifelong runner, I marked my athletic decline by noting an increase in minutes per mile from 7 to 14 over 40 years and wondered whether my cognitive decline might be comparable, if not so obvious. I had to admit to a bit of lost hand dexterity, less sharpness of eyesight, and slowed memory for the names of people and even of surgical instruments. Although I believed that my diagnostic acumen and decisions were unaffected, I weathered a sleepless night on call less well, requiring two or more full nights of eight hours’ sleep to recover my energy completely.
Part of the reluctance to cease surgical practice that I share with many colleagues my age is the fear of becoming irrelevant and unproductive. It was therefore critical to prepare for retirement from practice by identifying activities that I considered both meaningful and also challenging: writing and editing, teaching students and residents in surgical skills labs, teaching residents “open” surgical techniques on cadavers, advising younger colleagues when they have a challenging case in my area of expertise, and filling a myriad of needs in our department that match my skill set but that my younger counterparts are too busy to attend to.
I now also have the freedom to pursue activities for which I had little time during the years of intense practice, including service on nonprofit boards and other community activities. There may even come a day when my definition of self has fully accepted the word “retired,” even though I hope that day is many years in the future.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
The decision to stop practicing surgery is a monumental one when you have been a surgeon for almost 40 years, have loved operating, and have defined yourself by the word “surgeon.”
The decision to cease operating should at best be a personal one that the surgeon makes, rather than one imposed by others. The “others” could be an institutional policy mandating retirement at a given age, the results of a series of psychomotor examinations, or even a kind department chair’s suggestion that you should stop operating because your complications have increased and it is in your patients’ best interests. As we approach “a certain age,” I suspect that most surgeons would prefer to decide their own fate and, especially, to avoid the last of the three above options.
Literature is emerging about the aging physician and how best the decisions should be made about ceasing practice. A recent such article published online by some dear and respected colleagues (JAMA Surg. 2017 July 19;doi:10.1001/jamasurg.2017.2342) proposes that institutions and professional organizations develop policies to address the aging physician that leave “flexibility to customize the approach” lest regulators and legislators impose “more draconian measures.” Their suggestions include mandatory cognitive evaluation, voluntary annual physical examinations, and confidential peer evaluations of wellness and competence as physicians reach a certain (unspecified) age.
I most certainly concur with the authors’ well-reasoned arguments. As they relate, only a handful of institutions to date have developed policies that require assessments of physician wellness and competence at a given age. Most institutions still rely on physicians’ voluntary submission to physical examinations, cognitive testing, or peer referral of a colleague if declining function is observed. Yet we all know that individuals tend to overlook signs of declining physical and cognitive function both in themselves and in colleagues. Moreover, we all know that even the most carefully designed and implemented tests have shortcomings and may fail to identify the exact nature of an individual’s malady or fail to identify a remediable issue early. And just as individuals’ physical and cognitive abilities decline at different chronological ages, problems with burnout, mental illness, and substance abuse have no reliable age threshold and may be difficult to diagnose accurately.
Whatever the age of the individual, it is critical that a decline in function of a practitioner be addressed promptly and effectively, for the benefit of the affected individual, his or her patients, and the institution. It is therefore most appropriate for every institution to develop a firm policy to deal with concerns of competency of all staff members, regardless of age.
It is also appropriate for peers to pay attention to a colleague’s stumbles and have the courage to first initiate a dialogue directly with that person, referring the issue to an individual in authority if the direct approach fails. A culture that promotes responsible self-policing protects patients and the reputations of both the affected individual and the institution.
Most of us with “seniority” will recall situations during our training when surgeons with diminished physical or cognitive capacity continued operating well beyond their prime. In those days, it was not unusual for a chief resident to be told, “Your job is to scrub with Dr. X and keep him out of trouble.” As inappropriate as that was, we complied, all the while vowing that we would never let ourselves be in the same position when we aged.
It therefore became my habit as I aged to “listen to my body” and pay attention to evidence that my skills might be declining and perhaps it was time to hang up the scalpel. As an almost lifelong runner, I marked my athletic decline by noting an increase in minutes per mile from 7 to 14 over 40 years and wondered whether my cognitive decline might be comparable, if not so obvious. I had to admit to a bit of lost hand dexterity, less sharpness of eyesight, and slowed memory for the names of people and even of surgical instruments. Although I believed that my diagnostic acumen and decisions were unaffected, I weathered a sleepless night on call less well, requiring two or more full nights of eight hours’ sleep to recover my energy completely.
Part of the reluctance to cease surgical practice that I share with many colleagues my age is the fear of becoming irrelevant and unproductive. It was therefore critical to prepare for retirement from practice by identifying activities that I considered both meaningful and also challenging: writing and editing, teaching students and residents in surgical skills labs, teaching residents “open” surgical techniques on cadavers, advising younger colleagues when they have a challenging case in my area of expertise, and filling a myriad of needs in our department that match my skill set but that my younger counterparts are too busy to attend to.
I now also have the freedom to pursue activities for which I had little time during the years of intense practice, including service on nonprofit boards and other community activities. There may even come a day when my definition of self has fully accepted the word “retired,” even though I hope that day is many years in the future.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
The decision to stop practicing surgery is a monumental one when you have been a surgeon for almost 40 years, have loved operating, and have defined yourself by the word “surgeon.”
The decision to cease operating should at best be a personal one that the surgeon makes, rather than one imposed by others. The “others” could be an institutional policy mandating retirement at a given age, the results of a series of psychomotor examinations, or even a kind department chair’s suggestion that you should stop operating because your complications have increased and it is in your patients’ best interests. As we approach “a certain age,” I suspect that most surgeons would prefer to decide their own fate and, especially, to avoid the last of the three above options.
Literature is emerging about the aging physician and how best the decisions should be made about ceasing practice. A recent such article published online by some dear and respected colleagues (JAMA Surg. 2017 July 19;doi:10.1001/jamasurg.2017.2342) proposes that institutions and professional organizations develop policies to address the aging physician that leave “flexibility to customize the approach” lest regulators and legislators impose “more draconian measures.” Their suggestions include mandatory cognitive evaluation, voluntary annual physical examinations, and confidential peer evaluations of wellness and competence as physicians reach a certain (unspecified) age.
I most certainly concur with the authors’ well-reasoned arguments. As they relate, only a handful of institutions to date have developed policies that require assessments of physician wellness and competence at a given age. Most institutions still rely on physicians’ voluntary submission to physical examinations, cognitive testing, or peer referral of a colleague if declining function is observed. Yet we all know that individuals tend to overlook signs of declining physical and cognitive function both in themselves and in colleagues. Moreover, we all know that even the most carefully designed and implemented tests have shortcomings and may fail to identify the exact nature of an individual’s malady or fail to identify a remediable issue early. And just as individuals’ physical and cognitive abilities decline at different chronological ages, problems with burnout, mental illness, and substance abuse have no reliable age threshold and may be difficult to diagnose accurately.
Whatever the age of the individual, it is critical that a decline in function of a practitioner be addressed promptly and effectively, for the benefit of the affected individual, his or her patients, and the institution. It is therefore most appropriate for every institution to develop a firm policy to deal with concerns of competency of all staff members, regardless of age.
It is also appropriate for peers to pay attention to a colleague’s stumbles and have the courage to first initiate a dialogue directly with that person, referring the issue to an individual in authority if the direct approach fails. A culture that promotes responsible self-policing protects patients and the reputations of both the affected individual and the institution.
Most of us with “seniority” will recall situations during our training when surgeons with diminished physical or cognitive capacity continued operating well beyond their prime. In those days, it was not unusual for a chief resident to be told, “Your job is to scrub with Dr. X and keep him out of trouble.” As inappropriate as that was, we complied, all the while vowing that we would never let ourselves be in the same position when we aged.
It therefore became my habit as I aged to “listen to my body” and pay attention to evidence that my skills might be declining and perhaps it was time to hang up the scalpel. As an almost lifelong runner, I marked my athletic decline by noting an increase in minutes per mile from 7 to 14 over 40 years and wondered whether my cognitive decline might be comparable, if not so obvious. I had to admit to a bit of lost hand dexterity, less sharpness of eyesight, and slowed memory for the names of people and even of surgical instruments. Although I believed that my diagnostic acumen and decisions were unaffected, I weathered a sleepless night on call less well, requiring two or more full nights of eight hours’ sleep to recover my energy completely.
Part of the reluctance to cease surgical practice that I share with many colleagues my age is the fear of becoming irrelevant and unproductive. It was therefore critical to prepare for retirement from practice by identifying activities that I considered both meaningful and also challenging: writing and editing, teaching students and residents in surgical skills labs, teaching residents “open” surgical techniques on cadavers, advising younger colleagues when they have a challenging case in my area of expertise, and filling a myriad of needs in our department that match my skill set but that my younger counterparts are too busy to attend to.
I now also have the freedom to pursue activities for which I had little time during the years of intense practice, including service on nonprofit boards and other community activities. There may even come a day when my definition of self has fully accepted the word “retired,” even though I hope that day is many years in the future.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
From the Washington Office: Receiving an increase in Medicare payment and avoiding a penalty
We are now well over halfway through 2017, the initial year of the new Quality Payment Program (QPP) mandated by MACRA. Accordingly, I thought it might be useful to revisit the topic of the QPP and MIPS (Merit-based Incentive Payment System) for purposes of emphasizing the key steps surgeons should take if they want to potentially see an increase in their Medicare physician payment in 2019 based on their performance in 2017. At the same time, I also want to make sure that all surgeons understand the ease with which they can avoid a payment penalty.
First, I want to assure all who have yet to take any action that there is still more than adequate time to do so. You absolutely can still compete for a positive update, or at a minimum, avoid a penalty. Further, it is so easy to avoid a penalty that no surgeon should be resigned to accepting a penalty without having a look at the minimal reporting requirements necessary to avoid it.
One of the resources available on the ACS’ QPP website is an algorhythm intended to simplify surgeons’ decision making at their initial starting point. It is reproduced below:
1. Determine if all of your MIPS data will be reported by your institution or group via a Group Reporting option (GPRO).
a. If “YES,” you are done.
b. If “NO,” move to number 2.
2. Has CMS notified you that you are exempt from participating in MIPS due to the low-volume threshold?
a. If “YES,” you are done.
b. If “NO,” move to number 3.
3. If you want to compete for positive updates in your Medicare payment rates in 2019 (based on 2017 reporting), read the ACS Quality Payment Program Manual, watch the videos, and develop your plan.
4. If your goal is simply to avoid a penalty, CMS only requires data be reported for one of the following:
a. Required Base Score measures for your EHR (now known as Advancing Care Information) OR
b. One Improvement Activity for 90 days (report by attestation) OR
c. One Quality Measure on one patient (report by registry, QCDR, EHR, or claims)
Note: One is NOT required to have a certified EHR to avoid a penalty for 2017
5. If you did not report PQRS data and did not participate in the electronic health record meaningful use program in 2016 and have no intention of participating in MIPS in 2017:
a. Your lack of participation in 2016 programs will lead to a 10% negative payment adjustment in 2018.
b. Your lack of participation in MIPS in 2017 will lead to a 4% negative payment adjustment in 2019.
Note: This option is not recommended, as in future years the annual cuts will gradually increase to 9%.
MIPS is set up as a tournament model. In other words, “Losers” pay for “Winners.” Please do not put your money in someone else’s pocket. The ACS strongly encourages all Fellows to, at the minimum, participate at the level sufficient to avoid a penalty in 2017 and, thus, not serve as the “pay for” for another provider.
If you are not exempt from MIPS and therefore, one whose performance will be assessed in 2017, you still have plenty of time to start the process of reporting enough data to compete for a positive update. On the other hand, if your goal is simply to avoid a penalty in 2019, (based on your performance in 2017), you should take the few simple steps necessary to preclude such as outlined above.
We believe the QPP website, (www.facs.org/qpp), is an excellent resource for surgeons. It was designed to facilitate participation by those surgeons who must report for MIPS. As always, ACS staff are also available to answer your questions by phone or via e-mail: [email protected].
Until next month ….
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
We are now well over halfway through 2017, the initial year of the new Quality Payment Program (QPP) mandated by MACRA. Accordingly, I thought it might be useful to revisit the topic of the QPP and MIPS (Merit-based Incentive Payment System) for purposes of emphasizing the key steps surgeons should take if they want to potentially see an increase in their Medicare physician payment in 2019 based on their performance in 2017. At the same time, I also want to make sure that all surgeons understand the ease with which they can avoid a payment penalty.
First, I want to assure all who have yet to take any action that there is still more than adequate time to do so. You absolutely can still compete for a positive update, or at a minimum, avoid a penalty. Further, it is so easy to avoid a penalty that no surgeon should be resigned to accepting a penalty without having a look at the minimal reporting requirements necessary to avoid it.
One of the resources available on the ACS’ QPP website is an algorhythm intended to simplify surgeons’ decision making at their initial starting point. It is reproduced below:
1. Determine if all of your MIPS data will be reported by your institution or group via a Group Reporting option (GPRO).
a. If “YES,” you are done.
b. If “NO,” move to number 2.
2. Has CMS notified you that you are exempt from participating in MIPS due to the low-volume threshold?
a. If “YES,” you are done.
b. If “NO,” move to number 3.
3. If you want to compete for positive updates in your Medicare payment rates in 2019 (based on 2017 reporting), read the ACS Quality Payment Program Manual, watch the videos, and develop your plan.
4. If your goal is simply to avoid a penalty, CMS only requires data be reported for one of the following:
a. Required Base Score measures for your EHR (now known as Advancing Care Information) OR
b. One Improvement Activity for 90 days (report by attestation) OR
c. One Quality Measure on one patient (report by registry, QCDR, EHR, or claims)
Note: One is NOT required to have a certified EHR to avoid a penalty for 2017
5. If you did not report PQRS data and did not participate in the electronic health record meaningful use program in 2016 and have no intention of participating in MIPS in 2017:
a. Your lack of participation in 2016 programs will lead to a 10% negative payment adjustment in 2018.
b. Your lack of participation in MIPS in 2017 will lead to a 4% negative payment adjustment in 2019.
Note: This option is not recommended, as in future years the annual cuts will gradually increase to 9%.
MIPS is set up as a tournament model. In other words, “Losers” pay for “Winners.” Please do not put your money in someone else’s pocket. The ACS strongly encourages all Fellows to, at the minimum, participate at the level sufficient to avoid a penalty in 2017 and, thus, not serve as the “pay for” for another provider.
If you are not exempt from MIPS and therefore, one whose performance will be assessed in 2017, you still have plenty of time to start the process of reporting enough data to compete for a positive update. On the other hand, if your goal is simply to avoid a penalty in 2019, (based on your performance in 2017), you should take the few simple steps necessary to preclude such as outlined above.
We believe the QPP website, (www.facs.org/qpp), is an excellent resource for surgeons. It was designed to facilitate participation by those surgeons who must report for MIPS. As always, ACS staff are also available to answer your questions by phone or via e-mail: [email protected].
Until next month ….
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
We are now well over halfway through 2017, the initial year of the new Quality Payment Program (QPP) mandated by MACRA. Accordingly, I thought it might be useful to revisit the topic of the QPP and MIPS (Merit-based Incentive Payment System) for purposes of emphasizing the key steps surgeons should take if they want to potentially see an increase in their Medicare physician payment in 2019 based on their performance in 2017. At the same time, I also want to make sure that all surgeons understand the ease with which they can avoid a payment penalty.
First, I want to assure all who have yet to take any action that there is still more than adequate time to do so. You absolutely can still compete for a positive update, or at a minimum, avoid a penalty. Further, it is so easy to avoid a penalty that no surgeon should be resigned to accepting a penalty without having a look at the minimal reporting requirements necessary to avoid it.
One of the resources available on the ACS’ QPP website is an algorhythm intended to simplify surgeons’ decision making at their initial starting point. It is reproduced below:
1. Determine if all of your MIPS data will be reported by your institution or group via a Group Reporting option (GPRO).
a. If “YES,” you are done.
b. If “NO,” move to number 2.
2. Has CMS notified you that you are exempt from participating in MIPS due to the low-volume threshold?
a. If “YES,” you are done.
b. If “NO,” move to number 3.
3. If you want to compete for positive updates in your Medicare payment rates in 2019 (based on 2017 reporting), read the ACS Quality Payment Program Manual, watch the videos, and develop your plan.
4. If your goal is simply to avoid a penalty, CMS only requires data be reported for one of the following:
a. Required Base Score measures for your EHR (now known as Advancing Care Information) OR
b. One Improvement Activity for 90 days (report by attestation) OR
c. One Quality Measure on one patient (report by registry, QCDR, EHR, or claims)
Note: One is NOT required to have a certified EHR to avoid a penalty for 2017
5. If you did not report PQRS data and did not participate in the electronic health record meaningful use program in 2016 and have no intention of participating in MIPS in 2017:
a. Your lack of participation in 2016 programs will lead to a 10% negative payment adjustment in 2018.
b. Your lack of participation in MIPS in 2017 will lead to a 4% negative payment adjustment in 2019.
Note: This option is not recommended, as in future years the annual cuts will gradually increase to 9%.
MIPS is set up as a tournament model. In other words, “Losers” pay for “Winners.” Please do not put your money in someone else’s pocket. The ACS strongly encourages all Fellows to, at the minimum, participate at the level sufficient to avoid a penalty in 2017 and, thus, not serve as the “pay for” for another provider.
If you are not exempt from MIPS and therefore, one whose performance will be assessed in 2017, you still have plenty of time to start the process of reporting enough data to compete for a positive update. On the other hand, if your goal is simply to avoid a penalty in 2019, (based on your performance in 2017), you should take the few simple steps necessary to preclude such as outlined above.
We believe the QPP website, (www.facs.org/qpp), is an excellent resource for surgeons. It was designed to facilitate participation by those surgeons who must report for MIPS. As always, ACS staff are also available to answer your questions by phone or via e-mail: [email protected].
Until next month ….
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
Richard J. Finley, MD, FACS, FRCSC, to receive Distinguished Service Award
The Board of Regents of the American College of Surgeons (ACS) has chosen Richard J. Finley, MD, FACS, FRCSC, a general thoracic surgeon, Vancouver General and Surrey Memorial Hospitals, BC, and emeritus professor, department of surgery, University of British Columbia (UBC), Vancouver, to receive the 2017 Distinguished Service Award (DSA). The Regents will present the award—the College’s highest honor—Sunday, October 22, during the Convocation preceding Clinical Congress 2017 at the San Diego Convention Center, CA.
The Board of Regents is presenting the DSA to Dr. Finley in appreciation for his longstanding and devoted service as an ACS Fellow, the Chair (1993−1995) and Vice-Chair (1992−1993) of the Board of Governors (B/G), a member of the Board of Regents (2000−2009), and as ACS First Vice-President (2010). The award citation recognizes his “long-term commitment to improving graduate education for future generations” and his pioneering contributions in the area of health information technology, including his service as Chair of the ACS Web Portal Editorial Board (2005−2012) and Chair of the ACS Education Task Force on Practice-Based Learning and Improvement (2002−2009).
Commitment to education
Dr. Finley has devoted much of his career to surgical education. The many residents and fellows he has trained describe Dr. Finley as an outstanding teacher and mentor, enthusiastic and innovative, and an asset to residency education. Dr. Finley has participated in the training of 14 general thoracic surgeons who now practice in academic hospitals across Canada. He is the recipient of several teaching and scholarship awards, including the UBC department of surgery Master Teaching Award (1991) and Best Teacher, Interns and Residents, University of Western Ontario, London.
Prior to assuming the position of emeritus professor at UBC, he was professor of surgery (1989−2016); head, department of surgery (1989−2001); and head, division of thoracic surgery (1994−2014) at UBC. In addition, Dr. Finley was surgeon-in-chief at Vancouver Hospital (1997–2001); head (1989–2001), department of surgery, and medical director (1992), clinical practice unit, Vancouver Hospital & Health Sciences Center, BC; and consultant staff at British Columbia Cancer Agency, Vancouver (1989–2015). Previously, Dr. Finley was chief of surgery (1985–1988) and attending surgeon, Victoria Hospital, London, ON, and a consulting surgeon, University Hospital & Ontario Cancer Foundation (1979–1988).
After graduating with honors from the University of Western Ontario Medical School, he did an internship at Vancouver General Hospital, followed by residency in surgery and cardiothoracic surgery at the University of Western Ontario. He then completed a medical research fellowship at Harvard Medical School, Boston, MA, and another year of postgraduate training at the University of Toronto, department of surgery, division of thoracic surgery. Dr. Finley then returned to the University of Western Ontario, working his way up from assistant professor (1979–1983) to associate professor (1983–1989), department of surgery.
He has chaired multiple committees at the institutions where he has practiced and taught, including the faculty executive committee and surgical advisory committee at UBC and the surgical advisory committee, minimally invasive surgery, operating room council, and operating room executive team at Vancouver Hospital & Health Sciences Centre.
Dr. Finley’s areas of special interest and accomplishment include pulmonary and esophageal surgery; metabolic and cardiopulmonary responses to sepsis, trauma, and cancer; computed tomography-guided video-assisted thoracoscopic resection of small peripheral lung cancers; quality improvement of perioperative processes; and regionalization of thoracic surgery services in British Columbia. He has been awarded 12 competitive research or equivalent grants from the Canadian Institute of Health Research, the National Cancer Institute, and a number of health care organizations.
Dedicated leader
Dr. Finley has been a Fellow of the ACS since 1983. In addition to his many achievements within the organization described earlier, he served as an ACS Governor (1989–1995), working on the B/G Ambulatory Surgery (1991), Surgical Infection (1993), Surgical Practice (1993), Communications (1991–1995), and Executive (1990–1995) Committees. As an ACS Regent, he served on the Advisory Council for General Surgery (2000–2009), the Research and Optimal Patient Care Committee (Chair, 2009), the Nominating Committee (2005–2007, Chair 2008), and the Finance Committee (2002–2004).
Dr. Finley has served as president of the International James IV Surgical Association (1998–2001), the British Columbia Surgical Association (2006), and the Canadian Association of Thoracic Surgeons (2004–2006). He also served as a Vice-President of the American Surgical Association and Chair of the Canadian Association of Surgical Chairs. He has been a member of the editorial boards for the Journal of the American College of Surgeons (1999–2006), Annals of Surgery (2002–2015), and Canadian Journal of Surgery (2004–2009). He has authored or co-authored 103 journal articles and 23 book chapters and has delivered 117 invited lectureships.
The Board of Regents of the American College of Surgeons (ACS) has chosen Richard J. Finley, MD, FACS, FRCSC, a general thoracic surgeon, Vancouver General and Surrey Memorial Hospitals, BC, and emeritus professor, department of surgery, University of British Columbia (UBC), Vancouver, to receive the 2017 Distinguished Service Award (DSA). The Regents will present the award—the College’s highest honor—Sunday, October 22, during the Convocation preceding Clinical Congress 2017 at the San Diego Convention Center, CA.
The Board of Regents is presenting the DSA to Dr. Finley in appreciation for his longstanding and devoted service as an ACS Fellow, the Chair (1993−1995) and Vice-Chair (1992−1993) of the Board of Governors (B/G), a member of the Board of Regents (2000−2009), and as ACS First Vice-President (2010). The award citation recognizes his “long-term commitment to improving graduate education for future generations” and his pioneering contributions in the area of health information technology, including his service as Chair of the ACS Web Portal Editorial Board (2005−2012) and Chair of the ACS Education Task Force on Practice-Based Learning and Improvement (2002−2009).
Commitment to education
Dr. Finley has devoted much of his career to surgical education. The many residents and fellows he has trained describe Dr. Finley as an outstanding teacher and mentor, enthusiastic and innovative, and an asset to residency education. Dr. Finley has participated in the training of 14 general thoracic surgeons who now practice in academic hospitals across Canada. He is the recipient of several teaching and scholarship awards, including the UBC department of surgery Master Teaching Award (1991) and Best Teacher, Interns and Residents, University of Western Ontario, London.
Prior to assuming the position of emeritus professor at UBC, he was professor of surgery (1989−2016); head, department of surgery (1989−2001); and head, division of thoracic surgery (1994−2014) at UBC. In addition, Dr. Finley was surgeon-in-chief at Vancouver Hospital (1997–2001); head (1989–2001), department of surgery, and medical director (1992), clinical practice unit, Vancouver Hospital & Health Sciences Center, BC; and consultant staff at British Columbia Cancer Agency, Vancouver (1989–2015). Previously, Dr. Finley was chief of surgery (1985–1988) and attending surgeon, Victoria Hospital, London, ON, and a consulting surgeon, University Hospital & Ontario Cancer Foundation (1979–1988).
After graduating with honors from the University of Western Ontario Medical School, he did an internship at Vancouver General Hospital, followed by residency in surgery and cardiothoracic surgery at the University of Western Ontario. He then completed a medical research fellowship at Harvard Medical School, Boston, MA, and another year of postgraduate training at the University of Toronto, department of surgery, division of thoracic surgery. Dr. Finley then returned to the University of Western Ontario, working his way up from assistant professor (1979–1983) to associate professor (1983–1989), department of surgery.
He has chaired multiple committees at the institutions where he has practiced and taught, including the faculty executive committee and surgical advisory committee at UBC and the surgical advisory committee, minimally invasive surgery, operating room council, and operating room executive team at Vancouver Hospital & Health Sciences Centre.
Dr. Finley’s areas of special interest and accomplishment include pulmonary and esophageal surgery; metabolic and cardiopulmonary responses to sepsis, trauma, and cancer; computed tomography-guided video-assisted thoracoscopic resection of small peripheral lung cancers; quality improvement of perioperative processes; and regionalization of thoracic surgery services in British Columbia. He has been awarded 12 competitive research or equivalent grants from the Canadian Institute of Health Research, the National Cancer Institute, and a number of health care organizations.
Dedicated leader
Dr. Finley has been a Fellow of the ACS since 1983. In addition to his many achievements within the organization described earlier, he served as an ACS Governor (1989–1995), working on the B/G Ambulatory Surgery (1991), Surgical Infection (1993), Surgical Practice (1993), Communications (1991–1995), and Executive (1990–1995) Committees. As an ACS Regent, he served on the Advisory Council for General Surgery (2000–2009), the Research and Optimal Patient Care Committee (Chair, 2009), the Nominating Committee (2005–2007, Chair 2008), and the Finance Committee (2002–2004).
Dr. Finley has served as president of the International James IV Surgical Association (1998–2001), the British Columbia Surgical Association (2006), and the Canadian Association of Thoracic Surgeons (2004–2006). He also served as a Vice-President of the American Surgical Association and Chair of the Canadian Association of Surgical Chairs. He has been a member of the editorial boards for the Journal of the American College of Surgeons (1999–2006), Annals of Surgery (2002–2015), and Canadian Journal of Surgery (2004–2009). He has authored or co-authored 103 journal articles and 23 book chapters and has delivered 117 invited lectureships.
The Board of Regents of the American College of Surgeons (ACS) has chosen Richard J. Finley, MD, FACS, FRCSC, a general thoracic surgeon, Vancouver General and Surrey Memorial Hospitals, BC, and emeritus professor, department of surgery, University of British Columbia (UBC), Vancouver, to receive the 2017 Distinguished Service Award (DSA). The Regents will present the award—the College’s highest honor—Sunday, October 22, during the Convocation preceding Clinical Congress 2017 at the San Diego Convention Center, CA.
The Board of Regents is presenting the DSA to Dr. Finley in appreciation for his longstanding and devoted service as an ACS Fellow, the Chair (1993−1995) and Vice-Chair (1992−1993) of the Board of Governors (B/G), a member of the Board of Regents (2000−2009), and as ACS First Vice-President (2010). The award citation recognizes his “long-term commitment to improving graduate education for future generations” and his pioneering contributions in the area of health information technology, including his service as Chair of the ACS Web Portal Editorial Board (2005−2012) and Chair of the ACS Education Task Force on Practice-Based Learning and Improvement (2002−2009).
Commitment to education
Dr. Finley has devoted much of his career to surgical education. The many residents and fellows he has trained describe Dr. Finley as an outstanding teacher and mentor, enthusiastic and innovative, and an asset to residency education. Dr. Finley has participated in the training of 14 general thoracic surgeons who now practice in academic hospitals across Canada. He is the recipient of several teaching and scholarship awards, including the UBC department of surgery Master Teaching Award (1991) and Best Teacher, Interns and Residents, University of Western Ontario, London.
Prior to assuming the position of emeritus professor at UBC, he was professor of surgery (1989−2016); head, department of surgery (1989−2001); and head, division of thoracic surgery (1994−2014) at UBC. In addition, Dr. Finley was surgeon-in-chief at Vancouver Hospital (1997–2001); head (1989–2001), department of surgery, and medical director (1992), clinical practice unit, Vancouver Hospital & Health Sciences Center, BC; and consultant staff at British Columbia Cancer Agency, Vancouver (1989–2015). Previously, Dr. Finley was chief of surgery (1985–1988) and attending surgeon, Victoria Hospital, London, ON, and a consulting surgeon, University Hospital & Ontario Cancer Foundation (1979–1988).
After graduating with honors from the University of Western Ontario Medical School, he did an internship at Vancouver General Hospital, followed by residency in surgery and cardiothoracic surgery at the University of Western Ontario. He then completed a medical research fellowship at Harvard Medical School, Boston, MA, and another year of postgraduate training at the University of Toronto, department of surgery, division of thoracic surgery. Dr. Finley then returned to the University of Western Ontario, working his way up from assistant professor (1979–1983) to associate professor (1983–1989), department of surgery.
He has chaired multiple committees at the institutions where he has practiced and taught, including the faculty executive committee and surgical advisory committee at UBC and the surgical advisory committee, minimally invasive surgery, operating room council, and operating room executive team at Vancouver Hospital & Health Sciences Centre.
Dr. Finley’s areas of special interest and accomplishment include pulmonary and esophageal surgery; metabolic and cardiopulmonary responses to sepsis, trauma, and cancer; computed tomography-guided video-assisted thoracoscopic resection of small peripheral lung cancers; quality improvement of perioperative processes; and regionalization of thoracic surgery services in British Columbia. He has been awarded 12 competitive research or equivalent grants from the Canadian Institute of Health Research, the National Cancer Institute, and a number of health care organizations.
Dedicated leader
Dr. Finley has been a Fellow of the ACS since 1983. In addition to his many achievements within the organization described earlier, he served as an ACS Governor (1989–1995), working on the B/G Ambulatory Surgery (1991), Surgical Infection (1993), Surgical Practice (1993), Communications (1991–1995), and Executive (1990–1995) Committees. As an ACS Regent, he served on the Advisory Council for General Surgery (2000–2009), the Research and Optimal Patient Care Committee (Chair, 2009), the Nominating Committee (2005–2007, Chair 2008), and the Finance Committee (2002–2004).
Dr. Finley has served as president of the International James IV Surgical Association (1998–2001), the British Columbia Surgical Association (2006), and the Canadian Association of Thoracic Surgeons (2004–2006). He also served as a Vice-President of the American Surgical Association and Chair of the Canadian Association of Surgical Chairs. He has been a member of the editorial boards for the Journal of the American College of Surgeons (1999–2006), Annals of Surgery (2002–2015), and Canadian Journal of Surgery (2004–2009). He has authored or co-authored 103 journal articles and 23 book chapters and has delivered 117 invited lectureships.
Winds of change at the American Board of Surgery: An interview with Executive Director Jo Buyske, MD, FACS
Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.
Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.
We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.
Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?
Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.
SN: What has been the response from the Diplomates to the announcement?
Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.
SN: What happens now in this process of overhauling the recertification process?
Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.
Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.
Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.
The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.
The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?
Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.
We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?
Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.
It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?
Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.
SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.
SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.
Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.
Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.
We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.
Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?
Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.
SN: What has been the response from the Diplomates to the announcement?
Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.
SN: What happens now in this process of overhauling the recertification process?
Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.
Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.
Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.
The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.
The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?
Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.
We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?
Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.
It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?
Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.
SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.
SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.
Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.
Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.
We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.
Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?
Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.
SN: What has been the response from the Diplomates to the announcement?
Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.
SN: What happens now in this process of overhauling the recertification process?
Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.
Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.
Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.
The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.
The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?
Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.
We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?
Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.
It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?
Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.
SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.
SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.
Make teen suicide screenings a part of everyday practice
CHICAGO – at the annual meeting of the American Academy of Pediatrics.
An estimated 2 million teenagers, aged 15-19 years, have attempted suicide within the past year, based on data from the Centers for Disease Control and Prevention. According to the CDC’s 1991-2015 High School Youth Risk Behavior Survey data, nearly a third of students (30%) have felt so sad or helpless nearly daily for at least 2 weeks that they stopped doing their normal activities, and 18% had seriously considered suicide within the past year. One in seven (15%) had made a plan for attempting suicide, 9% had attempted suicide at least once, and 3% attempted suicide that required medical treatment. About twice as many females as males had considered, planned, and/or attempted suicide.
“The offspring of suicide attempters have a sixfold higher risk of suicide than their peers whose parents have not attempted suicide,” Dr. Cody said. Other major risk factors include a history of being bullied, a history of abuse, and a history of substance abuse, particularly alcohol and opioids.
Once you identify a patient at risk for suicide, Dr. Cody advised that you should follow a suicide assessment management protocol, such as the one developed by Angela Stanley, PsyD, of the Medical College of Wisconsin and the Children’s Hospital of Wisconsin, both in Milwaukee. Doctors should identify the teen’s intensity of suicidal ideation, ask how far they are in their plans, ascertain their access to means, create a safety plan, refer the patient for mental health care, and follow up frequently.
Dr. Cody emphasized that “suicide contracts” and “safety plans” are different things. Suicide pacts are agreements not to hurt oneself, whereas safety plans include concrete, collaborative, proactive steps a person will take if experiencing suicidal thoughts.
“There is no evidence that contracts prevent suicide, but a lot of research shows that safety or crisis plans are much more effective at preventing a person from committing suicide,” Dr. Cody stated.
The first step of screening is asking a patient directly whether they have ever wished they were dead or had thoughts about killing themselves.
“Some pediatricians are afraid to ask the questions because they’re afraid they’re going to put the idea of suicide in the child’s head, but there is no evidence that screening puts kids at risk,” Dr. Cody said. The other reason you may feel uneasy asking about self-harm is not knowing what to do if a teen says that she is feeling suicidal. That’s where an assessment protocol helps.
If a patient has considered suicide more than a month prior, it shouldn’t be ignored, although the situation may require less urgency but further follow-up. For those with more recent suicidal ideation but without a plan or intent, Dr. Cody recommends following up within 2 weeks because the adolescent’s situation may change.
For those with suicidal ideation and a plan, you should ask three questions:
- What ways of killing yourself have you thought about?
- How likely is it you will follow through on your plan?
- When you think about killing yourself, what stops you?
These questions can help you determine risk acuity: The more specific, realistic, available, and lethal a plan is, the more acute the risk. You then should ask questions to try to determine how likely the teen is to follow through, such as asking about his future plans, his connectedness with others, and his religious beliefs.
Asking about a plan helps determine how much access the patient has to a lethal, realistic means. Firearms are responsible for 52% of teen suicides, followed by hanging/suffocation (25%) and poisoning (16%).
“This is why it’s a really important part of social history to screen for guns in the house,” Dr. Cody told attendees. “I know it’s been really controversial, but it’s something that’s really important, especially if you have an adolescent in the house that’s having suicidal ideation.”
Teens with suicidal ideation and a plan but no intent require a safety plan along with follow-up within 1 week. Those with a plan and intent, or those with no intent but an unwillingness agree to a safety plan, should be immediately hospitalized, Dr. Cody said.
These suicide screenings should occur at annual well-child visits, Dr. Cody said, but they also should be done at acute visits; basically, any time you see your preteen and adolescent patients. Ideally, these should take place during alone time, without any parents present.
You also should share resources with your patients, including the National Suicide Prevention Lifeline at 1-800-273-8255 and the Crisis TextLine at 741741.
Dr. Cody reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – at the annual meeting of the American Academy of Pediatrics.
An estimated 2 million teenagers, aged 15-19 years, have attempted suicide within the past year, based on data from the Centers for Disease Control and Prevention. According to the CDC’s 1991-2015 High School Youth Risk Behavior Survey data, nearly a third of students (30%) have felt so sad or helpless nearly daily for at least 2 weeks that they stopped doing their normal activities, and 18% had seriously considered suicide within the past year. One in seven (15%) had made a plan for attempting suicide, 9% had attempted suicide at least once, and 3% attempted suicide that required medical treatment. About twice as many females as males had considered, planned, and/or attempted suicide.
“The offspring of suicide attempters have a sixfold higher risk of suicide than their peers whose parents have not attempted suicide,” Dr. Cody said. Other major risk factors include a history of being bullied, a history of abuse, and a history of substance abuse, particularly alcohol and opioids.
Once you identify a patient at risk for suicide, Dr. Cody advised that you should follow a suicide assessment management protocol, such as the one developed by Angela Stanley, PsyD, of the Medical College of Wisconsin and the Children’s Hospital of Wisconsin, both in Milwaukee. Doctors should identify the teen’s intensity of suicidal ideation, ask how far they are in their plans, ascertain their access to means, create a safety plan, refer the patient for mental health care, and follow up frequently.
Dr. Cody emphasized that “suicide contracts” and “safety plans” are different things. Suicide pacts are agreements not to hurt oneself, whereas safety plans include concrete, collaborative, proactive steps a person will take if experiencing suicidal thoughts.
“There is no evidence that contracts prevent suicide, but a lot of research shows that safety or crisis plans are much more effective at preventing a person from committing suicide,” Dr. Cody stated.
The first step of screening is asking a patient directly whether they have ever wished they were dead or had thoughts about killing themselves.
“Some pediatricians are afraid to ask the questions because they’re afraid they’re going to put the idea of suicide in the child’s head, but there is no evidence that screening puts kids at risk,” Dr. Cody said. The other reason you may feel uneasy asking about self-harm is not knowing what to do if a teen says that she is feeling suicidal. That’s where an assessment protocol helps.
If a patient has considered suicide more than a month prior, it shouldn’t be ignored, although the situation may require less urgency but further follow-up. For those with more recent suicidal ideation but without a plan or intent, Dr. Cody recommends following up within 2 weeks because the adolescent’s situation may change.
For those with suicidal ideation and a plan, you should ask three questions:
- What ways of killing yourself have you thought about?
- How likely is it you will follow through on your plan?
- When you think about killing yourself, what stops you?
These questions can help you determine risk acuity: The more specific, realistic, available, and lethal a plan is, the more acute the risk. You then should ask questions to try to determine how likely the teen is to follow through, such as asking about his future plans, his connectedness with others, and his religious beliefs.
Asking about a plan helps determine how much access the patient has to a lethal, realistic means. Firearms are responsible for 52% of teen suicides, followed by hanging/suffocation (25%) and poisoning (16%).
“This is why it’s a really important part of social history to screen for guns in the house,” Dr. Cody told attendees. “I know it’s been really controversial, but it’s something that’s really important, especially if you have an adolescent in the house that’s having suicidal ideation.”
Teens with suicidal ideation and a plan but no intent require a safety plan along with follow-up within 1 week. Those with a plan and intent, or those with no intent but an unwillingness agree to a safety plan, should be immediately hospitalized, Dr. Cody said.
These suicide screenings should occur at annual well-child visits, Dr. Cody said, but they also should be done at acute visits; basically, any time you see your preteen and adolescent patients. Ideally, these should take place during alone time, without any parents present.
You also should share resources with your patients, including the National Suicide Prevention Lifeline at 1-800-273-8255 and the Crisis TextLine at 741741.
Dr. Cody reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – at the annual meeting of the American Academy of Pediatrics.
An estimated 2 million teenagers, aged 15-19 years, have attempted suicide within the past year, based on data from the Centers for Disease Control and Prevention. According to the CDC’s 1991-2015 High School Youth Risk Behavior Survey data, nearly a third of students (30%) have felt so sad or helpless nearly daily for at least 2 weeks that they stopped doing their normal activities, and 18% had seriously considered suicide within the past year. One in seven (15%) had made a plan for attempting suicide, 9% had attempted suicide at least once, and 3% attempted suicide that required medical treatment. About twice as many females as males had considered, planned, and/or attempted suicide.
“The offspring of suicide attempters have a sixfold higher risk of suicide than their peers whose parents have not attempted suicide,” Dr. Cody said. Other major risk factors include a history of being bullied, a history of abuse, and a history of substance abuse, particularly alcohol and opioids.
Once you identify a patient at risk for suicide, Dr. Cody advised that you should follow a suicide assessment management protocol, such as the one developed by Angela Stanley, PsyD, of the Medical College of Wisconsin and the Children’s Hospital of Wisconsin, both in Milwaukee. Doctors should identify the teen’s intensity of suicidal ideation, ask how far they are in their plans, ascertain their access to means, create a safety plan, refer the patient for mental health care, and follow up frequently.
Dr. Cody emphasized that “suicide contracts” and “safety plans” are different things. Suicide pacts are agreements not to hurt oneself, whereas safety plans include concrete, collaborative, proactive steps a person will take if experiencing suicidal thoughts.
“There is no evidence that contracts prevent suicide, but a lot of research shows that safety or crisis plans are much more effective at preventing a person from committing suicide,” Dr. Cody stated.
The first step of screening is asking a patient directly whether they have ever wished they were dead or had thoughts about killing themselves.
“Some pediatricians are afraid to ask the questions because they’re afraid they’re going to put the idea of suicide in the child’s head, but there is no evidence that screening puts kids at risk,” Dr. Cody said. The other reason you may feel uneasy asking about self-harm is not knowing what to do if a teen says that she is feeling suicidal. That’s where an assessment protocol helps.
If a patient has considered suicide more than a month prior, it shouldn’t be ignored, although the situation may require less urgency but further follow-up. For those with more recent suicidal ideation but without a plan or intent, Dr. Cody recommends following up within 2 weeks because the adolescent’s situation may change.
For those with suicidal ideation and a plan, you should ask three questions:
- What ways of killing yourself have you thought about?
- How likely is it you will follow through on your plan?
- When you think about killing yourself, what stops you?
These questions can help you determine risk acuity: The more specific, realistic, available, and lethal a plan is, the more acute the risk. You then should ask questions to try to determine how likely the teen is to follow through, such as asking about his future plans, his connectedness with others, and his religious beliefs.
Asking about a plan helps determine how much access the patient has to a lethal, realistic means. Firearms are responsible for 52% of teen suicides, followed by hanging/suffocation (25%) and poisoning (16%).
“This is why it’s a really important part of social history to screen for guns in the house,” Dr. Cody told attendees. “I know it’s been really controversial, but it’s something that’s really important, especially if you have an adolescent in the house that’s having suicidal ideation.”
Teens with suicidal ideation and a plan but no intent require a safety plan along with follow-up within 1 week. Those with a plan and intent, or those with no intent but an unwillingness agree to a safety plan, should be immediately hospitalized, Dr. Cody said.
These suicide screenings should occur at annual well-child visits, Dr. Cody said, but they also should be done at acute visits; basically, any time you see your preteen and adolescent patients. Ideally, these should take place during alone time, without any parents present.
You also should share resources with your patients, including the National Suicide Prevention Lifeline at 1-800-273-8255 and the Crisis TextLine at 741741.
Dr. Cody reported having no disclosures, and no external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
Full-spectrum family practice can still include obstetrics
For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.
Cradle to grave
Dr. Hartline’s rural training classmate Rebecca Pfaff, MD, now lives and works in Vernon County, Wisc. The clinic and the small community hospital that are her practice home are in the small town of LaFarge. A native of Washington State, Dr. Pfaff thought she’d end up there after her undergraduate years at Wellesley College and her time at Meharry Medical College, a historically black medical school with a social justice focus in Nashville, Tenn.
She realized that in the right practice setting, she could find the scope she was seeking. “I became a family medicine doctor to do obstetrics, and to do family medicine,” she said.
Dr. Pfaff chose the Baraboo rural training track, still with the intention of eventually returning to practice in her home town of Port Angeles, Wash. There, the family practice group had already hired two Baraboo graduates, so they knew the strength of the program and recommended it to Dr. Pfaff.
Seeing patients living with the challenges of rural poverty, she said, helped her learn to care for women with substance use disorder and to gain experience caring for infants with neonatal abstinence syndrome. “That is the perfect setting for where family medicine thrives,” said Dr. Pfaff. Having established relationships with the mothers, she felt able to treat the mother-infant dyad as a unit, without judgment, and with natural opportunities for frequent follow-up.
Dr. Pfaff had a busy obstetrics practice in Baraboo and had the opportunity to perform cesarean sections. To feed her interest in low-intervention obstetrics, though, she sought and was able to secure a rotation in LaFarge, her eventual practice home.
Knowing she would return to LaFarge, Dr. Pfaff went on to complete a 1-year obstetrics fellowship at Swedish Hospital in Seattle. The obstetricians and family physicians there cared for high-risk patients from as far away as Alaska; her fellowship training, she said, was in many ways “the polar opposite” of the low-intervention, community-based work she’d done in Baraboo.
Still, she said, the fellowship gave her procedural expertise and boosted her confidence that she could handle many high-risk situations. She appreciated the perspective of some of her obstetrician instructors, who themselves had been solo practitioners in rural areas.
Her practice now, she says, is everything she’d hoped it would be. She sees patients in the clinic in a cradle-to-grave practice that includes many members of Vernon County, Wisconsin’s Amish community. Dr. Pfaff and her colleagues at the small clinic in LaFarge embrace the special challenges and rewards of obstetric care of a population that has traditionally had their babies at home.
The Amish community
Using low-intervention techniques is a priority, even when many Amish women have grand multiparity or present with other risk factors. “It’s not uncommon for us to see women on their twelfth or thirteenth pregnancy,” she said. Gestation dating is usually no more than a best guess, since women become pregnant while still amenorrheic from breastfeeding their last child.
Because the area’s Amish population has grown from a small group of founders who came to the hills of Vernon County in the late 1700s, there is an elevated rate of genetic disorders in the population, including metabolic disorders and congenital heart disease. Most Amish women return home within a few hours of delivery, and use no analgesia, even for breech and twin vaginal deliveries.
Though she’s comfortable with low-intervention care, Dr. Pfaff also performs cesarean sections at the community hospital when it’s indicated, sharing call duties with the community’s general surgeons. There’s no obstetrician in Vernon County.
The hospital is not equipped to care for preterm infants, so deliveries earlier than 36 weeks’ are referred, as are patients with abnormal placentation or fetal anomalies detected on ultrasound.
She loves the continuity that her practice now lets her have, said Dr. Pfaff. “When you’re seeing a woman in family medicine, instead of seeing her at 6 weeks, setting her up with contraception, and then seeing her again in a year, you’re seeing her every 2 weeks with that baby of hers,” she said. The care of mother and infant is so intertwined that sometimes it gives Dr. Pfaff pause, as when she tries to decide in whose chart she should be documenting. “They’re a unit at this time of their lives.”
When asked if she plans to stay put, Dr. Pfaff doesn’t hesitate. “Oh yes,” she said. “I’m so lucky.”
Dr. Hartline agreed. When asked what advice she’d give a trainee considering a rural, full-spectrum career path, she said, “This is a good life. Come and join us!”
Dr. Knight is an employee of AAFP. None of the physicians interviewed had financial conflicts of interest.
Correction, 9/22/17: An earlier version of this article misstated Dr. Munneke's title.
This article was updated 9/25/17.
[email protected]
On Twitter @karioakes
For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.
Cradle to grave
Dr. Hartline’s rural training classmate Rebecca Pfaff, MD, now lives and works in Vernon County, Wisc. The clinic and the small community hospital that are her practice home are in the small town of LaFarge. A native of Washington State, Dr. Pfaff thought she’d end up there after her undergraduate years at Wellesley College and her time at Meharry Medical College, a historically black medical school with a social justice focus in Nashville, Tenn.
She realized that in the right practice setting, she could find the scope she was seeking. “I became a family medicine doctor to do obstetrics, and to do family medicine,” she said.
Dr. Pfaff chose the Baraboo rural training track, still with the intention of eventually returning to practice in her home town of Port Angeles, Wash. There, the family practice group had already hired two Baraboo graduates, so they knew the strength of the program and recommended it to Dr. Pfaff.
Seeing patients living with the challenges of rural poverty, she said, helped her learn to care for women with substance use disorder and to gain experience caring for infants with neonatal abstinence syndrome. “That is the perfect setting for where family medicine thrives,” said Dr. Pfaff. Having established relationships with the mothers, she felt able to treat the mother-infant dyad as a unit, without judgment, and with natural opportunities for frequent follow-up.
Dr. Pfaff had a busy obstetrics practice in Baraboo and had the opportunity to perform cesarean sections. To feed her interest in low-intervention obstetrics, though, she sought and was able to secure a rotation in LaFarge, her eventual practice home.
Knowing she would return to LaFarge, Dr. Pfaff went on to complete a 1-year obstetrics fellowship at Swedish Hospital in Seattle. The obstetricians and family physicians there cared for high-risk patients from as far away as Alaska; her fellowship training, she said, was in many ways “the polar opposite” of the low-intervention, community-based work she’d done in Baraboo.
Still, she said, the fellowship gave her procedural expertise and boosted her confidence that she could handle many high-risk situations. She appreciated the perspective of some of her obstetrician instructors, who themselves had been solo practitioners in rural areas.
Her practice now, she says, is everything she’d hoped it would be. She sees patients in the clinic in a cradle-to-grave practice that includes many members of Vernon County, Wisconsin’s Amish community. Dr. Pfaff and her colleagues at the small clinic in LaFarge embrace the special challenges and rewards of obstetric care of a population that has traditionally had their babies at home.
The Amish community
Using low-intervention techniques is a priority, even when many Amish women have grand multiparity or present with other risk factors. “It’s not uncommon for us to see women on their twelfth or thirteenth pregnancy,” she said. Gestation dating is usually no more than a best guess, since women become pregnant while still amenorrheic from breastfeeding their last child.
Because the area’s Amish population has grown from a small group of founders who came to the hills of Vernon County in the late 1700s, there is an elevated rate of genetic disorders in the population, including metabolic disorders and congenital heart disease. Most Amish women return home within a few hours of delivery, and use no analgesia, even for breech and twin vaginal deliveries.
Though she’s comfortable with low-intervention care, Dr. Pfaff also performs cesarean sections at the community hospital when it’s indicated, sharing call duties with the community’s general surgeons. There’s no obstetrician in Vernon County.
The hospital is not equipped to care for preterm infants, so deliveries earlier than 36 weeks’ are referred, as are patients with abnormal placentation or fetal anomalies detected on ultrasound.
She loves the continuity that her practice now lets her have, said Dr. Pfaff. “When you’re seeing a woman in family medicine, instead of seeing her at 6 weeks, setting her up with contraception, and then seeing her again in a year, you’re seeing her every 2 weeks with that baby of hers,” she said. The care of mother and infant is so intertwined that sometimes it gives Dr. Pfaff pause, as when she tries to decide in whose chart she should be documenting. “They’re a unit at this time of their lives.”
When asked if she plans to stay put, Dr. Pfaff doesn’t hesitate. “Oh yes,” she said. “I’m so lucky.”
Dr. Hartline agreed. When asked what advice she’d give a trainee considering a rural, full-spectrum career path, she said, “This is a good life. Come and join us!”
Dr. Knight is an employee of AAFP. None of the physicians interviewed had financial conflicts of interest.
Correction, 9/22/17: An earlier version of this article misstated Dr. Munneke's title.
This article was updated 9/25/17.
[email protected]
On Twitter @karioakes
For some patients in rural or otherwise underserved settings, the nearest obstetrician may be counties away. Other patients, though, seek the continuity of care that can come when one doctor cares for the whole family through all phases of life.
And physicians who choose to incorporate obstetrics into their range of practice do so to serve their communities but also because of the profound satisfaction they find in providing families care of this scope.
The American Academy of Family Practice makes it clear that full-spectrum family medicine still includes obstetrics. “We continue to support the full scope of practice for family physicians and training that supports that scope,” said Clif Knight, MD, senior vice president of education at the American Academy of Family Practice. “We believe that all family physicians should have a solid foundation of education in obstetrics, knowing that many will choose not to perform deliveries once they finish residency,” said Dr. Knight.
For those who really want to make obstetrics a focus or who are interested in teaching, a year-long postresidency obstetrics fellowship might make sense. “We absolutely are supportive of those family medicine grads who want to do additional training. That makes great sense to us,” said Dr. Knight.
For some family physicians, keeping an obstetrics practice, with its high level of engagement and procedural expertise, may actually ensure against burnout. Family physicians may have chosen the specialty because of the high priority they place on a wide scope of care that still puts human relationships first – and obstetrics certainly checks off those boxes, he said.
“We work hard to support our members who want to continue practicing obstetrics,” said Dr. Knight, noting that there’s an annual obstetrics-focused CME conference. When he attended the conference a few years ago, Dr. Knight “was struck by how mission-driven those family practice physicians are who continue to do obstetrics as part of their scope of practice,” he said. “They treasure that opportunity.”
Rural areas are the practice setting for many of the 17% of family physicians who report that they practice obstetrics. The family practice residency at the University of Wisconsin–Madison’s School of Medicine and Public Health includes an option for a rural training track; strong obstetrics training is woven through the residency curriculum.
The Baraboo approach
Since its inception in 1996, the Baraboo (Wisc.) rural residency has had 29 graduates, enrolling up to two residents per year. Two-thirds of the graduates now practice obstetrics, 69% are in rural areas, and about half have stayed in Wisconsin, said Sharilyn Munneke, MD, assistant program director for the residency. Dr. Munneke also heads up the obstetrics and women’s health curriculum for the residency.*
Residents who choose the Baraboo rural site for their training will spend their first postgraduate year in Madison, the state capital. The first year features a busy obstetrics rotation at a large community hospital, giving all residents a solid labor and delivery foundation. Rural track trainees also spend a day a week at a continuity clinic in Baraboo, a community of about 12,000 that’s an hour north of Madison.
Beginning in the second year, residents move to Baraboo; there, under supervision, “they essentially start functioning as a family doctor,” said Dr. Munneke in an interview, adding that the residents also have inpatient obstetrics and intensive care unit training at Baraboo’s 100-bed St. Clare Hospital.
The clinic setting gives residents an introduction to the multigenerational care that’s the hallmark of rural family medicine, as each succeeding class of residents inherits the graduating class’ panels. Patients come from the town, from surrounding agricultural and recreational areas, and from the Ho-Chunk Native American tribe, many of whose members live in the area. Residents begin to build their obstetrics practice from the clinic, she said, managing prenatal care, labor, and delivery under the supervision of family practice physicians who do obstetrics.
There is no obstetrician at St. Clare Hospital, but the rural-track residents still have the opportunity to assist at cesarean deliveries. “Our surgeons do our C-sections,” said Dr. Munneke, so residents will scrub in to assist the general surgeon on call for cesarean deliveries.
Dr. Munneke said that there are plenty of opportunities during training to learn other gynecologic procedures as well. “I teach colposcopies; I teach endometrial biopsies. I wrote a grant so we could get the equipment to do informal ultrasounds in the clinic, to assess for twins or for fetal viability,” she said.
Family practice physicians and residents in Baraboo have a good working relationship with Madison maternal-fetal medicine specialists and the referral hospital, she said, so that, even for high-risk pregnancies, as much care as possible can be delivered close to home. This is important for families whose farming obligations and family situations might make a woman’s prolonged absence incredibly difficult, said Dr. Munneke. Though women are referred to Madison for deliveries before 36 weeks, residents still receive neonatal resuscitation training, so they become comfortable stabilizing fragile neonates until transport is arranged.
For Rachel Hartline, MD, the Baraboo training experience was just what she’d been looking for. After completing medical school in her native Virginia, she realized that the family physicians she’d rotated with had been “excellent role models;” at the same time, she said, “I realized that their [practice] scope was not the scope I wanted to have.”
During her time in Baraboo, Dr. Hartline, who finished her residency in 2015, appreciated the opportunity for the “additional layer” that cesarean section training added for her. Whenever possible, she scrubbed in on scheduled cesareans. “There was also a C-section pager that was passed among those who were learning cesareans,” for additional opportunities when crash cesareans occurred, she said.
“My goal was 50 cesareans” during training, said Dr. Hartline. “I was a little shy of that,” she said, so her new partners in Dodgeville, Wisc. agreed to continue to mentor her through her first few cesarean deliveries.
Now, she is in a practice that includes obstetricians, with whom she splits obstetrics 1:4. Dodgeville’s Upland Hills Hospital is a critical-access hospital where approximately 300 babies are delivered yearly. Dr. Hartline said she’s also often called on to do deliveries for other physicians at one of the three groups who practice at Upland Hills.
Having a collaborative relationship with the community’s obstetricians is a real plus, said Dr. Hartline, who performs cesarean sections and is comfortable with vacuum deliveries, but doesn’t do forceps deliveries. “If I have a patient that seems too high, I might call one of my partners,” she said.
Upland Hills, like St. Clare, does not have a neonatal intensive care unit, so deliveries before 36 weeks are referred elsewhere whenever possible.
Dr. Hartline said that she also enjoys the full spectrum of family practice in her clinic. The agricultural area where she’s situated is home to many farm families, who she says can be reluctant to seek care, so chronic disease management can be a challenge. She also sees a growing number of undocumented immigrants as that population grows in rural Wisconsin. “I see all ages; I don’t say ‘no’ to much,” she said.
“But obstetrics is a big part of the reason why I’m a family doctor. It’s so cool to be a part of bringing someone’s child into the world and to be able to be there for them,” she said.
Cradle to grave
Dr. Hartline’s rural training classmate Rebecca Pfaff, MD, now lives and works in Vernon County, Wisc. The clinic and the small community hospital that are her practice home are in the small town of LaFarge. A native of Washington State, Dr. Pfaff thought she’d end up there after her undergraduate years at Wellesley College and her time at Meharry Medical College, a historically black medical school with a social justice focus in Nashville, Tenn.
She realized that in the right practice setting, she could find the scope she was seeking. “I became a family medicine doctor to do obstetrics, and to do family medicine,” she said.
Dr. Pfaff chose the Baraboo rural training track, still with the intention of eventually returning to practice in her home town of Port Angeles, Wash. There, the family practice group had already hired two Baraboo graduates, so they knew the strength of the program and recommended it to Dr. Pfaff.
Seeing patients living with the challenges of rural poverty, she said, helped her learn to care for women with substance use disorder and to gain experience caring for infants with neonatal abstinence syndrome. “That is the perfect setting for where family medicine thrives,” said Dr. Pfaff. Having established relationships with the mothers, she felt able to treat the mother-infant dyad as a unit, without judgment, and with natural opportunities for frequent follow-up.
Dr. Pfaff had a busy obstetrics practice in Baraboo and had the opportunity to perform cesarean sections. To feed her interest in low-intervention obstetrics, though, she sought and was able to secure a rotation in LaFarge, her eventual practice home.
Knowing she would return to LaFarge, Dr. Pfaff went on to complete a 1-year obstetrics fellowship at Swedish Hospital in Seattle. The obstetricians and family physicians there cared for high-risk patients from as far away as Alaska; her fellowship training, she said, was in many ways “the polar opposite” of the low-intervention, community-based work she’d done in Baraboo.
Still, she said, the fellowship gave her procedural expertise and boosted her confidence that she could handle many high-risk situations. She appreciated the perspective of some of her obstetrician instructors, who themselves had been solo practitioners in rural areas.
Her practice now, she says, is everything she’d hoped it would be. She sees patients in the clinic in a cradle-to-grave practice that includes many members of Vernon County, Wisconsin’s Amish community. Dr. Pfaff and her colleagues at the small clinic in LaFarge embrace the special challenges and rewards of obstetric care of a population that has traditionally had their babies at home.
The Amish community
Using low-intervention techniques is a priority, even when many Amish women have grand multiparity or present with other risk factors. “It’s not uncommon for us to see women on their twelfth or thirteenth pregnancy,” she said. Gestation dating is usually no more than a best guess, since women become pregnant while still amenorrheic from breastfeeding their last child.
Because the area’s Amish population has grown from a small group of founders who came to the hills of Vernon County in the late 1700s, there is an elevated rate of genetic disorders in the population, including metabolic disorders and congenital heart disease. Most Amish women return home within a few hours of delivery, and use no analgesia, even for breech and twin vaginal deliveries.
Though she’s comfortable with low-intervention care, Dr. Pfaff also performs cesarean sections at the community hospital when it’s indicated, sharing call duties with the community’s general surgeons. There’s no obstetrician in Vernon County.
The hospital is not equipped to care for preterm infants, so deliveries earlier than 36 weeks’ are referred, as are patients with abnormal placentation or fetal anomalies detected on ultrasound.
She loves the continuity that her practice now lets her have, said Dr. Pfaff. “When you’re seeing a woman in family medicine, instead of seeing her at 6 weeks, setting her up with contraception, and then seeing her again in a year, you’re seeing her every 2 weeks with that baby of hers,” she said. The care of mother and infant is so intertwined that sometimes it gives Dr. Pfaff pause, as when she tries to decide in whose chart she should be documenting. “They’re a unit at this time of their lives.”
When asked if she plans to stay put, Dr. Pfaff doesn’t hesitate. “Oh yes,” she said. “I’m so lucky.”
Dr. Hartline agreed. When asked what advice she’d give a trainee considering a rural, full-spectrum career path, she said, “This is a good life. Come and join us!”
Dr. Knight is an employee of AAFP. None of the physicians interviewed had financial conflicts of interest.
Correction, 9/22/17: An earlier version of this article misstated Dr. Munneke's title.
This article was updated 9/25/17.
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On Twitter @karioakes
ACOG urges standardization of postpartum hemorrhage treatment
Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).
ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).
“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”
The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.
The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.
“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.
Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.
“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”
Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).
ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).
“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”
The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.
The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.
“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.
Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.
“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”
Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).
ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).
“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”
The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.
The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.
“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.
Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.
“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”
FROM OBSTETRICS & GYNECOLOGY
Docs, insurers condemn latest ‘repeal and replace’ plan
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
No difference in survival between x-ray or CT NSCLC follow-up
Madrid – Computed tomography scans do not appear to be superior to plain old chest x-rays for follow-up of patients with completely resected non–small cell lung cancer (NSCLC), results of a randomized clinical trial suggest.
Among 1,775 patients followed out to 10 years with either a “minimal” protocol – consisting of history, physical exam, and periodic chest x-rays – or a “maximal” protocol – including CT scans of the thorax and upper abdomen, as well as bronchoscopy for squamous-cell carcinomas – there were no significant differences in overall survival at either 3, 5, or 8 years of follow-up, reported Virginie Westeel, MD, from the Centre Hospitalier Régional Universitaire of the Hôpital Jean Minjoz in Besançon, France.
In hopes of finding that answer, Dr. Westeel and colleagues in the French Cooperative Thoracic Oncology Group conducted a clinical trial comparing the standard follow-up approach recommended in most clinical guidelines, as described by Dr. Westeel, with an experimental protocol consisting of history and exam plus chest x-ray, CT scans, and fiber-optic bronchoscopy (mandatory for squamous- and large-cell carcinomas, optional for adenocarcinomas).
Patients with completely resected stage I, II, and IIIA tumors, and T4 tumors with pulmonary nodules in the same lobe, were randomly assigned to follow-up with one of the two protocols.
In each trial arm, the assigned procedures were repeated every 6 months after randomization for the first 2 years, then yearly until 5 years.
After a median follow-up of 8.7 years, there was no significant difference in the primary endpoint of overall survival. Median OS was 123.6 months in the maximal protocol group, compared with 99.7 months in the minimal protocol group (P = .037)
The 3-, 5-, and 8-year survival rates for the maximal and minimal protocols, respectively, were 76.1% vs. 77.3%, 65.8% vs. 66.7%, and 54.6% vs. 51.7%.
Because there appeared to be a separation of the survival curve beginning around 8 years, the investigators performed an exploratory 2-year landmark analysis.
They found that, among patients who had a recurrence within 24 months of randomization, there was no difference in OS between each follow-up protocol. However, among those patients with no recurrence within 24 months of resection, the median OS was not reached among patients assigned to the maximal protocol versus 129.3 months for those assigned to the minimal protocol (P = .04).
Patients without early recurrence had higher rates of secondary primary cancers, and for these patients, early detection with CT-based surveillance could explain the differences in overall survival, Dr. Westeel said.
“Our suggestion for practice is that, because there is no survival difference, both follow-up protocols are acceptable. However, a CT scan every 6 months is probably of no value in the first 2 years,” but yearly chest CTs to detect second primary cancers early may be of interest, she said.
Enriqueta Felip, MD, from Vall D’Hebron Institute of Oncology in Barcelona, who was not involved in the trial, commented that, while the study needed to be conducted, it was unlikely to change her clinical practice because of potential differences among patients with varying stages of NSCLC at the time of resection.
“I think it’s an important trial, [but] tomorrow I will follow my patients with a CT scan,” she said.
Dr. Felip was an invited expert at the briefing.
The study was supported by the French Ministry of Health, Fondation de France, and Laboratoire Lilly. Dr. Westeel and Dr. Felip reported no conflicts of interest relevant to the study.
Madrid – Computed tomography scans do not appear to be superior to plain old chest x-rays for follow-up of patients with completely resected non–small cell lung cancer (NSCLC), results of a randomized clinical trial suggest.
Among 1,775 patients followed out to 10 years with either a “minimal” protocol – consisting of history, physical exam, and periodic chest x-rays – or a “maximal” protocol – including CT scans of the thorax and upper abdomen, as well as bronchoscopy for squamous-cell carcinomas – there were no significant differences in overall survival at either 3, 5, or 8 years of follow-up, reported Virginie Westeel, MD, from the Centre Hospitalier Régional Universitaire of the Hôpital Jean Minjoz in Besançon, France.
In hopes of finding that answer, Dr. Westeel and colleagues in the French Cooperative Thoracic Oncology Group conducted a clinical trial comparing the standard follow-up approach recommended in most clinical guidelines, as described by Dr. Westeel, with an experimental protocol consisting of history and exam plus chest x-ray, CT scans, and fiber-optic bronchoscopy (mandatory for squamous- and large-cell carcinomas, optional for adenocarcinomas).
Patients with completely resected stage I, II, and IIIA tumors, and T4 tumors with pulmonary nodules in the same lobe, were randomly assigned to follow-up with one of the two protocols.
In each trial arm, the assigned procedures were repeated every 6 months after randomization for the first 2 years, then yearly until 5 years.
After a median follow-up of 8.7 years, there was no significant difference in the primary endpoint of overall survival. Median OS was 123.6 months in the maximal protocol group, compared with 99.7 months in the minimal protocol group (P = .037)
The 3-, 5-, and 8-year survival rates for the maximal and minimal protocols, respectively, were 76.1% vs. 77.3%, 65.8% vs. 66.7%, and 54.6% vs. 51.7%.
Because there appeared to be a separation of the survival curve beginning around 8 years, the investigators performed an exploratory 2-year landmark analysis.
They found that, among patients who had a recurrence within 24 months of randomization, there was no difference in OS between each follow-up protocol. However, among those patients with no recurrence within 24 months of resection, the median OS was not reached among patients assigned to the maximal protocol versus 129.3 months for those assigned to the minimal protocol (P = .04).
Patients without early recurrence had higher rates of secondary primary cancers, and for these patients, early detection with CT-based surveillance could explain the differences in overall survival, Dr. Westeel said.
“Our suggestion for practice is that, because there is no survival difference, both follow-up protocols are acceptable. However, a CT scan every 6 months is probably of no value in the first 2 years,” but yearly chest CTs to detect second primary cancers early may be of interest, she said.
Enriqueta Felip, MD, from Vall D’Hebron Institute of Oncology in Barcelona, who was not involved in the trial, commented that, while the study needed to be conducted, it was unlikely to change her clinical practice because of potential differences among patients with varying stages of NSCLC at the time of resection.
“I think it’s an important trial, [but] tomorrow I will follow my patients with a CT scan,” she said.
Dr. Felip was an invited expert at the briefing.
The study was supported by the French Ministry of Health, Fondation de France, and Laboratoire Lilly. Dr. Westeel and Dr. Felip reported no conflicts of interest relevant to the study.
Madrid – Computed tomography scans do not appear to be superior to plain old chest x-rays for follow-up of patients with completely resected non–small cell lung cancer (NSCLC), results of a randomized clinical trial suggest.
Among 1,775 patients followed out to 10 years with either a “minimal” protocol – consisting of history, physical exam, and periodic chest x-rays – or a “maximal” protocol – including CT scans of the thorax and upper abdomen, as well as bronchoscopy for squamous-cell carcinomas – there were no significant differences in overall survival at either 3, 5, or 8 years of follow-up, reported Virginie Westeel, MD, from the Centre Hospitalier Régional Universitaire of the Hôpital Jean Minjoz in Besançon, France.
In hopes of finding that answer, Dr. Westeel and colleagues in the French Cooperative Thoracic Oncology Group conducted a clinical trial comparing the standard follow-up approach recommended in most clinical guidelines, as described by Dr. Westeel, with an experimental protocol consisting of history and exam plus chest x-ray, CT scans, and fiber-optic bronchoscopy (mandatory for squamous- and large-cell carcinomas, optional for adenocarcinomas).
Patients with completely resected stage I, II, and IIIA tumors, and T4 tumors with pulmonary nodules in the same lobe, were randomly assigned to follow-up with one of the two protocols.
In each trial arm, the assigned procedures were repeated every 6 months after randomization for the first 2 years, then yearly until 5 years.
After a median follow-up of 8.7 years, there was no significant difference in the primary endpoint of overall survival. Median OS was 123.6 months in the maximal protocol group, compared with 99.7 months in the minimal protocol group (P = .037)
The 3-, 5-, and 8-year survival rates for the maximal and minimal protocols, respectively, were 76.1% vs. 77.3%, 65.8% vs. 66.7%, and 54.6% vs. 51.7%.
Because there appeared to be a separation of the survival curve beginning around 8 years, the investigators performed an exploratory 2-year landmark analysis.
They found that, among patients who had a recurrence within 24 months of randomization, there was no difference in OS between each follow-up protocol. However, among those patients with no recurrence within 24 months of resection, the median OS was not reached among patients assigned to the maximal protocol versus 129.3 months for those assigned to the minimal protocol (P = .04).
Patients without early recurrence had higher rates of secondary primary cancers, and for these patients, early detection with CT-based surveillance could explain the differences in overall survival, Dr. Westeel said.
“Our suggestion for practice is that, because there is no survival difference, both follow-up protocols are acceptable. However, a CT scan every 6 months is probably of no value in the first 2 years,” but yearly chest CTs to detect second primary cancers early may be of interest, she said.
Enriqueta Felip, MD, from Vall D’Hebron Institute of Oncology in Barcelona, who was not involved in the trial, commented that, while the study needed to be conducted, it was unlikely to change her clinical practice because of potential differences among patients with varying stages of NSCLC at the time of resection.
“I think it’s an important trial, [but] tomorrow I will follow my patients with a CT scan,” she said.
Dr. Felip was an invited expert at the briefing.
The study was supported by the French Ministry of Health, Fondation de France, and Laboratoire Lilly. Dr. Westeel and Dr. Felip reported no conflicts of interest relevant to the study.
AT ESMO 2017
Key clinical point: There were no differences in long-term overall survival among patients with resected NSCLC followed with x-rays and those followed with CT scans.
Major finding: Overall survival rates at 3, 5, and 8 years were similar among patients followed with minimal or maximal protocols.
Data source: Randomized controlled trial in 1,775 patients with completely resected non–small cell lung cancer.
Disclosures: The study was supported by the French Ministry of Health, Fondation de France, and Laboratoire Lilly. Dr. Westeel and Dr. Felip reported no conflicts of interest relevant to the study.
When is it really recurrent strep throat?
CHICAGO – When a child is sitting in your exam room with recurrent strep pharyngitis, the first question to ask yourself is “Is it real?”
According to pediatric infectious disease specialist John Bradley, MD, the answer to that question comes with careful attention to the history and clinical presentation, but titers and viral polymerase chain reaction tests can also help clarify the diagnosis.
Although that involves some detective work and perhaps some legwork by the provider or the office staff, it’s worth the effort, especially in an era of increased concerns about antimicrobial stewardship, said Dr. Bradley during an antimicrobial update session at the annual meeting of the American Academy of Pediatrics.
“Are the episodes really documented by you in your office?” asked Dr. Bradley. If so, the job is easier. If not, it’s important to differentiate whether documentation of the strep infection was done by culture, whether it was done by an extremely sensitive rapid test, or whether any testing has been done at all, said Dr. Bradley, chief of the division of infectious diseases at the University of California, San Diego.
Somehow, said Dr. Bradley, it’s still true that all group A streptococci are susceptible to penicillin, but penicillin does not always work. There’s about a 10% failure rate for reasons that are not completely understood. Perhaps some individuals have other oropharyngeal flora that produce beta-lactamases, thereby negating penicillin’s efficacy against the strep, he added.
One very good clue as to whether the child has recurrent strep is the appearance of the throat, said Dr. Bradley. A viral illness also can produce a very red posterior oropharynx, so – unless there’s frank pus – it’s unlikely to be strep pharyngitis.
Some patients will, in fact, have recurrent strep, but some patients who might even have positive rapid strep tests may actually be carriers.
So, “what the heck is the carrier state?” asked Dr. Bradley. Although a rapid strep test will occasionally be positive, he explained, the culture is only weakly positive, with growth that’s usually less than 1+. The child who’s a carrier is not symptomatic, will not have an elevated antistreptolysin O titer, and is not contagious. Also, the child will not respond to penicillin treatment.
How can clinicians differentiate recurrent strep from a child with frequent viral illnesses who’s a carrier?
“For the standard case of ‘recurrent strep,’ please get cultures and document the density of group A strep to rule out the carrier state,” said Dr. Bradley. Having parents text pictures of the throat during an episode – for which his facility has a secure portal – can save families an office visit. A negative antistreptolysin O titer can help rule out a recurrent infection, he added.
When a child is having recurrent bouts of pharyngitis, but the clinical picture isn’t clearly consistent with strep, physicians can consider submitting multiplex viral polymerase chain reaction tests. “This can give the family an alternative diagnosis” and reassure parents that it’s safe to hold off on antibiotics, noted Dr. Bradley.
Culturing between episodes of pharyngitis, when the patient is asymptomatic, can also help determine whether a child is a carrier. Sometimes, it makes sense to culture the whole family, and there have also been reports of family pets being Group A strep reservoirs, said Dr. Bradley.
For recurrent infection, choose a broad spectrum agent that will knock back both Group A strep and the oral flora that may be producing beta-lactamases or adhesion molecules that negate penicillin’s efficacy. One logical choice is clindamycin for 10 days, although some strains are resistant. Another good choice is amoxicillin/clavulanate for 10 days or 10 days of a cephalosporin. Penicillin can still be used if it’s augmented by oral rifampin during the last 4 days of the 10-day course.
Long-term prophylaxis can also be considered for stubborn recurrences, he noted.
Dr. Bradley reported no relevant conflicts of interest.
CHICAGO – When a child is sitting in your exam room with recurrent strep pharyngitis, the first question to ask yourself is “Is it real?”
According to pediatric infectious disease specialist John Bradley, MD, the answer to that question comes with careful attention to the history and clinical presentation, but titers and viral polymerase chain reaction tests can also help clarify the diagnosis.
Although that involves some detective work and perhaps some legwork by the provider or the office staff, it’s worth the effort, especially in an era of increased concerns about antimicrobial stewardship, said Dr. Bradley during an antimicrobial update session at the annual meeting of the American Academy of Pediatrics.
“Are the episodes really documented by you in your office?” asked Dr. Bradley. If so, the job is easier. If not, it’s important to differentiate whether documentation of the strep infection was done by culture, whether it was done by an extremely sensitive rapid test, or whether any testing has been done at all, said Dr. Bradley, chief of the division of infectious diseases at the University of California, San Diego.
Somehow, said Dr. Bradley, it’s still true that all group A streptococci are susceptible to penicillin, but penicillin does not always work. There’s about a 10% failure rate for reasons that are not completely understood. Perhaps some individuals have other oropharyngeal flora that produce beta-lactamases, thereby negating penicillin’s efficacy against the strep, he added.
One very good clue as to whether the child has recurrent strep is the appearance of the throat, said Dr. Bradley. A viral illness also can produce a very red posterior oropharynx, so – unless there’s frank pus – it’s unlikely to be strep pharyngitis.
Some patients will, in fact, have recurrent strep, but some patients who might even have positive rapid strep tests may actually be carriers.
So, “what the heck is the carrier state?” asked Dr. Bradley. Although a rapid strep test will occasionally be positive, he explained, the culture is only weakly positive, with growth that’s usually less than 1+. The child who’s a carrier is not symptomatic, will not have an elevated antistreptolysin O titer, and is not contagious. Also, the child will not respond to penicillin treatment.
How can clinicians differentiate recurrent strep from a child with frequent viral illnesses who’s a carrier?
“For the standard case of ‘recurrent strep,’ please get cultures and document the density of group A strep to rule out the carrier state,” said Dr. Bradley. Having parents text pictures of the throat during an episode – for which his facility has a secure portal – can save families an office visit. A negative antistreptolysin O titer can help rule out a recurrent infection, he added.
When a child is having recurrent bouts of pharyngitis, but the clinical picture isn’t clearly consistent with strep, physicians can consider submitting multiplex viral polymerase chain reaction tests. “This can give the family an alternative diagnosis” and reassure parents that it’s safe to hold off on antibiotics, noted Dr. Bradley.
Culturing between episodes of pharyngitis, when the patient is asymptomatic, can also help determine whether a child is a carrier. Sometimes, it makes sense to culture the whole family, and there have also been reports of family pets being Group A strep reservoirs, said Dr. Bradley.
For recurrent infection, choose a broad spectrum agent that will knock back both Group A strep and the oral flora that may be producing beta-lactamases or adhesion molecules that negate penicillin’s efficacy. One logical choice is clindamycin for 10 days, although some strains are resistant. Another good choice is amoxicillin/clavulanate for 10 days or 10 days of a cephalosporin. Penicillin can still be used if it’s augmented by oral rifampin during the last 4 days of the 10-day course.
Long-term prophylaxis can also be considered for stubborn recurrences, he noted.
Dr. Bradley reported no relevant conflicts of interest.
CHICAGO – When a child is sitting in your exam room with recurrent strep pharyngitis, the first question to ask yourself is “Is it real?”
According to pediatric infectious disease specialist John Bradley, MD, the answer to that question comes with careful attention to the history and clinical presentation, but titers and viral polymerase chain reaction tests can also help clarify the diagnosis.
Although that involves some detective work and perhaps some legwork by the provider or the office staff, it’s worth the effort, especially in an era of increased concerns about antimicrobial stewardship, said Dr. Bradley during an antimicrobial update session at the annual meeting of the American Academy of Pediatrics.
“Are the episodes really documented by you in your office?” asked Dr. Bradley. If so, the job is easier. If not, it’s important to differentiate whether documentation of the strep infection was done by culture, whether it was done by an extremely sensitive rapid test, or whether any testing has been done at all, said Dr. Bradley, chief of the division of infectious diseases at the University of California, San Diego.
Somehow, said Dr. Bradley, it’s still true that all group A streptococci are susceptible to penicillin, but penicillin does not always work. There’s about a 10% failure rate for reasons that are not completely understood. Perhaps some individuals have other oropharyngeal flora that produce beta-lactamases, thereby negating penicillin’s efficacy against the strep, he added.
One very good clue as to whether the child has recurrent strep is the appearance of the throat, said Dr. Bradley. A viral illness also can produce a very red posterior oropharynx, so – unless there’s frank pus – it’s unlikely to be strep pharyngitis.
Some patients will, in fact, have recurrent strep, but some patients who might even have positive rapid strep tests may actually be carriers.
So, “what the heck is the carrier state?” asked Dr. Bradley. Although a rapid strep test will occasionally be positive, he explained, the culture is only weakly positive, with growth that’s usually less than 1+. The child who’s a carrier is not symptomatic, will not have an elevated antistreptolysin O titer, and is not contagious. Also, the child will not respond to penicillin treatment.
How can clinicians differentiate recurrent strep from a child with frequent viral illnesses who’s a carrier?
“For the standard case of ‘recurrent strep,’ please get cultures and document the density of group A strep to rule out the carrier state,” said Dr. Bradley. Having parents text pictures of the throat during an episode – for which his facility has a secure portal – can save families an office visit. A negative antistreptolysin O titer can help rule out a recurrent infection, he added.
When a child is having recurrent bouts of pharyngitis, but the clinical picture isn’t clearly consistent with strep, physicians can consider submitting multiplex viral polymerase chain reaction tests. “This can give the family an alternative diagnosis” and reassure parents that it’s safe to hold off on antibiotics, noted Dr. Bradley.
Culturing between episodes of pharyngitis, when the patient is asymptomatic, can also help determine whether a child is a carrier. Sometimes, it makes sense to culture the whole family, and there have also been reports of family pets being Group A strep reservoirs, said Dr. Bradley.
For recurrent infection, choose a broad spectrum agent that will knock back both Group A strep and the oral flora that may be producing beta-lactamases or adhesion molecules that negate penicillin’s efficacy. One logical choice is clindamycin for 10 days, although some strains are resistant. Another good choice is amoxicillin/clavulanate for 10 days or 10 days of a cephalosporin. Penicillin can still be used if it’s augmented by oral rifampin during the last 4 days of the 10-day course.
Long-term prophylaxis can also be considered for stubborn recurrences, he noted.
Dr. Bradley reported no relevant conflicts of interest.
EXPERT ANALYSIS FROM AAP 2017