Gynecologic cancers contribute to approximately 15% of cancer survivorship care for women. Many patients share surveillance visits between their gynecologic oncologist and their ob.gyn. or primary care physician to capitalize on preexisting relationships and ensure the provision of comprehensive wellness care. Providing high quality surveillance care is challenging because it requires vigilance in the detection of recurrence but also avoidance of unnecessary, costly, and inaccurate testing.

The oncologic benefits for various surveillance guidelines are not well established by prospective studies. However, in updated surveillance recommendations, the Society of Gynecologic Oncology (SGO) takes available data, costs, and benefits into consideration.¹ The guidelines, authored by Ritu Salani, MD, provide an excellent resource for understanding appropriate testing and evaluation during surveillance care.

Dr. Rossi

Endometrial cancer

Endometrial cancer recurs most commonly among women with a history of advanced stage cancer or early stage disease with high/intermediate risk factors, but all survivors should be evaluated regularly for recurrence. The vagina is the most common site for recurrence. Fortunately, many vaginal recurrences can be cured with salvage therapies.

Women with the lowest risk for recurrence (stage IA, grades 1 and 2 disease) who did not originally qualify for adjuvant therapy can be followed every 6 months for 2 years and then annually.

Vaginal cytology is no longer recommended for the routine surveillance of endometrial cancer because of its poor sensitivity in detecting recurrence and low positive predictive value (particularly after vaginal radiation).² Any suspicious lesions identified on speculum examination should be biopsied, rather than sampled with cytologic smear. Routine imaging (with CT or PET/CT) and cancer antigen (CA) 125 tumor marker assessment is not supported unless the initial stage was advanced. These tests should be reserved for confirmation of concerning symptoms or examination findings.

This group of patients has particular survivorship needs with respect to obesity interventions. Obesity is associated with poor prognosis from endometrial cancer, and patients should be counseled about this and offered strategies for weight loss and lifestyle modification. Lynch syndrome testing and colon cancer screening are also an important consideration in this population.
 

Ovarian cancer

Ovarian cancer recurrence rates are high, and, while salvage therapies are rarely curative, enduring responses may be achieved in some patients, making surveillance visits critical. The SGO recommends surveillance visits every 3 months in the first 2 years, every 4 months in year 3, and then every 6 months for an additional 2 years. At these visits, patients should be queried about symptoms with particular emphasis on peritoneal signs (bloating, distension, gastrointestinal disturbance, and abdominal pain) as most recurrences will be within the peritoneal cavity.

CA 125 tumor marker elevation during the surveillance phase may signal recurrence prior to the development of symptoms but initiating chemotherapy early because of elevations in CA 125 does not improve survival.³ However, in the platinum-sensitive population with a longer disease-free interval, earlier detection of recurrence by CA 125 may identify patients in whom complete secondary cytoreduction is more attainable and is associated with improved survival.⁴ Therefore, the SGO suggests that CA 125 assessment is optional. The benefits and limitations of earlier detection of recurrence should be discussed with each patient. This recommendation differs for survivors of nonepithelial ovarian cancers (such as germ-cell or sex-cord stromal), in which case the measurement of the appropriate tumor markers (such as alpha-fetoprotein, human chorionic gonadotropin, and inhibin) should be performed routinely as part of surveillance evaluation.

Evidence does not support routine imaging (such as CT or PET). It should be reserved as a confirmatory measure for patients with concerning symptoms, examination findings, or elevations in tumor markers. When ovarian cancer has been treated with fertility-preserving surgery in women of younger reproductive ages, pelvic ultrasounds may be used as part of their surveillance care to monitor retained ovaries and pelvic structures.

BRCA-gene testing should be offered to all women with epithelial ovarian, fallopian tube, and primary peritoneal cancer as it impacts future cancer risk, as well as chemotherapy selection.⁵
 

Cervical cancer

In the first 2 years after completing primary treatment for cervical cancer, those at high risk for recurrence (including those who were recommended to adjuvant therapy) should be evaluated every 3 months for 2 years, followed by visits at 6-month intervals for an additional 3 years. Low-risk patients can be followed every 6 months for 2 years, followed by annual visits thereafter.

Pap testing should be performed annually, rather than at each surveillance visit. It should not to detect recurrence – for which it has poor sensitivity and specificity – but rather to detect new HPV-related dysplasia.⁶

Many patients with cervical cancer have a tobacco use history, placing them at risk for other cancers. Educate patients about the risk and provide cessation assistance.
 

Vulvar cancer

Prognosis for early stage vulvar cancer is very good; however, local recurrences are common (as much as 40%) in the 10 years following diagnosis.⁷ It is important to thoroughly inspect the vulva, vagina, and cervix at each surveillance visit. In high-risk patients, examinations should take place every 3 months for the first 2 years after completing primary treatment and every 6 months until 5 years post treatment. Low-risk patients can be followed every 6 months for 2 years and annually thereafter.

Identification and early treatment of dysplasia is important. Careful attention should also be made to palpation of the inguinal nodal regions. One in 10 women will have a late recurrence (greater than 5 years), so vulvar inspections should continue at least annually for the remainder of a woman’s life.
 

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.

References

1. Gynecol Oncol. 2017 Mar 31. doi: 10.1016/j.ygno.2017.03.022.

2. Obstet Gynecol. 2013 Jan;121(1):129-35.

3. Lancet. 2010 Oct 2;376(9747):1155-63.

4. Gynecol Oncol. 2009 Jan;112(1):265-74.

5. Gynecol Oncol. 2015 Jan;136(1):3-7.

6. Obstet Gynecol. 2011 Sep;118(3):548-53.

7. Gynecol Oncol. 2016 Jan;140(1):8-14.

Gynecologic cancers contribute to approximately 15% of cancer survivorship care for women. Many patients share surveillance visits between their gynecologic oncologist and their ob.gyn. or primary care physician to capitalize on preexisting relationships and ensure the provision of comprehensive wellness care. Providing high quality surveillance care is challenging because it requires vigilance in the detection of recurrence but also avoidance of unnecessary, costly, and inaccurate testing.

The oncologic benefits for various surveillance guidelines are not well established by prospective studies. However, in updated surveillance recommendations, the Society of Gynecologic Oncology (SGO) takes available data, costs, and benefits into consideration.¹ The guidelines, authored by Ritu Salani, MD, provide an excellent resource for understanding appropriate testing and evaluation during surveillance care.

Dr. Rossi

Endometrial cancer

Endometrial cancer recurs most commonly among women with a history of advanced stage cancer or early stage disease with high/intermediate risk factors, but all survivors should be evaluated regularly for recurrence. The vagina is the most common site for recurrence. Fortunately, many vaginal recurrences can be cured with salvage therapies.

Women with the lowest risk for recurrence (stage IA, grades 1 and 2 disease) who did not originally qualify for adjuvant therapy can be followed every 6 months for 2 years and then annually.

Vaginal cytology is no longer recommended for the routine surveillance of endometrial cancer because of its poor sensitivity in detecting recurrence and low positive predictive value (particularly after vaginal radiation).² Any suspicious lesions identified on speculum examination should be biopsied, rather than sampled with cytologic smear. Routine imaging (with CT or PET/CT) and cancer antigen (CA) 125 tumor marker assessment is not supported unless the initial stage was advanced. These tests should be reserved for confirmation of concerning symptoms or examination findings.

This group of patients has particular survivorship needs with respect to obesity interventions. Obesity is associated with poor prognosis from endometrial cancer, and patients should be counseled about this and offered strategies for weight loss and lifestyle modification. Lynch syndrome testing and colon cancer screening are also an important consideration in this population.
 

Ovarian cancer

Ovarian cancer recurrence rates are high, and, while salvage therapies are rarely curative, enduring responses may be achieved in some patients, making surveillance visits critical. The SGO recommends surveillance visits every 3 months in the first 2 years, every 4 months in year 3, and then every 6 months for an additional 2 years. At these visits, patients should be queried about symptoms with particular emphasis on peritoneal signs (bloating, distension, gastrointestinal disturbance, and abdominal pain) as most recurrences will be within the peritoneal cavity.

CA 125 tumor marker elevation during the surveillance phase may signal recurrence prior to the development of symptoms but initiating chemotherapy early because of elevations in CA 125 does not improve survival.³ However, in the platinum-sensitive population with a longer disease-free interval, earlier detection of recurrence by CA 125 may identify patients in whom complete secondary cytoreduction is more attainable and is associated with improved survival.⁴ Therefore, the SGO suggests that CA 125 assessment is optional. The benefits and limitations of earlier detection of recurrence should be discussed with each patient. This recommendation differs for survivors of nonepithelial ovarian cancers (such as germ-cell or sex-cord stromal), in which case the measurement of the appropriate tumor markers (such as alpha-fetoprotein, human chorionic gonadotropin, and inhibin) should be performed routinely as part of surveillance evaluation.

Evidence does not support routine imaging (such as CT or PET). It should be reserved as a confirmatory measure for patients with concerning symptoms, examination findings, or elevations in tumor markers. When ovarian cancer has been treated with fertility-preserving surgery in women of younger reproductive ages, pelvic ultrasounds may be used as part of their surveillance care to monitor retained ovaries and pelvic structures.

BRCA-gene testing should be offered to all women with epithelial ovarian, fallopian tube, and primary peritoneal cancer as it impacts future cancer risk, as well as chemotherapy selection.⁵
 

Cervical cancer

In the first 2 years after completing primary treatment for cervical cancer, those at high risk for recurrence (including those who were recommended to adjuvant therapy) should be evaluated every 3 months for 2 years, followed by visits at 6-month intervals for an additional 3 years. Low-risk patients can be followed every 6 months for 2 years, followed by annual visits thereafter.

Pap testing should be performed annually, rather than at each surveillance visit. It should not to detect recurrence – for which it has poor sensitivity and specificity – but rather to detect new HPV-related dysplasia.⁶

Many patients with cervical cancer have a tobacco use history, placing them at risk for other cancers. Educate patients about the risk and provide cessation assistance.
 

Vulvar cancer

Prognosis for early stage vulvar cancer is very good; however, local recurrences are common (as much as 40%) in the 10 years following diagnosis.⁷ It is important to thoroughly inspect the vulva, vagina, and cervix at each surveillance visit. In high-risk patients, examinations should take place every 3 months for the first 2 years after completing primary treatment and every 6 months until 5 years post treatment. Low-risk patients can be followed every 6 months for 2 years and annually thereafter.

Identification and early treatment of dysplasia is important. Careful attention should also be made to palpation of the inguinal nodal regions. One in 10 women will have a late recurrence (greater than 5 years), so vulvar inspections should continue at least annually for the remainder of a woman’s life.
 

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.

References

1. Gynecol Oncol. 2017 Mar 31. doi: 10.1016/j.ygno.2017.03.022.

2. Obstet Gynecol. 2013 Jan;121(1):129-35.

3. Lancet. 2010 Oct 2;376(9747):1155-63.

4. Gynecol Oncol. 2009 Jan;112(1):265-74.

5. Gynecol Oncol. 2015 Jan;136(1):3-7.

6. Obstet Gynecol. 2011 Sep;118(3):548-53.

7. Gynecol Oncol. 2016 Jan;140(1):8-14.

Gynecologic cancers contribute to approximately 15% of cancer survivorship care for women. Many patients share surveillance visits between their gynecologic oncologist and their ob.gyn. or primary care physician to capitalize on preexisting relationships and ensure the provision of comprehensive wellness care. Providing high quality surveillance care is challenging because it requires vigilance in the detection of recurrence but also avoidance of unnecessary, costly, and inaccurate testing.

The oncologic benefits for various surveillance guidelines are not well established by prospective studies. However, in updated surveillance recommendations, the Society of Gynecologic Oncology (SGO) takes available data, costs, and benefits into consideration.¹ The guidelines, authored by Ritu Salani, MD, provide an excellent resource for understanding appropriate testing and evaluation during surveillance care.

Dr. Rossi

Endometrial cancer

Endometrial cancer recurs most commonly among women with a history of advanced stage cancer or early stage disease with high/intermediate risk factors, but all survivors should be evaluated regularly for recurrence. The vagina is the most common site for recurrence. Fortunately, many vaginal recurrences can be cured with salvage therapies.

Women with the lowest risk for recurrence (stage IA, grades 1 and 2 disease) who did not originally qualify for adjuvant therapy can be followed every 6 months for 2 years and then annually.

Vaginal cytology is no longer recommended for the routine surveillance of endometrial cancer because of its poor sensitivity in detecting recurrence and low positive predictive value (particularly after vaginal radiation).² Any suspicious lesions identified on speculum examination should be biopsied, rather than sampled with cytologic smear. Routine imaging (with CT or PET/CT) and cancer antigen (CA) 125 tumor marker assessment is not supported unless the initial stage was advanced. These tests should be reserved for confirmation of concerning symptoms or examination findings.

This group of patients has particular survivorship needs with respect to obesity interventions. Obesity is associated with poor prognosis from endometrial cancer, and patients should be counseled about this and offered strategies for weight loss and lifestyle modification. Lynch syndrome testing and colon cancer screening are also an important consideration in this population.
 

Ovarian cancer

Ovarian cancer recurrence rates are high, and, while salvage therapies are rarely curative, enduring responses may be achieved in some patients, making surveillance visits critical. The SGO recommends surveillance visits every 3 months in the first 2 years, every 4 months in year 3, and then every 6 months for an additional 2 years. At these visits, patients should be queried about symptoms with particular emphasis on peritoneal signs (bloating, distension, gastrointestinal disturbance, and abdominal pain) as most recurrences will be within the peritoneal cavity.

CA 125 tumor marker elevation during the surveillance phase may signal recurrence prior to the development of symptoms but initiating chemotherapy early because of elevations in CA 125 does not improve survival.³ However, in the platinum-sensitive population with a longer disease-free interval, earlier detection of recurrence by CA 125 may identify patients in whom complete secondary cytoreduction is more attainable and is associated with improved survival.⁴ Therefore, the SGO suggests that CA 125 assessment is optional. The benefits and limitations of earlier detection of recurrence should be discussed with each patient. This recommendation differs for survivors of nonepithelial ovarian cancers (such as germ-cell or sex-cord stromal), in which case the measurement of the appropriate tumor markers (such as alpha-fetoprotein, human chorionic gonadotropin, and inhibin) should be performed routinely as part of surveillance evaluation.

Evidence does not support routine imaging (such as CT or PET). It should be reserved as a confirmatory measure for patients with concerning symptoms, examination findings, or elevations in tumor markers. When ovarian cancer has been treated with fertility-preserving surgery in women of younger reproductive ages, pelvic ultrasounds may be used as part of their surveillance care to monitor retained ovaries and pelvic structures.

BRCA-gene testing should be offered to all women with epithelial ovarian, fallopian tube, and primary peritoneal cancer as it impacts future cancer risk, as well as chemotherapy selection.⁵
 

Cervical cancer

In the first 2 years after completing primary treatment for cervical cancer, those at high risk for recurrence (including those who were recommended to adjuvant therapy) should be evaluated every 3 months for 2 years, followed by visits at 6-month intervals for an additional 3 years. Low-risk patients can be followed every 6 months for 2 years, followed by annual visits thereafter.

Pap testing should be performed annually, rather than at each surveillance visit. It should not to detect recurrence – for which it has poor sensitivity and specificity – but rather to detect new HPV-related dysplasia.⁶

Many patients with cervical cancer have a tobacco use history, placing them at risk for other cancers. Educate patients about the risk and provide cessation assistance.
 

Vulvar cancer

Prognosis for early stage vulvar cancer is very good; however, local recurrences are common (as much as 40%) in the 10 years following diagnosis.⁷ It is important to thoroughly inspect the vulva, vagina, and cervix at each surveillance visit. In high-risk patients, examinations should take place every 3 months for the first 2 years after completing primary treatment and every 6 months until 5 years post treatment. Low-risk patients can be followed every 6 months for 2 years and annually thereafter.

Identification and early treatment of dysplasia is important. Careful attention should also be made to palpation of the inguinal nodal regions. One in 10 women will have a late recurrence (greater than 5 years), so vulvar inspections should continue at least annually for the remainder of a woman’s life.
 

Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.

References

1. Gynecol Oncol. 2017 Mar 31. doi: 10.1016/j.ygno.2017.03.022.

2. Obstet Gynecol. 2013 Jan;121(1):129-35.

3. Lancet. 2010 Oct 2;376(9747):1155-63.

4. Gynecol Oncol. 2009 Jan;112(1):265-74.

5. Gynecol Oncol. 2015 Jan;136(1):3-7.

6. Obstet Gynecol. 2011 Sep;118(3):548-53.

7. Gynecol Oncol. 2016 Jan;140(1):8-14.

Editor’s Note: This is the fourth installment of a six-part series that will review key concepts and articles that ob.gyns. can use to prepare for the American Board of Obstetrics and Gynecology Maintenance of Certification examination. The series is adapted from Ob/Gyn Board Master (obgynboardmaster.com), an online board review course created by Erudyte Inc. The series will cover issues in reproductive endocrinology and infertility, maternal-fetal medicine, gynecologic oncology, and female pelvic medicine, as well as general test-taking and study tips.

The American College of Obstetricians and Gynecologists’ “Practice Bulletins” are important practice management guidelines for ob.gyn. clinicians. The Practice Bulletins are rich sources of material often tested on board exams. In February 2016, ACOG issued a revised Practice Bulletin (#161) on external cephalic version outlining clinical considerations and recommendations and providing an algorithm for patient management.¹ We recommend you read this bulletin and review this topic carefully.

Let’s begin with a possible medical board question: According to the Practice Bulletin, which of the following is TRUE about external cephalic version (ECV)?

A. Success rate is lower in women with a previous cesarean delivery.

B. Placental location affects the success rate.

C. External cephalic version should be stopped after 15 minutes.

D. Women at 37 weeks’ gestation are preferred candidates.

E. Tocolysis decreases success rate.

The correct answer is D.

Women at 37 weeks’ gestation are the preferred candidates for an ECV because spontaneous version would likely have already occurred by this time and the risk of spontaneous reversion is lower. Answers A-C and E are incorrect statements.

Key points

Women at 37 weeks’ gestation are the preferred candidates for an ECV.

The overall pooled success rate for ECV is 58% with a 6% pooled complication rate.

The use of parenteral tocolysis has been associated with increased success rates of ECV, though there are not enough data to make a recommendation regarding use of regional anesthesia with the procedure.

Literature summary

ECV is a procedure designed to turn a fetus into vertex presentation by applying external pressure to a woman’s abdomen. Women at 37 weeks’ gestation are the preferred candidates. At this gestational age, spontaneous version is most likely to have occurred, and there is decreased risk of spontaneous reversion after the ECV. All patients who are near term and found to have a fetus in a nonvertex presentation should be offered an ECV as long as there are no contraindications to the procedure. ECV is not appropriate for women who have a contraindication to a vaginal delivery.

There are limited studies of ECV in women who undergo the procedure in early labor and in those who have had a previous uterine surgery. ECV success rates are not affected by a previous cesarean delivery, though the risks of uterine rupture are not clear. The procedure should be attempted only in settings where cesarean delivery services are immediately available.

The success rates of ECV have been reported to be anywhere from 16% to 100%, with an overall pooled success of 58% with a 6% pooled complication rate. Some studies have documented higher success rates with higher parity and a transverse or oblique fetal lie. However, placental location, maternal weight, and amniotic fluid volume have not been consistently found to be predictive of ECV success. The use of parenteral tocolysis has been associated with increased success rates of ECV, though there are not enough data to make a recommendation regarding use of regional anesthesia with the procedure.

ECV should be stopped in the face of a prolonged or significant fetal bradycardia or if the patient is experiencing intolerable levels of discomfort. However, there are no guidelines to recommend the total time limit of the procedure. After the ECV, there should be fetal heart rate monitoring for at least 30 minutes and anti-D immune globulin should be administered to those women who are Rh-negative if delivery is not anticipated in the next 72 hours.
 

Dr. Siddighi is editor-in-chief of the Ob/Gyn Board Master and director of female pelvic medicine and reconstructive surgery and director of grand rounds at Loma Linda University Health in California. Ob.Gyn. News and Ob/Gyn Board Master are owned by the same parent company, Frontline Medical Communications.

Reference

1. Obstet Gynecol. 2016 Feb;127(2):e54-61.

Editor’s Note: This is the fourth installment of a six-part series that will review key concepts and articles that ob.gyns. can use to prepare for the American Board of Obstetrics and Gynecology Maintenance of Certification examination. The series is adapted from Ob/Gyn Board Master (obgynboardmaster.com), an online board review course created by Erudyte Inc. The series will cover issues in reproductive endocrinology and infertility, maternal-fetal medicine, gynecologic oncology, and female pelvic medicine, as well as general test-taking and study tips.

The American College of Obstetricians and Gynecologists’ “Practice Bulletins” are important practice management guidelines for ob.gyn. clinicians. The Practice Bulletins are rich sources of material often tested on board exams. In February 2016, ACOG issued a revised Practice Bulletin (#161) on external cephalic version outlining clinical considerations and recommendations and providing an algorithm for patient management.¹ We recommend you read this bulletin and review this topic carefully.

Let’s begin with a possible medical board question: According to the Practice Bulletin, which of the following is TRUE about external cephalic version (ECV)?

A. Success rate is lower in women with a previous cesarean delivery.

B. Placental location affects the success rate.

C. External cephalic version should be stopped after 15 minutes.

D. Women at 37 weeks’ gestation are preferred candidates.

E. Tocolysis decreases success rate.

The correct answer is D.

Women at 37 weeks’ gestation are the preferred candidates for an ECV because spontaneous version would likely have already occurred by this time and the risk of spontaneous reversion is lower. Answers A-C and E are incorrect statements.

Key points

Women at 37 weeks’ gestation are the preferred candidates for an ECV.

The overall pooled success rate for ECV is 58% with a 6% pooled complication rate.

The use of parenteral tocolysis has been associated with increased success rates of ECV, though there are not enough data to make a recommendation regarding use of regional anesthesia with the procedure.

Literature summary

ECV is a procedure designed to turn a fetus into vertex presentation by applying external pressure to a woman’s abdomen. Women at 37 weeks’ gestation are the preferred candidates. At this gestational age, spontaneous version is most likely to have occurred, and there is decreased risk of spontaneous reversion after the ECV. All patients who are near term and found to have a fetus in a nonvertex presentation should be offered an ECV as long as there are no contraindications to the procedure. ECV is not appropriate for women who have a contraindication to a vaginal delivery.

There are limited studies of ECV in women who undergo the procedure in early labor and in those who have had a previous uterine surgery. ECV success rates are not affected by a previous cesarean delivery, though the risks of uterine rupture are not clear. The procedure should be attempted only in settings where cesarean delivery services are immediately available.

The success rates of ECV have been reported to be anywhere from 16% to 100%, with an overall pooled success of 58% with a 6% pooled complication rate. Some studies have documented higher success rates with higher parity and a transverse or oblique fetal lie. However, placental location, maternal weight, and amniotic fluid volume have not been consistently found to be predictive of ECV success. The use of parenteral tocolysis has been associated with increased success rates of ECV, though there are not enough data to make a recommendation regarding use of regional anesthesia with the procedure.

ECV should be stopped in the face of a prolonged or significant fetal bradycardia or if the patient is experiencing intolerable levels of discomfort. However, there are no guidelines to recommend the total time limit of the procedure. After the ECV, there should be fetal heart rate monitoring for at least 30 minutes and anti-D immune globulin should be administered to those women who are Rh-negative if delivery is not anticipated in the next 72 hours.
 

Dr. Siddighi is editor-in-chief of the Ob/Gyn Board Master and director of female pelvic medicine and reconstructive surgery and director of grand rounds at Loma Linda University Health in California. Ob.Gyn. News and Ob/Gyn Board Master are owned by the same parent company, Frontline Medical Communications.

Reference

1. Obstet Gynecol. 2016 Feb;127(2):e54-61.

Editor’s Note: This is the fourth installment of a six-part series that will review key concepts and articles that ob.gyns. can use to prepare for the American Board of Obstetrics and Gynecology Maintenance of Certification examination. The series is adapted from Ob/Gyn Board Master (obgynboardmaster.com), an online board review course created by Erudyte Inc. The series will cover issues in reproductive endocrinology and infertility, maternal-fetal medicine, gynecologic oncology, and female pelvic medicine, as well as general test-taking and study tips.

The American College of Obstetricians and Gynecologists’ “Practice Bulletins” are important practice management guidelines for ob.gyn. clinicians. The Practice Bulletins are rich sources of material often tested on board exams. In February 2016, ACOG issued a revised Practice Bulletin (#161) on external cephalic version outlining clinical considerations and recommendations and providing an algorithm for patient management.¹ We recommend you read this bulletin and review this topic carefully.

Let’s begin with a possible medical board question: According to the Practice Bulletin, which of the following is TRUE about external cephalic version (ECV)?

A. Success rate is lower in women with a previous cesarean delivery.

B. Placental location affects the success rate.

C. External cephalic version should be stopped after 15 minutes.

D. Women at 37 weeks’ gestation are preferred candidates.

E. Tocolysis decreases success rate.

The correct answer is D.

Women at 37 weeks’ gestation are the preferred candidates for an ECV because spontaneous version would likely have already occurred by this time and the risk of spontaneous reversion is lower. Answers A-C and E are incorrect statements.

Key points

Women at 37 weeks’ gestation are the preferred candidates for an ECV.

The overall pooled success rate for ECV is 58% with a 6% pooled complication rate.

The use of parenteral tocolysis has been associated with increased success rates of ECV, though there are not enough data to make a recommendation regarding use of regional anesthesia with the procedure.

Literature summary

ECV is a procedure designed to turn a fetus into vertex presentation by applying external pressure to a woman’s abdomen. Women at 37 weeks’ gestation are the preferred candidates. At this gestational age, spontaneous version is most likely to have occurred, and there is decreased risk of spontaneous reversion after the ECV. All patients who are near term and found to have a fetus in a nonvertex presentation should be offered an ECV as long as there are no contraindications to the procedure. ECV is not appropriate for women who have a contraindication to a vaginal delivery.

There are limited studies of ECV in women who undergo the procedure in early labor and in those who have had a previous uterine surgery. ECV success rates are not affected by a previous cesarean delivery, though the risks of uterine rupture are not clear. The procedure should be attempted only in settings where cesarean delivery services are immediately available.

The success rates of ECV have been reported to be anywhere from 16% to 100%, with an overall pooled success of 58% with a 6% pooled complication rate. Some studies have documented higher success rates with higher parity and a transverse or oblique fetal lie. However, placental location, maternal weight, and amniotic fluid volume have not been consistently found to be predictive of ECV success. The use of parenteral tocolysis has been associated with increased success rates of ECV, though there are not enough data to make a recommendation regarding use of regional anesthesia with the procedure.

ECV should be stopped in the face of a prolonged or significant fetal bradycardia or if the patient is experiencing intolerable levels of discomfort. However, there are no guidelines to recommend the total time limit of the procedure. After the ECV, there should be fetal heart rate monitoring for at least 30 minutes and anti-D immune globulin should be administered to those women who are Rh-negative if delivery is not anticipated in the next 72 hours.
 

Dr. Siddighi is editor-in-chief of the Ob/Gyn Board Master and director of female pelvic medicine and reconstructive surgery and director of grand rounds at Loma Linda University Health in California. Ob.Gyn. News and Ob/Gyn Board Master are owned by the same parent company, Frontline Medical Communications.

Reference

1. Obstet Gynecol. 2016 Feb;127(2):e54-61.

HM17 kicks off today with the presentation of the annual SHM Awards of Excellence, which honor work done in service to HM. A nod to the past, as it were. As those physicians are honored, others will be given their prizes as the winners of the Best of Research and Innovations in 2017, a nod to the present state of HM’s investigative spirit.

HM17 kicks off today with the presentation of the annual SHM Awards of Excellence, which honor work done in service to HM. A nod to the past, as it were. As those physicians are honored, others will be given their prizes as the winners of the Best of Research and Innovations in 2017, a nod to the present state of HM’s investigative spirit.

HM17 kicks off today with the presentation of the annual SHM Awards of Excellence, which honor work done in service to HM. A nod to the past, as it were. As those physicians are honored, others will be given their prizes as the winners of the Best of Research and Innovations in 2017, a nod to the present state of HM’s investigative spirit.

The National Institute of Occupational Safety and Health (NIOSH) released 2 new modules for tracking sharps incidents, blood, and body fluid exposures. The Occupational Health Safety Network (OHSN), a free, voluntary system “uniquely available” to U.S. health care facilities, collects injury, data such as date of injury or illness, location of incident, description of illness, and days away from work. The information is intended to help facilities identify high-risk jobs, develop interventions for safety and health of hospital staff, and objectively measure impact over time.

The modules join others that track incidence of slips, trips, and falls; patient handling injuries; and workplace violence.

The OHSN developers say that the secure electronic system hosts facilities across 20 states, all providing data to the web-based portal. The system allows participants to determine the root cause for each incident, analyzes the data, and presents the results in easy-to-read charts. Members can use OHSN to analyze and report workplace-specific data to illustrate the magnitude of injury and illness events among workers, monitor trends, and access a library of resources specific to health care.

As the pool of participants expands, “an increasingly more accurate picture can be drawn,” NIOSH says, and recommendations, interventions, and prevention strategies utilized.

To enroll, visit https://www.cdc.gov/niosh/topics/ohsn/enrollment.html?s_cid=3ni7d2niupdateOHSN-Enroll032017.

The National Institute of Occupational Safety and Health (NIOSH) released 2 new modules for tracking sharps incidents, blood, and body fluid exposures. The Occupational Health Safety Network (OHSN), a free, voluntary system “uniquely available” to U.S. health care facilities, collects injury, data such as date of injury or illness, location of incident, description of illness, and days away from work. The information is intended to help facilities identify high-risk jobs, develop interventions for safety and health of hospital staff, and objectively measure impact over time.

The modules join others that track incidence of slips, trips, and falls; patient handling injuries; and workplace violence.

The OHSN developers say that the secure electronic system hosts facilities across 20 states, all providing data to the web-based portal. The system allows participants to determine the root cause for each incident, analyzes the data, and presents the results in easy-to-read charts. Members can use OHSN to analyze and report workplace-specific data to illustrate the magnitude of injury and illness events among workers, monitor trends, and access a library of resources specific to health care.

As the pool of participants expands, “an increasingly more accurate picture can be drawn,” NIOSH says, and recommendations, interventions, and prevention strategies utilized.

To enroll, visit https://www.cdc.gov/niosh/topics/ohsn/enrollment.html?s_cid=3ni7d2niupdateOHSN-Enroll032017.

The National Institute of Occupational Safety and Health (NIOSH) released 2 new modules for tracking sharps incidents, blood, and body fluid exposures. The Occupational Health Safety Network (OHSN), a free, voluntary system “uniquely available” to U.S. health care facilities, collects injury, data such as date of injury or illness, location of incident, description of illness, and days away from work. The information is intended to help facilities identify high-risk jobs, develop interventions for safety and health of hospital staff, and objectively measure impact over time.

The modules join others that track incidence of slips, trips, and falls; patient handling injuries; and workplace violence.

The OHSN developers say that the secure electronic system hosts facilities across 20 states, all providing data to the web-based portal. The system allows participants to determine the root cause for each incident, analyzes the data, and presents the results in easy-to-read charts. Members can use OHSN to analyze and report workplace-specific data to illustrate the magnitude of injury and illness events among workers, monitor trends, and access a library of resources specific to health care.

As the pool of participants expands, “an increasingly more accurate picture can be drawn,” NIOSH says, and recommendations, interventions, and prevention strategies utilized.

To enroll, visit https://www.cdc.gov/niosh/topics/ohsn/enrollment.html?s_cid=3ni7d2niupdateOHSN-Enroll032017.

Pediatric hospital medicine (PHM) is a fast-moving field, so having the best information is part of being a good doctor. But try going through all the relevant journals every month and pulling out the relevant findings. It’s a tall task.

Never fear! Akshata Hopkins, MD, an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., and Amit Singh, MD, of Stanford (Calif.) Children’s Health, have done the work for you. They reviewed every issue from 18 relevant journals over the last year and chose studies that are “hot topics” and involve important, evolving clinical questions that any physician caring for hospitalized children should know about.
As pediatric hospitalists, “we’re looking at articles from a pediatric hospital medicine standpoint, but the way that we chose the articles was based on topics that are prevalent to not only academic centers but community centers – and so it’s more broad,” Dr. Hopkins said. “The topics themselves are not necessarily new, but there are nuances to management [for which] every year there is new data that’s coming out. So what we’ve done is digest it for them.”

[[{"fid":"195832","view_mode":"medstat_image_flush_right","attributes":{"alt":"Dr. Akshata Hopkins","height":"220","width":"146","class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Akshata Hopkins","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Akshata Hopkins","field_file_image_credit[und][0][value]":""}}}]]Their session at 5:30 p.m. today, “Pediatric Update: Top Articles in Pediatric Hospital Medicine 2016,” will touch on both clinical and systems issues, often with a case used as a way to introduce topics, followed by a review of findings from a recent article. Dr. Hopkins said that questions will be answered throughout the session. Topics will include the management of young febrile infants, nasogastric feeding in bronchiolitis, prediction of severe pneumonia outcomes in children, and a review of quality measures that include patient experience and antibiotic stewardship.

“With the rise of more PCR testing and discussions of Choosing Wisely and high-value care, there’s more testing available,” Dr. Hopkins said. “But what is that going to cost versus what are the benefits that it brings? Are these tests valuable and in what way? And that’s kind of a hot topic. It depends on the age of the child and actually the results of [testing] are a little surprising.”

Pediatric Update: Top Articles in Pediatric Hospital Medicine 2016
Wednesday, 5:30–6:20 p.m.

Pediatric hospital medicine (PHM) is a fast-moving field, so having the best information is part of being a good doctor. But try going through all the relevant journals every month and pulling out the relevant findings. It’s a tall task.

Never fear! Akshata Hopkins, MD, an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., and Amit Singh, MD, of Stanford (Calif.) Children’s Health, have done the work for you. They reviewed every issue from 18 relevant journals over the last year and chose studies that are “hot topics” and involve important, evolving clinical questions that any physician caring for hospitalized children should know about.
As pediatric hospitalists, “we’re looking at articles from a pediatric hospital medicine standpoint, but the way that we chose the articles was based on topics that are prevalent to not only academic centers but community centers – and so it’s more broad,” Dr. Hopkins said. “The topics themselves are not necessarily new, but there are nuances to management [for which] every year there is new data that’s coming out. So what we’ve done is digest it for them.”

[[{"fid":"195832","view_mode":"medstat_image_flush_right","attributes":{"alt":"Dr. Akshata Hopkins","height":"220","width":"146","class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Akshata Hopkins","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Akshata Hopkins","field_file_image_credit[und][0][value]":""}}}]]Their session at 5:30 p.m. today, “Pediatric Update: Top Articles in Pediatric Hospital Medicine 2016,” will touch on both clinical and systems issues, often with a case used as a way to introduce topics, followed by a review of findings from a recent article. Dr. Hopkins said that questions will be answered throughout the session. Topics will include the management of young febrile infants, nasogastric feeding in bronchiolitis, prediction of severe pneumonia outcomes in children, and a review of quality measures that include patient experience and antibiotic stewardship.

“With the rise of more PCR testing and discussions of Choosing Wisely and high-value care, there’s more testing available,” Dr. Hopkins said. “But what is that going to cost versus what are the benefits that it brings? Are these tests valuable and in what way? And that’s kind of a hot topic. It depends on the age of the child and actually the results of [testing] are a little surprising.”

Pediatric Update: Top Articles in Pediatric Hospital Medicine 2016
Wednesday, 5:30–6:20 p.m.

Pediatric hospital medicine (PHM) is a fast-moving field, so having the best information is part of being a good doctor. But try going through all the relevant journals every month and pulling out the relevant findings. It’s a tall task.

Never fear! Akshata Hopkins, MD, an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla., and Amit Singh, MD, of Stanford (Calif.) Children’s Health, have done the work for you. They reviewed every issue from 18 relevant journals over the last year and chose studies that are “hot topics” and involve important, evolving clinical questions that any physician caring for hospitalized children should know about.
As pediatric hospitalists, “we’re looking at articles from a pediatric hospital medicine standpoint, but the way that we chose the articles was based on topics that are prevalent to not only academic centers but community centers – and so it’s more broad,” Dr. Hopkins said. “The topics themselves are not necessarily new, but there are nuances to management [for which] every year there is new data that’s coming out. So what we’ve done is digest it for them.”

[[{"fid":"195832","view_mode":"medstat_image_flush_right","attributes":{"alt":"Dr. Akshata Hopkins","height":"220","width":"146","class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Akshata Hopkins","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Akshata Hopkins","field_file_image_credit[und][0][value]":""}}}]]Their session at 5:30 p.m. today, “Pediatric Update: Top Articles in Pediatric Hospital Medicine 2016,” will touch on both clinical and systems issues, often with a case used as a way to introduce topics, followed by a review of findings from a recent article. Dr. Hopkins said that questions will be answered throughout the session. Topics will include the management of young febrile infants, nasogastric feeding in bronchiolitis, prediction of severe pneumonia outcomes in children, and a review of quality measures that include patient experience and antibiotic stewardship.

“With the rise of more PCR testing and discussions of Choosing Wisely and high-value care, there’s more testing available,” Dr. Hopkins said. “But what is that going to cost versus what are the benefits that it brings? Are these tests valuable and in what way? And that’s kind of a hot topic. It depends on the age of the child and actually the results of [testing] are a little surprising.”

Pediatric Update: Top Articles in Pediatric Hospital Medicine 2016
Wednesday, 5:30–6:20 p.m.

The cost of health care is on the lips of everyone, from the thousands of HM17 attendees to congressional leaders to President Donald Trump. Yet, one long-promoted answer – telemedicine practiced by telehospitalists – is not as widely adopted as its proponents say it should be. After Wednesday’s session, “Foundations of a Hospital Medicine Telemedicine Program,” which begins at 4:15 p.m., at least a few more physicians will see it as an option.

“The timing is there,” said copresenter Talbot “Mac” McCormick, MD, president and chief executive officer of Eagle Telemedicine of Atlanta. “Telemedicine has come of age.”

[[{"fid":"194482","view_mode":"medstat_image_flush_left","attributes":{"alt":"Dr. Talbot \\\u0022Mac\u0022 McCormick, Eagle telemedicine, Atlanta","height":"220","width":"157","class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Dr. Talbot \u0022Mac\u0022 McCormick","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Dr. Talbot \u0022Mac\u0022 McCormick","field_file_image_credit[und][0][value]":""}}}]]Copresenter Shannon Carpenter, BS, MBA, vice president at Charlotte, N.C.–based Carolinas Healthcare System, said telemedicine is a “relevancy issue.”

“We are hearing so much about a need for an alternative care model, [and] the virtual-care model is incredibly relevant in today’s environment,” Ms. Carpenter said. Adding to telemedicine’s basic advantage is its ability to help alleviate staffing issues.

Foundations of a Hospital Medicine Telemedicine Program
Wednesday, 4:15–5:20 p.m.
Available via HM17 On Demand

The cost of health care is on the lips of everyone, from the thousands of HM17 attendees to congressional leaders to President Donald Trump. Yet, one long-promoted answer – telemedicine practiced by telehospitalists – is not as widely adopted as its proponents say it should be. After Wednesday’s session, “Foundations of a Hospital Medicine Telemedicine Program,” which begins at 4:15 p.m., at least a few more physicians will see it as an option.

“The timing is there,” said copresenter Talbot “Mac” McCormick, MD, president and chief executive officer of Eagle Telemedicine of Atlanta. “Telemedicine has come of age.”

[[{"fid":"194482","view_mode":"medstat_image_flush_left","attributes":{"alt":"Dr. Talbot \\\u0022Mac\u0022 McCormick, Eagle telemedicine, Atlanta","height":"220","width":"157","class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Dr. Talbot \u0022Mac\u0022 McCormick","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Dr. Talbot \u0022Mac\u0022 McCormick","field_file_image_credit[und][0][value]":""}}}]]Copresenter Shannon Carpenter, BS, MBA, vice president at Charlotte, N.C.–based Carolinas Healthcare System, said telemedicine is a “relevancy issue.”

“We are hearing so much about a need for an alternative care model, [and] the virtual-care model is incredibly relevant in today’s environment,” Ms. Carpenter said. Adding to telemedicine’s basic advantage is its ability to help alleviate staffing issues.

Foundations of a Hospital Medicine Telemedicine Program
Wednesday, 4:15–5:20 p.m.
Available via HM17 On Demand

The cost of health care is on the lips of everyone, from the thousands of HM17 attendees to congressional leaders to President Donald Trump. Yet, one long-promoted answer – telemedicine practiced by telehospitalists – is not as widely adopted as its proponents say it should be. After Wednesday’s session, “Foundations of a Hospital Medicine Telemedicine Program,” which begins at 4:15 p.m., at least a few more physicians will see it as an option.

“The timing is there,” said copresenter Talbot “Mac” McCormick, MD, president and chief executive officer of Eagle Telemedicine of Atlanta. “Telemedicine has come of age.”

[[{"fid":"194482","view_mode":"medstat_image_flush_left","attributes":{"alt":"Dr. Talbot \\\u0022Mac\u0022 McCormick, Eagle telemedicine, Atlanta","height":"220","width":"157","class":"media-element file-medstat-image-flush-left","data-delta":"1"},"fields":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Dr. Talbot \u0022Mac\u0022 McCormick","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_left","field_file_image_caption[und][0][value]":"Dr. Talbot \u0022Mac\u0022 McCormick","field_file_image_credit[und][0][value]":""}}}]]Copresenter Shannon Carpenter, BS, MBA, vice president at Charlotte, N.C.–based Carolinas Healthcare System, said telemedicine is a “relevancy issue.”

“We are hearing so much about a need for an alternative care model, [and] the virtual-care model is incredibly relevant in today’s environment,” Ms. Carpenter said. Adding to telemedicine’s basic advantage is its ability to help alleviate staffing issues.

Foundations of a Hospital Medicine Telemedicine Program
Wednesday, 4:15–5:20 p.m.
Available via HM17 On Demand

Day 1 has already raised the bar for the SHM Annual Meeting. Day 2, Wednesday, will set a whole new standard with courses, speakers, content, and perspective.

Leading off the day will be the presentation of the best of Research and Innovations. This year, we had hundreds of submissions, and the kickoff of Day 2 will showcase the very best of the best! Following immediately, we will recognize the winners of the SHM Awards of Excellence.

Dr. Harte is outgoing president of SHM and president of Cleveland Clinic Akron General and Southern Region.

Day 1 has already raised the bar for the SHM Annual Meeting. Day 2, Wednesday, will set a whole new standard with courses, speakers, content, and perspective.

Leading off the day will be the presentation of the best of Research and Innovations. This year, we had hundreds of submissions, and the kickoff of Day 2 will showcase the very best of the best! Following immediately, we will recognize the winners of the SHM Awards of Excellence.

Dr. Harte is outgoing president of SHM and president of Cleveland Clinic Akron General and Southern Region.

Day 1 has already raised the bar for the SHM Annual Meeting. Day 2, Wednesday, will set a whole new standard with courses, speakers, content, and perspective.

Leading off the day will be the presentation of the best of Research and Innovations. This year, we had hundreds of submissions, and the kickoff of Day 2 will showcase the very best of the best! Following immediately, we will recognize the winners of the SHM Awards of Excellence.

Dr. Harte is outgoing president of SHM and president of Cleveland Clinic Akron General and Southern Region.

In an ongoing effort to improve oversight and to protect potential whistleblowers at the VA, President Trump has signed a new executive order creating the Office of Accountability and Whistleblower Protection. The executive order establishes an office that will report directly to VA Secretary David. J. Shulkin, MD. “Accountability is an important issue to us at VA and something that we’re focusing on to make sure that we have employees who work and are committed to the mission of serving our veterans,” Dr. Shulkin explained at an April 26 press conference. “When we find employees that have deviated from those values, we want to make sure that we can move them outside the VA and not have them working at VA.”

The new office is not the first effort at the VA to protect whistleblowers or to expedite the removal of employees. In 2014 the Office of Accountability and Review was established to increase central office scrutiny of senior-level executives at local and regional VA facilities. In contrast Dr. Shulkin noted, “This is a broader office that will be taking a look at all of our employees.” The current VA Whistleblower Office, created just last year will be incorporated into the new office, according to Dr. Shulkin.

Related: VA Secretary Shulkin Calls for New Powers to Fire VA Employees

Not everyone greeted the announcement with praise. “This rush to fire feds faster, first at VA, but with attempts to spread it across government, comes with a serious risk,” argued Washington Post columnist Joe Davidson. “Yes, due process rights can be slow and cumbersome. They protect, however, not just employees, but more importantly, also the public from a politicized system that favors citizens of one political party over another. Reforms must respect civil service protections. They should be acknowledged by government leaders and not be ignored as they were at the signing.”

Officials at the Project on Government Oversight expressed concern that whistleblowers should have an independent channel to report their concerns. Like the current whistleblower office, the new structure “may do far more damage than good,” the organization reported “It is incredibly important that whistleblowers have the ability to go to an independent office to report wrongdoing, since an internal office could be pressured to act in the VA’s interest by covering up problems and silencing whistleblowers.”

Related: VA Launches Investigation into Cincinnati Facility Mismanagement

Dr. Shulkin insisted that the office did not negate the need for the new legislation that he has called for that would speed the process of firing problem employees. Nor will the new office replace the hot line set up by the White House for veteran complaints about VA service. “These are all 3 efforts that are important for us to identify issues that are preventing us from doing the very best job that we can,” he explained. “We’re keeping our employees and our executives accountable to the values, to be able to work at the VA.  We are soliciting input from veterans who feel that they have issues that they want to share with us, and that’s what the hotline will be doing.” 

While the focus on the effort is on employees malfeasance, Dr. Shulkin cautioned that the VA was still concerned about employee morale and protecting whistleblowers from retaliation. “Our employees have to feel safe, when they see something, to tell us about it,” he explained. “The message is clear that we will not tolerate whistleblower retaliation in the [VA]. And we will take actions if we do determine that retaliation has been imposed upon an employee who has come forth with an issue.”

Related: Deputy Secretary of Veterans Affairs Gibson Defends VA Discipline Guidelines

Dr. Shulkin also announced a new task force that would tackle fraud, waste, and abuse, “to make sure that we are aggressively investigating any issues that might lead to the waste of taxpayer dollars.”

In an ongoing effort to improve oversight and to protect potential whistleblowers at the VA, President Trump has signed a new executive order creating the Office of Accountability and Whistleblower Protection. The executive order establishes an office that will report directly to VA Secretary David. J. Shulkin, MD. “Accountability is an important issue to us at VA and something that we’re focusing on to make sure that we have employees who work and are committed to the mission of serving our veterans,” Dr. Shulkin explained at an April 26 press conference. “When we find employees that have deviated from those values, we want to make sure that we can move them outside the VA and not have them working at VA.”

The new office is not the first effort at the VA to protect whistleblowers or to expedite the removal of employees. In 2014 the Office of Accountability and Review was established to increase central office scrutiny of senior-level executives at local and regional VA facilities. In contrast Dr. Shulkin noted, “This is a broader office that will be taking a look at all of our employees.” The current VA Whistleblower Office, created just last year will be incorporated into the new office, according to Dr. Shulkin.

Related: VA Secretary Shulkin Calls for New Powers to Fire VA Employees

Not everyone greeted the announcement with praise. “This rush to fire feds faster, first at VA, but with attempts to spread it across government, comes with a serious risk,” argued Washington Post columnist Joe Davidson. “Yes, due process rights can be slow and cumbersome. They protect, however, not just employees, but more importantly, also the public from a politicized system that favors citizens of one political party over another. Reforms must respect civil service protections. They should be acknowledged by government leaders and not be ignored as they were at the signing.”

Officials at the Project on Government Oversight expressed concern that whistleblowers should have an independent channel to report their concerns. Like the current whistleblower office, the new structure “may do far more damage than good,” the organization reported “It is incredibly important that whistleblowers have the ability to go to an independent office to report wrongdoing, since an internal office could be pressured to act in the VA’s interest by covering up problems and silencing whistleblowers.”

Related: VA Launches Investigation into Cincinnati Facility Mismanagement

Dr. Shulkin insisted that the office did not negate the need for the new legislation that he has called for that would speed the process of firing problem employees. Nor will the new office replace the hot line set up by the White House for veteran complaints about VA service. “These are all 3 efforts that are important for us to identify issues that are preventing us from doing the very best job that we can,” he explained. “We’re keeping our employees and our executives accountable to the values, to be able to work at the VA.  We are soliciting input from veterans who feel that they have issues that they want to share with us, and that’s what the hotline will be doing.” 

While the focus on the effort is on employees malfeasance, Dr. Shulkin cautioned that the VA was still concerned about employee morale and protecting whistleblowers from retaliation. “Our employees have to feel safe, when they see something, to tell us about it,” he explained. “The message is clear that we will not tolerate whistleblower retaliation in the [VA]. And we will take actions if we do determine that retaliation has been imposed upon an employee who has come forth with an issue.”

Related: Deputy Secretary of Veterans Affairs Gibson Defends VA Discipline Guidelines

Dr. Shulkin also announced a new task force that would tackle fraud, waste, and abuse, “to make sure that we are aggressively investigating any issues that might lead to the waste of taxpayer dollars.”

In an ongoing effort to improve oversight and to protect potential whistleblowers at the VA, President Trump has signed a new executive order creating the Office of Accountability and Whistleblower Protection. The executive order establishes an office that will report directly to VA Secretary David. J. Shulkin, MD. “Accountability is an important issue to us at VA and something that we’re focusing on to make sure that we have employees who work and are committed to the mission of serving our veterans,” Dr. Shulkin explained at an April 26 press conference. “When we find employees that have deviated from those values, we want to make sure that we can move them outside the VA and not have them working at VA.”

The new office is not the first effort at the VA to protect whistleblowers or to expedite the removal of employees. In 2014 the Office of Accountability and Review was established to increase central office scrutiny of senior-level executives at local and regional VA facilities. In contrast Dr. Shulkin noted, “This is a broader office that will be taking a look at all of our employees.” The current VA Whistleblower Office, created just last year will be incorporated into the new office, according to Dr. Shulkin.

Related: VA Secretary Shulkin Calls for New Powers to Fire VA Employees

Not everyone greeted the announcement with praise. “This rush to fire feds faster, first at VA, but with attempts to spread it across government, comes with a serious risk,” argued Washington Post columnist Joe Davidson. “Yes, due process rights can be slow and cumbersome. They protect, however, not just employees, but more importantly, also the public from a politicized system that favors citizens of one political party over another. Reforms must respect civil service protections. They should be acknowledged by government leaders and not be ignored as they were at the signing.”

Officials at the Project on Government Oversight expressed concern that whistleblowers should have an independent channel to report their concerns. Like the current whistleblower office, the new structure “may do far more damage than good,” the organization reported “It is incredibly important that whistleblowers have the ability to go to an independent office to report wrongdoing, since an internal office could be pressured to act in the VA’s interest by covering up problems and silencing whistleblowers.”

Related: VA Launches Investigation into Cincinnati Facility Mismanagement

Dr. Shulkin insisted that the office did not negate the need for the new legislation that he has called for that would speed the process of firing problem employees. Nor will the new office replace the hot line set up by the White House for veteran complaints about VA service. “These are all 3 efforts that are important for us to identify issues that are preventing us from doing the very best job that we can,” he explained. “We’re keeping our employees and our executives accountable to the values, to be able to work at the VA.  We are soliciting input from veterans who feel that they have issues that they want to share with us, and that’s what the hotline will be doing.” 

While the focus on the effort is on employees malfeasance, Dr. Shulkin cautioned that the VA was still concerned about employee morale and protecting whistleblowers from retaliation. “Our employees have to feel safe, when they see something, to tell us about it,” he explained. “The message is clear that we will not tolerate whistleblower retaliation in the [VA]. And we will take actions if we do determine that retaliation has been imposed upon an employee who has come forth with an issue.”

Related: Deputy Secretary of Veterans Affairs Gibson Defends VA Discipline Guidelines

Dr. Shulkin also announced a new task force that would tackle fraud, waste, and abuse, “to make sure that we are aggressively investigating any issues that might lead to the waste of taxpayer dollars.”

ANSWER

The ECG is remarkable for sinus tachycardia and left ventricular hypertrophy. Equal numbers of P and QRS complexes with a consistent PR interval indicate sinus tachycardia. High voltages in the limb leads (R in lead I and S in lead III ≥ 25 mm) or precordial leads (S in lead V₁ and R in lead V₅ or V₆ ≥ 35 mm) constitute left ventricular hypertrophy.

ANSWER

The ECG is remarkable for sinus tachycardia and left ventricular hypertrophy. Equal numbers of P and QRS complexes with a consistent PR interval indicate sinus tachycardia. High voltages in the limb leads (R in lead I and S in lead III ≥ 25 mm) or precordial leads (S in lead V₁ and R in lead V₅ or V₆ ≥ 35 mm) constitute left ventricular hypertrophy.

ANSWER

The ECG is remarkable for sinus tachycardia and left ventricular hypertrophy. Equal numbers of P and QRS complexes with a consistent PR interval indicate sinus tachycardia. High voltages in the limb leads (R in lead I and S in lead III ≥ 25 mm) or precordial leads (S in lead V₁ and R in lead V₅ or V₆ ≥ 35 mm) constitute left ventricular hypertrophy.

As a 99-year-old friend neared the end of her life, she offered a lesson for the health care world, said Deborah Korenstein, MD, chief of general internal medicine and director of clinical effectiveness at Memorial Sloan Kettering Cancer Center, N.Y., in the Tuesday session “Finding High Value Inpatient Care at the End of Life.”

The woman, nicknamed “Mitch,” had bluntly made her preference clear, Dr. Korenstein said: “She wanted to live independently as long as she could, and then, she wanted to be dead.”

But when a pathology report showed urothelial cancer, that preference didn’t stop an oncology urologist from suggesting that Mitch enter a clinical trial on an unproven therapy. Worse, Mitch initially said “yes” to this idea, seemingly because she thought that’s what she was expected to say.

It was only when Dr. Korenstein spoke with her that she changed her mind, entered inpatient hospice care, and died peacefully.

“I think it’s a cautionary tale about when a patient is crystal clear about their wishes,” she said. “The wave of the medical system kind of pushes them along in a particular direction that may go against their wishes.”

Dr. Korenstein said U.S. health care system does fairly well in some areas – for instance, research shows that about 60% of people die in their preferred location, whether at home or somewhere else. But it does not do so well in others – a 2013 Journal of General Internal Medicine study found that, during 2002-2008, Medicare beneficiaries typically spent $39,000 out of pocket on their medical care, and in 25% of cases, what they spent exceeded the total value of their assets.

As far as individual preferences, these tend to correlate poorly with the care that people actually get, Dr. Korenstein said. Patients often don’t express their wishes, doctors are poor judges of what matters to individual people, and care is largely driven by physician preferences and by the care setting involved, she said.

Given those problems, she said, “we cannot possibly be providing high-value individualized care.”

Hospitalists are well positioned to help patients’ preferences align with care, she added. Sometimes, a sustained relationship with a patient, while generally a positive thing, might lead a provider to become invested in their care in “ways that are not always rational.” So a hospitalist can have a helpful vantage point.

As a 99-year-old friend neared the end of her life, she offered a lesson for the health care world, said Deborah Korenstein, MD, chief of general internal medicine and director of clinical effectiveness at Memorial Sloan Kettering Cancer Center, N.Y., in the Tuesday session “Finding High Value Inpatient Care at the End of Life.”

The woman, nicknamed “Mitch,” had bluntly made her preference clear, Dr. Korenstein said: “She wanted to live independently as long as she could, and then, she wanted to be dead.”

But when a pathology report showed urothelial cancer, that preference didn’t stop an oncology urologist from suggesting that Mitch enter a clinical trial on an unproven therapy. Worse, Mitch initially said “yes” to this idea, seemingly because she thought that’s what she was expected to say.

It was only when Dr. Korenstein spoke with her that she changed her mind, entered inpatient hospice care, and died peacefully.

“I think it’s a cautionary tale about when a patient is crystal clear about their wishes,” she said. “The wave of the medical system kind of pushes them along in a particular direction that may go against their wishes.”

Dr. Korenstein said U.S. health care system does fairly well in some areas – for instance, research shows that about 60% of people die in their preferred location, whether at home or somewhere else. But it does not do so well in others – a 2013 Journal of General Internal Medicine study found that, during 2002-2008, Medicare beneficiaries typically spent $39,000 out of pocket on their medical care, and in 25% of cases, what they spent exceeded the total value of their assets.

As far as individual preferences, these tend to correlate poorly with the care that people actually get, Dr. Korenstein said. Patients often don’t express their wishes, doctors are poor judges of what matters to individual people, and care is largely driven by physician preferences and by the care setting involved, she said.

Given those problems, she said, “we cannot possibly be providing high-value individualized care.”

Hospitalists are well positioned to help patients’ preferences align with care, she added. Sometimes, a sustained relationship with a patient, while generally a positive thing, might lead a provider to become invested in their care in “ways that are not always rational.” So a hospitalist can have a helpful vantage point.

As a 99-year-old friend neared the end of her life, she offered a lesson for the health care world, said Deborah Korenstein, MD, chief of general internal medicine and director of clinical effectiveness at Memorial Sloan Kettering Cancer Center, N.Y., in the Tuesday session “Finding High Value Inpatient Care at the End of Life.”

The woman, nicknamed “Mitch,” had bluntly made her preference clear, Dr. Korenstein said: “She wanted to live independently as long as she could, and then, she wanted to be dead.”

But when a pathology report showed urothelial cancer, that preference didn’t stop an oncology urologist from suggesting that Mitch enter a clinical trial on an unproven therapy. Worse, Mitch initially said “yes” to this idea, seemingly because she thought that’s what she was expected to say.

It was only when Dr. Korenstein spoke with her that she changed her mind, entered inpatient hospice care, and died peacefully.

“I think it’s a cautionary tale about when a patient is crystal clear about their wishes,” she said. “The wave of the medical system kind of pushes them along in a particular direction that may go against their wishes.”

Dr. Korenstein said U.S. health care system does fairly well in some areas – for instance, research shows that about 60% of people die in their preferred location, whether at home or somewhere else. But it does not do so well in others – a 2013 Journal of General Internal Medicine study found that, during 2002-2008, Medicare beneficiaries typically spent $39,000 out of pocket on their medical care, and in 25% of cases, what they spent exceeded the total value of their assets.

As far as individual preferences, these tend to correlate poorly with the care that people actually get, Dr. Korenstein said. Patients often don’t express their wishes, doctors are poor judges of what matters to individual people, and care is largely driven by physician preferences and by the care setting involved, she said.

Given those problems, she said, “we cannot possibly be providing high-value individualized care.”

Hospitalists are well positioned to help patients’ preferences align with care, she added. Sometimes, a sustained relationship with a patient, while generally a positive thing, might lead a provider to become invested in their care in “ways that are not always rational.” So a hospitalist can have a helpful vantage point.