In December 2016, Federal Practitioner sat down with Shereef M. Elnahal, MD, MBA, VHA chief quality & safety officer, to discuss the VA Diffusion of Excellence (VADOE) program, which seeks to change VA culture and reward employees who have developed innovative programs that increase patient satisfaction, access to care, and clinical results, among other VA priorities. A recent JAMA article by Dr. Elnahal, VA Secretary Nominee David Shulkin, MD, and Deputy Under Secretary for Health for Organizational Excellence Carolyn Clancy, MD, highlights how VADOE can be a model for excellence at other large-scale health care systems.  

According to Dr. Elnahal, in 1 year, more than 400 VADOE programs have been submitted, more than 20 have been replicated at multiple sites, and 8 are targeted nationally, including a virtual tumor board and clinical pharmacy best practices. “We really empower and recognize the frontline employees who not only contribute the best practices but who replicate them,” Dr. Elnahal told Federal Practitioner. “Essentially, we give them a systemwide leadership role… This is part of many different initiatives that are trying to recognize and elevate the great work that physicians do and really improve their morale and reduce burnout.”

In December 2016, Federal Practitioner sat down with Shereef M. Elnahal, MD, MBA, VHA chief quality & safety officer, to discuss the VA Diffusion of Excellence (VADOE) program, which seeks to change VA culture and reward employees who have developed innovative programs that increase patient satisfaction, access to care, and clinical results, among other VA priorities. A recent JAMA article by Dr. Elnahal, VA Secretary Nominee David Shulkin, MD, and Deputy Under Secretary for Health for Organizational Excellence Carolyn Clancy, MD, highlights how VADOE can be a model for excellence at other large-scale health care systems.  

According to Dr. Elnahal, in 1 year, more than 400 VADOE programs have been submitted, more than 20 have been replicated at multiple sites, and 8 are targeted nationally, including a virtual tumor board and clinical pharmacy best practices. “We really empower and recognize the frontline employees who not only contribute the best practices but who replicate them,” Dr. Elnahal told Federal Practitioner. “Essentially, we give them a systemwide leadership role… This is part of many different initiatives that are trying to recognize and elevate the great work that physicians do and really improve their morale and reduce burnout.”

In December 2016, Federal Practitioner sat down with Shereef M. Elnahal, MD, MBA, VHA chief quality & safety officer, to discuss the VA Diffusion of Excellence (VADOE) program, which seeks to change VA culture and reward employees who have developed innovative programs that increase patient satisfaction, access to care, and clinical results, among other VA priorities. A recent JAMA article by Dr. Elnahal, VA Secretary Nominee David Shulkin, MD, and Deputy Under Secretary for Health for Organizational Excellence Carolyn Clancy, MD, highlights how VADOE can be a model for excellence at other large-scale health care systems.  

According to Dr. Elnahal, in 1 year, more than 400 VADOE programs have been submitted, more than 20 have been replicated at multiple sites, and 8 are targeted nationally, including a virtual tumor board and clinical pharmacy best practices. “We really empower and recognize the frontline employees who not only contribute the best practices but who replicate them,” Dr. Elnahal told Federal Practitioner. “Essentially, we give them a systemwide leadership role… This is part of many different initiatives that are trying to recognize and elevate the great work that physicians do and really improve their morale and reduce burnout.”

Blood donor
Photo by Marja Helander

The Irish Blood Transfusion Service (IBTS) has lifted the lifetime ban on blood donations from men who have sex with men (MSM).

However, prospective MSM blood donors are still subject to deferral.

Now, MSMs are allowed to donate blood in Ireland if it has been more than 12 months since their last sexual contact with a man and if they meet the other blood donor selection criteria.

The IBTS has also introduced new regulations relating to individuals with a history of specific, notifiable sexually transmitted infections (STIs).

These individuals are now allowed to donate blood 5 years after they have completed treatment for their STIs.

“In June of last year, I accepted the recommendations of the IBTS to change their blood donation deferral policies for men who have sex with men, as well as for donors who have had a sexually transmitted infection,” said Ireland’s Health Minister, Simon Harris.

“I would like to take this opportunity to thank the IBTS for their work over the past 6 months, which, today, sees these recommendations brought to fruition within the timescale agreed. [T]he IBTS will continue to keep all deferral policies under active review in the light of scientific evidence, emerging infections, and international experience.”

MSM deferral

The change in deferral policy relating to MSMs follows a 2-year review of the issues by the IBTS.

The agency hosted an international symposium on the topic in April 2016. Experts from 7 countries who had either lifted, or were in the process of lifting, their lifetime ban on MSM blood donors presented their respective stances, research, and the rationale behind their decisions.

The IBTS said its change to a 1-year deferral period for MSMs is supported by the most current scientific evidence available and brings Ireland into line with similar policies in the UK, Canada, and the US.

STI-related deferral

The IBTS said the 1-year deferral policy for MSMs will protect against the risk of HIV transmission. However, there is concern that it may not be sufficient to deal with an emerging infection. 

Therefore, the board of the IBTS decided that individuals who have had a notifiable STI, such as chlamydia or genital herpes, should be deferred from donating blood for 5 years after completing treatment for that STI.  

Individuals who have had syphilis, gonorrhea, lymphogranuloma venereum, or granuloma inguinale are (and have been) permanently banned from donating blood.

Individuals who have taken medication to prevent HIV infection are also deferred from donating blood for 5 years after they take the medication.

Safety of the blood supply

“The IBTS provides a safe, reliable, and robust blood service to the Irish health system and has the necessary program and procedures in place to protect both donors and recipients of blood and blood products,” Harris said.

All prospective blood donors in Ireland undergo nucleic acid testing for a number of diseases, including HIV, hepatitis B, and hepatitis C. This is the most sensitive method of testing available.

The risk of transmitted infection of blood is at its highest when individuals donate blood during the 5- to 15-day period following exposure to a virus.

There is no biological measure to detect infectivity during this period and, as a consequence, the IBTS temporarily or permanently defers, on average, 1 in 10 people from giving blood.

Blood donor
Photo by Marja Helander

The Irish Blood Transfusion Service (IBTS) has lifted the lifetime ban on blood donations from men who have sex with men (MSM).

However, prospective MSM blood donors are still subject to deferral.

Now, MSMs are allowed to donate blood in Ireland if it has been more than 12 months since their last sexual contact with a man and if they meet the other blood donor selection criteria.

The IBTS has also introduced new regulations relating to individuals with a history of specific, notifiable sexually transmitted infections (STIs).

These individuals are now allowed to donate blood 5 years after they have completed treatment for their STIs.

“In June of last year, I accepted the recommendations of the IBTS to change their blood donation deferral policies for men who have sex with men, as well as for donors who have had a sexually transmitted infection,” said Ireland’s Health Minister, Simon Harris.

“I would like to take this opportunity to thank the IBTS for their work over the past 6 months, which, today, sees these recommendations brought to fruition within the timescale agreed. [T]he IBTS will continue to keep all deferral policies under active review in the light of scientific evidence, emerging infections, and international experience.”

MSM deferral

The change in deferral policy relating to MSMs follows a 2-year review of the issues by the IBTS.

The agency hosted an international symposium on the topic in April 2016. Experts from 7 countries who had either lifted, or were in the process of lifting, their lifetime ban on MSM blood donors presented their respective stances, research, and the rationale behind their decisions.

The IBTS said its change to a 1-year deferral period for MSMs is supported by the most current scientific evidence available and brings Ireland into line with similar policies in the UK, Canada, and the US.

STI-related deferral

The IBTS said the 1-year deferral policy for MSMs will protect against the risk of HIV transmission. However, there is concern that it may not be sufficient to deal with an emerging infection. 

Therefore, the board of the IBTS decided that individuals who have had a notifiable STI, such as chlamydia or genital herpes, should be deferred from donating blood for 5 years after completing treatment for that STI.  

Individuals who have had syphilis, gonorrhea, lymphogranuloma venereum, or granuloma inguinale are (and have been) permanently banned from donating blood.

Individuals who have taken medication to prevent HIV infection are also deferred from donating blood for 5 years after they take the medication.

Safety of the blood supply

“The IBTS provides a safe, reliable, and robust blood service to the Irish health system and has the necessary program and procedures in place to protect both donors and recipients of blood and blood products,” Harris said.

All prospective blood donors in Ireland undergo nucleic acid testing for a number of diseases, including HIV, hepatitis B, and hepatitis C. This is the most sensitive method of testing available.

The risk of transmitted infection of blood is at its highest when individuals donate blood during the 5- to 15-day period following exposure to a virus.

There is no biological measure to detect infectivity during this period and, as a consequence, the IBTS temporarily or permanently defers, on average, 1 in 10 people from giving blood.

Blood donor
Photo by Marja Helander

The Irish Blood Transfusion Service (IBTS) has lifted the lifetime ban on blood donations from men who have sex with men (MSM).

However, prospective MSM blood donors are still subject to deferral.

Now, MSMs are allowed to donate blood in Ireland if it has been more than 12 months since their last sexual contact with a man and if they meet the other blood donor selection criteria.

The IBTS has also introduced new regulations relating to individuals with a history of specific, notifiable sexually transmitted infections (STIs).

These individuals are now allowed to donate blood 5 years after they have completed treatment for their STIs.

“In June of last year, I accepted the recommendations of the IBTS to change their blood donation deferral policies for men who have sex with men, as well as for donors who have had a sexually transmitted infection,” said Ireland’s Health Minister, Simon Harris.

“I would like to take this opportunity to thank the IBTS for their work over the past 6 months, which, today, sees these recommendations brought to fruition within the timescale agreed. [T]he IBTS will continue to keep all deferral policies under active review in the light of scientific evidence, emerging infections, and international experience.”

MSM deferral

The change in deferral policy relating to MSMs follows a 2-year review of the issues by the IBTS.

The agency hosted an international symposium on the topic in April 2016. Experts from 7 countries who had either lifted, or were in the process of lifting, their lifetime ban on MSM blood donors presented their respective stances, research, and the rationale behind their decisions.

The IBTS said its change to a 1-year deferral period for MSMs is supported by the most current scientific evidence available and brings Ireland into line with similar policies in the UK, Canada, and the US.

STI-related deferral

The IBTS said the 1-year deferral policy for MSMs will protect against the risk of HIV transmission. However, there is concern that it may not be sufficient to deal with an emerging infection. 

Therefore, the board of the IBTS decided that individuals who have had a notifiable STI, such as chlamydia or genital herpes, should be deferred from donating blood for 5 years after completing treatment for that STI.  

Individuals who have had syphilis, gonorrhea, lymphogranuloma venereum, or granuloma inguinale are (and have been) permanently banned from donating blood.

Individuals who have taken medication to prevent HIV infection are also deferred from donating blood for 5 years after they take the medication.

Safety of the blood supply

“The IBTS provides a safe, reliable, and robust blood service to the Irish health system and has the necessary program and procedures in place to protect both donors and recipients of blood and blood products,” Harris said.

All prospective blood donors in Ireland undergo nucleic acid testing for a number of diseases, including HIV, hepatitis B, and hepatitis C. This is the most sensitive method of testing available.

The risk of transmitted infection of blood is at its highest when individuals donate blood during the 5- to 15-day period following exposure to a virus.

There is no biological measure to detect infectivity during this period and, as a consequence, the IBTS temporarily or permanently defers, on average, 1 in 10 people from giving blood.

Umbilical cord clamping
Photo by Meutia Chaerani
and Indradi Soemardjan

Delaying umbilical cord clamping by a few minutes can reduce the risk of anemia several months after birth, according to research published in JAMA Pediatrics.

A randomized clinical trial showed that delaying cord clamping by 3 minutes or more after birth—rather than clamping within 1 minute of birth—reduced the prevalence of anemia, iron deficiency, and iron deficiency anemia in infants at 8 months and 12 months of age.

Ola Andersson, MD, PhD, of Uppsala University in Uppsala, Sweden, and his colleagues conducted this research in Nepal, a country with a high prevalence of anemia.

The study included 540 infants—281 boys and 259 girls—with a mean gestational age of 39.2 weeks. Half of the subjects were randomized to delayed cord clamping (3 minutes or more after birth) or early cord clamping (within 1 minute of birth).

At 8 months of age, 78.5% of infants from the delayed clamping group and 69.6% from the early clamping group returned for blood sampling.

Results showed that infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.4 g/dL and 10.2 g/dL, respectively (P=0.008).

Infants in the delayed clamping group also had a lower incidence of:

• Anemia (hemoglobin level <11.0 g/dL)—73.0% and 82.2%, respectively (P=0.01)
• Iron deficiency—22.2% and 38.1%, respectively (P<0.001)
• Iron deficiency anemia—19.3% and 33.3%, respectively (P<0.001).

The relative risk (RR) of anemia was 0.89, the RR of iron deficiency was 0.58, and the RR of iron deficiency anemia was 0.58.

Results were similar when the infants reached 12 months of age, although all the between-group differences were not statistically significant.

Again, infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.3 g/dL and 10.1 g/dL, respectively (P=0.02).

And infants in the delayed clamping group had a lower incidence of:

• Anemia—77.8% and 85.9%, respectively (P=0.02)
• Iron deficiency—35.6% and 43%, respectively (P=0.09)
• Iron deficiency anemia—30.4% and 37.8%, respectively (P=0.08).

The RR of anemia was 0.91, the RR of iron deficiency was 0.83, and the RR of iron deficiency anemia was 0.80.

The researchers said this study shows that delayed cord clamping was an effective intervention to reduce anemia in a high-risk population, with minimal cost and without apparent adverse effects.

The team believes that, if this intervention were implemented on a global scale, this could translate to 5 million fewer infants with anemia at 8 months of age.

Umbilical cord clamping
Photo by Meutia Chaerani
and Indradi Soemardjan

Delaying umbilical cord clamping by a few minutes can reduce the risk of anemia several months after birth, according to research published in JAMA Pediatrics.

A randomized clinical trial showed that delaying cord clamping by 3 minutes or more after birth—rather than clamping within 1 minute of birth—reduced the prevalence of anemia, iron deficiency, and iron deficiency anemia in infants at 8 months and 12 months of age.

Ola Andersson, MD, PhD, of Uppsala University in Uppsala, Sweden, and his colleagues conducted this research in Nepal, a country with a high prevalence of anemia.

The study included 540 infants—281 boys and 259 girls—with a mean gestational age of 39.2 weeks. Half of the subjects were randomized to delayed cord clamping (3 minutes or more after birth) or early cord clamping (within 1 minute of birth).

At 8 months of age, 78.5% of infants from the delayed clamping group and 69.6% from the early clamping group returned for blood sampling.

Results showed that infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.4 g/dL and 10.2 g/dL, respectively (P=0.008).

Infants in the delayed clamping group also had a lower incidence of:

• Anemia (hemoglobin level <11.0 g/dL)—73.0% and 82.2%, respectively (P=0.01)
• Iron deficiency—22.2% and 38.1%, respectively (P<0.001)
• Iron deficiency anemia—19.3% and 33.3%, respectively (P<0.001).

The relative risk (RR) of anemia was 0.89, the RR of iron deficiency was 0.58, and the RR of iron deficiency anemia was 0.58.

Results were similar when the infants reached 12 months of age, although all the between-group differences were not statistically significant.

Again, infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.3 g/dL and 10.1 g/dL, respectively (P=0.02).

And infants in the delayed clamping group had a lower incidence of:

• Anemia—77.8% and 85.9%, respectively (P=0.02)
• Iron deficiency—35.6% and 43%, respectively (P=0.09)
• Iron deficiency anemia—30.4% and 37.8%, respectively (P=0.08).

The RR of anemia was 0.91, the RR of iron deficiency was 0.83, and the RR of iron deficiency anemia was 0.80.

The researchers said this study shows that delayed cord clamping was an effective intervention to reduce anemia in a high-risk population, with minimal cost and without apparent adverse effects.

The team believes that, if this intervention were implemented on a global scale, this could translate to 5 million fewer infants with anemia at 8 months of age.

Umbilical cord clamping
Photo by Meutia Chaerani
and Indradi Soemardjan

Delaying umbilical cord clamping by a few minutes can reduce the risk of anemia several months after birth, according to research published in JAMA Pediatrics.

A randomized clinical trial showed that delaying cord clamping by 3 minutes or more after birth—rather than clamping within 1 minute of birth—reduced the prevalence of anemia, iron deficiency, and iron deficiency anemia in infants at 8 months and 12 months of age.

Ola Andersson, MD, PhD, of Uppsala University in Uppsala, Sweden, and his colleagues conducted this research in Nepal, a country with a high prevalence of anemia.

The study included 540 infants—281 boys and 259 girls—with a mean gestational age of 39.2 weeks. Half of the subjects were randomized to delayed cord clamping (3 minutes or more after birth) or early cord clamping (within 1 minute of birth).

At 8 months of age, 78.5% of infants from the delayed clamping group and 69.6% from the early clamping group returned for blood sampling.

Results showed that infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.4 g/dL and 10.2 g/dL, respectively (P=0.008).

Infants in the delayed clamping group also had a lower incidence of:

• Anemia (hemoglobin level <11.0 g/dL)—73.0% and 82.2%, respectively (P=0.01)
• Iron deficiency—22.2% and 38.1%, respectively (P<0.001)
• Iron deficiency anemia—19.3% and 33.3%, respectively (P<0.001).

The relative risk (RR) of anemia was 0.89, the RR of iron deficiency was 0.58, and the RR of iron deficiency anemia was 0.58.

Results were similar when the infants reached 12 months of age, although all the between-group differences were not statistically significant.

Again, infants in the delayed clamping group had higher levels of hemoglobin than infants in the early clamping group—10.3 g/dL and 10.1 g/dL, respectively (P=0.02).

And infants in the delayed clamping group had a lower incidence of:

• Anemia—77.8% and 85.9%, respectively (P=0.02)
• Iron deficiency—35.6% and 43%, respectively (P=0.09)
• Iron deficiency anemia—30.4% and 37.8%, respectively (P=0.08).

The RR of anemia was 0.91, the RR of iron deficiency was 0.83, and the RR of iron deficiency anemia was 0.80.

The researchers said this study shows that delayed cord clamping was an effective intervention to reduce anemia in a high-risk population, with minimal cost and without apparent adverse effects.

The team believes that, if this intervention were implemented on a global scale, this could translate to 5 million fewer infants with anemia at 8 months of age.

Micrograph showing
multiple myeloma

Preclinical research published in Oncotarget has provided new insights regarding how the protein EZH2 affects the development of multiple myeloma (MM) and reinforces the idea that EZH2 inhibition may be a way to treat MM.

Previous research by the same group suggested that EZH2 is a potential therapeutic target in MM.

With the current study, the group further investigated the anti-myeloma mechanisms mediated by EZH2 inhibition.

They found that targeting EZH2 with an agent known as UNC1999 reduces the expression of 4 MM-associated oncogenes—IRF-4, XBP-1, PRDM1/BLIMP-1, and c-MYC.

“The role of oncogenes in the development of cancer is to potentiate the survival of the cancer cell, which, instead of undergoing cell death, as is usually the case when the cell is not functioning properly, continues to divide and proliferate,” said study author Helena Jernberg-Wiklund, PhD, of Uppsala University in Uppsala, Sweden.

“In our study, we identified 4 oncogenes that showed lower activity in cells treated with the EZH2 inhibitor as compared to control-treated cells. All 4 genes have previously been shown to be associated with the development of multiple myeloma. This confirms our previous findings that inhibition of EZH2 could be used as a means to treat multiple myeloma.”

However, the researchers were puzzled by the fact that inhibition of EZH2 could decrease the activity of the oncogenes.

The chemical histone modification performed by EZH2 leads to decreased activity of affected genes. Therefore, inhibition of EZH2 should result in a reduced level of chemical modifications, which, in turn, should result in increased gene activity.

“The answer is that there are other genetic factors involved, called microRNAs,” Dr Jernberg-Wiklund said. “In the cells treated with the EZH2 inhibitor, we found 2 microRNA genes with increased activity, and we believe that the oncogenes are regulated by these microRNAs.”

“What happens then is that, when EZH2 is inhibited, there is a reduced histone modification at the microRNA genes. This leads to an increased synthesis of the microRNAs, which, in turn, decreases the activity of the oncogenes. This is a completely new mechanism for EZH2 action.”

The microRNAs the researchers identified are miR-125a-3p and miR-320c. The team found that miR-125a-3p and miR-320c were targets of EZH2 and H3K27me3 in MM cell lines and primary cells.

The researchers said these results support their previous work suggesting EZH2 could be a therapeutic target in MM.

Micrograph showing
multiple myeloma

Preclinical research published in Oncotarget has provided new insights regarding how the protein EZH2 affects the development of multiple myeloma (MM) and reinforces the idea that EZH2 inhibition may be a way to treat MM.

Previous research by the same group suggested that EZH2 is a potential therapeutic target in MM.

With the current study, the group further investigated the anti-myeloma mechanisms mediated by EZH2 inhibition.

They found that targeting EZH2 with an agent known as UNC1999 reduces the expression of 4 MM-associated oncogenes—IRF-4, XBP-1, PRDM1/BLIMP-1, and c-MYC.

“The role of oncogenes in the development of cancer is to potentiate the survival of the cancer cell, which, instead of undergoing cell death, as is usually the case when the cell is not functioning properly, continues to divide and proliferate,” said study author Helena Jernberg-Wiklund, PhD, of Uppsala University in Uppsala, Sweden.

“In our study, we identified 4 oncogenes that showed lower activity in cells treated with the EZH2 inhibitor as compared to control-treated cells. All 4 genes have previously been shown to be associated with the development of multiple myeloma. This confirms our previous findings that inhibition of EZH2 could be used as a means to treat multiple myeloma.”

However, the researchers were puzzled by the fact that inhibition of EZH2 could decrease the activity of the oncogenes.

The chemical histone modification performed by EZH2 leads to decreased activity of affected genes. Therefore, inhibition of EZH2 should result in a reduced level of chemical modifications, which, in turn, should result in increased gene activity.

“The answer is that there are other genetic factors involved, called microRNAs,” Dr Jernberg-Wiklund said. “In the cells treated with the EZH2 inhibitor, we found 2 microRNA genes with increased activity, and we believe that the oncogenes are regulated by these microRNAs.”

“What happens then is that, when EZH2 is inhibited, there is a reduced histone modification at the microRNA genes. This leads to an increased synthesis of the microRNAs, which, in turn, decreases the activity of the oncogenes. This is a completely new mechanism for EZH2 action.”

The microRNAs the researchers identified are miR-125a-3p and miR-320c. The team found that miR-125a-3p and miR-320c were targets of EZH2 and H3K27me3 in MM cell lines and primary cells.

The researchers said these results support their previous work suggesting EZH2 could be a therapeutic target in MM.

Micrograph showing
multiple myeloma

Preclinical research published in Oncotarget has provided new insights regarding how the protein EZH2 affects the development of multiple myeloma (MM) and reinforces the idea that EZH2 inhibition may be a way to treat MM.

Previous research by the same group suggested that EZH2 is a potential therapeutic target in MM.

With the current study, the group further investigated the anti-myeloma mechanisms mediated by EZH2 inhibition.

They found that targeting EZH2 with an agent known as UNC1999 reduces the expression of 4 MM-associated oncogenes—IRF-4, XBP-1, PRDM1/BLIMP-1, and c-MYC.

“The role of oncogenes in the development of cancer is to potentiate the survival of the cancer cell, which, instead of undergoing cell death, as is usually the case when the cell is not functioning properly, continues to divide and proliferate,” said study author Helena Jernberg-Wiklund, PhD, of Uppsala University in Uppsala, Sweden.

“In our study, we identified 4 oncogenes that showed lower activity in cells treated with the EZH2 inhibitor as compared to control-treated cells. All 4 genes have previously been shown to be associated with the development of multiple myeloma. This confirms our previous findings that inhibition of EZH2 could be used as a means to treat multiple myeloma.”

However, the researchers were puzzled by the fact that inhibition of EZH2 could decrease the activity of the oncogenes.

The chemical histone modification performed by EZH2 leads to decreased activity of affected genes. Therefore, inhibition of EZH2 should result in a reduced level of chemical modifications, which, in turn, should result in increased gene activity.

“The answer is that there are other genetic factors involved, called microRNAs,” Dr Jernberg-Wiklund said. “In the cells treated with the EZH2 inhibitor, we found 2 microRNA genes with increased activity, and we believe that the oncogenes are regulated by these microRNAs.”

“What happens then is that, when EZH2 is inhibited, there is a reduced histone modification at the microRNA genes. This leads to an increased synthesis of the microRNAs, which, in turn, decreases the activity of the oncogenes. This is a completely new mechanism for EZH2 action.”

The microRNAs the researchers identified are miR-125a-3p and miR-320c. The team found that miR-125a-3p and miR-320c were targets of EZH2 and H3K27me3 in MM cell lines and primary cells.

The researchers said these results support their previous work suggesting EZH2 could be a therapeutic target in MM.

Cows in Karnataka, India
Photo by Ilya Mauter

The goal of eliminating malaria in countries like India could be more achievable if mosquito-control efforts take into account the relationship between mosquitoes and cattle, according to an international team of researchers.

The group analyzed 2 mosquito

species found in Odisha, the state with the highest number of malaria cases in

India, and found that both species fed on cattle as well as humans.

“In many parts of the world, the mosquitoes responsible for transmitting malaria are specialist feeders on humans and often rest within human houses,” said Matthew Thomas, PhD, of Pennsylvania State University in University Park, Pennsylvania.

“We found that, in an area of India that has a high burden of malaria, most of the mosquitoes that are known to transmit malaria rest in cattle sheds and feed on both cows and humans.”

Dr Thomas and his colleagues reported these findings in Scientific Reports.

According to the researchers, cattle sheds in India are often next to, and sometimes even share a wall with, human houses. However, current malaria control efforts are restricted to domestic dwellings only.

“Given this cattle-shed ‘refuge’ for mosquitoes, focusing only on humans with regard to malaria control is a bit like treating the tip of an iceberg,” said study author Jessica Waite, PhD, also of Pennsylvania State University.

She, Dr Thomas, and their colleagues determined the importance of cows in the malaria-control problem by capturing adult mosquitoes in different habitats within 6 villages in Odisha state—which has the highest number of malaria cases in the country—and noting where the mosquitoes had been resting.

The team then used molecular techniques to determine which species of mosquitoes had been captured and which hosts they had been feeding on.

The researchers collected 1774 Anopheles culicifacies mosquitoes and 169 Anopheles fluviatilis mosquitoes across all study sites.

Both species were denser in cattle sheds than in human dwellings, and both were feeding on humans as well as cattle.

Next, the researchers used their field-collected data to help build a computer model that simulated the life of an adult mosquito. The team used the model to explore how best to control the mosquitoes to have maximum impact on malaria transmission in these villages.

“Our model analysis suggests that conventional control tools—such as insecticide-treated bed nets and indoor insecticide sprays—are less effective when mosquitoes exhibit ‘zoophilic’ behaviors (having an attraction to nonhuman animals),” Dr Thomas said.

“However, extending controls to better target the zoophilic mosquitoes—for example, by broadening coverage of non-repellant insecticide sprays to include cattle sheds—could help reduce transmission dramatically.”

Dr Waite added that the model suggests very little cattle-based vector control effort would be required to drive malaria transmission in the region to elimination.

“We show that directing even modest amounts of effort to specifically increase mosquito mortality associated with zoophilic behavior can shift the balance towards elimination,” she said.

“Understanding the dynamic between humans, cattle, and mosquitoes could have major implications for malaria control policy and practice, not only in India, but in other areas where transmission is sustained by zoophilic vectors,” Dr Thomas said.

“Specifically, optimizing use of existing tools will be essential to achieving the ambitious 2030 elimination target set by the World Health Organization, which aims to decrease malaria cases globally by 90% compared to 2015 levels and eliminate malaria in at least 35 additional countries by 2030.”

Cows in Karnataka, India
Photo by Ilya Mauter

The goal of eliminating malaria in countries like India could be more achievable if mosquito-control efforts take into account the relationship between mosquitoes and cattle, according to an international team of researchers.

The group analyzed 2 mosquito

species found in Odisha, the state with the highest number of malaria cases in

India, and found that both species fed on cattle as well as humans.

“In many parts of the world, the mosquitoes responsible for transmitting malaria are specialist feeders on humans and often rest within human houses,” said Matthew Thomas, PhD, of Pennsylvania State University in University Park, Pennsylvania.

“We found that, in an area of India that has a high burden of malaria, most of the mosquitoes that are known to transmit malaria rest in cattle sheds and feed on both cows and humans.”

Dr Thomas and his colleagues reported these findings in Scientific Reports.

According to the researchers, cattle sheds in India are often next to, and sometimes even share a wall with, human houses. However, current malaria control efforts are restricted to domestic dwellings only.

“Given this cattle-shed ‘refuge’ for mosquitoes, focusing only on humans with regard to malaria control is a bit like treating the tip of an iceberg,” said study author Jessica Waite, PhD, also of Pennsylvania State University.

She, Dr Thomas, and their colleagues determined the importance of cows in the malaria-control problem by capturing adult mosquitoes in different habitats within 6 villages in Odisha state—which has the highest number of malaria cases in the country—and noting where the mosquitoes had been resting.

The team then used molecular techniques to determine which species of mosquitoes had been captured and which hosts they had been feeding on.

The researchers collected 1774 Anopheles culicifacies mosquitoes and 169 Anopheles fluviatilis mosquitoes across all study sites.

Both species were denser in cattle sheds than in human dwellings, and both were feeding on humans as well as cattle.

Next, the researchers used their field-collected data to help build a computer model that simulated the life of an adult mosquito. The team used the model to explore how best to control the mosquitoes to have maximum impact on malaria transmission in these villages.

“Our model analysis suggests that conventional control tools—such as insecticide-treated bed nets and indoor insecticide sprays—are less effective when mosquitoes exhibit ‘zoophilic’ behaviors (having an attraction to nonhuman animals),” Dr Thomas said.

“However, extending controls to better target the zoophilic mosquitoes—for example, by broadening coverage of non-repellant insecticide sprays to include cattle sheds—could help reduce transmission dramatically.”

Dr Waite added that the model suggests very little cattle-based vector control effort would be required to drive malaria transmission in the region to elimination.

“We show that directing even modest amounts of effort to specifically increase mosquito mortality associated with zoophilic behavior can shift the balance towards elimination,” she said.

“Understanding the dynamic between humans, cattle, and mosquitoes could have major implications for malaria control policy and practice, not only in India, but in other areas where transmission is sustained by zoophilic vectors,” Dr Thomas said.

“Specifically, optimizing use of existing tools will be essential to achieving the ambitious 2030 elimination target set by the World Health Organization, which aims to decrease malaria cases globally by 90% compared to 2015 levels and eliminate malaria in at least 35 additional countries by 2030.”

Cows in Karnataka, India
Photo by Ilya Mauter

The goal of eliminating malaria in countries like India could be more achievable if mosquito-control efforts take into account the relationship between mosquitoes and cattle, according to an international team of researchers.

The group analyzed 2 mosquito

species found in Odisha, the state with the highest number of malaria cases in

India, and found that both species fed on cattle as well as humans.

“In many parts of the world, the mosquitoes responsible for transmitting malaria are specialist feeders on humans and often rest within human houses,” said Matthew Thomas, PhD, of Pennsylvania State University in University Park, Pennsylvania.

“We found that, in an area of India that has a high burden of malaria, most of the mosquitoes that are known to transmit malaria rest in cattle sheds and feed on both cows and humans.”

Dr Thomas and his colleagues reported these findings in Scientific Reports.

According to the researchers, cattle sheds in India are often next to, and sometimes even share a wall with, human houses. However, current malaria control efforts are restricted to domestic dwellings only.

“Given this cattle-shed ‘refuge’ for mosquitoes, focusing only on humans with regard to malaria control is a bit like treating the tip of an iceberg,” said study author Jessica Waite, PhD, also of Pennsylvania State University.

She, Dr Thomas, and their colleagues determined the importance of cows in the malaria-control problem by capturing adult mosquitoes in different habitats within 6 villages in Odisha state—which has the highest number of malaria cases in the country—and noting where the mosquitoes had been resting.

The team then used molecular techniques to determine which species of mosquitoes had been captured and which hosts they had been feeding on.

The researchers collected 1774 Anopheles culicifacies mosquitoes and 169 Anopheles fluviatilis mosquitoes across all study sites.

Both species were denser in cattle sheds than in human dwellings, and both were feeding on humans as well as cattle.

Next, the researchers used their field-collected data to help build a computer model that simulated the life of an adult mosquito. The team used the model to explore how best to control the mosquitoes to have maximum impact on malaria transmission in these villages.

“Our model analysis suggests that conventional control tools—such as insecticide-treated bed nets and indoor insecticide sprays—are less effective when mosquitoes exhibit ‘zoophilic’ behaviors (having an attraction to nonhuman animals),” Dr Thomas said.

“However, extending controls to better target the zoophilic mosquitoes—for example, by broadening coverage of non-repellant insecticide sprays to include cattle sheds—could help reduce transmission dramatically.”

Dr Waite added that the model suggests very little cattle-based vector control effort would be required to drive malaria transmission in the region to elimination.

“We show that directing even modest amounts of effort to specifically increase mosquito mortality associated with zoophilic behavior can shift the balance towards elimination,” she said.

“Understanding the dynamic between humans, cattle, and mosquitoes could have major implications for malaria control policy and practice, not only in India, but in other areas where transmission is sustained by zoophilic vectors,” Dr Thomas said.

“Specifically, optimizing use of existing tools will be essential to achieving the ambitious 2030 elimination target set by the World Health Organization, which aims to decrease malaria cases globally by 90% compared to 2015 levels and eliminate malaria in at least 35 additional countries by 2030.”

People in the military are somewhat nomadic by necessity: They move around a lot, and their medical records should be just as mobile, says Army Brig. Gen. John Cho, deputy chief of staff for support for the Army’s Medical Command, in an article for Health.mil. Cho is the functional champion on development of MHS Genesis, the new electronic health record that is replacing less agile DoD legacy systems.

Related: IHS Pilots Improved Version of Health Records

Developed with input from more than 850 experts in the field around the world, MHS Genesis is intended to fix shortcomings in the current system. It will integrate medical and dental records throughout the continuum of care, from point of injury to the military treatment facility where the care is provided.

Benefits include the ability to monitor a beneficiary’s health status through health data, tracking, and alerting capabilities; improved ability to monitor patient safety, outcomes, and operational and medical readiness; improved access to integrated, evidence-based health care delivery and decision-making; and increased sharing of health information across the spectrum of military operations, the VA, and civilian health care organizations.

Related: How Safe Are Patients’ Electronic Records?

MHS Genesis will support the availability of electronic health records for > 9.4 million DoD beneficiaries and approximately 205,000 MHS personnel globally. The new system is currently being tested, with rollout in the Pacific Northwest scheduled for early 2017. The system expected to be ready throughout the MHS in 5 years.

People in the military are somewhat nomadic by necessity: They move around a lot, and their medical records should be just as mobile, says Army Brig. Gen. John Cho, deputy chief of staff for support for the Army’s Medical Command, in an article for Health.mil. Cho is the functional champion on development of MHS Genesis, the new electronic health record that is replacing less agile DoD legacy systems.

Related: IHS Pilots Improved Version of Health Records

Developed with input from more than 850 experts in the field around the world, MHS Genesis is intended to fix shortcomings in the current system. It will integrate medical and dental records throughout the continuum of care, from point of injury to the military treatment facility where the care is provided.

Benefits include the ability to monitor a beneficiary’s health status through health data, tracking, and alerting capabilities; improved ability to monitor patient safety, outcomes, and operational and medical readiness; improved access to integrated, evidence-based health care delivery and decision-making; and increased sharing of health information across the spectrum of military operations, the VA, and civilian health care organizations.

Related: How Safe Are Patients’ Electronic Records?

MHS Genesis will support the availability of electronic health records for > 9.4 million DoD beneficiaries and approximately 205,000 MHS personnel globally. The new system is currently being tested, with rollout in the Pacific Northwest scheduled for early 2017. The system expected to be ready throughout the MHS in 5 years.

People in the military are somewhat nomadic by necessity: They move around a lot, and their medical records should be just as mobile, says Army Brig. Gen. John Cho, deputy chief of staff for support for the Army’s Medical Command, in an article for Health.mil. Cho is the functional champion on development of MHS Genesis, the new electronic health record that is replacing less agile DoD legacy systems.

Related: IHS Pilots Improved Version of Health Records

Developed with input from more than 850 experts in the field around the world, MHS Genesis is intended to fix shortcomings in the current system. It will integrate medical and dental records throughout the continuum of care, from point of injury to the military treatment facility where the care is provided.

Benefits include the ability to monitor a beneficiary’s health status through health data, tracking, and alerting capabilities; improved ability to monitor patient safety, outcomes, and operational and medical readiness; improved access to integrated, evidence-based health care delivery and decision-making; and increased sharing of health information across the spectrum of military operations, the VA, and civilian health care organizations.

Related: How Safe Are Patients’ Electronic Records?

MHS Genesis will support the availability of electronic health records for > 9.4 million DoD beneficiaries and approximately 205,000 MHS personnel globally. The new system is currently being tested, with rollout in the Pacific Northwest scheduled for early 2017. The system expected to be ready throughout the MHS in 5 years.

Clinical question: Does therapeutic anticoagulation of isolated calf deep vein thrombosis (DVT) decrease risk for proximal DVT or PE?

Background: Optimal management of isolated calf DVT lacks consensus.

Study design: Single-center, retrospective, cohort study.

Setting: Large academic hospital.

Nevertheless, 9.2% of control patients and 3.3% of exposure patients developed a proximal DVT or PE. The anticoagulation group was associated with lower likelihood of proximal DVT or PE (risk ratio 0.36; 95% CI, 0.15-0.84) but an increased risk of bleeding (8.6%), compared with the nonexposure group (2.2%). Sensitivity analysis did not alter the observed association.

Bottom line: Therapeutic anticoagulation for isolated calf DVT may be warranted to decrease the risk for proximal DVT or PE but with an increased risk of bleeding. Randomized trials are needed to clarify the risk versus benefit.

Citation: Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. doi: 10.1001/jamasurg.2016.1770.


Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does therapeutic anticoagulation of isolated calf deep vein thrombosis (DVT) decrease risk for proximal DVT or PE?

Background: Optimal management of isolated calf DVT lacks consensus.

Study design: Single-center, retrospective, cohort study.

Setting: Large academic hospital.

Nevertheless, 9.2% of control patients and 3.3% of exposure patients developed a proximal DVT or PE. The anticoagulation group was associated with lower likelihood of proximal DVT or PE (risk ratio 0.36; 95% CI, 0.15-0.84) but an increased risk of bleeding (8.6%), compared with the nonexposure group (2.2%). Sensitivity analysis did not alter the observed association.

Bottom line: Therapeutic anticoagulation for isolated calf DVT may be warranted to decrease the risk for proximal DVT or PE but with an increased risk of bleeding. Randomized trials are needed to clarify the risk versus benefit.

Citation: Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. doi: 10.1001/jamasurg.2016.1770.


Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Clinical question: Does therapeutic anticoagulation of isolated calf deep vein thrombosis (DVT) decrease risk for proximal DVT or PE?

Background: Optimal management of isolated calf DVT lacks consensus.

Study design: Single-center, retrospective, cohort study.

Setting: Large academic hospital.

Nevertheless, 9.2% of control patients and 3.3% of exposure patients developed a proximal DVT or PE. The anticoagulation group was associated with lower likelihood of proximal DVT or PE (risk ratio 0.36; 95% CI, 0.15-0.84) but an increased risk of bleeding (8.6%), compared with the nonexposure group (2.2%). Sensitivity analysis did not alter the observed association.

Bottom line: Therapeutic anticoagulation for isolated calf DVT may be warranted to decrease the risk for proximal DVT or PE but with an increased risk of bleeding. Randomized trials are needed to clarify the risk versus benefit.

Citation: Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. doi: 10.1001/jamasurg.2016.1770.


Dr. Zuleta is an assistant professor and associate program director of the Jackson Memorial/University of Miami Internal Medicine residency training program and the site director of the program at University of Miami Hospital.

Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving.  The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.

Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).

Courtesy Mayo Clinic

A new paradigm of burnout

The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.

Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.

“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.

Unintended consequences of the individual solution

The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.

The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”

Organizational strategies to reduce burnout

Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.

1. Naming the issue and assessing the problem

Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.

2. Harnessing the power of leadership

Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.

3. Developing targeted interventions

Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.

Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
 

4. Cultivating community at work

Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.

5. Rethinking rewards and incentives

Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.

6. Aligning values and strengthening culture

The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.

7. Promoting flexibility and work-life integration

Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”

8. Providing resources to promote resilience and self-care

The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”

9. Funding organizational research

Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.

Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”
 

[email protected]

Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving.  The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.

Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).

Courtesy Mayo Clinic

A new paradigm of burnout

The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.

Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.

“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.

Unintended consequences of the individual solution

The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.

The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”

Organizational strategies to reduce burnout

Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.

1. Naming the issue and assessing the problem

Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.

2. Harnessing the power of leadership

Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.

3. Developing targeted interventions

Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.

Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
 

4. Cultivating community at work

Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.

5. Rethinking rewards and incentives

Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.

6. Aligning values and strengthening culture

The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.

7. Promoting flexibility and work-life integration

Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”

8. Providing resources to promote resilience and self-care

The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”

9. Funding organizational research

Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.

Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”
 

[email protected]

Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving.  The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.

Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).

Courtesy Mayo Clinic

A new paradigm of burnout

The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.

Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.

“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.

Unintended consequences of the individual solution

The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.

The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”

Organizational strategies to reduce burnout

Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.

1. Naming the issue and assessing the problem

Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.

2. Harnessing the power of leadership

Studies have found that management behaviors and strategies of supervisors are key components of physician well-being. The bottom line is that physician supervisors must accept a share of responsibility for burnout in those they manage. Leaders can be chosen on the basis of their ability to listen, engage, develop, and lead, and but they can also be trained to improve. In addition, leaders should be regularly assessed by those whom they lead. Dr. Shanafelt and Dr. Noseworthy argue that a crucial element of successful leadership involves recognizing unique interests and talents of individual physicians whom they manage and facilitating professional development so that each staff member spends about 20% of work time engaged in activities that he or she finds most meaningful.

3. Developing targeted interventions

Just as all politics is local, the study suggests that many sources of burnout are local as well. For example, although a high clerical burden on physicians may be a universal driver of burnout, it manifests differently in each institutional setting. The key here is to dig into the specific structural driver at the unit or ward level, engage physicians in analysis and problem-solving, and implement a plan to address the problem.

Dr. Shanafelt noted, “We organize the drivers of engagement and burnout around seven dimensions: workload, efficiency, flexibility/control, community at work, organizational culture and values, work-life integration, and meaning in work. Each of these dimensions has organizational and individual components. Work units should begin by identifying which one or two dimensions are the biggest challenges for the group and then begin a stepwise process to address them.”
 

4. Cultivating community at work

Peer support, a long-standing source of strength among surgeons and other physicians, unintentionally has been eroded in many modern medical institutions. There is ample evidence that this loss of collegiality is tied to burnout. “These interactions have been an unintended casualty of increasing productivity expectations, documentation requirements, and clerical burden. [Many organizations have eliminated] formal spaces for physicians to interact (e.g., physicians’ lounge or dining room) without recognizing the important role that this dedicated space played in fostering interpersonal connections among physicians.” The Mayo Clinic and other institutions are reversing this trend by creating dedicated physician rooms for breaks, snacks, and a venue for peer interaction and camaraderie.

5. Rethinking rewards and incentives

Compensation is now commonly linked to productivity in many health care organizations, but this approach has some profound drawbacks: It can lead to physician burnout. Incentive structures based on patient satisfaction and quality metrics can have similar unintended consequences. All these incentive structures can combine to drive physicians to overwork. “Physicians may be particularly vulnerable to overwork due to high levels of education debt, their desire to ‘do everything for their patients,’ unhealthy role modeling by colleagues, and normalization of extreme work hours during the training process.” The investigators do not claim to have the ultimate answer to the problem of incentives that create unhealthy work patterns, but they argue that it is critical for leaders to recognize the potential unintended consequences of the productivity reward/incentive model and consider strategies to prevent overwork leading to burnout.

6. Aligning values and strengthening culture

The investigators also describe Mayo’s efforts to pursue self-appraisal of alignment of mission, values, and culture. They also describe the regular use of an all-staff survey, which has on occasion yielded candid feedback that, while not always flattering, has been the basis of a profound institutional rethink. The willingness of leadership to be receptive to hard truths from physicians is the foundation of institutional learning about burnout prevention and encourages engagement of the staff.

7. Promoting flexibility and work-life integration

Allowing employees greater flexibility in how and when they work is a management strategy that is gaining ground in many industries. Increasing part-time positions and expanding options for the work day have both been found to help prevent burnout and also help physicians recover from burnout. In addition, “institutions should also comprehensively examine the structure of their vacation benefits, coverage for life events (e.g., birth of a child, illness/death in family), approach to scheduling, and strategy for coverage of nights and weekends. Compensation practices that disincentivize using vacation time are shortsighted and should be eliminated.”

8. Providing resources to promote resilience and self-care

The solutions to burnout have been aimed at the individual and involve stress-reduction training and other personal management strategies. A metastudy of the interventions mentions psychoeducation, counseling, wellness management, interpersonal communication, and mindfulness meditation (J Nerv Ment Dis. 2014 May;202:353-9). But without concomitant structural reform, these individual solutions can backfire. “When individually focused offerings are not coupled with sincere efforts to address the system-based issues contributing to burnout, this approach is typically met with skepticism and resistance by physicians (‘They are implying I am the problem’). In this context, the response to well-intentioned ‘resilience training’ is frequently a cynical one (‘You only want to make me more resilient so you can further increase my workload’).”

9. Funding organizational research

Organizational science is a well-developed field of study. But cutting-edge management models such as the learning organization, participatory management, and collaborative action planning have been slow in coming to health care institutions. Dr. Shanafelt and Dr. Noseworthy argue that “vanguard institutions” such as the Mayo Clinic (which began its Program on Physician Well-Being in 2008), Stanford (Calif.) University, and other innovative institutions have the responsibility of developing evidence-based strategies to combat burnout that smaller institutions can implement.

Burnout among physicians is now on the radar of leadership in many health care institutions. Evidence on the cost and consequences is accumulating, and it becoming increasingly difficult to ignore what is happening to many physicians. Dr. Shanafelt projected an increasing need for operational solutions at the organizational level to address the problem. He said, “We need evidence to guide organizations to implement changes that truly make a difference, not well-intentioned but ineffective programs. Now that organizations recognize the strong business case, they are ready to invest resources to address this issue but they need to know it is money well spent and that there is an evidence-base to justify the investment.”
 

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As third-party payers become stingier and stingier with their payments, it becomes more and more important to hold them accountable for decisions that impact patient care – and your revenue. Physicians have the right to a full and fair appeal review of all rejected and underpaid claims; yet surprisingly, less than 5% of denied dermatology claims are appealed, according to one study.

Many practitioners seem to feel that appeals are simply not worth the time and effort, particularly in a high-volume field such as dermatology; but since the chance that appealing will increase your reimbursement is more than 50%, it is usually well worth the effort – particularly in the current climate of steadily decreasing reimbursements. Furthermore, once insurers become aware that you are scrutinizing your payment statements and challenging all unwarranted rejections, they will be less cavalier in denying legitimate claims.

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

As third-party payers become stingier and stingier with their payments, it becomes more and more important to hold them accountable for decisions that impact patient care – and your revenue. Physicians have the right to a full and fair appeal review of all rejected and underpaid claims; yet surprisingly, less than 5% of denied dermatology claims are appealed, according to one study.

Many practitioners seem to feel that appeals are simply not worth the time and effort, particularly in a high-volume field such as dermatology; but since the chance that appealing will increase your reimbursement is more than 50%, it is usually well worth the effort – particularly in the current climate of steadily decreasing reimbursements. Furthermore, once insurers become aware that you are scrutinizing your payment statements and challenging all unwarranted rejections, they will be less cavalier in denying legitimate claims.

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

As third-party payers become stingier and stingier with their payments, it becomes more and more important to hold them accountable for decisions that impact patient care – and your revenue. Physicians have the right to a full and fair appeal review of all rejected and underpaid claims; yet surprisingly, less than 5% of denied dermatology claims are appealed, according to one study.

Many practitioners seem to feel that appeals are simply not worth the time and effort, particularly in a high-volume field such as dermatology; but since the chance that appealing will increase your reimbursement is more than 50%, it is usually well worth the effort – particularly in the current climate of steadily decreasing reimbursements. Furthermore, once insurers become aware that you are scrutinizing your payment statements and challenging all unwarranted rejections, they will be less cavalier in denying legitimate claims.

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

In a global survey, 88% of respondents knew that unprotected sun exposure leads to skin cancer, but less than 60% “always” or “often” applied sunscreen to their faces, arms, and legs, researchers said.

Many respondents also reported ignoring whole categories of sun-protective behaviors – such as wearing long sleeves and seeking shade – and lacked knowledge about individual risk factors for skin cancer, such as skin type and size of moles, Sophie Seite, PhD, and her coauthors reported in the Journal of the European Academy of Dermatology and Venereology. These data suggest “that messaging needs to be specifically targeted for at-risk demographics (especially by age, gender, skin type, and country),” they added.

karenfoleyphotography/Thinkstock

In a global survey, 88% of respondents knew that unprotected sun exposure leads to skin cancer, but less than 60% “always” or “often” applied sunscreen to their faces, arms, and legs, researchers said.

Many respondents also reported ignoring whole categories of sun-protective behaviors – such as wearing long sleeves and seeking shade – and lacked knowledge about individual risk factors for skin cancer, such as skin type and size of moles, Sophie Seite, PhD, and her coauthors reported in the Journal of the European Academy of Dermatology and Venereology. These data suggest “that messaging needs to be specifically targeted for at-risk demographics (especially by age, gender, skin type, and country),” they added.

karenfoleyphotography/Thinkstock

In a global survey, 88% of respondents knew that unprotected sun exposure leads to skin cancer, but less than 60% “always” or “often” applied sunscreen to their faces, arms, and legs, researchers said.

Many respondents also reported ignoring whole categories of sun-protective behaviors – such as wearing long sleeves and seeking shade – and lacked knowledge about individual risk factors for skin cancer, such as skin type and size of moles, Sophie Seite, PhD, and her coauthors reported in the Journal of the European Academy of Dermatology and Venereology. These data suggest “that messaging needs to be specifically targeted for at-risk demographics (especially by age, gender, skin type, and country),” they added.

karenfoleyphotography/Thinkstock