Click here to listen to Dr. Cigarroa

Click here to listen to Dr. Cigarroa

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Click here to listen to Dr. Dressler

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Click here to listen to Dr. Dressler

Critical-care experts point to three types of competency that are crucial for any hospitalist working within an ICU environment. First, hospitalists need a solid knowledge base of the pharmacology, physiology, and pathophysiology of critical illnesses and conditions such as renal failure, respiratory failure, cardiac failure, sepsis, and seizures.

Second, providers need to acquire an array of psychomotor and interpersonal skills. Core skills like endotracheal intubation, chest-tube placement, and arterial and central venous catheterization are essential. But so are broader abilities like bringing people together to work as a team, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta.

“Does that sound familiar? It’s what hospitalists do,” he says. “So the conceptual structure of a high-functioning intensivist team is nearly identical to the conceptual structure of a high-functioning hospitalist team; it’s just located in a smaller area, with a higher acuity patient population.”

Dr. Siegal emphasizes the importance of inpatient procedural skills, which he says are no longer emphasized in internal-medicine training. “The good news is, those skills are definable, are fairly easily taught, and are simply a matter of repetition,” he says.

Finally, hospitalists need to adopt the right attitude about what care is or isn’t possible for critically-ill patients, and how families can be integrated into complex, culturally-sensitive decision-making about difficult topics such as organ donation.

“That’s very different when the patient is unable to speak for him or herself,” Dr. Buchman says. “There’s a list of what I would call attitudinal competencies, which is longer than I think most people understand it to be to be an effective clinician. … Although all of them, to some degree, overlap with experience during residency training, they are often at a complexity level that can only be mastered through additional training.”

Bryn Nelson is a freelance medical writer in Seattle.

Critical-care experts point to three types of competency that are crucial for any hospitalist working within an ICU environment. First, hospitalists need a solid knowledge base of the pharmacology, physiology, and pathophysiology of critical illnesses and conditions such as renal failure, respiratory failure, cardiac failure, sepsis, and seizures.

Second, providers need to acquire an array of psychomotor and interpersonal skills. Core skills like endotracheal intubation, chest-tube placement, and arterial and central venous catheterization are essential. But so are broader abilities like bringing people together to work as a team, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta.

“Does that sound familiar? It’s what hospitalists do,” he says. “So the conceptual structure of a high-functioning intensivist team is nearly identical to the conceptual structure of a high-functioning hospitalist team; it’s just located in a smaller area, with a higher acuity patient population.”

Dr. Siegal emphasizes the importance of inpatient procedural skills, which he says are no longer emphasized in internal-medicine training. “The good news is, those skills are definable, are fairly easily taught, and are simply a matter of repetition,” he says.

Finally, hospitalists need to adopt the right attitude about what care is or isn’t possible for critically-ill patients, and how families can be integrated into complex, culturally-sensitive decision-making about difficult topics such as organ donation.

“That’s very different when the patient is unable to speak for him or herself,” Dr. Buchman says. “There’s a list of what I would call attitudinal competencies, which is longer than I think most people understand it to be to be an effective clinician. … Although all of them, to some degree, overlap with experience during residency training, they are often at a complexity level that can only be mastered through additional training.”

Bryn Nelson is a freelance medical writer in Seattle.

Critical-care experts point to three types of competency that are crucial for any hospitalist working within an ICU environment. First, hospitalists need a solid knowledge base of the pharmacology, physiology, and pathophysiology of critical illnesses and conditions such as renal failure, respiratory failure, cardiac failure, sepsis, and seizures.

Second, providers need to acquire an array of psychomotor and interpersonal skills. Core skills like endotracheal intubation, chest-tube placement, and arterial and central venous catheterization are essential. But so are broader abilities like bringing people together to work as a team, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta.

“Does that sound familiar? It’s what hospitalists do,” he says. “So the conceptual structure of a high-functioning intensivist team is nearly identical to the conceptual structure of a high-functioning hospitalist team; it’s just located in a smaller area, with a higher acuity patient population.”

Dr. Siegal emphasizes the importance of inpatient procedural skills, which he says are no longer emphasized in internal-medicine training. “The good news is, those skills are definable, are fairly easily taught, and are simply a matter of repetition,” he says.

Finally, hospitalists need to adopt the right attitude about what care is or isn’t possible for critically-ill patients, and how families can be integrated into complex, culturally-sensitive decision-making about difficult topics such as organ donation.

“That’s very different when the patient is unable to speak for him or herself,” Dr. Buchman says. “There’s a list of what I would call attitudinal competencies, which is longer than I think most people understand it to be to be an effective clinician. … Although all of them, to some degree, overlap with experience during residency training, they are often at a complexity level that can only be mastered through additional training.”

Bryn Nelson is a freelance medical writer in Seattle.

The new era of penalizing hospitals for higher-than-predicted 30-day avoidable readmissions rates has begun. Under the federal Hospital Readmissions Reduction Program, some calculate a hospital's excessive readmissions rate for each applicable condition.

Penalties for the current fiscal year—FY 2013, which began Oct. 1, 2012—will be based on discharges that occurred during the three-year period from July 1, 2008, to June 30, 2011, according to the program guidelines. For hospitals that don't improve, the penalty grows to a maximum 2% next year (FY14) and 3% in FY15.

Hospitalists are not penalized directly for readmissions, and many hospitalists are wondering about the extent to which they're responsible for a readmission after the patient leaves the hospital, notes Mark Williams, MD, FACP, MHM, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

Dr. Williams is the principal investigator of SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), one of several national quality initiatives that teach hospitals and other healthcare providers how to improve transitions of care through such techniques as patient coaching and community partnerships.

"These new penalties mean that hospitals will start talking to their physicians about readmissions, and looking for methods to incentivize the hospitalists to get involved in preventing them," Dr. Williams says.

The new era of penalizing hospitals for higher-than-predicted 30-day avoidable readmissions rates has begun. Under the federal Hospital Readmissions Reduction Program, some calculate a hospital's excessive readmissions rate for each applicable condition.

Penalties for the current fiscal year—FY 2013, which began Oct. 1, 2012—will be based on discharges that occurred during the three-year period from July 1, 2008, to June 30, 2011, according to the program guidelines. For hospitals that don't improve, the penalty grows to a maximum 2% next year (FY14) and 3% in FY15.

Hospitalists are not penalized directly for readmissions, and many hospitalists are wondering about the extent to which they're responsible for a readmission after the patient leaves the hospital, notes Mark Williams, MD, FACP, MHM, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

Dr. Williams is the principal investigator of SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), one of several national quality initiatives that teach hospitals and other healthcare providers how to improve transitions of care through such techniques as patient coaching and community partnerships.

"These new penalties mean that hospitals will start talking to their physicians about readmissions, and looking for methods to incentivize the hospitalists to get involved in preventing them," Dr. Williams says.

The new era of penalizing hospitals for higher-than-predicted 30-day avoidable readmissions rates has begun. Under the federal Hospital Readmissions Reduction Program, some calculate a hospital's excessive readmissions rate for each applicable condition.

Penalties for the current fiscal year—FY 2013, which began Oct. 1, 2012—will be based on discharges that occurred during the three-year period from July 1, 2008, to June 30, 2011, according to the program guidelines. For hospitals that don't improve, the penalty grows to a maximum 2% next year (FY14) and 3% in FY15.

Hospitalists are not penalized directly for readmissions, and many hospitalists are wondering about the extent to which they're responsible for a readmission after the patient leaves the hospital, notes Mark Williams, MD, FACP, MHM, chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

Dr. Williams is the principal investigator of SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), one of several national quality initiatives that teach hospitals and other healthcare providers how to improve transitions of care through such techniques as patient coaching and community partnerships.

"These new penalties mean that hospitals will start talking to their physicians about readmissions, and looking for methods to incentivize the hospitalists to get involved in preventing them," Dr. Williams says.

Bringing a neurohospitalist service into an academic medical center can reduce neurological patients' length of stay (LOS) at the facility, according to a study in Neurology.

The retrospective cohort study, "Effect of a Neurohospitalist Service on Outcomes at an Academic Medical Center," found that the mean LOS dropped to 4.6 days while the neurohospitalist service was in place, compared with 6.3 days during the pre-neurohospitalist period. However, adding the service didn't significantly reduce the median cost of care delivery ($6,758 vs. $7,241; P=0.25) or in-hospital mortality rate (1.6% vs. 1.2%; P=0.61), the study noted.

Lead author Vanja Douglas, MD, health sciences assistant clinical professor in the department of neurology at the University of California at San Francisco (UCSF) School of Medicine, says the study's impact is limited by its single-center universe of data. The study was conducted at a UCSF Medical Center in October 2006, but Dr. Douglas hopes similar studies at other academic or community centers will replicate the findings.

"If the current model people have in place is not necessarily focused on outcomes like LOS and cost, then making a change to a neurohospitalist model is likely to positively affect those outcomes," says Dr. Douglas, editor in chief of The Neurohospitalist.

Investigators tracked administrative data starting 21 months before UCSF added a neurohospitalist service and 27 months after. The service was comprised of one neurohospitalist focused solely on inpatients, which allowed other staff neurologists to focus on consultative cases throughout the hospital. Dr. Douglas says as HM groups look to improve their scope of practice and bottom line, studies such as his can lay the groundwork to make the investment.

"A lot of the groups that contract with hospitals are interested in partnering with subspecialty hospitalists," Dr. Douglas adds. "A neurohospitalist model has the potential to work, and the potential to improve outcomes."

Bringing a neurohospitalist service into an academic medical center can reduce neurological patients' length of stay (LOS) at the facility, according to a study in Neurology.

The retrospective cohort study, "Effect of a Neurohospitalist Service on Outcomes at an Academic Medical Center," found that the mean LOS dropped to 4.6 days while the neurohospitalist service was in place, compared with 6.3 days during the pre-neurohospitalist period. However, adding the service didn't significantly reduce the median cost of care delivery ($6,758 vs. $7,241; P=0.25) or in-hospital mortality rate (1.6% vs. 1.2%; P=0.61), the study noted.

Lead author Vanja Douglas, MD, health sciences assistant clinical professor in the department of neurology at the University of California at San Francisco (UCSF) School of Medicine, says the study's impact is limited by its single-center universe of data. The study was conducted at a UCSF Medical Center in October 2006, but Dr. Douglas hopes similar studies at other academic or community centers will replicate the findings.

"If the current model people have in place is not necessarily focused on outcomes like LOS and cost, then making a change to a neurohospitalist model is likely to positively affect those outcomes," says Dr. Douglas, editor in chief of The Neurohospitalist.

Investigators tracked administrative data starting 21 months before UCSF added a neurohospitalist service and 27 months after. The service was comprised of one neurohospitalist focused solely on inpatients, which allowed other staff neurologists to focus on consultative cases throughout the hospital. Dr. Douglas says as HM groups look to improve their scope of practice and bottom line, studies such as his can lay the groundwork to make the investment.

"A lot of the groups that contract with hospitals are interested in partnering with subspecialty hospitalists," Dr. Douglas adds. "A neurohospitalist model has the potential to work, and the potential to improve outcomes."

Bringing a neurohospitalist service into an academic medical center can reduce neurological patients' length of stay (LOS) at the facility, according to a study in Neurology.

The retrospective cohort study, "Effect of a Neurohospitalist Service on Outcomes at an Academic Medical Center," found that the mean LOS dropped to 4.6 days while the neurohospitalist service was in place, compared with 6.3 days during the pre-neurohospitalist period. However, adding the service didn't significantly reduce the median cost of care delivery ($6,758 vs. $7,241; P=0.25) or in-hospital mortality rate (1.6% vs. 1.2%; P=0.61), the study noted.

Lead author Vanja Douglas, MD, health sciences assistant clinical professor in the department of neurology at the University of California at San Francisco (UCSF) School of Medicine, says the study's impact is limited by its single-center universe of data. The study was conducted at a UCSF Medical Center in October 2006, but Dr. Douglas hopes similar studies at other academic or community centers will replicate the findings.

"If the current model people have in place is not necessarily focused on outcomes like LOS and cost, then making a change to a neurohospitalist model is likely to positively affect those outcomes," says Dr. Douglas, editor in chief of The Neurohospitalist.

Investigators tracked administrative data starting 21 months before UCSF added a neurohospitalist service and 27 months after. The service was comprised of one neurohospitalist focused solely on inpatients, which allowed other staff neurologists to focus on consultative cases throughout the hospital. Dr. Douglas says as HM groups look to improve their scope of practice and bottom line, studies such as his can lay the groundwork to make the investment.

"A lot of the groups that contract with hospitals are interested in partnering with subspecialty hospitalists," Dr. Douglas adds. "A neurohospitalist model has the potential to work, and the potential to improve outcomes."

Did you notice that your practice was slower than normal last February? In fact, if you plot your patient census over a few years, you will probably discover that it dips every February. And you will discover other slow periods, like December, and busy months during other parts of the year.

Seasonal fluctuations are a reality in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January and February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are on vacation. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change through advertising or by sending out an e-mail blast, but, unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep-pockets game requiring long, expensive campaigns that are only practical for a large, nationwide corporation.

Take soup, for example. For many years, canned soup was purchased and consumed almost exclusively during the winter months because it was universally perceived as a cold-weather product. After years of pervasive advertising extolling its nutritional virtues (remember Campbell’s slogan "Soup is good food"?), the soup industry succeeded in convincing the public to buy their product year round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean that there is nothing we can do about our practices’ seasonal variations? Not at all, but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

Plotting seasonality is easy: You can make a graph using Microsoft Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2-3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively, you can plot patient visits per month. I do both.

Once you know your seasonality, review your options, which could mean modifying your own habits when necessary. If you typically take a vacation in August, for example, you many want to reconsider if August is one of your busiest months. Consider vacationing during predictable slow periods instead.

Although I have said that you can’t change most seasonal behavior, it is possible to "retrain" some of your long-time, loyal patients to come in during slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November, encouraging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive: Why not advertise during slow periods to fill the empty slots? Because you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

Then, try to flatten your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, which would be the seasonal peaks. Once in your practice, some of them can then be shifted into slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail Dr. Eastern at our editorial offices at [email protected].

Did you notice that your practice was slower than normal last February? In fact, if you plot your patient census over a few years, you will probably discover that it dips every February. And you will discover other slow periods, like December, and busy months during other parts of the year.

Seasonal fluctuations are a reality in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January and February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are on vacation. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change through advertising or by sending out an e-mail blast, but, unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep-pockets game requiring long, expensive campaigns that are only practical for a large, nationwide corporation.

Take soup, for example. For many years, canned soup was purchased and consumed almost exclusively during the winter months because it was universally perceived as a cold-weather product. After years of pervasive advertising extolling its nutritional virtues (remember Campbell’s slogan "Soup is good food"?), the soup industry succeeded in convincing the public to buy their product year round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean that there is nothing we can do about our practices’ seasonal variations? Not at all, but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

Plotting seasonality is easy: You can make a graph using Microsoft Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2-3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively, you can plot patient visits per month. I do both.

Once you know your seasonality, review your options, which could mean modifying your own habits when necessary. If you typically take a vacation in August, for example, you many want to reconsider if August is one of your busiest months. Consider vacationing during predictable slow periods instead.

Although I have said that you can’t change most seasonal behavior, it is possible to "retrain" some of your long-time, loyal patients to come in during slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November, encouraging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive: Why not advertise during slow periods to fill the empty slots? Because you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

Then, try to flatten your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, which would be the seasonal peaks. Once in your practice, some of them can then be shifted into slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail Dr. Eastern at our editorial offices at [email protected].

Did you notice that your practice was slower than normal last February? In fact, if you plot your patient census over a few years, you will probably discover that it dips every February. And you will discover other slow periods, like December, and busy months during other parts of the year.

Seasonal fluctuations are a reality in every business, including private medical practices. Why are people more or less willing to spend money at certain times of the year? Analysts usually blame slow business during January and February on reluctance to buy products or services after the holiday season. They attribute summer peaks to everything from warm weather to an increased propensity to buy when students are on vacation. It is not always easy – or necessary – to explain seasonality. The point is that such behavior patterns do exist.

It would seem that this behavior would be easy to change through advertising or by sending out an e-mail blast, but, unfortunately, altering a seasonal pattern is not an option for a small private practice. It can be done, but it is a deep-pockets game requiring long, expensive campaigns that are only practical for a large, nationwide corporation.

Take soup, for example. For many years, canned soup was purchased and consumed almost exclusively during the winter months because it was universally perceived as a cold-weather product. After years of pervasive advertising extolling its nutritional virtues (remember Campbell’s slogan "Soup is good food"?), the soup industry succeeded in convincing the public to buy their product year round. Obviously, that kind of large-scale behavior modification is not practical for a local medical practice.

Does that mean that there is nothing we can do about our practices’ seasonal variations? Not at all, but we must work within the realities of our patients’ seasonal behavior, rather than attempting to change that behavior outright.

Plotting seasonality is easy: You can make a graph using Microsoft Excel in a few minutes. Ask your office manager or accountant for month-by-month billing figures for the last 2-3 years. (Make sure it’s the amount billed, not collected, since the latter lags the former by several weeks at least.) Plot those figures on the vertical arm and time (in months) on the horizontal. Alternatively, you can plot patient visits per month. I do both.

Once you know your seasonality, review your options, which could mean modifying your own habits when necessary. If you typically take a vacation in August, for example, you many want to reconsider if August is one of your busiest months. Consider vacationing during predictable slow periods instead.

Although I have said that you can’t change most seasonal behavior, it is possible to "retrain" some of your long-time, loyal patients to come in during slower periods for at least some of their care. Use insurance company rules as a financial incentive, where possible. Many of my patients are on Medicare, so I send a notice to all of them in early November, encouraging them to come in during December (one of my light months) before their deductible has to be paid again.

If you advertise your services, do the bulk of it during your busiest months. That might seem counterintuitive: Why not advertise during slow periods to fill the empty slots? Because you cannot change seasonal behavior with a low-budget, local advertising campaign; physicians who attempt it invariably get a poor response. Advertise during your busy periods, when seasonal patterns predict that potential patients are more willing to spend money and are more likely to respond to your message.

Then, try to flatten your seasonal dips by persuading as many existing patients as possible to return during slower seasons. You can then encourage new patients to make appointments when they are receptive to purchasing new services, which would be the seasonal peaks. Once in your practice, some of them can then be shifted into slower periods, especially for predictable, periodic care.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail Dr. Eastern at our editorial offices at [email protected].

WASHINGTON – Oropharyngeal squamous cell cancer patients who underwent transoral robotic surgery had an overall 2-year survival rate of 87%, with no significant differences between patients who were positive vs. negative for the human papillomavirus, based on data from 52 patients.

HPV is associated with 45%-70% of cases of oropharyngeal squamous cell carcinoma (OPSCCa), said Dr. Kiran Kakarala, who conducted the study at Ohio State University in Columbus.

Previous studies have shown a significant difference in survival rates for patients with HPV-positive tumors, compared with those with negative tumors, Dr. Kakarala said. However, other studies have suggested that the use of transoral robotic surgery (TORS) for OPSCCa patients could narrow the gap in survival based on HPV status.

Dr. Kakarala and his colleagues reviewed data from 52 patients who underwent TORS with neck dissection and postoperative adjuvant treatment for previously untreated OPSCCa. The patients were part of a prospective single-arm cohort study at a single academic medical center.

HPV status was available for 42 patients; 36 were positive and 6 were negative. Demographic characteristics were not significantly different between the HPV-positive and negative patients. The mean age of the HPV-positive patients was 59 years, and the mean age of the negative patients was 57 years. The tonsil was the primary tumor site in 89% of the positive patients and 83% of the negative patients; the base of the tongue was the primary site in 11% of the positive patients and 17% of the negative patients.

HPV-positive patients had significantly higher N classifications based on the TNM Classification of Malignant Tumors, compared with HPV-negative patients (P = .015), and a significantly higher stage (P = .017). No significant differences were found in the number of HPV-positive vs. negative patients who received postoperative radiation or chemotherapy.

The 2-year survival rate was 87% for all 52 patients, 92% for HPV-positive patients, and 75% for HPV-negative patients. Two-year disease-specific survival rates were 92%, 92%, and 75%, respectively. Two-year disease-free survival rates were 86%, 97%, and 50%, respectively.

"The 2-year overall survival and disease-specific survival were not statistically different between HPV-positive and negative patients treated with TORS followed by radiation with or without chemotherapy as indicated," Dr. Kakarala said.

The study was limited by its small size and retrospective design, but the findings suggest a role for minimally invasive TORS in OPSCCa patients, he said.

"Randomized trials incorporating minimally invasive transoral surgical procedures with radiation therapy and chemotherapy, and comparing survival, quality of life, and cost outcomes between these treatment modalities, are indicated," he added.

The findings were presented at the annual meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation.

Dr. Kakarala had no financial conflicts to disclose.

WASHINGTON – Oropharyngeal squamous cell cancer patients who underwent transoral robotic surgery had an overall 2-year survival rate of 87%, with no significant differences between patients who were positive vs. negative for the human papillomavirus, based on data from 52 patients.

HPV is associated with 45%-70% of cases of oropharyngeal squamous cell carcinoma (OPSCCa), said Dr. Kiran Kakarala, who conducted the study at Ohio State University in Columbus.

Previous studies have shown a significant difference in survival rates for patients with HPV-positive tumors, compared with those with negative tumors, Dr. Kakarala said. However, other studies have suggested that the use of transoral robotic surgery (TORS) for OPSCCa patients could narrow the gap in survival based on HPV status.

Dr. Kakarala and his colleagues reviewed data from 52 patients who underwent TORS with neck dissection and postoperative adjuvant treatment for previously untreated OPSCCa. The patients were part of a prospective single-arm cohort study at a single academic medical center.

HPV status was available for 42 patients; 36 were positive and 6 were negative. Demographic characteristics were not significantly different between the HPV-positive and negative patients. The mean age of the HPV-positive patients was 59 years, and the mean age of the negative patients was 57 years. The tonsil was the primary tumor site in 89% of the positive patients and 83% of the negative patients; the base of the tongue was the primary site in 11% of the positive patients and 17% of the negative patients.

HPV-positive patients had significantly higher N classifications based on the TNM Classification of Malignant Tumors, compared with HPV-negative patients (P = .015), and a significantly higher stage (P = .017). No significant differences were found in the number of HPV-positive vs. negative patients who received postoperative radiation or chemotherapy.

The 2-year survival rate was 87% for all 52 patients, 92% for HPV-positive patients, and 75% for HPV-negative patients. Two-year disease-specific survival rates were 92%, 92%, and 75%, respectively. Two-year disease-free survival rates were 86%, 97%, and 50%, respectively.

"The 2-year overall survival and disease-specific survival were not statistically different between HPV-positive and negative patients treated with TORS followed by radiation with or without chemotherapy as indicated," Dr. Kakarala said.

The study was limited by its small size and retrospective design, but the findings suggest a role for minimally invasive TORS in OPSCCa patients, he said.

"Randomized trials incorporating minimally invasive transoral surgical procedures with radiation therapy and chemotherapy, and comparing survival, quality of life, and cost outcomes between these treatment modalities, are indicated," he added.

The findings were presented at the annual meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation.

Dr. Kakarala had no financial conflicts to disclose.

WASHINGTON – Oropharyngeal squamous cell cancer patients who underwent transoral robotic surgery had an overall 2-year survival rate of 87%, with no significant differences between patients who were positive vs. negative for the human papillomavirus, based on data from 52 patients.

HPV is associated with 45%-70% of cases of oropharyngeal squamous cell carcinoma (OPSCCa), said Dr. Kiran Kakarala, who conducted the study at Ohio State University in Columbus.

Previous studies have shown a significant difference in survival rates for patients with HPV-positive tumors, compared with those with negative tumors, Dr. Kakarala said. However, other studies have suggested that the use of transoral robotic surgery (TORS) for OPSCCa patients could narrow the gap in survival based on HPV status.

Dr. Kakarala and his colleagues reviewed data from 52 patients who underwent TORS with neck dissection and postoperative adjuvant treatment for previously untreated OPSCCa. The patients were part of a prospective single-arm cohort study at a single academic medical center.

HPV status was available for 42 patients; 36 were positive and 6 were negative. Demographic characteristics were not significantly different between the HPV-positive and negative patients. The mean age of the HPV-positive patients was 59 years, and the mean age of the negative patients was 57 years. The tonsil was the primary tumor site in 89% of the positive patients and 83% of the negative patients; the base of the tongue was the primary site in 11% of the positive patients and 17% of the negative patients.

HPV-positive patients had significantly higher N classifications based on the TNM Classification of Malignant Tumors, compared with HPV-negative patients (P = .015), and a significantly higher stage (P = .017). No significant differences were found in the number of HPV-positive vs. negative patients who received postoperative radiation or chemotherapy.

The 2-year survival rate was 87% for all 52 patients, 92% for HPV-positive patients, and 75% for HPV-negative patients. Two-year disease-specific survival rates were 92%, 92%, and 75%, respectively. Two-year disease-free survival rates were 86%, 97%, and 50%, respectively.

"The 2-year overall survival and disease-specific survival were not statistically different between HPV-positive and negative patients treated with TORS followed by radiation with or without chemotherapy as indicated," Dr. Kakarala said.

The study was limited by its small size and retrospective design, but the findings suggest a role for minimally invasive TORS in OPSCCa patients, he said.

"Randomized trials incorporating minimally invasive transoral surgical procedures with radiation therapy and chemotherapy, and comparing survival, quality of life, and cost outcomes between these treatment modalities, are indicated," he added.

The findings were presented at the annual meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation.

Dr. Kakarala had no financial conflicts to disclose.

NEWPORT BEACH, CALIF. – Most gout patients need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to gout expert Dr. Brian Mandell.

Probably more than half of people need more than 300 mg "if you are going to get to the target level of [6 mg/dL serum urate or lower]. Most people probably need closer to 400 mg," he said (Ann. Rheum. Dis. 1998;57:545-9).

A good target serum urate level is 6 mg/dL. "If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

In a bid to get physicians to use a treat-to-target approach in gout management, Dr. Mandell noted that "you can only treat urate successfully if you measure it after you start therapy," something not all clinicians do. "The correct dose is the dose that drops your urate," said Dr. Mandell, professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, "I always start low at 50 mg/dL" and titrate upward, he said.

"There’s no rush in trying to drop the level. It’s a lifelong disease." When counseling patients about hypersensitivity reactions, Dr. Mandell said that he advises them to stop the drug as soon as they notice a rash and then call him.

Pegylated uricase is "incredibly effective for lowering serum urate," as well, he said. When pegylated uricase is "given as an IV infusion, serum urate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer," Dr. Mandell noted.

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases their risk of an infusion reaction. In that case, "stop the drug," he said.

For management of an acute gout attack, Dr. Mandell said he often chooses anakinra (Kineret) so long as patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, "any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone," he advised.

Colchicine can work "if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks," he said.

Narcotics don’t work well on inflammatory pain and so are not a good choice for an acute attack, Dr. Mandell noted.

A normal serum urate level does not necessarily rule out a gout attack. "Stick a needle in the joint at some point in time to make sure gout is the diagnosis," he said.

Dr. Mandell is a consultant for Novartis, Pfizer, Takeda, and other companies.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – Most gout patients need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to gout expert Dr. Brian Mandell.

Probably more than half of people need more than 300 mg "if you are going to get to the target level of [6 mg/dL serum urate or lower]. Most people probably need closer to 400 mg," he said (Ann. Rheum. Dis. 1998;57:545-9).

A good target serum urate level is 6 mg/dL. "If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

In a bid to get physicians to use a treat-to-target approach in gout management, Dr. Mandell noted that "you can only treat urate successfully if you measure it after you start therapy," something not all clinicians do. "The correct dose is the dose that drops your urate," said Dr. Mandell, professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, "I always start low at 50 mg/dL" and titrate upward, he said.

"There’s no rush in trying to drop the level. It’s a lifelong disease." When counseling patients about hypersensitivity reactions, Dr. Mandell said that he advises them to stop the drug as soon as they notice a rash and then call him.

Pegylated uricase is "incredibly effective for lowering serum urate," as well, he said. When pegylated uricase is "given as an IV infusion, serum urate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer," Dr. Mandell noted.

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases their risk of an infusion reaction. In that case, "stop the drug," he said.

For management of an acute gout attack, Dr. Mandell said he often chooses anakinra (Kineret) so long as patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, "any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone," he advised.

Colchicine can work "if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks," he said.

Narcotics don’t work well on inflammatory pain and so are not a good choice for an acute attack, Dr. Mandell noted.

A normal serum urate level does not necessarily rule out a gout attack. "Stick a needle in the joint at some point in time to make sure gout is the diagnosis," he said.

Dr. Mandell is a consultant for Novartis, Pfizer, Takeda, and other companies.

SDEF and this news organization are owned by Frontline Medical Communications.

NEWPORT BEACH, CALIF. – Most gout patients need more than the standard and widely used dose of 300 mg/day of allopurinol to lower their serum urate level enough to prevent flares, according to gout expert Dr. Brian Mandell.

Probably more than half of people need more than 300 mg "if you are going to get to the target level of [6 mg/dL serum urate or lower]. Most people probably need closer to 400 mg," he said (Ann. Rheum. Dis. 1998;57:545-9).

A good target serum urate level is 6 mg/dL. "If you’re at 6, the urate is unlikely to precipitate, [and] you really do dramatically decrease the frequency of attacks," he said at Perspectives in Rheumatic Diseases 2012, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

In a bid to get physicians to use a treat-to-target approach in gout management, Dr. Mandell noted that "you can only treat urate successfully if you measure it after you start therapy," something not all clinicians do. "The correct dose is the dose that drops your urate," said Dr. Mandell, professor and chair of medicine at the Cleveland Clinic.

To avoid triggering a gout flare from too-abrupt urate lowering and to help avoid hypersensitivity reactions, "I always start low at 50 mg/dL" and titrate upward, he said.

"There’s no rush in trying to drop the level. It’s a lifelong disease." When counseling patients about hypersensitivity reactions, Dr. Mandell said that he advises them to stop the drug as soon as they notice a rash and then call him.

Pegylated uricase is "incredibly effective for lowering serum urate," as well, he said. When pegylated uricase is "given as an IV infusion, serum urate plummets to about 0.5 mg/dL and stays down for 2 weeks or longer," Dr. Mandell noted.

Patients should be warned, however, of the risk of flares with the quick urate drop. Also, if they don’t have such a robust response, it probably means they have antibodies to pegylated uricase, which also increases their risk of an infusion reaction. In that case, "stop the drug," he said.

For management of an acute gout attack, Dr. Mandell said he often chooses anakinra (Kineret) so long as patients are in the hospital and can be monitored for infections and other potential problems.

Indomethacin is another option. In fact, "any NSAID will work if you use high enough doses. You need to treat until the attack resolves and then for a couple days longer to really make sure the attack is gone," he advised.

Colchicine can work "if you catch the attack early, but it’s not a panacea. It’s a great drug for prophylaxis but not to treat acute attacks," he said.

Narcotics don’t work well on inflammatory pain and so are not a good choice for an acute attack, Dr. Mandell noted.

A normal serum urate level does not necessarily rule out a gout attack. "Stick a needle in the joint at some point in time to make sure gout is the diagnosis," he said.

Dr. Mandell is a consultant for Novartis, Pfizer, Takeda, and other companies.

SDEF and this news organization are owned by Frontline Medical Communications.

There is a recent and needed interest in fostering the maturation of surgical trainees, both in the scientific literature and the lay press. Much of this focus has been on the mentorship and educational development of the surgeon in training. As a point of reference, there were 56 citations in PubMed for the calendar year 2012 (January through September) with mentorship or educator and surgery as keywords. This spans the spectrum from conveying technical skills in the operating room and on the wards, to transferring knowledge, to navigating the intricate dynamics of starting a practice.

While there is a great deal of commonality between a mentor and educator, there are subtle differences. Merriam-Webster has a definition of a mentor as "a trusted counselor or guide." An educator is defined as "one skilled in teaching." As what I believe to be a demonstration of the understanding that there are nuances of becoming a skilled educator, the Joint Council on Thoracic Surgery Education (JCTSE) and The Society of Thoracic Surgeons (STS) jointly sponsor the Educate the Educators (EtE) program. The EtE program’s purpose is to enhance the teaching skills of cardiothoracic surgery faculty.

I recently had the fortunate opportunity to attend and participate in this year’s EtE course held this July 27-29 at The William and Ida Friday Center for Continuing Education at the University of North Carolina, Chapel Hill. This informative course was directed by Dr. Edward Verrier (University of Washington), Dr. Ara Vaporciyan (The University of Texas M.D. Anderson Cancer Center) and Dr. Stephen Yang (The Johns Hopkins University). The EtE program, which had 37 attendees, was run concurrently with this year’s Thoracic Surgery Directors Association 5th Annual Cardiothoracic Surgery Boot Camp.

The course focused on developing a framework for an effective educational environment – one where the trainee is able to learn, retain, and utilize the knowledge or skills. The need to engage learners at all the levels was especially poignant to cardiothoracic surgery education where the team and students span from medical students to general surgery residents to thoracic residents and fellows. Developing a deeper understanding of the level of pre-knowledge will become even more critical as integrated training programs expand.

Understanding the needs of the learner – especially as it relates to the development of curriculum – was a focus of Dr. Vaporciyan’s discussions. The field of curriculum development and assessment is beyond the scope of this article, but hinges on understanding curriculum as a process. The process begins with assessing the needs of the learner. It is followed by a thorough understanding of the goals and objectives of the educational experience. Finally, the materials, methods, and instructors are molded to best utilize their strengths. This approach ultimately makes the learning relevant to the trainee and optimally engages them. The ongoing engagement allows feedback to be best used to measure a trainee’s strengths and weaknesses. The educator then facilitates the process.

A large amount of time was dedicated to understanding the learner of today. This was spearheaded by a luncheon lecture and subsequent direct discussions with Dr. Mark Taylor, M.S.W., Ed.D on the generational changes of learners. What was most interesting, to this attendee, was the influence of intergenerational, cultural, and technological factors on the trainee of today and how those stereotypes (justified and unjustified) are carried through to the current training paradigm. Dr. Taylor’s talks were nicely augmented by those of Dr. Yang on utilizing deliberate teaching. This process focuses on setting objectives for a particular encounter (e.g., surgical case, bedside rounds, lecture) and providing feedback immediately.

The approach to deliberate teaching was especially relevant to today’s thoracic residency paradigm where work-hours are limited. To this end, an approach to maximally optimize learning, placing detailed background preparation with the trainee so that when they participate they are up to speed. That is to say, the majority of the content would be delivered off-line. The trainees are then held responsible for this information so that the learning encounter can be productive and focused on deeper understanding eliminating confusion.

Then the educational encounter would not be a regurgitation of information available elsewhere, but a conversation. This would enable the adult learner of the 21st century to utilize the study method and approach that is most effective for them and their lifestyle.

The commitment of the JTSCE and STS to improving thoracic resident education through the EtE program is outstanding. The EtE program is a very valuable resource for those with an interest in thoracic surgical education to expand their knowledge base.

There is a recent and needed interest in fostering the maturation of surgical trainees, both in the scientific literature and the lay press. Much of this focus has been on the mentorship and educational development of the surgeon in training. As a point of reference, there were 56 citations in PubMed for the calendar year 2012 (January through September) with mentorship or educator and surgery as keywords. This spans the spectrum from conveying technical skills in the operating room and on the wards, to transferring knowledge, to navigating the intricate dynamics of starting a practice.

While there is a great deal of commonality between a mentor and educator, there are subtle differences. Merriam-Webster has a definition of a mentor as "a trusted counselor or guide." An educator is defined as "one skilled in teaching." As what I believe to be a demonstration of the understanding that there are nuances of becoming a skilled educator, the Joint Council on Thoracic Surgery Education (JCTSE) and The Society of Thoracic Surgeons (STS) jointly sponsor the Educate the Educators (EtE) program. The EtE program’s purpose is to enhance the teaching skills of cardiothoracic surgery faculty.

I recently had the fortunate opportunity to attend and participate in this year’s EtE course held this July 27-29 at The William and Ida Friday Center for Continuing Education at the University of North Carolina, Chapel Hill. This informative course was directed by Dr. Edward Verrier (University of Washington), Dr. Ara Vaporciyan (The University of Texas M.D. Anderson Cancer Center) and Dr. Stephen Yang (The Johns Hopkins University). The EtE program, which had 37 attendees, was run concurrently with this year’s Thoracic Surgery Directors Association 5th Annual Cardiothoracic Surgery Boot Camp.

The course focused on developing a framework for an effective educational environment – one where the trainee is able to learn, retain, and utilize the knowledge or skills. The need to engage learners at all the levels was especially poignant to cardiothoracic surgery education where the team and students span from medical students to general surgery residents to thoracic residents and fellows. Developing a deeper understanding of the level of pre-knowledge will become even more critical as integrated training programs expand.

Understanding the needs of the learner – especially as it relates to the development of curriculum – was a focus of Dr. Vaporciyan’s discussions. The field of curriculum development and assessment is beyond the scope of this article, but hinges on understanding curriculum as a process. The process begins with assessing the needs of the learner. It is followed by a thorough understanding of the goals and objectives of the educational experience. Finally, the materials, methods, and instructors are molded to best utilize their strengths. This approach ultimately makes the learning relevant to the trainee and optimally engages them. The ongoing engagement allows feedback to be best used to measure a trainee’s strengths and weaknesses. The educator then facilitates the process.

A large amount of time was dedicated to understanding the learner of today. This was spearheaded by a luncheon lecture and subsequent direct discussions with Dr. Mark Taylor, M.S.W., Ed.D on the generational changes of learners. What was most interesting, to this attendee, was the influence of intergenerational, cultural, and technological factors on the trainee of today and how those stereotypes (justified and unjustified) are carried through to the current training paradigm. Dr. Taylor’s talks were nicely augmented by those of Dr. Yang on utilizing deliberate teaching. This process focuses on setting objectives for a particular encounter (e.g., surgical case, bedside rounds, lecture) and providing feedback immediately.

The approach to deliberate teaching was especially relevant to today’s thoracic residency paradigm where work-hours are limited. To this end, an approach to maximally optimize learning, placing detailed background preparation with the trainee so that when they participate they are up to speed. That is to say, the majority of the content would be delivered off-line. The trainees are then held responsible for this information so that the learning encounter can be productive and focused on deeper understanding eliminating confusion.

Then the educational encounter would not be a regurgitation of information available elsewhere, but a conversation. This would enable the adult learner of the 21st century to utilize the study method and approach that is most effective for them and their lifestyle.

The commitment of the JTSCE and STS to improving thoracic resident education through the EtE program is outstanding. The EtE program is a very valuable resource for those with an interest in thoracic surgical education to expand their knowledge base.

There is a recent and needed interest in fostering the maturation of surgical trainees, both in the scientific literature and the lay press. Much of this focus has been on the mentorship and educational development of the surgeon in training. As a point of reference, there were 56 citations in PubMed for the calendar year 2012 (January through September) with mentorship or educator and surgery as keywords. This spans the spectrum from conveying technical skills in the operating room and on the wards, to transferring knowledge, to navigating the intricate dynamics of starting a practice.

While there is a great deal of commonality between a mentor and educator, there are subtle differences. Merriam-Webster has a definition of a mentor as "a trusted counselor or guide." An educator is defined as "one skilled in teaching." As what I believe to be a demonstration of the understanding that there are nuances of becoming a skilled educator, the Joint Council on Thoracic Surgery Education (JCTSE) and The Society of Thoracic Surgeons (STS) jointly sponsor the Educate the Educators (EtE) program. The EtE program’s purpose is to enhance the teaching skills of cardiothoracic surgery faculty.

I recently had the fortunate opportunity to attend and participate in this year’s EtE course held this July 27-29 at The William and Ida Friday Center for Continuing Education at the University of North Carolina, Chapel Hill. This informative course was directed by Dr. Edward Verrier (University of Washington), Dr. Ara Vaporciyan (The University of Texas M.D. Anderson Cancer Center) and Dr. Stephen Yang (The Johns Hopkins University). The EtE program, which had 37 attendees, was run concurrently with this year’s Thoracic Surgery Directors Association 5th Annual Cardiothoracic Surgery Boot Camp.

The course focused on developing a framework for an effective educational environment – one where the trainee is able to learn, retain, and utilize the knowledge or skills. The need to engage learners at all the levels was especially poignant to cardiothoracic surgery education where the team and students span from medical students to general surgery residents to thoracic residents and fellows. Developing a deeper understanding of the level of pre-knowledge will become even more critical as integrated training programs expand.

Understanding the needs of the learner – especially as it relates to the development of curriculum – was a focus of Dr. Vaporciyan’s discussions. The field of curriculum development and assessment is beyond the scope of this article, but hinges on understanding curriculum as a process. The process begins with assessing the needs of the learner. It is followed by a thorough understanding of the goals and objectives of the educational experience. Finally, the materials, methods, and instructors are molded to best utilize their strengths. This approach ultimately makes the learning relevant to the trainee and optimally engages them. The ongoing engagement allows feedback to be best used to measure a trainee’s strengths and weaknesses. The educator then facilitates the process.

A large amount of time was dedicated to understanding the learner of today. This was spearheaded by a luncheon lecture and subsequent direct discussions with Dr. Mark Taylor, M.S.W., Ed.D on the generational changes of learners. What was most interesting, to this attendee, was the influence of intergenerational, cultural, and technological factors on the trainee of today and how those stereotypes (justified and unjustified) are carried through to the current training paradigm. Dr. Taylor’s talks were nicely augmented by those of Dr. Yang on utilizing deliberate teaching. This process focuses on setting objectives for a particular encounter (e.g., surgical case, bedside rounds, lecture) and providing feedback immediately.

The approach to deliberate teaching was especially relevant to today’s thoracic residency paradigm where work-hours are limited. To this end, an approach to maximally optimize learning, placing detailed background preparation with the trainee so that when they participate they are up to speed. That is to say, the majority of the content would be delivered off-line. The trainees are then held responsible for this information so that the learning encounter can be productive and focused on deeper understanding eliminating confusion.

Then the educational encounter would not be a regurgitation of information available elsewhere, but a conversation. This would enable the adult learner of the 21st century to utilize the study method and approach that is most effective for them and their lifestyle.

The commitment of the JTSCE and STS to improving thoracic resident education through the EtE program is outstanding. The EtE program is a very valuable resource for those with an interest in thoracic surgical education to expand their knowledge base.