Making history and recording history are rarely thought of in the same context; however occasionally the two are one and the same. Such is the case as the the Michigan Vascular Center, a private vascular practice located in Flint, Michigan, enters its 50th year of service to its community and state. Barring documentation to the contrary, we believe the Michigan Vascular Center is the oldest and longest running private practice vascular surgery group in the country. What follows is a brief summary of its remarkable history.

Its founder was Dr. Albert Macksood, the son of a Lebanese immigrant-physician Joseph Macksood, who returned home to Flint on July 1, 1963, after completing his surgical training with Dr. Emerick Szilagyi’s group at the Henry Ford Hospital in Detroit, Michigan. Those were the formative years of our specialty and Dr. Macksood brought to Flint skills few in the country possessed. Confident in his ability, imbued with boundless energy and an uncanny ability to engage any and all in meaningful dialogue.

Dr. Al was advised by his father to only practice vascular surgery, unusual for those years, so as not to compete with the general surgeons who lacked his vascular skills. Most remarkable about Dr. Macksood, however, was his simple, yet revolutionary, philosophy: “cover the waterfront” ( three Flint area hospitals which have had continuous emergency coverage since) , add only fellowship trained physicians as the need dictated and create a true group practice such that the patients belonged to, and were treated by, all partners. This created an equal work load and compensation and allowed all to have a life by making time for family and interests predictable. It also created power in numbers with the opportunity and support to broaden our horizons.

As the practice grew, Dr. Macksood tapped Dr. Szilagyi’s program for recruits. By 1975 three additional vascular surgeons – Dr. Al Morgan (’65), Dr. Rick Sherrin (’70) and I (’75) joined. This fact- that the first four members came from Dr. Szilagyi’s program- was important to our early success because all shared a common culture and work ethic- we were in synch- we shared the same philosophical approach to the patient and the practice of our specialty. This made incorporating a new partner a seamless experience. Since then vascular surgeons from other institutions have joined- Drs. Ippolito and McIlduff and Fortin from the Cleveland Clinic, Dr. Kinning from Ohio, Dr. Molnar from Vanderbuilt, Dr. Becker from Wayne State and Dr. Malhotra from the Albany Vascular Group. Currently we are recruiting fellows from the Medical College of Wisconsin and the Mayo Clinic.

As with all vascular practices, the transition into the endovascular arena during the ‘90s and early 2000 presented challenges’ Thanks to our networking with reps from the various medical device companies (Kathy Patterson then with Bard, Cheryl Lubin from Boston Scientific and Amy Ketola/John Toddhunter/ Matt Borenzweig then with Medtronic), vascular surgeons such as Dr. Vic Burnhardt, Dr. Ted Diethrich in Arizona and international physicians such as Dr. Antonio in Modena, Italy and Drs. Cremonesi and Castriota in Ravenna, Italy, our members were able to travel nationally and internationally to work with these men and gain the necessary skills for aortic endografting and carotid stenting.

By 2002 we established our Michigan Vascular Research Center for the numerous clinical trials we were involved in and offered hands on experience to teach other vascular surgeons the art of carotid stenting.

Our center has grown in response to the needs of our vascular practice and the vascular patient. Over the past several years we have added two free standing outpatient diagnostic/angioaccess centers and a free standing VeinSolutions Center. Our latest addition is a Mobility Center to enable the amputee to regain mobility. It has proven to be a great psychological boost to the amputee. On November 5, 2012, we will know if we are approved for a 5-2 vascular fellowship program.

As with any endeavor, the owners have to “tend to the store.” As a private practice group we realize we are responsible to each other and for the success of our practice. We risk our capital in our expansion decisions and this provides us with the opportunity to move swiftly, without layers of bureaucratic approval. We meet every two weeks to review and plan medical and business issues, always with an eye toward future developments and opportunities to improve the care of our patients.

We are very proud of our independent, private practice vascular center, planning for another 50 years, and believe that by adhering to our cultural values, we will make The Michigan Vascular Center a member of the 100 year club. The current health reform agenda presents challenges yet given the size of our group, we feel confident in the value and cost-effective systems we provide and believe we will find opportunity. We look forward to the future.

Carlo A. Dall’Olmo, MD,

For the Michigan Vascular Center Group

[For the complete story of the Center by Dr. Dall’Olmo, please visit our website at www.vascularspecialistonline.com.]

Making history and recording history are rarely thought of in the same context; however occasionally the two are one and the same. Such is the case as the the Michigan Vascular Center, a private vascular practice located in Flint, Michigan, enters its 50th year of service to its community and state. Barring documentation to the contrary, we believe the Michigan Vascular Center is the oldest and longest running private practice vascular surgery group in the country. What follows is a brief summary of its remarkable history.

Its founder was Dr. Albert Macksood, the son of a Lebanese immigrant-physician Joseph Macksood, who returned home to Flint on July 1, 1963, after completing his surgical training with Dr. Emerick Szilagyi’s group at the Henry Ford Hospital in Detroit, Michigan. Those were the formative years of our specialty and Dr. Macksood brought to Flint skills few in the country possessed. Confident in his ability, imbued with boundless energy and an uncanny ability to engage any and all in meaningful dialogue.

Dr. Al was advised by his father to only practice vascular surgery, unusual for those years, so as not to compete with the general surgeons who lacked his vascular skills. Most remarkable about Dr. Macksood, however, was his simple, yet revolutionary, philosophy: “cover the waterfront” ( three Flint area hospitals which have had continuous emergency coverage since) , add only fellowship trained physicians as the need dictated and create a true group practice such that the patients belonged to, and were treated by, all partners. This created an equal work load and compensation and allowed all to have a life by making time for family and interests predictable. It also created power in numbers with the opportunity and support to broaden our horizons.

As the practice grew, Dr. Macksood tapped Dr. Szilagyi’s program for recruits. By 1975 three additional vascular surgeons – Dr. Al Morgan (’65), Dr. Rick Sherrin (’70) and I (’75) joined. This fact- that the first four members came from Dr. Szilagyi’s program- was important to our early success because all shared a common culture and work ethic- we were in synch- we shared the same philosophical approach to the patient and the practice of our specialty. This made incorporating a new partner a seamless experience. Since then vascular surgeons from other institutions have joined- Drs. Ippolito and McIlduff and Fortin from the Cleveland Clinic, Dr. Kinning from Ohio, Dr. Molnar from Vanderbuilt, Dr. Becker from Wayne State and Dr. Malhotra from the Albany Vascular Group. Currently we are recruiting fellows from the Medical College of Wisconsin and the Mayo Clinic.

As with all vascular practices, the transition into the endovascular arena during the ‘90s and early 2000 presented challenges’ Thanks to our networking with reps from the various medical device companies (Kathy Patterson then with Bard, Cheryl Lubin from Boston Scientific and Amy Ketola/John Toddhunter/ Matt Borenzweig then with Medtronic), vascular surgeons such as Dr. Vic Burnhardt, Dr. Ted Diethrich in Arizona and international physicians such as Dr. Antonio in Modena, Italy and Drs. Cremonesi and Castriota in Ravenna, Italy, our members were able to travel nationally and internationally to work with these men and gain the necessary skills for aortic endografting and carotid stenting.

By 2002 we established our Michigan Vascular Research Center for the numerous clinical trials we were involved in and offered hands on experience to teach other vascular surgeons the art of carotid stenting.

Our center has grown in response to the needs of our vascular practice and the vascular patient. Over the past several years we have added two free standing outpatient diagnostic/angioaccess centers and a free standing VeinSolutions Center. Our latest addition is a Mobility Center to enable the amputee to regain mobility. It has proven to be a great psychological boost to the amputee. On November 5, 2012, we will know if we are approved for a 5-2 vascular fellowship program.

As with any endeavor, the owners have to “tend to the store.” As a private practice group we realize we are responsible to each other and for the success of our practice. We risk our capital in our expansion decisions and this provides us with the opportunity to move swiftly, without layers of bureaucratic approval. We meet every two weeks to review and plan medical and business issues, always with an eye toward future developments and opportunities to improve the care of our patients.

We are very proud of our independent, private practice vascular center, planning for another 50 years, and believe that by adhering to our cultural values, we will make The Michigan Vascular Center a member of the 100 year club. The current health reform agenda presents challenges yet given the size of our group, we feel confident in the value and cost-effective systems we provide and believe we will find opportunity. We look forward to the future.

Carlo A. Dall’Olmo, MD,

For the Michigan Vascular Center Group

[For the complete story of the Center by Dr. Dall’Olmo, please visit our website at www.vascularspecialistonline.com.]

Making history and recording history are rarely thought of in the same context; however occasionally the two are one and the same. Such is the case as the the Michigan Vascular Center, a private vascular practice located in Flint, Michigan, enters its 50th year of service to its community and state. Barring documentation to the contrary, we believe the Michigan Vascular Center is the oldest and longest running private practice vascular surgery group in the country. What follows is a brief summary of its remarkable history.

Its founder was Dr. Albert Macksood, the son of a Lebanese immigrant-physician Joseph Macksood, who returned home to Flint on July 1, 1963, after completing his surgical training with Dr. Emerick Szilagyi’s group at the Henry Ford Hospital in Detroit, Michigan. Those were the formative years of our specialty and Dr. Macksood brought to Flint skills few in the country possessed. Confident in his ability, imbued with boundless energy and an uncanny ability to engage any and all in meaningful dialogue.

Dr. Al was advised by his father to only practice vascular surgery, unusual for those years, so as not to compete with the general surgeons who lacked his vascular skills. Most remarkable about Dr. Macksood, however, was his simple, yet revolutionary, philosophy: “cover the waterfront” ( three Flint area hospitals which have had continuous emergency coverage since) , add only fellowship trained physicians as the need dictated and create a true group practice such that the patients belonged to, and were treated by, all partners. This created an equal work load and compensation and allowed all to have a life by making time for family and interests predictable. It also created power in numbers with the opportunity and support to broaden our horizons.

As the practice grew, Dr. Macksood tapped Dr. Szilagyi’s program for recruits. By 1975 three additional vascular surgeons – Dr. Al Morgan (’65), Dr. Rick Sherrin (’70) and I (’75) joined. This fact- that the first four members came from Dr. Szilagyi’s program- was important to our early success because all shared a common culture and work ethic- we were in synch- we shared the same philosophical approach to the patient and the practice of our specialty. This made incorporating a new partner a seamless experience. Since then vascular surgeons from other institutions have joined- Drs. Ippolito and McIlduff and Fortin from the Cleveland Clinic, Dr. Kinning from Ohio, Dr. Molnar from Vanderbuilt, Dr. Becker from Wayne State and Dr. Malhotra from the Albany Vascular Group. Currently we are recruiting fellows from the Medical College of Wisconsin and the Mayo Clinic.

As with all vascular practices, the transition into the endovascular arena during the ‘90s and early 2000 presented challenges’ Thanks to our networking with reps from the various medical device companies (Kathy Patterson then with Bard, Cheryl Lubin from Boston Scientific and Amy Ketola/John Toddhunter/ Matt Borenzweig then with Medtronic), vascular surgeons such as Dr. Vic Burnhardt, Dr. Ted Diethrich in Arizona and international physicians such as Dr. Antonio in Modena, Italy and Drs. Cremonesi and Castriota in Ravenna, Italy, our members were able to travel nationally and internationally to work with these men and gain the necessary skills for aortic endografting and carotid stenting.

By 2002 we established our Michigan Vascular Research Center for the numerous clinical trials we were involved in and offered hands on experience to teach other vascular surgeons the art of carotid stenting.

Our center has grown in response to the needs of our vascular practice and the vascular patient. Over the past several years we have added two free standing outpatient diagnostic/angioaccess centers and a free standing VeinSolutions Center. Our latest addition is a Mobility Center to enable the amputee to regain mobility. It has proven to be a great psychological boost to the amputee. On November 5, 2012, we will know if we are approved for a 5-2 vascular fellowship program.

As with any endeavor, the owners have to “tend to the store.” As a private practice group we realize we are responsible to each other and for the success of our practice. We risk our capital in our expansion decisions and this provides us with the opportunity to move swiftly, without layers of bureaucratic approval. We meet every two weeks to review and plan medical and business issues, always with an eye toward future developments and opportunities to improve the care of our patients.

We are very proud of our independent, private practice vascular center, planning for another 50 years, and believe that by adhering to our cultural values, we will make The Michigan Vascular Center a member of the 100 year club. The current health reform agenda presents challenges yet given the size of our group, we feel confident in the value and cost-effective systems we provide and believe we will find opportunity. We look forward to the future.

Carlo A. Dall’Olmo, MD,

For the Michigan Vascular Center Group

[For the complete story of the Center by Dr. Dall’Olmo, please visit our website at www.vascularspecialistonline.com.]

CHICAGO – Treatment of calcified femoropopliteal lesions with orbital atherectomy led to similar 12-month patency as balloon angioplasty but with a reduced need for stenting, in a randomized, controlled study with 50 patients.

Orbital atherectomy changed vessel compliance, which allowed lower pressure balloon dilatation and hence less vessel disruption, which appeared to produce a low rate of restenosis with minimal stent use. "Lower dissection rates and reduced use of bail-out stents preserves treatment options in the future," said Dr. Raymond Dattilo in a poster at the Annual Scientific Session of the American College of Cardiology. Minimizing stent use in distal, superficial femoral and popliteal arteries also reduces the risk of stent fracture, said Dr. Dattilo, a cardiologist and director of endovascular medicine at St. Francis Health Center in Topeka, Kan.

He ran the COMPLIANCE 360° study to determine whether orbital atherectomy of calcified femoropopliteal lesions using the Diamondback Orbital Atherectomy System reduced the need for stenting without diminishing 12-month vessel patency when compared with percutaneous balloon angioplasty and selected stent use. The study enrolled 50 patients with 65 femoropopliteal lesions. Randomization resulted in two treatment arms with similar patients and types of lesions (based on degree of calcification and plaque morphology). The only statistically-significant difference between the two treatment arms was the percent of patients with diabetes, which affected 18 (72%) patients randomized to orbital atherectomy and 10 (40%) patients treated with balloon angioplasty and bail-out stenting.

Maximum balloon pressure used during angioplasty was 4 atmospheres in the 25 patients treated with orbital atherectomy, and 9 atmospheres in the 25 patients who did not undergo atherectomy. Two patients treated with atherectomy, (8%) required a bail-out stent, compared with 21 (84%) in the angioplasty group, a statistically significant difference.

At 6 months after treatment, 16 of 22 patients (73%) in the atherectomy group with 6-month follow-up had avoided stent placement, were free from target lesion revascularization, and had no restenosis as assessed by duplex ultrasound. Among 24 patients in the balloon angioplasty group assessed after 6 months, two patients (8%) met these same efficacy criteria.

After 12 months, five patients in the atherectomy group of 20 with 12-month follow-up had restenosis or repeat target lesion revascularization, compared with five of 21 patients with angioplasty. The 12-month results showed that the two strategies resulted in similar rates of long-term vessel patency, but the atherectomy patients avoided stent placement.

The COMPLIANCE 360° study was sponsored by Cardiovascular Systems. Dr. Dattilo said he has received financial support from Cardiovascular Systems.☐

CHICAGO – Treatment of calcified femoropopliteal lesions with orbital atherectomy led to similar 12-month patency as balloon angioplasty but with a reduced need for stenting, in a randomized, controlled study with 50 patients.

Orbital atherectomy changed vessel compliance, which allowed lower pressure balloon dilatation and hence less vessel disruption, which appeared to produce a low rate of restenosis with minimal stent use. "Lower dissection rates and reduced use of bail-out stents preserves treatment options in the future," said Dr. Raymond Dattilo in a poster at the Annual Scientific Session of the American College of Cardiology. Minimizing stent use in distal, superficial femoral and popliteal arteries also reduces the risk of stent fracture, said Dr. Dattilo, a cardiologist and director of endovascular medicine at St. Francis Health Center in Topeka, Kan.

He ran the COMPLIANCE 360° study to determine whether orbital atherectomy of calcified femoropopliteal lesions using the Diamondback Orbital Atherectomy System reduced the need for stenting without diminishing 12-month vessel patency when compared with percutaneous balloon angioplasty and selected stent use. The study enrolled 50 patients with 65 femoropopliteal lesions. Randomization resulted in two treatment arms with similar patients and types of lesions (based on degree of calcification and plaque morphology). The only statistically-significant difference between the two treatment arms was the percent of patients with diabetes, which affected 18 (72%) patients randomized to orbital atherectomy and 10 (40%) patients treated with balloon angioplasty and bail-out stenting.

Maximum balloon pressure used during angioplasty was 4 atmospheres in the 25 patients treated with orbital atherectomy, and 9 atmospheres in the 25 patients who did not undergo atherectomy. Two patients treated with atherectomy, (8%) required a bail-out stent, compared with 21 (84%) in the angioplasty group, a statistically significant difference.

At 6 months after treatment, 16 of 22 patients (73%) in the atherectomy group with 6-month follow-up had avoided stent placement, were free from target lesion revascularization, and had no restenosis as assessed by duplex ultrasound. Among 24 patients in the balloon angioplasty group assessed after 6 months, two patients (8%) met these same efficacy criteria.

After 12 months, five patients in the atherectomy group of 20 with 12-month follow-up had restenosis or repeat target lesion revascularization, compared with five of 21 patients with angioplasty. The 12-month results showed that the two strategies resulted in similar rates of long-term vessel patency, but the atherectomy patients avoided stent placement.

The COMPLIANCE 360° study was sponsored by Cardiovascular Systems. Dr. Dattilo said he has received financial support from Cardiovascular Systems.☐

CHICAGO – Treatment of calcified femoropopliteal lesions with orbital atherectomy led to similar 12-month patency as balloon angioplasty but with a reduced need for stenting, in a randomized, controlled study with 50 patients.

Orbital atherectomy changed vessel compliance, which allowed lower pressure balloon dilatation and hence less vessel disruption, which appeared to produce a low rate of restenosis with minimal stent use. "Lower dissection rates and reduced use of bail-out stents preserves treatment options in the future," said Dr. Raymond Dattilo in a poster at the Annual Scientific Session of the American College of Cardiology. Minimizing stent use in distal, superficial femoral and popliteal arteries also reduces the risk of stent fracture, said Dr. Dattilo, a cardiologist and director of endovascular medicine at St. Francis Health Center in Topeka, Kan.

He ran the COMPLIANCE 360° study to determine whether orbital atherectomy of calcified femoropopliteal lesions using the Diamondback Orbital Atherectomy System reduced the need for stenting without diminishing 12-month vessel patency when compared with percutaneous balloon angioplasty and selected stent use. The study enrolled 50 patients with 65 femoropopliteal lesions. Randomization resulted in two treatment arms with similar patients and types of lesions (based on degree of calcification and plaque morphology). The only statistically-significant difference between the two treatment arms was the percent of patients with diabetes, which affected 18 (72%) patients randomized to orbital atherectomy and 10 (40%) patients treated with balloon angioplasty and bail-out stenting.

Maximum balloon pressure used during angioplasty was 4 atmospheres in the 25 patients treated with orbital atherectomy, and 9 atmospheres in the 25 patients who did not undergo atherectomy. Two patients treated with atherectomy, (8%) required a bail-out stent, compared with 21 (84%) in the angioplasty group, a statistically significant difference.

At 6 months after treatment, 16 of 22 patients (73%) in the atherectomy group with 6-month follow-up had avoided stent placement, were free from target lesion revascularization, and had no restenosis as assessed by duplex ultrasound. Among 24 patients in the balloon angioplasty group assessed after 6 months, two patients (8%) met these same efficacy criteria.

After 12 months, five patients in the atherectomy group of 20 with 12-month follow-up had restenosis or repeat target lesion revascularization, compared with five of 21 patients with angioplasty. The 12-month results showed that the two strategies resulted in similar rates of long-term vessel patency, but the atherectomy patients avoided stent placement.

The COMPLIANCE 360° study was sponsored by Cardiovascular Systems. Dr. Dattilo said he has received financial support from Cardiovascular Systems.☐

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Ms. Palermo and her husband sit in my office at National Jewish Health in Denver. She has come from Florida to our hospital, a nationally known respiratory center, for evaluation of her intractable asthma and allergies.

She is a quiet, sad, middle-aged woman who sits slumped in her chair and looks away frequently, as if to say, "What is the point of this interview?" She minimizes all her symptoms, while her spouse, who sits slightly downstage, provides me with nonverbal support as my questions about depression and anxiety roll out.

Mr. Palermo nods when I ask about sadness, and touches his wife gently when I ask whether her illness has restricted her current activities. She begins to deny social withdrawal, but – with her husband’s gentle prompting – reluctantly agrees.

"But it is because of my illness; I am not mental," she says.

"I understand," I reply. "Anxiety and depression are common in chronic asthma. Any chronic illness is a stress, especially if poorly controlled. Anxiety and depression can occur when people are under stress. Some people have very sensitive airways. How you manage stress and how you manage your asthma and your triggers are important.

"Let’s just say that psychiatrists specialize in this area, because we see plenty of people with asthma who also have anxiety and depression."

About 1 in 10 people with asthma have panic disorder (J. Consult. Clin. Psychol. 2002;70:691-711).

I add that the good news is that depression and anxiety are treatable, and that her quality of life can be improved with psychiatric care.

What can be done in one session? I give a diagnosis, outline a treatment plan, and help the spouse who has been floundering and not knowing what is best to do. I briefly review the couple’s relational functioning by asking the following questions:

• How has the illness changed things between you?

• How do you respond when your spouse gets ill?

• What can your spouse do that will help you get better?

• Can you ask your spouse for help and support?

• Can you work on your spouse’s health problem together?

• It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?

• Are there times in the past where you have successfully solved difficult problems? How did you do that?

These dyadic questions are constructed to encourage relational problem identification, improve communication, and promote solutions. An outline of how to improve the couple’s relational functioning can be provided in a consultation letter that goes to the patient and her primary care physician.

Primary care physicians are pleased to support behavioral health interventions such as increasing exercise, making dietary changes, and stopping smoking. With information about a couple’s relational functioning, primary care physicians can support change in dysfunctional transactions that have evolved around illness symptoms.

Elderly patients and their spouses will sometimes ask whether it is too late to change engrained transactions. Not at all. If family intervention is framed as "a way that a couple can work together to solve the problem of managing chronic illness," change becomes manageable and less daunting. When simple education and supportive education do not work, referral to a skilled family therapist can occur. Most couples and families benefit from brief psychoeducation that is delivered as part of the patient’s appointment.

How do you differentiate which couples need less and which need more help? Try this question: "What was your relationship like before your spouse became ill?

If they respond that they have always had problems, this is an indication that relational dysfunction preceded the stress of chronic illness, and suggests that more in-depth assessment and treatment might be needed.

For practitioners, the goals of family-focused interventions usually include the following (Fam. Syst. Health 2002 [doi:10.1037/h0089481]):

• Help family members agree collaborate on a program of disease management in ways that are consistent with their beliefs and style.

• Help family members manage stress by preventing the disease from dominating family life and discouraging normal developmental and personal goals.

• Help the family deal with the losses that chronic illness can create.

• Mobilize the family’s natural support system to provide education and support for all family members involved in disease management.

• Reduce the social isolation and resulting anxiety and depression that disease management can create in the patient and family members.

• Reorganize the family – with adjustments of roles and expectations as needed – to ensure optimal patient self-care.

A waiting-room handout can also be helpful for families of patients with chronic illness. Because their ability to provide consistent illness management is crucial for the patient’s optimal outcome, we encourage family members to keep the following goals of therapy in mind:

• To help families cope with and manage the continuing stresses inherent in chronic disease management as a team, rather than as individuals.

• To mobilize the patient’s natural support system, to enhance family closeness, to increase mutually supportive interactions among family members, and to build additional extrafamilial support with the goal of improving disease management and the health and well-being of patients and all family members.

• To minimize intrafamilial hostility and criticism, and to reduce the adverse effects of external stress and disease-related trauma on family life.

Family members of the chronically medically ill usually are receptive to meeting with a psychiatrist. Often, the patient is depressed, anxious, or struggling to cope, and the requests of the spouse to get help are frequently dismissed. Patients feel that if their medical condition gets better, they will feel better. All their effort is focused on finding the "right doctor or the right treatment" for their medical problems. Understandably, patients do not want to accept that they have a chronic illness, and they resist thinking about making adjustments to their lives.

Ms. Palermo, however, did seem receptive to change. "So I am not crazy?" she asked. "So there is hope for me?"

"Let’s work on this together," Mr. Palermo said. "We can still enjoy life, even if we can’t do the things we used to do."

I scheduled a further appointment with them to review their relational functioning in more depth, and to clarify their individual and dyadic coping skills. If they are interested, we will work together on the difficulties that they identify. A family systems intervention can be short, focused, and completed in 6-8 sessions.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

— Kerri Wachter

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

— Kerri Wachter

Instead of focusing exclusively on risk factors for youth violence, it’s time to start looking at protective factors.  At least that’s what a CDC expert panel recommended in a special supplement of the American Journal of Preventive Medicine.

Homicide continues to be the second leading cause of death for youth aged15-24, and the leading cause of death for African American youth, according the CDC. More than 700,000 young people aged 10 to 24 were treated in emergency departments in 2010 for injuries sustained due to violence.

While identifying risk factors for teen violence is a necessary component of combating the problem, the experts recognize that it’s also important to identify factors that protect youth against youth embracing violence — such as resilience, positive youth development and community assets. “Most youth, even those living in high risk situations, are not violent and more must be learned about the factors that are helping youth, protecting them from engaging in violent behavior so that others can benefit,” the experts wrote in the supplement.

The CDC convened the Expert Panel on Protective Factors for Youth Violence Perpetration to clarify unresolved definitional and analytic issues on protective factors; review the state of evidence regarding the factors that appropriately can be labeled as direct protective, buffering protective, or both; carry out new analyses of major longitudinal surveys of youth to discover new knowledge about protective factors; an assessing the implications of research identifying protective factors for prevention programs, policies, and future research. This supplement presents the group’s work on direct protective factors — in particular identifying factors that exhibit mostly direct protective effects.

For more information about youth violence in the United States, check out a number of resources available on the CDC’s violence prevention Web page.

— Kerri Wachter

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Median compensation for adult hospitalists rose to $233,855 in 2011, a 6% increase from the year prior, while productivity remained nearly static, according to recently released data. This latest uptick in HM compensation means that hospitalist pay has jumped more than 27% since 2008, when unadjusted figures pegged median hospitalist compensation at $183,900 nationwide.

The data, which excludes academic hospitalists, were reported in the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. The rise comes despite little movement in the number of work relative-value units (wRVUs) hospitalists are producing. In 2011, the median physician wRVU rate was 4,159, a 0.17% drop from the year prior.

"Over time, the industry has recognized there is a strong demand and there is a need for these types of practitioners," says Todd Evenson, MGMA director of data solutions. Evenson says he sees no immediate hurdles to the continued growth of hospitalist compensation, as hospitalists have established themselves as major players in most hospitals.

Although wRVUs might appear stable—they've ticked up 1.26% since 2010—the measure might not be as closely tied to compensation as healthcare reform redefines payment and reimbursement models, Evenson says. For example, bundled payments tied to quality of care and outcomes could have a limited impact on wRVUs but be a major driver of compensation.

Just how high compensation can climb, Evenson says, will depend on "the payment mechanisms that we start to see fall out of the legislation that occurs. ... As that evolves, I can't say I know the ceiling."

The report compiled data on 3,192 full-time hospitalists nationwide. Slightly more than 54% of the respondents worked in hospital-owned practices, while 27% are in physician-owned groups. The rest reported "other" practice models.

The MGMA survey data will be incorporated into SHM's State of Hospital Medicine report, due out later next month. In addition to information on individual physicians collected by MGMA, SHM's report includes group-level data valuable to HM groups, including financial data (subsidies and CPT code distribution) and staffing and scheduling.

Median compensation for adult hospitalists rose to $233,855 in 2011, a 6% increase from the year prior, while productivity remained nearly static, according to recently released data. This latest uptick in HM compensation means that hospitalist pay has jumped more than 27% since 2008, when unadjusted figures pegged median hospitalist compensation at $183,900 nationwide.

The data, which excludes academic hospitalists, were reported in the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. The rise comes despite little movement in the number of work relative-value units (wRVUs) hospitalists are producing. In 2011, the median physician wRVU rate was 4,159, a 0.17% drop from the year prior.

"Over time, the industry has recognized there is a strong demand and there is a need for these types of practitioners," says Todd Evenson, MGMA director of data solutions. Evenson says he sees no immediate hurdles to the continued growth of hospitalist compensation, as hospitalists have established themselves as major players in most hospitals.

Although wRVUs might appear stable—they've ticked up 1.26% since 2010—the measure might not be as closely tied to compensation as healthcare reform redefines payment and reimbursement models, Evenson says. For example, bundled payments tied to quality of care and outcomes could have a limited impact on wRVUs but be a major driver of compensation.

Just how high compensation can climb, Evenson says, will depend on "the payment mechanisms that we start to see fall out of the legislation that occurs. ... As that evolves, I can't say I know the ceiling."

The report compiled data on 3,192 full-time hospitalists nationwide. Slightly more than 54% of the respondents worked in hospital-owned practices, while 27% are in physician-owned groups. The rest reported "other" practice models.

The MGMA survey data will be incorporated into SHM's State of Hospital Medicine report, due out later next month. In addition to information on individual physicians collected by MGMA, SHM's report includes group-level data valuable to HM groups, including financial data (subsidies and CPT code distribution) and staffing and scheduling.

Median compensation for adult hospitalists rose to $233,855 in 2011, a 6% increase from the year prior, while productivity remained nearly static, according to recently released data. This latest uptick in HM compensation means that hospitalist pay has jumped more than 27% since 2008, when unadjusted figures pegged median hospitalist compensation at $183,900 nationwide.

The data, which excludes academic hospitalists, were reported in the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. The rise comes despite little movement in the number of work relative-value units (wRVUs) hospitalists are producing. In 2011, the median physician wRVU rate was 4,159, a 0.17% drop from the year prior.

"Over time, the industry has recognized there is a strong demand and there is a need for these types of practitioners," says Todd Evenson, MGMA director of data solutions. Evenson says he sees no immediate hurdles to the continued growth of hospitalist compensation, as hospitalists have established themselves as major players in most hospitals.

Although wRVUs might appear stable—they've ticked up 1.26% since 2010—the measure might not be as closely tied to compensation as healthcare reform redefines payment and reimbursement models, Evenson says. For example, bundled payments tied to quality of care and outcomes could have a limited impact on wRVUs but be a major driver of compensation.

Just how high compensation can climb, Evenson says, will depend on "the payment mechanisms that we start to see fall out of the legislation that occurs. ... As that evolves, I can't say I know the ceiling."

The report compiled data on 3,192 full-time hospitalists nationwide. Slightly more than 54% of the respondents worked in hospital-owned practices, while 27% are in physician-owned groups. The rest reported "other" practice models.

The MGMA survey data will be incorporated into SHM's State of Hospital Medicine report, due out later next month. In addition to information on individual physicians collected by MGMA, SHM's report includes group-level data valuable to HM groups, including financial data (subsidies and CPT code distribution) and staffing and scheduling.

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Unpublished data from a British study of dedicated psychiatric hospitalists shows clear improvements in 17 of 23 measured outcomes, according to the study's lead researcher.

Julian Beezhold, MD, a consultant in emergency psychiatry at Norfolk and Suffolk NHS Foundation Trust (formerly Norfolk and Waveney Mental Health Foundation Trust) presented the data at the annual meeting of the American Psychiatric Association in May in Philadelphia.

The researchers investigated 5,000 patients over nearly eight years. By switching coverage from 13 consultant psychiatrists to dedicated-unit psychiatric hospitalists, the study showed lengths of stay on two inpatient psychiatry units cut in half (just over 11 days from nearly 22 days). Researchers also found reductions in violent episodes and self-harm. Demand for beds on the units declined steadily during the study, resulting in consolidation down to one unit.

"We found overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold says. "We found that dedicated doctors are able to achieve better quality of care simply because they are there, able to respond to crises and to change treatment plans more quickly when that is needed."

Psychiatry practice differs from most specialty practice in the United Kingdom, he adds, but the recent trend has been toward a larger division between office-based and hospital-based practices.

In the U.S., models of coverage for acute psychiatric patients include specialized psychiatric hospitals, dedicated psychiatric units within general hospitals, and patients admitted to general hospital units whose psychiatric care is managed by consultation-liaison psychiatrists, says Abigail Donovan, MD, a psychiatrist at Massachusetts General Hospital in Boston.

"At Mass General, we have access to all of these approaches," she says, adding that the new data "reinforces the way we've been doing things with dedicated psychiatric hospitalists—showing the tangible results of this model."

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

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

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

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

Now that the Supreme Court has upheld the constitutionality of most of the Affordable Care Act, it behooves us to take a closer look at that law’s potential impact on physicians.

Last year I wrote that most physicians would see few changes in the near term, largely because the essential changes sought by physicians – tort reform, and revision of the ill-conceived Medicare compensation rules that threaten to cut payments by 25% every few months – were never addressed.

That said, many of the law’s provisions did favor physicians in the short term. As of last year, insurers could no longer cancel policies already issued, nor could they exclude applicants who were previously uninsurable because of chronic ailments. This provision indirectly triggered the Supreme Court’s involvement, since insurers cannot afford to cover patients with existing conditions without a mandate that all individuals purchase coverage. (Without that, healthy people would have no reason to buy insurance until they got sick, the equivalent of waiting to buy fire insurance until your house was aflame.) The case before the court centered on the constitutionality of the individual mandate, which was upheld.

Other highlights of the Affordable Care Act include prohibition of lifetime coverage limits and guaranteed coverage of dependents on their parents’ policies until they are 26 years old. Early retirees do not have to risk going uninsured until they qualify for Medicare, and Medicare’s infamous "doughnut hole" is gradually closing. Small businesses now receive tax-credit incentives to insure their workers.

All of this adds up to more paying patients, with better insurance. However, as additional provisions come online this year, the long-range potential impact on private practitioners becomes more uncertain, and more ominous.

"Physician payment reforms" will begin to appear. Although no one yet knows exactly what that means, the law mandates the formation of "accountable care organizations" to "improve quality and efficiency of care." The buzzword will be outcomes – the better your measurable results, the higher your reimbursements. This is supposed to reward quality of care over volume of procedures, but the result could be exactly the opposite if less-motivated providers cherry pick the quick, easy, least-risky cases and refer anything time consuming or complex to tertiary centers.

In 2013, Medicare will introduce a national program of payment bundling. A single hospital admission, for example, will be paid with a single bundled payment that will have to be divided among the hospital and treating physicians. The idea, ostensibly, is to encourage physicians and hospitals to work together to "better coordinate patient care," but arguments over how to divide the pie could, once again, have the opposite effect.

And it won’t take long for hospitals to figure out that they can keep the whole pie if the partnering physicians are their employees. So look for more private offices to be absorbed by hospitals, which already employ almost a third of all physicians.

By 2014, states will have to set up "SHOP Exchanges" (Small Business Health Options Programs), allowing small businesses (defined as 100 employees or less) to pool their resources to buy health insurance. Most people will, by then, be required to have health insurance coverage or pay a fine if they don’t. Employers not offering coverage will face fines and other penalties, and health insurance companies will begin paying a fee based on their market share, which will no doubt be passed along to those they insure, nullifying some of the savings garnered by the SHOP Exchanges, which are already predicted to be marginal.

The big Medicaid expansion will be in place by 2014 as well, but few physicians are likely to accept more Medicaid patients unless compensation increases. That is unlikely to happen without substantial reductions in the states’ woeful budget deficits – and probably not even then, since state governments already complain about their Medicaid budgets. Hospitals, with their deeper pockets, will get most of the new Medicaid patients and will hire even more physicians away from private practice to treat them.

If this sounds like a potential problem for private practice as we know it, it is. Then again, it’s too early for reliable predictions: The recent Supreme Court decision notwithstanding, there is a lot of potential leeway in the new law’s future specifications; and a lot can happen between now and full implementation, from modifications and amendments to outright repeal. Only time will tell.

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

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

Dr. Peter Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago.