Perspectives

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

The primary comorbidity of psoriasis is psoriatic arthritis (PsA). The true incidence of PsA has long been an issue of debate. To estimate the incidence of PsA in patients with psoriasis and to identify risk factors for its development, Eder at al conducted a prospective cohort study involving psoriasis patients without arthritis at study entry that was published online in Arthritis & Rheumatology.

The investigators collected information from patients concerning lifestyle habits, comorbidities, psoriasis activity, and medications. The patients were evaluated at enrollment and annually. A general physical examination, assessment of psoriasis severity, and assessment for the development of musculoskeletal symptoms were conducted at each visit. A diagnosis of PsA was determined by a rheumatologist on the basis of clinical, laboratory, and imaging data; patients also had to fulfill the CASPAR (Classification Criteria for Psoriatic Arthritis) criteria (confirmed cases). The annual incidence of PsA was estimated using an event per person-years analysis.

The results from 464 patients who were followed for 8 years were analyzed. The annual incidence of confirmed PsA was 2.7 per 100 patients with psoriasis (95% CI, 2.1-3.6). Overall, 51 patients developed PsA over the course of the study and an additional 9 were considered suspect cases.

The following baseline variables were associated with the development of PsA in multivariate analysis: severe psoriasis (relative risk [RR], 5.4; P=.006), low level of education (college/university vs high school incomplete: RR, 4.5; P=.005; high school education vs high school incomplete: RR, 3.3; P=.049), and use of retinoid medications (RR, 3.4; P=.02). In addition, psoriatic nail pitting (RR, 2.5; P=.002) and uveitis (RR, 31.5; P<.001) were time-dependent predictors for PsA development.

The authors concluded that the incidence of PsA in patients with psoriasis was higher than previously reported. Possible factors for this finding might include differences in patient recruitment as well as self-reported PsA diagnoses.

What’s the issue?

This prospective analysis is interesting. The incidence of PsA was higher than reported. It reinforces the need for continual evaluation of joint symptoms in patients with psoriasis, even if they have had psoriasis for many years. How will this analysis impact your evaluation of psoriatic patients?

We want to know your views! Tell us what you think.

The primary comorbidity of psoriasis is psoriatic arthritis (PsA). The true incidence of PsA has long been an issue of debate. To estimate the incidence of PsA in patients with psoriasis and to identify risk factors for its development, Eder at al conducted a prospective cohort study involving psoriasis patients without arthritis at study entry that was published online in Arthritis & Rheumatology.

The investigators collected information from patients concerning lifestyle habits, comorbidities, psoriasis activity, and medications. The patients were evaluated at enrollment and annually. A general physical examination, assessment of psoriasis severity, and assessment for the development of musculoskeletal symptoms were conducted at each visit. A diagnosis of PsA was determined by a rheumatologist on the basis of clinical, laboratory, and imaging data; patients also had to fulfill the CASPAR (Classification Criteria for Psoriatic Arthritis) criteria (confirmed cases). The annual incidence of PsA was estimated using an event per person-years analysis.

The results from 464 patients who were followed for 8 years were analyzed. The annual incidence of confirmed PsA was 2.7 per 100 patients with psoriasis (95% CI, 2.1-3.6). Overall, 51 patients developed PsA over the course of the study and an additional 9 were considered suspect cases.

The following baseline variables were associated with the development of PsA in multivariate analysis: severe psoriasis (relative risk [RR], 5.4; P=.006), low level of education (college/university vs high school incomplete: RR, 4.5; P=.005; high school education vs high school incomplete: RR, 3.3; P=.049), and use of retinoid medications (RR, 3.4; P=.02). In addition, psoriatic nail pitting (RR, 2.5; P=.002) and uveitis (RR, 31.5; P<.001) were time-dependent predictors for PsA development.

The authors concluded that the incidence of PsA in patients with psoriasis was higher than previously reported. Possible factors for this finding might include differences in patient recruitment as well as self-reported PsA diagnoses.

What’s the issue?

This prospective analysis is interesting. The incidence of PsA was higher than reported. It reinforces the need for continual evaluation of joint symptoms in patients with psoriasis, even if they have had psoriasis for many years. How will this analysis impact your evaluation of psoriatic patients?

We want to know your views! Tell us what you think.

The primary comorbidity of psoriasis is psoriatic arthritis (PsA). The true incidence of PsA has long been an issue of debate. To estimate the incidence of PsA in patients with psoriasis and to identify risk factors for its development, Eder at al conducted a prospective cohort study involving psoriasis patients without arthritis at study entry that was published online in Arthritis & Rheumatology.

The investigators collected information from patients concerning lifestyle habits, comorbidities, psoriasis activity, and medications. The patients were evaluated at enrollment and annually. A general physical examination, assessment of psoriasis severity, and assessment for the development of musculoskeletal symptoms were conducted at each visit. A diagnosis of PsA was determined by a rheumatologist on the basis of clinical, laboratory, and imaging data; patients also had to fulfill the CASPAR (Classification Criteria for Psoriatic Arthritis) criteria (confirmed cases). The annual incidence of PsA was estimated using an event per person-years analysis.

The results from 464 patients who were followed for 8 years were analyzed. The annual incidence of confirmed PsA was 2.7 per 100 patients with psoriasis (95% CI, 2.1-3.6). Overall, 51 patients developed PsA over the course of the study and an additional 9 were considered suspect cases.

The following baseline variables were associated with the development of PsA in multivariate analysis: severe psoriasis (relative risk [RR], 5.4; P=.006), low level of education (college/university vs high school incomplete: RR, 4.5; P=.005; high school education vs high school incomplete: RR, 3.3; P=.049), and use of retinoid medications (RR, 3.4; P=.02). In addition, psoriatic nail pitting (RR, 2.5; P=.002) and uveitis (RR, 31.5; P<.001) were time-dependent predictors for PsA development.

The authors concluded that the incidence of PsA in patients with psoriasis was higher than previously reported. Possible factors for this finding might include differences in patient recruitment as well as self-reported PsA diagnoses.

What’s the issue?

This prospective analysis is interesting. The incidence of PsA was higher than reported. It reinforces the need for continual evaluation of joint symptoms in patients with psoriasis, even if they have had psoriasis for many years. How will this analysis impact your evaluation of psoriatic patients?

We want to know your views! Tell us what you think.

In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

We want to know your views! Tell us what you think.

In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

We want to know your views! Tell us what you think.

In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

We want to know your views! Tell us what you think.

After 12 years as a private practice ob.gyn., Dr. Brigid McCue was beginning to feel overwhelmed. She loved her work, but keeping up with the kaleidoscope of care components and ever-changing clinical developments was daunting.

“I felt like it was hard to stay really good at all the different aspects of care,” Dr. McCue said. “I was doing fine with obstetrics, and I felt like I was managing my office well, but it’s hard to stay on top of the latest developments, especially in surgical areas. The other thing that was really hard to keep up with was the business aspect of medicine and running a private practice.”

So when an opportunity presented itself, Dr. McCue leaped at the chance to narrow her expertise to obstetrical hospital medicine. She helped establish the ob.gyn. hospitalist program at Beth Israel Deaconess Hospital-Plymouth in Massachusetts, and now serves as chief of ob.gyn. and midwifery for the hospital.

Beth Israel Deaconess Hospital-Plymouth

“I love the fact that I now have the time to get really good at [what] I really like, [such as] labor and delivery,” said Dr. McCue, who is president of the Society of OB/GYN Hospitalists. “Since I made this change, I feel like I’m so much more on top of things. I do simulations here on my unit over things like shoulder dystocia. When I was in private practice, I would go to one meeting a year and pray that I never had a shoulder dystocia [case]. Now I really understand the whole process and I take the time to run through that with my midwives and my other nurses and doctors.”

Dr. McCue is one of a growing number of ob.gyns. who have chosen to target their expertise to a single subspecialty or concentrated practice area. Data show subspecialization is on the rise in ob.gyn.

From 1985 to 2015, certificates issued by the American Board of Obstetrics and Gynecology (ABOG) for gynecologic oncology nearly tripled, and certificates issued for reproductive endocrinology and infertility more than doubled, according to data provided by the American Board of Medical Specialties (ABMS). Certificates issued for maternal-fetal medicine rose from 35 in 1985 to 100 in 2015.

Opportunities for ob.gyns. to subspecialize have steadily increased over the last 50 years. The subspecialties of maternal-fetal medicine, gynecologic oncology, and reproductive endocrinology and infertility were first approved for certification by ABOG in 1973. In 1983, ABMS approved a certificate of “added qualification” for ob.gyns. who complete fellowships in critical care. In 1995, ABOG and the American Board of Urology started the subspecialty of female pelvic medicine and reconstructive surgery, which was approved for certification by ABMS in 2011.

ABMS also approved a certificate of “added qualification” for ob.gyns. who complete a fellowship in hospice and palliative medicine in 2008. And fellowships now exist for minimally invasive gynecologic surgery and ob.gyn. hospital medicine.

The reasons that ob.gyns. choose to subspecialize are multifold, said Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill., and one of the medical editors of the Ob.Gyn. News column, Master Class.

“Physicians subspecialize so that they can provide more medical and surgical expertise for a given population,” he said. “Secondly, physicians may be driven to subspecialize for lifestyle reasons. Generalists refer to subspecialists when technical expertise is desired to help with a clinical situation and potentially reduce medical legal risk.”

Ultimately, it’s patients who benefit from the increased care provided by subspecialists, noted Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology, and women’s health at Rutgers, the State University of New Jersey, Newark. Generalist ob.gyns. are tremendously knowledgeable and experienced, he said, but there’s no way for them to know every area, he said. It’s the difference between someone who might be doing a complicated surgery one or twice a year versus someone who is doing that surgery once or twice a week, he added.

“That is ultimately helpful for patients,” Dr. Einstein said. “It’s really about outcomes. This is all better for the patient. That’s the most important thing.”

Not every consequence of subspecialization is positive, however.

“As with everything, subspecialization has both positive and negative effects,” said Dr. Sandra Ann Carson, vice president for education at the American College of Obstetricians and Gynecologists. “The more time one has to focus on a small area, the better that area becomes. However, if all you have is a hammer, everything looks like a nail. The larger population may not need the care that someone with a rare disease may need.”

Dr. Miller refers to this challenge as “losing the forest.” He explains that subspecialists sometimes become so focused on their area of expertise, that they may overlook suitable treatment plans with which they are unfamiliar. An infertility specialist, for example, who neglects to consider a minimally invasive surgical procedure that could allow a patient to become pregnant naturally and instead recommends in vitro fertilization treatment.

“The infertility specialist does not have that particular skill and therefore directs that patient to IVF,” Dr. Miller said. “In the process of subspecializing, we have a tendency to lose the forest and look only at the trees.”

Finding a job is another challenge for the growing number of subspecialists. In many cases, fellowship-trained minimally invasive gynecologic surgeons may have to go back to practicing general gynecology because of a lack of positions, Dr. Miller said.

“We have to be careful that we do not “oversubspecialize” so that we are oversaturating the field,” he said.

In the future, the number of ob.gyn subspecialists will likely continue to grow and become more refined, said Dr. Dana M. Chase, a gynecologic oncologist at the University of Arizona Cancer Center in Phoenix.

“I think subspecialists will continue to become more and more developed,” Dr. Chase said. “Perhaps, some areas like family planning or minimally invasive surgery may grow further and become board certified.”

Dr. Carson foresees subspecialization becoming more focused on centralized teaching hospitals, with patients who need special care being sent to these hubs.

“Telemedicine and long-distance communication with a local obstetrician-gynecologist managing the whole patient will allow the best of both worlds,” she said.

Regardless of how subspecialist growth evolves, general ob.gyns. and other primary care physicians will always be needed, said Dr. Mary E. Norton, a maternal-fetal medicine specialist and clinical geneticist at the Fetal Treatment Center at the University of California, San Francisco.

“With increasing complexity, experts are needed to interpret advances,” Dr. Norton said. “However, patients also need a ‘medical home’ and primary provider who sees the big picture, and provides ongoing care beyond a single pregnancy or pregnancy complication.”

Why I chose to subspecialize

“I went to medical school with a particular interest in obstetrics. Once there, I was exposed to pediatrics and to high-risk OB, which I found to be fascinating. I particularly enjoyed my exposure to genetics during my pediatrics rotation and cared for a few children with genetic diseases that had a big impact and made a substantial impression on me. I ultimately decided to pursue an ob.gyn. residency and loved the OB part, particularly the prenatal genetics and high-risk OB. I found the balance of maternal and fetal medicine to be an exciting opportunity to care for two patients. I did an elective in prenatal diagnosis during my third year, including a bit of research, and was hooked.”

Dr. Mary E. Norton, a maternal-fetal medicine specialist and a clinical geneticist at the Fetal Treatment Center at the University of California, San Francisco.

“In my second year of residency, I became really interested in [gynecology-oncology] because I was fascinated by the surgery and interested in the chemotherapy practice, which is interesting because there’s always new research and new agents and interesting changes in how you treat the various cancers. It’s a very comprehensive, research-based field and that was fascinating to me. It’s a very busy subspecialty with very complex cases on multiple levels. You do these radical surgeries but then you have to be really involved in the choice for which chemotherapy agent to use, what type of radiation to give, and you also get really involved with the families ... Every case is so different and you treat women who are 16 years old, but you also treat women who are 96 years old. You see women from all walks of life with all sorts of different issues. The ability to really get involved with cancer research is a great part of the field.”

Dr. Dana M. Chase, a gynecologic oncologist at the University of Arizona Cancer Center, Phoenix.

“I took the opportunity to come to a new program where they were looking for an ob.gyn. hospitalist. That was exciting for me because I got to help establish the program... I feel like we’re a better department because I’m here monitoring labor, but I’m also writing protocols and making sure everyone is up to date. And I still get to do what I love the most, which is birth and babies.”

Dr. Brigid McCue, an ob.gyn. hospitalist and chief of ob.gyn. and midwifery, Beth Israel Deaconess Hospital-Plymouth, Massachusetts.

“I never considered delivering babies for the rest of my life. I was always focused on treating infertile couples. I completed my fellowship in reproductive endocrinology-infertility at the University of Pennsylvania, Philadelphia, at a time when in vitro fertilization was in its infancy and the laparoscope and hysteroscope were virtually diagnostic tools ... As IVF became more successful, I felt it was essential to add this expertise to my armamentarium ... It is truly gratifying to be part of a subspecialty that has advanced so far that the majority of our patients are able to achieve pregnancy via IVF.”

Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill.

“During medical school, I was very interested in the surgical aspects of patient care. When I rotated in gyn-oncology – now knowing that I rotated with some of the best gyn-oncologists who ever practiced – I found myself drawn to the complexity of surgery, acuity of the patients, and the close relationships gyn-oncologists have with their patients. It hit me like a brick that this was the specialty for me. During my residency and fellowship, I was particularly drawn to the multiple modalities we use to treat cancers. I relished the idea that through clinical trials, gyn-oncologists keep pushing the bar to solve the cancer problem. What we do now is different than what we did 5 years ago. It keeps us professionally challenged all the time.”

Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology and women’s health at Rutgers, the State University of New Jersey, Newark.

Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.

[email protected]

On Twitter @legal_med

After 12 years as a private practice ob.gyn., Dr. Brigid McCue was beginning to feel overwhelmed. She loved her work, but keeping up with the kaleidoscope of care components and ever-changing clinical developments was daunting.

“I felt like it was hard to stay really good at all the different aspects of care,” Dr. McCue said. “I was doing fine with obstetrics, and I felt like I was managing my office well, but it’s hard to stay on top of the latest developments, especially in surgical areas. The other thing that was really hard to keep up with was the business aspect of medicine and running a private practice.”

So when an opportunity presented itself, Dr. McCue leaped at the chance to narrow her expertise to obstetrical hospital medicine. She helped establish the ob.gyn. hospitalist program at Beth Israel Deaconess Hospital-Plymouth in Massachusetts, and now serves as chief of ob.gyn. and midwifery for the hospital.

Beth Israel Deaconess Hospital-Plymouth

“I love the fact that I now have the time to get really good at [what] I really like, [such as] labor and delivery,” said Dr. McCue, who is president of the Society of OB/GYN Hospitalists. “Since I made this change, I feel like I’m so much more on top of things. I do simulations here on my unit over things like shoulder dystocia. When I was in private practice, I would go to one meeting a year and pray that I never had a shoulder dystocia [case]. Now I really understand the whole process and I take the time to run through that with my midwives and my other nurses and doctors.”

Dr. McCue is one of a growing number of ob.gyns. who have chosen to target their expertise to a single subspecialty or concentrated practice area. Data show subspecialization is on the rise in ob.gyn.

From 1985 to 2015, certificates issued by the American Board of Obstetrics and Gynecology (ABOG) for gynecologic oncology nearly tripled, and certificates issued for reproductive endocrinology and infertility more than doubled, according to data provided by the American Board of Medical Specialties (ABMS). Certificates issued for maternal-fetal medicine rose from 35 in 1985 to 100 in 2015.

Opportunities for ob.gyns. to subspecialize have steadily increased over the last 50 years. The subspecialties of maternal-fetal medicine, gynecologic oncology, and reproductive endocrinology and infertility were first approved for certification by ABOG in 1973. In 1983, ABMS approved a certificate of “added qualification” for ob.gyns. who complete fellowships in critical care. In 1995, ABOG and the American Board of Urology started the subspecialty of female pelvic medicine and reconstructive surgery, which was approved for certification by ABMS in 2011.

ABMS also approved a certificate of “added qualification” for ob.gyns. who complete a fellowship in hospice and palliative medicine in 2008. And fellowships now exist for minimally invasive gynecologic surgery and ob.gyn. hospital medicine.

The reasons that ob.gyns. choose to subspecialize are multifold, said Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill., and one of the medical editors of the Ob.Gyn. News column, Master Class.

“Physicians subspecialize so that they can provide more medical and surgical expertise for a given population,” he said. “Secondly, physicians may be driven to subspecialize for lifestyle reasons. Generalists refer to subspecialists when technical expertise is desired to help with a clinical situation and potentially reduce medical legal risk.”

Ultimately, it’s patients who benefit from the increased care provided by subspecialists, noted Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology, and women’s health at Rutgers, the State University of New Jersey, Newark. Generalist ob.gyns. are tremendously knowledgeable and experienced, he said, but there’s no way for them to know every area, he said. It’s the difference between someone who might be doing a complicated surgery one or twice a year versus someone who is doing that surgery once or twice a week, he added.

“That is ultimately helpful for patients,” Dr. Einstein said. “It’s really about outcomes. This is all better for the patient. That’s the most important thing.”

Not every consequence of subspecialization is positive, however.

“As with everything, subspecialization has both positive and negative effects,” said Dr. Sandra Ann Carson, vice president for education at the American College of Obstetricians and Gynecologists. “The more time one has to focus on a small area, the better that area becomes. However, if all you have is a hammer, everything looks like a nail. The larger population may not need the care that someone with a rare disease may need.”

Dr. Miller refers to this challenge as “losing the forest.” He explains that subspecialists sometimes become so focused on their area of expertise, that they may overlook suitable treatment plans with which they are unfamiliar. An infertility specialist, for example, who neglects to consider a minimally invasive surgical procedure that could allow a patient to become pregnant naturally and instead recommends in vitro fertilization treatment.

“The infertility specialist does not have that particular skill and therefore directs that patient to IVF,” Dr. Miller said. “In the process of subspecializing, we have a tendency to lose the forest and look only at the trees.”

Finding a job is another challenge for the growing number of subspecialists. In many cases, fellowship-trained minimally invasive gynecologic surgeons may have to go back to practicing general gynecology because of a lack of positions, Dr. Miller said.

“We have to be careful that we do not “oversubspecialize” so that we are oversaturating the field,” he said.

In the future, the number of ob.gyn subspecialists will likely continue to grow and become more refined, said Dr. Dana M. Chase, a gynecologic oncologist at the University of Arizona Cancer Center in Phoenix.

“I think subspecialists will continue to become more and more developed,” Dr. Chase said. “Perhaps, some areas like family planning or minimally invasive surgery may grow further and become board certified.”

Dr. Carson foresees subspecialization becoming more focused on centralized teaching hospitals, with patients who need special care being sent to these hubs.

“Telemedicine and long-distance communication with a local obstetrician-gynecologist managing the whole patient will allow the best of both worlds,” she said.

Regardless of how subspecialist growth evolves, general ob.gyns. and other primary care physicians will always be needed, said Dr. Mary E. Norton, a maternal-fetal medicine specialist and clinical geneticist at the Fetal Treatment Center at the University of California, San Francisco.

“With increasing complexity, experts are needed to interpret advances,” Dr. Norton said. “However, patients also need a ‘medical home’ and primary provider who sees the big picture, and provides ongoing care beyond a single pregnancy or pregnancy complication.”

Why I chose to subspecialize

“I went to medical school with a particular interest in obstetrics. Once there, I was exposed to pediatrics and to high-risk OB, which I found to be fascinating. I particularly enjoyed my exposure to genetics during my pediatrics rotation and cared for a few children with genetic diseases that had a big impact and made a substantial impression on me. I ultimately decided to pursue an ob.gyn. residency and loved the OB part, particularly the prenatal genetics and high-risk OB. I found the balance of maternal and fetal medicine to be an exciting opportunity to care for two patients. I did an elective in prenatal diagnosis during my third year, including a bit of research, and was hooked.”

Dr. Mary E. Norton, a maternal-fetal medicine specialist and a clinical geneticist at the Fetal Treatment Center at the University of California, San Francisco.

“In my second year of residency, I became really interested in [gynecology-oncology] because I was fascinated by the surgery and interested in the chemotherapy practice, which is interesting because there’s always new research and new agents and interesting changes in how you treat the various cancers. It’s a very comprehensive, research-based field and that was fascinating to me. It’s a very busy subspecialty with very complex cases on multiple levels. You do these radical surgeries but then you have to be really involved in the choice for which chemotherapy agent to use, what type of radiation to give, and you also get really involved with the families ... Every case is so different and you treat women who are 16 years old, but you also treat women who are 96 years old. You see women from all walks of life with all sorts of different issues. The ability to really get involved with cancer research is a great part of the field.”

Dr. Dana M. Chase, a gynecologic oncologist at the University of Arizona Cancer Center, Phoenix.

“I took the opportunity to come to a new program where they were looking for an ob.gyn. hospitalist. That was exciting for me because I got to help establish the program... I feel like we’re a better department because I’m here monitoring labor, but I’m also writing protocols and making sure everyone is up to date. And I still get to do what I love the most, which is birth and babies.”

Dr. Brigid McCue, an ob.gyn. hospitalist and chief of ob.gyn. and midwifery, Beth Israel Deaconess Hospital-Plymouth, Massachusetts.

“I never considered delivering babies for the rest of my life. I was always focused on treating infertile couples. I completed my fellowship in reproductive endocrinology-infertility at the University of Pennsylvania, Philadelphia, at a time when in vitro fertilization was in its infancy and the laparoscope and hysteroscope were virtually diagnostic tools ... As IVF became more successful, I felt it was essential to add this expertise to my armamentarium ... It is truly gratifying to be part of a subspecialty that has advanced so far that the majority of our patients are able to achieve pregnancy via IVF.”

Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill.

“During medical school, I was very interested in the surgical aspects of patient care. When I rotated in gyn-oncology – now knowing that I rotated with some of the best gyn-oncologists who ever practiced – I found myself drawn to the complexity of surgery, acuity of the patients, and the close relationships gyn-oncologists have with their patients. It hit me like a brick that this was the specialty for me. During my residency and fellowship, I was particularly drawn to the multiple modalities we use to treat cancers. I relished the idea that through clinical trials, gyn-oncologists keep pushing the bar to solve the cancer problem. What we do now is different than what we did 5 years ago. It keeps us professionally challenged all the time.”

Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology and women’s health at Rutgers, the State University of New Jersey, Newark.

Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.

[email protected]

On Twitter @legal_med

After 12 years as a private practice ob.gyn., Dr. Brigid McCue was beginning to feel overwhelmed. She loved her work, but keeping up with the kaleidoscope of care components and ever-changing clinical developments was daunting.

“I felt like it was hard to stay really good at all the different aspects of care,” Dr. McCue said. “I was doing fine with obstetrics, and I felt like I was managing my office well, but it’s hard to stay on top of the latest developments, especially in surgical areas. The other thing that was really hard to keep up with was the business aspect of medicine and running a private practice.”

So when an opportunity presented itself, Dr. McCue leaped at the chance to narrow her expertise to obstetrical hospital medicine. She helped establish the ob.gyn. hospitalist program at Beth Israel Deaconess Hospital-Plymouth in Massachusetts, and now serves as chief of ob.gyn. and midwifery for the hospital.

Beth Israel Deaconess Hospital-Plymouth

“I love the fact that I now have the time to get really good at [what] I really like, [such as] labor and delivery,” said Dr. McCue, who is president of the Society of OB/GYN Hospitalists. “Since I made this change, I feel like I’m so much more on top of things. I do simulations here on my unit over things like shoulder dystocia. When I was in private practice, I would go to one meeting a year and pray that I never had a shoulder dystocia [case]. Now I really understand the whole process and I take the time to run through that with my midwives and my other nurses and doctors.”

Dr. McCue is one of a growing number of ob.gyns. who have chosen to target their expertise to a single subspecialty or concentrated practice area. Data show subspecialization is on the rise in ob.gyn.

From 1985 to 2015, certificates issued by the American Board of Obstetrics and Gynecology (ABOG) for gynecologic oncology nearly tripled, and certificates issued for reproductive endocrinology and infertility more than doubled, according to data provided by the American Board of Medical Specialties (ABMS). Certificates issued for maternal-fetal medicine rose from 35 in 1985 to 100 in 2015.

Opportunities for ob.gyns. to subspecialize have steadily increased over the last 50 years. The subspecialties of maternal-fetal medicine, gynecologic oncology, and reproductive endocrinology and infertility were first approved for certification by ABOG in 1973. In 1983, ABMS approved a certificate of “added qualification” for ob.gyns. who complete fellowships in critical care. In 1995, ABOG and the American Board of Urology started the subspecialty of female pelvic medicine and reconstructive surgery, which was approved for certification by ABMS in 2011.

ABMS also approved a certificate of “added qualification” for ob.gyns. who complete a fellowship in hospice and palliative medicine in 2008. And fellowships now exist for minimally invasive gynecologic surgery and ob.gyn. hospital medicine.

The reasons that ob.gyns. choose to subspecialize are multifold, said Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill., and one of the medical editors of the Ob.Gyn. News column, Master Class.

“Physicians subspecialize so that they can provide more medical and surgical expertise for a given population,” he said. “Secondly, physicians may be driven to subspecialize for lifestyle reasons. Generalists refer to subspecialists when technical expertise is desired to help with a clinical situation and potentially reduce medical legal risk.”

Ultimately, it’s patients who benefit from the increased care provided by subspecialists, noted Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology, and women’s health at Rutgers, the State University of New Jersey, Newark. Generalist ob.gyns. are tremendously knowledgeable and experienced, he said, but there’s no way for them to know every area, he said. It’s the difference between someone who might be doing a complicated surgery one or twice a year versus someone who is doing that surgery once or twice a week, he added.

“That is ultimately helpful for patients,” Dr. Einstein said. “It’s really about outcomes. This is all better for the patient. That’s the most important thing.”

Not every consequence of subspecialization is positive, however.

“As with everything, subspecialization has both positive and negative effects,” said Dr. Sandra Ann Carson, vice president for education at the American College of Obstetricians and Gynecologists. “The more time one has to focus on a small area, the better that area becomes. However, if all you have is a hammer, everything looks like a nail. The larger population may not need the care that someone with a rare disease may need.”

Dr. Miller refers to this challenge as “losing the forest.” He explains that subspecialists sometimes become so focused on their area of expertise, that they may overlook suitable treatment plans with which they are unfamiliar. An infertility specialist, for example, who neglects to consider a minimally invasive surgical procedure that could allow a patient to become pregnant naturally and instead recommends in vitro fertilization treatment.

“The infertility specialist does not have that particular skill and therefore directs that patient to IVF,” Dr. Miller said. “In the process of subspecializing, we have a tendency to lose the forest and look only at the trees.”

Finding a job is another challenge for the growing number of subspecialists. In many cases, fellowship-trained minimally invasive gynecologic surgeons may have to go back to practicing general gynecology because of a lack of positions, Dr. Miller said.

“We have to be careful that we do not “oversubspecialize” so that we are oversaturating the field,” he said.

In the future, the number of ob.gyn subspecialists will likely continue to grow and become more refined, said Dr. Dana M. Chase, a gynecologic oncologist at the University of Arizona Cancer Center in Phoenix.

“I think subspecialists will continue to become more and more developed,” Dr. Chase said. “Perhaps, some areas like family planning or minimally invasive surgery may grow further and become board certified.”

Dr. Carson foresees subspecialization becoming more focused on centralized teaching hospitals, with patients who need special care being sent to these hubs.

“Telemedicine and long-distance communication with a local obstetrician-gynecologist managing the whole patient will allow the best of both worlds,” she said.

Regardless of how subspecialist growth evolves, general ob.gyns. and other primary care physicians will always be needed, said Dr. Mary E. Norton, a maternal-fetal medicine specialist and clinical geneticist at the Fetal Treatment Center at the University of California, San Francisco.

“With increasing complexity, experts are needed to interpret advances,” Dr. Norton said. “However, patients also need a ‘medical home’ and primary provider who sees the big picture, and provides ongoing care beyond a single pregnancy or pregnancy complication.”

Why I chose to subspecialize

“I went to medical school with a particular interest in obstetrics. Once there, I was exposed to pediatrics and to high-risk OB, which I found to be fascinating. I particularly enjoyed my exposure to genetics during my pediatrics rotation and cared for a few children with genetic diseases that had a big impact and made a substantial impression on me. I ultimately decided to pursue an ob.gyn. residency and loved the OB part, particularly the prenatal genetics and high-risk OB. I found the balance of maternal and fetal medicine to be an exciting opportunity to care for two patients. I did an elective in prenatal diagnosis during my third year, including a bit of research, and was hooked.”

Dr. Mary E. Norton, a maternal-fetal medicine specialist and a clinical geneticist at the Fetal Treatment Center at the University of California, San Francisco.

“In my second year of residency, I became really interested in [gynecology-oncology] because I was fascinated by the surgery and interested in the chemotherapy practice, which is interesting because there’s always new research and new agents and interesting changes in how you treat the various cancers. It’s a very comprehensive, research-based field and that was fascinating to me. It’s a very busy subspecialty with very complex cases on multiple levels. You do these radical surgeries but then you have to be really involved in the choice for which chemotherapy agent to use, what type of radiation to give, and you also get really involved with the families ... Every case is so different and you treat women who are 16 years old, but you also treat women who are 96 years old. You see women from all walks of life with all sorts of different issues. The ability to really get involved with cancer research is a great part of the field.”

Dr. Dana M. Chase, a gynecologic oncologist at the University of Arizona Cancer Center, Phoenix.

“I took the opportunity to come to a new program where they were looking for an ob.gyn. hospitalist. That was exciting for me because I got to help establish the program... I feel like we’re a better department because I’m here monitoring labor, but I’m also writing protocols and making sure everyone is up to date. And I still get to do what I love the most, which is birth and babies.”

Dr. Brigid McCue, an ob.gyn. hospitalist and chief of ob.gyn. and midwifery, Beth Israel Deaconess Hospital-Plymouth, Massachusetts.

“I never considered delivering babies for the rest of my life. I was always focused on treating infertile couples. I completed my fellowship in reproductive endocrinology-infertility at the University of Pennsylvania, Philadelphia, at a time when in vitro fertilization was in its infancy and the laparoscope and hysteroscope were virtually diagnostic tools ... As IVF became more successful, I felt it was essential to add this expertise to my armamentarium ... It is truly gratifying to be part of a subspecialty that has advanced so far that the majority of our patients are able to achieve pregnancy via IVF.”

Dr. Charles E. Miller, a reproductive endocrinologist and minimally invasive gynecologic surgeon in Naperville and Schaumburg, Ill.

“During medical school, I was very interested in the surgical aspects of patient care. When I rotated in gyn-oncology – now knowing that I rotated with some of the best gyn-oncologists who ever practiced – I found myself drawn to the complexity of surgery, acuity of the patients, and the close relationships gyn-oncologists have with their patients. It hit me like a brick that this was the specialty for me. During my residency and fellowship, I was particularly drawn to the multiple modalities we use to treat cancers. I relished the idea that through clinical trials, gyn-oncologists keep pushing the bar to solve the cancer problem. What we do now is different than what we did 5 years ago. It keeps us professionally challenged all the time.”

Dr. Mark H. Einstein, a gynecologic oncologist and chair of obstetrics, gynecology and women’s health at Rutgers, the State University of New Jersey, Newark.

Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.

[email protected]

On Twitter @legal_med

It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.

One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.

The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.

However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.

There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.

The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.

Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.

The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.

All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.

What do you think is the optimal and safest role for PEs in a dermatology practice?

We want to know your views! Tell us what you think.

It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.

One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.

The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.

However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.

There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.

The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.

Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.

The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.

All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.

What do you think is the optimal and safest role for PEs in a dermatology practice?

We want to know your views! Tell us what you think.

It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.

One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.

The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.

However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.

There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.

The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.

Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.

The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.

All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.

What do you think is the optimal and safest role for PEs in a dermatology practice?

We want to know your views! Tell us what you think.

Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.

An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.

In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.

Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.

Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.

What’s the issue?

Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?

We want to know your views! Tell us what you think.

Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.

An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.

In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.

Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.

Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.

What’s the issue?

Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?

We want to know your views! Tell us what you think.

Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.

An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.

In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.

Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.

Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.

What’s the issue?

Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?

We want to know your views! Tell us what you think.

One of the biggest burdens of modern clinical dermatology practice is the ability to obtain appropriate drug therapy for patients. In the current health care environment, insurance formularies have become increasingly restrictive and more individuals have to deal with high-deductible insurance plans.

In a JAMA Dermatology study published online on November 25, Rosenberg and Rosenberg sought to determine changes in the prices of commonly prescribed dermatologic medications since 2009 and identify trends in price increases for different classes of drugs. To perform this analysis, they sent surveys to 4 national chain pharmacies requesting price information for commonly prescribed dermatologic therapies in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs.

The findings of the analysis were staggering. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled over the study period. The mean price increase for this group of drugs was 401% during the entire survey period.

Rosenberg and Rosenberg grouped the price increase by therapeutic class. Prices of topical antineoplastic therapies had the largest mean absolute and percentage increase ($10,926.58 [1240%]). Prices of drugs in the anti-infective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications had a mean increase of 195%, and prices of topical corticosteroids experienced a mean increase of 290%. Selected generic drugs examined in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Rosenberg and Rosenberg noted that the increases for commonly prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services. They did not detect any specific trend to explain the substantial increase in the costs of dermatologic prescription drugs and they did not investigate reasons for the price increases.

What’s the issue?

Price increases for psoriatic and other therapies are creating barriers to both our appropriate treatment of patients and our ability to effectively practice medicine. How are you coping with this challenge in your practice?

We want to know your views! Tell us what you think.

One of the biggest burdens of modern clinical dermatology practice is the ability to obtain appropriate drug therapy for patients. In the current health care environment, insurance formularies have become increasingly restrictive and more individuals have to deal with high-deductible insurance plans.

In a JAMA Dermatology study published online on November 25, Rosenberg and Rosenberg sought to determine changes in the prices of commonly prescribed dermatologic medications since 2009 and identify trends in price increases for different classes of drugs. To perform this analysis, they sent surveys to 4 national chain pharmacies requesting price information for commonly prescribed dermatologic therapies in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs.

The findings of the analysis were staggering. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled over the study period. The mean price increase for this group of drugs was 401% during the entire survey period.

Rosenberg and Rosenberg grouped the price increase by therapeutic class. Prices of topical antineoplastic therapies had the largest mean absolute and percentage increase ($10,926.58 [1240%]). Prices of drugs in the anti-infective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications had a mean increase of 195%, and prices of topical corticosteroids experienced a mean increase of 290%. Selected generic drugs examined in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Rosenberg and Rosenberg noted that the increases for commonly prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services. They did not detect any specific trend to explain the substantial increase in the costs of dermatologic prescription drugs and they did not investigate reasons for the price increases.

What’s the issue?

Price increases for psoriatic and other therapies are creating barriers to both our appropriate treatment of patients and our ability to effectively practice medicine. How are you coping with this challenge in your practice?

We want to know your views! Tell us what you think.

One of the biggest burdens of modern clinical dermatology practice is the ability to obtain appropriate drug therapy for patients. In the current health care environment, insurance formularies have become increasingly restrictive and more individuals have to deal with high-deductible insurance plans.

In a JAMA Dermatology study published online on November 25, Rosenberg and Rosenberg sought to determine changes in the prices of commonly prescribed dermatologic medications since 2009 and identify trends in price increases for different classes of drugs. To perform this analysis, they sent surveys to 4 national chain pharmacies requesting price information for commonly prescribed dermatologic therapies in 2009, 2011, 2014, and 2015. The initial survey requested information on 72 brand-name drugs.

The findings of the analysis were staggering. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled over the study period. The mean price increase for this group of drugs was 401% during the entire survey period.

Rosenberg and Rosenberg grouped the price increase by therapeutic class. Prices of topical antineoplastic therapies had the largest mean absolute and percentage increase ($10,926.58 [1240%]). Prices of drugs in the anti-infective class had the smallest mean absolute increase ($333.99); prices of psoriasis medications had the smallest mean percentage increase (180%). Prices of acne and rosacea medications had a mean increase of 195%, and prices of topical corticosteroids experienced a mean increase of 290%. Selected generic drugs examined in 2011 and 2014 also increased a mean of 279% during the 3-year period.

Rosenberg and Rosenberg noted that the increases for commonly prescribed medications greatly outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services. They did not detect any specific trend to explain the substantial increase in the costs of dermatologic prescription drugs and they did not investigate reasons for the price increases.

What’s the issue?

Price increases for psoriatic and other therapies are creating barriers to both our appropriate treatment of patients and our ability to effectively practice medicine. How are you coping with this challenge in your practice?

We want to know your views! Tell us what you think.

We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.

Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.

I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.

Coming to terms

About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?

The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.

I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.

Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.

Surgery often not the answer

After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”

It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat ... long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.

In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine (ABOM). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.

Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.

Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.

Addressing personal challenges

Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.

Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.

Regarding simple transference and countertransference ... many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.

Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”

Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.

We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.

Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.

I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.

Coming to terms

About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?

The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.

I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.

Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.

Surgery often not the answer

After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”

It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat ... long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.

In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine (ABOM). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.

Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.

Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.

Addressing personal challenges

Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.

Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.

Regarding simple transference and countertransference ... many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.

Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”

Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.

We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.

Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.

I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.

Coming to terms

About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?

The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.

I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.

Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.

Surgery often not the answer

After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”

It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat ... long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.

In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine (ABOM). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.

Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.

Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.

Addressing personal challenges

Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.

Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.

Regarding simple transference and countertransference ... many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.

Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”

Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.

In a JAMA Dermatology article published online on December 2, Lee et al challenged the commonly held belief that laboratory studies should be monitored frequently for patients on isotretinoin. In this systematic review and meta-analysis, abnormalities in liver function tests (LFTs), complete blood cell count (CBC), and lipid panel were compared in a set of 22 randomized clinical trials and 4 retrospective studies (1574 patients). Results revealed changes in the mean laboratory values from baseline (99% CI) of the following: aspartate aminotransferase, 22.67 U/L (19.94–25.41 U/L); alanine aminotransferase, 21.77 U/L (18.96–24.59 U/L); alkaline phosphatase, 88.35 U/L (58.94–117.76 U/L); white blood cell count portion of CBC, 6890/µL (5700–8030/µL); lipid panel (triglycerides, 119.98 mg/dL [98.58–141.39 mg/dL]; total cholesterol, 184.74 mg/dL [178.17–191.31 mg/dL]; low-density lipoprotein cholesterol, 109.23 mg/dL [103.68–114.79 mg/dL]; high-density lipoprotein cholesterol, 42.80 mg/dL [39.84–45.76 mg/dL]).

Although these laboratory values were altered as noted above, only 0.5% of patients exhibited test results statistically above or below the mean laboratory values. Additionally, of these laboratory abnormalities, mean changes were not considered to be high risk based on National Institutes of Health clinical center reference ranges.

What’s the issue?

Last year the residents in-training in our department noted variations in what each faculty member was recommending for isotretinoin laboratory monitoring. Practices ranged from initial then monthly full CBC, LFTs, and lipid panel, to those who only checked these laboratory results initially and at 1 month, to those who only performed review of systems-germane parameters. After reviewing the literature, individual preferences, and cost comparisons, a consensus was reached: tests for aspartate aminotransferase, alanine aminotransferase (in lieu of LFT panel), total cholesterol, triglycerides (in lieu of lipid panel), and relevant pregnancy screens would be performed initially, at month 1, and at month 2.

Lee et al also determined that monthly laboratory testing may not be necessary, especially for this low-risk category of patients, but further study is required to determine if there is a standardized way to approach laboratory testing from a safety and economic standpoint, as each dermatologist who prescribes isotretinoin can identify individual cases in which laboratory monitoring was helpful or uncovered individual comorbidities or toxicities in addition to instances where blood work was prohibitively redundant and expensive.

What is your approach to blood work in isotretinoin patients, and can you identify individual patient populations that require more or less stringent laboratory monitoring?

We want to know your views! Tell us what you think.

In a JAMA Dermatology article published online on December 2, Lee et al challenged the commonly held belief that laboratory studies should be monitored frequently for patients on isotretinoin. In this systematic review and meta-analysis, abnormalities in liver function tests (LFTs), complete blood cell count (CBC), and lipid panel were compared in a set of 22 randomized clinical trials and 4 retrospective studies (1574 patients). Results revealed changes in the mean laboratory values from baseline (99% CI) of the following: aspartate aminotransferase, 22.67 U/L (19.94–25.41 U/L); alanine aminotransferase, 21.77 U/L (18.96–24.59 U/L); alkaline phosphatase, 88.35 U/L (58.94–117.76 U/L); white blood cell count portion of CBC, 6890/µL (5700–8030/µL); lipid panel (triglycerides, 119.98 mg/dL [98.58–141.39 mg/dL]; total cholesterol, 184.74 mg/dL [178.17–191.31 mg/dL]; low-density lipoprotein cholesterol, 109.23 mg/dL [103.68–114.79 mg/dL]; high-density lipoprotein cholesterol, 42.80 mg/dL [39.84–45.76 mg/dL]).

Although these laboratory values were altered as noted above, only 0.5% of patients exhibited test results statistically above or below the mean laboratory values. Additionally, of these laboratory abnormalities, mean changes were not considered to be high risk based on National Institutes of Health clinical center reference ranges.

What’s the issue?

Last year the residents in-training in our department noted variations in what each faculty member was recommending for isotretinoin laboratory monitoring. Practices ranged from initial then monthly full CBC, LFTs, and lipid panel, to those who only checked these laboratory results initially and at 1 month, to those who only performed review of systems-germane parameters. After reviewing the literature, individual preferences, and cost comparisons, a consensus was reached: tests for aspartate aminotransferase, alanine aminotransferase (in lieu of LFT panel), total cholesterol, triglycerides (in lieu of lipid panel), and relevant pregnancy screens would be performed initially, at month 1, and at month 2.

Lee et al also determined that monthly laboratory testing may not be necessary, especially for this low-risk category of patients, but further study is required to determine if there is a standardized way to approach laboratory testing from a safety and economic standpoint, as each dermatologist who prescribes isotretinoin can identify individual cases in which laboratory monitoring was helpful or uncovered individual comorbidities or toxicities in addition to instances where blood work was prohibitively redundant and expensive.

What is your approach to blood work in isotretinoin patients, and can you identify individual patient populations that require more or less stringent laboratory monitoring?

We want to know your views! Tell us what you think.

In a JAMA Dermatology article published online on December 2, Lee et al challenged the commonly held belief that laboratory studies should be monitored frequently for patients on isotretinoin. In this systematic review and meta-analysis, abnormalities in liver function tests (LFTs), complete blood cell count (CBC), and lipid panel were compared in a set of 22 randomized clinical trials and 4 retrospective studies (1574 patients). Results revealed changes in the mean laboratory values from baseline (99% CI) of the following: aspartate aminotransferase, 22.67 U/L (19.94–25.41 U/L); alanine aminotransferase, 21.77 U/L (18.96–24.59 U/L); alkaline phosphatase, 88.35 U/L (58.94–117.76 U/L); white blood cell count portion of CBC, 6890/µL (5700–8030/µL); lipid panel (triglycerides, 119.98 mg/dL [98.58–141.39 mg/dL]; total cholesterol, 184.74 mg/dL [178.17–191.31 mg/dL]; low-density lipoprotein cholesterol, 109.23 mg/dL [103.68–114.79 mg/dL]; high-density lipoprotein cholesterol, 42.80 mg/dL [39.84–45.76 mg/dL]).

Although these laboratory values were altered as noted above, only 0.5% of patients exhibited test results statistically above or below the mean laboratory values. Additionally, of these laboratory abnormalities, mean changes were not considered to be high risk based on National Institutes of Health clinical center reference ranges.

What’s the issue?

Last year the residents in-training in our department noted variations in what each faculty member was recommending for isotretinoin laboratory monitoring. Practices ranged from initial then monthly full CBC, LFTs, and lipid panel, to those who only checked these laboratory results initially and at 1 month, to those who only performed review of systems-germane parameters. After reviewing the literature, individual preferences, and cost comparisons, a consensus was reached: tests for aspartate aminotransferase, alanine aminotransferase (in lieu of LFT panel), total cholesterol, triglycerides (in lieu of lipid panel), and relevant pregnancy screens would be performed initially, at month 1, and at month 2.

Lee et al also determined that monthly laboratory testing may not be necessary, especially for this low-risk category of patients, but further study is required to determine if there is a standardized way to approach laboratory testing from a safety and economic standpoint, as each dermatologist who prescribes isotretinoin can identify individual cases in which laboratory monitoring was helpful or uncovered individual comorbidities or toxicities in addition to instances where blood work was prohibitively redundant and expensive.

What is your approach to blood work in isotretinoin patients, and can you identify individual patient populations that require more or less stringent laboratory monitoring?

We want to know your views! Tell us what you think.

I hadn’t originally planned to be an obstetrician-gynecologist; in fact, I trained as an internist for 2 years. But as I became more exposed to the real-life experience of medical care, I realized that ob.gyn. would allow me to take care of women in all facets of their lives, from family planning to childbirth to endocrine problems and even depression.

Having joined the American College of Obstetricians and Gynecologists in 1965, my tenure as an ob.gyn. has spanned almost the exact length of this 50th anniversary retrospective of Ob.Gyn.News. But in my experience, those early days of my practice were actually the turning point for our specialty.

I’m an observer, not a historian. But I can’t imagine that any other specialty was more impacted by societal change in the mid-1960s than ours.

Courtesy Rivermend Health

For one thing, when I was training, we were an overwhelmingly male group of residents who were learning about how to take care of women. Our commitment was not in question, but our ability to truly connect with women was certainly underdeveloped.

I’m gratified now to see that the demographics of ob.gyn. have changed, because they should. Without disrespecting my male ob.gyn. brethren, I was pleased to see that more than 80% of ob.gyn. trainees are now women. Importantly, many of them are learning now from female ob.gyns. This foretells a future in which connections between patient and physician are as strong as they should be.

Moreover, ob.gyn. trainees today have the highest proportions of African American and Hispanic trainees compared with any other specialty. We are doing a better job of representing, within our ranks, the women whom we treat. This continues to bolster our relationships, and in no other field is a trusting, intimate relationship as important as in ours.

Of course, the mid-1960s also heralded dramatic changes within reproductive health. Women were beginning to dip their toes into being able to control their own fertility and, in so doing, to prevent pregnancy. This also gave us the opportunity to focus on a woman’s greater well-being, helping her to address her own health before becoming pregnant. It pivoted the role of the ob.gyn. and charted us on a course to being, for many women, their primary point of care. And it gave women educational, professional, and economic opportunities the likes of which had never existed before.

Outside of fertility planning, we also began to make inroads in obstetric care – and to make some mistakes. The 1960s heralded some developments that we still embrace, but we also began a path toward dependence on technology and overinvasive care that we are trying to step away from today.

And, we had difficult conversations then that we have now. The more things change, the more they stay the same.

One of the most exciting, and essential, changes that I have seen since I began my career is the voice of the woman in ob.gyn. care. We speak with our patients. We screen them for depression and for intimate partner violence. We discuss their lives and whether they are using the birth control that is best for them. We try to reflect their own preferences in our approach to their labor and delivery. We missed an opportunity to do this in the past, to discuss a woman’s social history. We know now that there is more to a woman’s well-being than whether she smokes and drinks.

It makes sense that our specialty has changed, because we are the only specialty dedicated to women, and the last 50 years have brought about intense societal change for women.

We still have further to go. We can be slow to evolve, and we constantly face challenges that other specialties don’t confront. But I believe that the same dedication to women that inspired me to go into ob.gyn. 50 years ago is the same inspiration that is leading today’s trainees to do the same.

Dr. Pion is a clinical professor at the UCLA School of Medicine. He has served on the faculty of the University of Washington and the University of Hawaii, and worked for more than 25 years in the development and production of TV and radio programming on health care. He is a fellow of the American College of Obstetricians and Gynecologists.

I hadn’t originally planned to be an obstetrician-gynecologist; in fact, I trained as an internist for 2 years. But as I became more exposed to the real-life experience of medical care, I realized that ob.gyn. would allow me to take care of women in all facets of their lives, from family planning to childbirth to endocrine problems and even depression.

Having joined the American College of Obstetricians and Gynecologists in 1965, my tenure as an ob.gyn. has spanned almost the exact length of this 50th anniversary retrospective of Ob.Gyn.News. But in my experience, those early days of my practice were actually the turning point for our specialty.

I’m an observer, not a historian. But I can’t imagine that any other specialty was more impacted by societal change in the mid-1960s than ours.

Courtesy Rivermend Health

For one thing, when I was training, we were an overwhelmingly male group of residents who were learning about how to take care of women. Our commitment was not in question, but our ability to truly connect with women was certainly underdeveloped.

I’m gratified now to see that the demographics of ob.gyn. have changed, because they should. Without disrespecting my male ob.gyn. brethren, I was pleased to see that more than 80% of ob.gyn. trainees are now women. Importantly, many of them are learning now from female ob.gyns. This foretells a future in which connections between patient and physician are as strong as they should be.

Moreover, ob.gyn. trainees today have the highest proportions of African American and Hispanic trainees compared with any other specialty. We are doing a better job of representing, within our ranks, the women whom we treat. This continues to bolster our relationships, and in no other field is a trusting, intimate relationship as important as in ours.

Of course, the mid-1960s also heralded dramatic changes within reproductive health. Women were beginning to dip their toes into being able to control their own fertility and, in so doing, to prevent pregnancy. This also gave us the opportunity to focus on a woman’s greater well-being, helping her to address her own health before becoming pregnant. It pivoted the role of the ob.gyn. and charted us on a course to being, for many women, their primary point of care. And it gave women educational, professional, and economic opportunities the likes of which had never existed before.

Outside of fertility planning, we also began to make inroads in obstetric care – and to make some mistakes. The 1960s heralded some developments that we still embrace, but we also began a path toward dependence on technology and overinvasive care that we are trying to step away from today.

And, we had difficult conversations then that we have now. The more things change, the more they stay the same.

One of the most exciting, and essential, changes that I have seen since I began my career is the voice of the woman in ob.gyn. care. We speak with our patients. We screen them for depression and for intimate partner violence. We discuss their lives and whether they are using the birth control that is best for them. We try to reflect their own preferences in our approach to their labor and delivery. We missed an opportunity to do this in the past, to discuss a woman’s social history. We know now that there is more to a woman’s well-being than whether she smokes and drinks.

It makes sense that our specialty has changed, because we are the only specialty dedicated to women, and the last 50 years have brought about intense societal change for women.

We still have further to go. We can be slow to evolve, and we constantly face challenges that other specialties don’t confront. But I believe that the same dedication to women that inspired me to go into ob.gyn. 50 years ago is the same inspiration that is leading today’s trainees to do the same.

Dr. Pion is a clinical professor at the UCLA School of Medicine. He has served on the faculty of the University of Washington and the University of Hawaii, and worked for more than 25 years in the development and production of TV and radio programming on health care. He is a fellow of the American College of Obstetricians and Gynecologists.

I hadn’t originally planned to be an obstetrician-gynecologist; in fact, I trained as an internist for 2 years. But as I became more exposed to the real-life experience of medical care, I realized that ob.gyn. would allow me to take care of women in all facets of their lives, from family planning to childbirth to endocrine problems and even depression.

Having joined the American College of Obstetricians and Gynecologists in 1965, my tenure as an ob.gyn. has spanned almost the exact length of this 50th anniversary retrospective of Ob.Gyn.News. But in my experience, those early days of my practice were actually the turning point for our specialty.

I’m an observer, not a historian. But I can’t imagine that any other specialty was more impacted by societal change in the mid-1960s than ours.

Courtesy Rivermend Health

For one thing, when I was training, we were an overwhelmingly male group of residents who were learning about how to take care of women. Our commitment was not in question, but our ability to truly connect with women was certainly underdeveloped.

I’m gratified now to see that the demographics of ob.gyn. have changed, because they should. Without disrespecting my male ob.gyn. brethren, I was pleased to see that more than 80% of ob.gyn. trainees are now women. Importantly, many of them are learning now from female ob.gyns. This foretells a future in which connections between patient and physician are as strong as they should be.

Moreover, ob.gyn. trainees today have the highest proportions of African American and Hispanic trainees compared with any other specialty. We are doing a better job of representing, within our ranks, the women whom we treat. This continues to bolster our relationships, and in no other field is a trusting, intimate relationship as important as in ours.

Of course, the mid-1960s also heralded dramatic changes within reproductive health. Women were beginning to dip their toes into being able to control their own fertility and, in so doing, to prevent pregnancy. This also gave us the opportunity to focus on a woman’s greater well-being, helping her to address her own health before becoming pregnant. It pivoted the role of the ob.gyn. and charted us on a course to being, for many women, their primary point of care. And it gave women educational, professional, and economic opportunities the likes of which had never existed before.

Outside of fertility planning, we also began to make inroads in obstetric care – and to make some mistakes. The 1960s heralded some developments that we still embrace, but we also began a path toward dependence on technology and overinvasive care that we are trying to step away from today.

And, we had difficult conversations then that we have now. The more things change, the more they stay the same.

One of the most exciting, and essential, changes that I have seen since I began my career is the voice of the woman in ob.gyn. care. We speak with our patients. We screen them for depression and for intimate partner violence. We discuss their lives and whether they are using the birth control that is best for them. We try to reflect their own preferences in our approach to their labor and delivery. We missed an opportunity to do this in the past, to discuss a woman’s social history. We know now that there is more to a woman’s well-being than whether she smokes and drinks.

It makes sense that our specialty has changed, because we are the only specialty dedicated to women, and the last 50 years have brought about intense societal change for women.

We still have further to go. We can be slow to evolve, and we constantly face challenges that other specialties don’t confront. But I believe that the same dedication to women that inspired me to go into ob.gyn. 50 years ago is the same inspiration that is leading today’s trainees to do the same.

Dr. Pion is a clinical professor at the UCLA School of Medicine. He has served on the faculty of the University of Washington and the University of Hawaii, and worked for more than 25 years in the development and production of TV and radio programming on health care. He is a fellow of the American College of Obstetricians and Gynecologists.