Doug Brunk

The way Dr. John A. Kitzhaber sees it, Americans can't afford to sit back and wait for the future of health care to unfold before them; they should assume an active role in shaping its future.

"If people are unable or unwilling to agree among themselves on a vision for the future, the political process cannot and will not do it for them—and we will be destined to continue to be shackled to the failed policies of the past," he warned at the November 2007 annual meeting of the Society of Clinical Surgery in Portland, Ore. "By default, we will be allowing our future to become a matter of chance rather than a matter of choice. I think we are better than that."

In January 2006, Dr. Kitzhaber, the former governor of Oregon, founded the Archimedes Movement, a grassroots organization that takes a "we can do better" approach to the governance and delivery of health care. The movement is "committed to providing a safe forum in which citizens and stakeholders alike can be brought together to create a shared vision of a new health care system, a space in which we can ask, 'If anything were possible, what would a better system look like?,'" he said.

The name refers to Archimedes, the mathematician who invented the lever and is reputed to have said, "Give me a lever and a place to stand, and I can move the Earth."

A key strategy of the effort is to agree on what a new health care system should look like, and to expose the contradictions and inequities of the current system and create a "tension" between the status quo and a vision for a new system.

Dr. Kitzhaber, an emergency physician who governed Oregon from 1995 to 2003, said he believes there should be a different standard for the part of health care that is financed by public resources and the portion that is financed by private resources. "We must demand that we get an actual health benefit for the public dollars we allocate for health care, a positive return on investment, [and] the effective and efficient use of public tax dollars. And, since these are public resources—resources held in common—we must demand that their allocation benefits all of our citizens, not just some of them; that it does not leave 47 million people behind."

As an example, he said that people who wish to buy an expensive brand name drug when a much cheaper generic is just as effective clinically, and just as safe, should be able to do so with their own personal resources. Public resources should not be used to subsidize the difference in cost. Similarly, he said that expectant parents who want an ultrasound to determine the sex of their unborn child when the procedure is not indicated clinically for a normal term pregnancy should be able to get that—but again, the cost should not be subsidized with public resources.

To date, the Archimedes Movement has conducted public forums and vision-sharing meetings with more than 3,000 Oregonians in 30 chapters, 13 hospital CEOs, 11 insurer and health plan executives, dozens of physicians and nurses, leaders of national state and labor organizations, and representatives of more than 50 non-health-related businesses in the state.

The resulting consensus led to the Oregon Better Health Act, which was introduced in the 2007 Oregon legislature as Senate Bill 27. It proposes that Oregonians have access to a "core benefit" of essential health services, and seeks to realign financial incentives to ensure fair and reasonable payment to providers, value-based cost sharing for consumers, and a transition to a more efficient delivery system.

Although SB 27 did not pass in the 2007 session, the enthusiasm it generated from citizens and stakeholders propelled the Archimedes Movement into the limelight. It also produced three documents that offer a conceptual framework for a new system in the state and that may serve as a foundation for bringing about national reform. The documents—a Statement of Intent, Principles, and a Framework—are available at www.wecandobetter.org

The movement provides a space where we can ask, 'If anything were possible, what would a better system look like?' DR. KITZHABER

The way Dr. John A. Kitzhaber sees it, Americans can't afford to sit back and wait for the future of health care to unfold before them; they should assume an active role in shaping its future.

"If people are unable or unwilling to agree among themselves on a vision for the future, the political process cannot and will not do it for them—and we will be destined to continue to be shackled to the failed policies of the past," he warned at the November 2007 annual meeting of the Society of Clinical Surgery in Portland, Ore. "By default, we will be allowing our future to become a matter of chance rather than a matter of choice. I think we are better than that."

In January 2006, Dr. Kitzhaber, the former governor of Oregon, founded the Archimedes Movement, a grassroots organization that takes a "we can do better" approach to the governance and delivery of health care. The movement is "committed to providing a safe forum in which citizens and stakeholders alike can be brought together to create a shared vision of a new health care system, a space in which we can ask, 'If anything were possible, what would a better system look like?,'" he said.

The name refers to Archimedes, the mathematician who invented the lever and is reputed to have said, "Give me a lever and a place to stand, and I can move the Earth."

A key strategy of the effort is to agree on what a new health care system should look like, and to expose the contradictions and inequities of the current system and create a "tension" between the status quo and a vision for a new system.

Dr. Kitzhaber, an emergency physician who governed Oregon from 1995 to 2003, said he believes there should be a different standard for the part of health care that is financed by public resources and the portion that is financed by private resources. "We must demand that we get an actual health benefit for the public dollars we allocate for health care, a positive return on investment, [and] the effective and efficient use of public tax dollars. And, since these are public resources—resources held in common—we must demand that their allocation benefits all of our citizens, not just some of them; that it does not leave 47 million people behind."

As an example, he said that people who wish to buy an expensive brand name drug when a much cheaper generic is just as effective clinically, and just as safe, should be able to do so with their own personal resources. Public resources should not be used to subsidize the difference in cost. Similarly, he said that expectant parents who want an ultrasound to determine the sex of their unborn child when the procedure is not indicated clinically for a normal term pregnancy should be able to get that—but again, the cost should not be subsidized with public resources.

To date, the Archimedes Movement has conducted public forums and vision-sharing meetings with more than 3,000 Oregonians in 30 chapters, 13 hospital CEOs, 11 insurer and health plan executives, dozens of physicians and nurses, leaders of national state and labor organizations, and representatives of more than 50 non-health-related businesses in the state.

The resulting consensus led to the Oregon Better Health Act, which was introduced in the 2007 Oregon legislature as Senate Bill 27. It proposes that Oregonians have access to a "core benefit" of essential health services, and seeks to realign financial incentives to ensure fair and reasonable payment to providers, value-based cost sharing for consumers, and a transition to a more efficient delivery system.

Although SB 27 did not pass in the 2007 session, the enthusiasm it generated from citizens and stakeholders propelled the Archimedes Movement into the limelight. It also produced three documents that offer a conceptual framework for a new system in the state and that may serve as a foundation for bringing about national reform. The documents—a Statement of Intent, Principles, and a Framework—are available at www.wecandobetter.org

The movement provides a space where we can ask, 'If anything were possible, what would a better system look like?' DR. KITZHABER

The way Dr. John A. Kitzhaber sees it, Americans can't afford to sit back and wait for the future of health care to unfold before them; they should assume an active role in shaping its future.

"If people are unable or unwilling to agree among themselves on a vision for the future, the political process cannot and will not do it for them—and we will be destined to continue to be shackled to the failed policies of the past," he warned at the November 2007 annual meeting of the Society of Clinical Surgery in Portland, Ore. "By default, we will be allowing our future to become a matter of chance rather than a matter of choice. I think we are better than that."

In January 2006, Dr. Kitzhaber, the former governor of Oregon, founded the Archimedes Movement, a grassroots organization that takes a "we can do better" approach to the governance and delivery of health care. The movement is "committed to providing a safe forum in which citizens and stakeholders alike can be brought together to create a shared vision of a new health care system, a space in which we can ask, 'If anything were possible, what would a better system look like?,'" he said.

The name refers to Archimedes, the mathematician who invented the lever and is reputed to have said, "Give me a lever and a place to stand, and I can move the Earth."

A key strategy of the effort is to agree on what a new health care system should look like, and to expose the contradictions and inequities of the current system and create a "tension" between the status quo and a vision for a new system.

Dr. Kitzhaber, an emergency physician who governed Oregon from 1995 to 2003, said he believes there should be a different standard for the part of health care that is financed by public resources and the portion that is financed by private resources. "We must demand that we get an actual health benefit for the public dollars we allocate for health care, a positive return on investment, [and] the effective and efficient use of public tax dollars. And, since these are public resources—resources held in common—we must demand that their allocation benefits all of our citizens, not just some of them; that it does not leave 47 million people behind."

As an example, he said that people who wish to buy an expensive brand name drug when a much cheaper generic is just as effective clinically, and just as safe, should be able to do so with their own personal resources. Public resources should not be used to subsidize the difference in cost. Similarly, he said that expectant parents who want an ultrasound to determine the sex of their unborn child when the procedure is not indicated clinically for a normal term pregnancy should be able to get that—but again, the cost should not be subsidized with public resources.

To date, the Archimedes Movement has conducted public forums and vision-sharing meetings with more than 3,000 Oregonians in 30 chapters, 13 hospital CEOs, 11 insurer and health plan executives, dozens of physicians and nurses, leaders of national state and labor organizations, and representatives of more than 50 non-health-related businesses in the state.

The resulting consensus led to the Oregon Better Health Act, which was introduced in the 2007 Oregon legislature as Senate Bill 27. It proposes that Oregonians have access to a "core benefit" of essential health services, and seeks to realign financial incentives to ensure fair and reasonable payment to providers, value-based cost sharing for consumers, and a transition to a more efficient delivery system.

Although SB 27 did not pass in the 2007 session, the enthusiasm it generated from citizens and stakeholders propelled the Archimedes Movement into the limelight. It also produced three documents that offer a conceptual framework for a new system in the state and that may serve as a foundation for bringing about national reform. The documents—a Statement of Intent, Principles, and a Framework—are available at www.wecandobetter.org

The movement provides a space where we can ask, 'If anything were possible, what would a better system look like?' DR. KITZHABER

CORONADO, CALIF. — One out of six medical students at a private Midwestern medical school reported prior use of at least one club drug, results from a survey found.

“Therefore, physicians should be cognizant, when treating medical students, physicians, or other health care workers, that we are not excluded from substance abuse,” Dr. Alex Horowitz said in an interview after presenting the study during a poster session at the annual meeting of the American Academy of Addiction Psychiatry. “The same principles should be applied when assessing health care workers for substance use as when assessing the rest of the population.”

In what he said is the first study of its kind, Dr. Horowitz and his associates asked 340 students at a private Midwestern medical school to complete an anonymous survey about their use of and attitudes about club drugs. Generation I club drugs were defined as cocaine and LSD; generation II club drugs included methylenedioxymethamphetamine (also known as Ecstasy), methamphetamine, gamma hydroxybutyrate (GHB), Rohypnol, ketamine, and dextromethorphan.

Nearly half (46%) of the respondents were first-year medical students, 34% were second-year students, and 20% were third-year students. The overall prevalence of lifetime club drug use was 17%, with Ecstasy and cocaine as the most popular agents of choice (12% and 6%, respectively), reported Dr. Horowitz, psychiatric unit chief of the methadone treatment program at Bellevue Hospital Center, New York.

He noted that the prevalence of medical students' lifetime Ecstasy use was similar to that of their peers in the general population, as reported in the National Institute on Drug Abuse's 2004 “Monitoring the Future” survey. However, the use of generation I club drugs by medical students was lower than that of their peers in the general population, an association that remains unclear.

Compared with students aged 21–25 years, those aged 26 and older were more likely to have used the generation I drugs (cocaine, 16% vs. 4%, respectively; LSD, 14% vs. 2%). However, no relationship was found between age and use of generation II club drugs in general.

Students who reported never using club drugs perceived regular cocaine use as posing the greatest risk to health (89%), followed by Ecstasy (72%).

For students who reported lifetime use of at least one club drug, the perceived risk of using cocaine and Ecstasy regularly was significantly lower (75% and 58%, respectively). The use of club drugs did not differ between men and women, but women found them to be generally more harmful than men did.

“There appears to be a correlation between knowledge/perceived harmfulness of each drug and drug use,” said Dr. Horowitz, of the department of psychiatry at New York University, also in New York. “Therefore, increasing formal medical student education on club drugs would help them be aware of dangers of club drug use, and also would help them know how to then assess and treat their patients who use club drugs.”

A greater number of students thought it would be necessary to revoke the license of physicians who were currently using generation I club drugs than those who were using generation II club drugs (27% vs. 20%, respectively). Women were more likely than men to endorse license revocation for physicians currently using generation I club drugs (33% vs. 22%, respectively) and for those currently using generation II club drugs (26% vs. 15%, respectively).

Dr. Horowitz acknowledged that the self-reported nature of the study is a limitation. “Some medical students may underreport their drug use for fear of having anyone find out, despite the anonymity of the survey,” he said.

Another limitation is that the data were collected in a classroom setting, which means that participants were limited to students more likely to attend class. However, the survey was administered in a class that was considered mandatory.

CORONADO, CALIF. — One out of six medical students at a private Midwestern medical school reported prior use of at least one club drug, results from a survey found.

“Therefore, physicians should be cognizant, when treating medical students, physicians, or other health care workers, that we are not excluded from substance abuse,” Dr. Alex Horowitz said in an interview after presenting the study during a poster session at the annual meeting of the American Academy of Addiction Psychiatry. “The same principles should be applied when assessing health care workers for substance use as when assessing the rest of the population.”

In what he said is the first study of its kind, Dr. Horowitz and his associates asked 340 students at a private Midwestern medical school to complete an anonymous survey about their use of and attitudes about club drugs. Generation I club drugs were defined as cocaine and LSD; generation II club drugs included methylenedioxymethamphetamine (also known as Ecstasy), methamphetamine, gamma hydroxybutyrate (GHB), Rohypnol, ketamine, and dextromethorphan.

Nearly half (46%) of the respondents were first-year medical students, 34% were second-year students, and 20% were third-year students. The overall prevalence of lifetime club drug use was 17%, with Ecstasy and cocaine as the most popular agents of choice (12% and 6%, respectively), reported Dr. Horowitz, psychiatric unit chief of the methadone treatment program at Bellevue Hospital Center, New York.

He noted that the prevalence of medical students' lifetime Ecstasy use was similar to that of their peers in the general population, as reported in the National Institute on Drug Abuse's 2004 “Monitoring the Future” survey. However, the use of generation I club drugs by medical students was lower than that of their peers in the general population, an association that remains unclear.

Compared with students aged 21–25 years, those aged 26 and older were more likely to have used the generation I drugs (cocaine, 16% vs. 4%, respectively; LSD, 14% vs. 2%). However, no relationship was found between age and use of generation II club drugs in general.

Students who reported never using club drugs perceived regular cocaine use as posing the greatest risk to health (89%), followed by Ecstasy (72%).

For students who reported lifetime use of at least one club drug, the perceived risk of using cocaine and Ecstasy regularly was significantly lower (75% and 58%, respectively). The use of club drugs did not differ between men and women, but women found them to be generally more harmful than men did.

“There appears to be a correlation between knowledge/perceived harmfulness of each drug and drug use,” said Dr. Horowitz, of the department of psychiatry at New York University, also in New York. “Therefore, increasing formal medical student education on club drugs would help them be aware of dangers of club drug use, and also would help them know how to then assess and treat their patients who use club drugs.”

A greater number of students thought it would be necessary to revoke the license of physicians who were currently using generation I club drugs than those who were using generation II club drugs (27% vs. 20%, respectively). Women were more likely than men to endorse license revocation for physicians currently using generation I club drugs (33% vs. 22%, respectively) and for those currently using generation II club drugs (26% vs. 15%, respectively).

Dr. Horowitz acknowledged that the self-reported nature of the study is a limitation. “Some medical students may underreport their drug use for fear of having anyone find out, despite the anonymity of the survey,” he said.

Another limitation is that the data were collected in a classroom setting, which means that participants were limited to students more likely to attend class. However, the survey was administered in a class that was considered mandatory.

CORONADO, CALIF. — One out of six medical students at a private Midwestern medical school reported prior use of at least one club drug, results from a survey found.

“Therefore, physicians should be cognizant, when treating medical students, physicians, or other health care workers, that we are not excluded from substance abuse,” Dr. Alex Horowitz said in an interview after presenting the study during a poster session at the annual meeting of the American Academy of Addiction Psychiatry. “The same principles should be applied when assessing health care workers for substance use as when assessing the rest of the population.”

In what he said is the first study of its kind, Dr. Horowitz and his associates asked 340 students at a private Midwestern medical school to complete an anonymous survey about their use of and attitudes about club drugs. Generation I club drugs were defined as cocaine and LSD; generation II club drugs included methylenedioxymethamphetamine (also known as Ecstasy), methamphetamine, gamma hydroxybutyrate (GHB), Rohypnol, ketamine, and dextromethorphan.

Nearly half (46%) of the respondents were first-year medical students, 34% were second-year students, and 20% were third-year students. The overall prevalence of lifetime club drug use was 17%, with Ecstasy and cocaine as the most popular agents of choice (12% and 6%, respectively), reported Dr. Horowitz, psychiatric unit chief of the methadone treatment program at Bellevue Hospital Center, New York.

He noted that the prevalence of medical students' lifetime Ecstasy use was similar to that of their peers in the general population, as reported in the National Institute on Drug Abuse's 2004 “Monitoring the Future” survey. However, the use of generation I club drugs by medical students was lower than that of their peers in the general population, an association that remains unclear.

Compared with students aged 21–25 years, those aged 26 and older were more likely to have used the generation I drugs (cocaine, 16% vs. 4%, respectively; LSD, 14% vs. 2%). However, no relationship was found between age and use of generation II club drugs in general.

Students who reported never using club drugs perceived regular cocaine use as posing the greatest risk to health (89%), followed by Ecstasy (72%).

For students who reported lifetime use of at least one club drug, the perceived risk of using cocaine and Ecstasy regularly was significantly lower (75% and 58%, respectively). The use of club drugs did not differ between men and women, but women found them to be generally more harmful than men did.

“There appears to be a correlation between knowledge/perceived harmfulness of each drug and drug use,” said Dr. Horowitz, of the department of psychiatry at New York University, also in New York. “Therefore, increasing formal medical student education on club drugs would help them be aware of dangers of club drug use, and also would help them know how to then assess and treat their patients who use club drugs.”

A greater number of students thought it would be necessary to revoke the license of physicians who were currently using generation I club drugs than those who were using generation II club drugs (27% vs. 20%, respectively). Women were more likely than men to endorse license revocation for physicians currently using generation I club drugs (33% vs. 22%, respectively) and for those currently using generation II club drugs (26% vs. 15%, respectively).

Dr. Horowitz acknowledged that the self-reported nature of the study is a limitation. “Some medical students may underreport their drug use for fear of having anyone find out, despite the anonymity of the survey,” he said.

Another limitation is that the data were collected in a classroom setting, which means that participants were limited to students more likely to attend class. However, the survey was administered in a class that was considered mandatory.

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level, he said.

He also recommended that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35).

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8). “Anesthesia is overrepresented among impaired physicians because of access to addictive agents, and because in some cases people go into anesthesia attracted to the idea of handling and having access to opioids,” Dr. Galanter said.

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter said he considers the 12-step component of the CPH program essential to overall success. Given the need for full abstinence before returning to practice, he pointed out, these spiritually oriented 12-step programs are uniquely valuable in ensuring an optimal outcome.

“It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using.

“It's an issue of tremendous importance in terms of our investigation of future psychosocial modalities.”

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level, he said.

He also recommended that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35).

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8). “Anesthesia is overrepresented among impaired physicians because of access to addictive agents, and because in some cases people go into anesthesia attracted to the idea of handling and having access to opioids,” Dr. Galanter said.

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter said he considers the 12-step component of the CPH program essential to overall success. Given the need for full abstinence before returning to practice, he pointed out, these spiritually oriented 12-step programs are uniquely valuable in ensuring an optimal outcome.

“It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using.

“It's an issue of tremendous importance in terms of our investigation of future psychosocial modalities.”

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level, he said.

He also recommended that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35).

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8). “Anesthesia is overrepresented among impaired physicians because of access to addictive agents, and because in some cases people go into anesthesia attracted to the idea of handling and having access to opioids,” Dr. Galanter said.

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter said he considers the 12-step component of the CPH program essential to overall success. Given the need for full abstinence before returning to practice, he pointed out, these spiritually oriented 12-step programs are uniquely valuable in ensuring an optimal outcome.

“It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using.

“It's an issue of tremendous importance in terms of our investigation of future psychosocial modalities.”

SAN DIEGO — When it comes to diagnosing endometriosis, visual inspection is not enough, Dr. Georgine Lamvu said at the annual meeting of the International Pelvic Pain Society.

“We need to be more careful to use excisional biopsies during laparoscopies and careful about the thorough evaluation of the pelvic structures, to record these so we can keep track of the infiltration, size, and distribution of the lesions,” said Dr. Lamvu of the department of obstetrics and gynecology at the Florida Hospital, Orlando.

She went on to note that not all endometriosis causes chronic pelvic pain. In one study of 15 patients with presumed endometriosis who went on to have conscious laparoscopic pain mapping, endometriotic lesions reproduced pain in 7 patients, all of whom had histologic confirmation of the diagnosis. Endometriotic lesions did not reproduce pain in eight cases.

“Seven of nine cases with histologically confirmed endometriosis mapped their pain to endometriotic lesions but none of the six cases in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to 'endometriotic' lesions,” she said. “So although it's very important to confirm [the diagnosis with] histology, we should not always assume that because you have pathology you'll have pain.”

Level A evidence suggests that endometriosis is associated with chronic pelvic pain in 50%–70% of patients. “This still does not answer the question: Is endometriosis the source of their pain?” Dr. Lamvu said. “Eighty percent of women with chronic pelvic pain also end up being diagnosed with endometriosis at some point. That does not mean that the endometriosis is the source of pain.”

Other potential causes of pelvic pain to rule out include urinary sources such as interstitial cystitis, gastrointestinal sources such as irritable bowel syndrome, and musculoskeletal trigger points.

“It's important to explain to patients with chronic pelvic pain that they may have symptomatic endometriosis or that they may have been misdiagnosed with endometriosis,” she said. “It's also important to explain to them that endometriosis can be inadequately treated and can exacerbate pain from other sources.”

The pathophysiology of endometriosis remains unclear but one concept developed in 1949 called the composite theory has gained the attention of researchers in recent years.

This theory suggests that a variety of immunologic and genetic factors may mediate endometriosis, including direct extension into myometrium and adjacent organs, exfoliation of viable endometrial cells through tubes, and implantation of these cells into the peritoneum and adjacent organs.

“There [are] a lot of convincing data that retrograde menstruation and implantation of endometrial fragments are the primary mode of developing endometriosis in the peritoneal cavity, but it's definitely not the only process,” Dr. Lamvu said. “Research is now focusing on mechanisms that are involved in the attachment and the clearance of viable endometrium from the pelvic cavity. So the focus has come to alterations in the immune system.”

Current treatment for endometriosis associated with pelvic pain includes observation with palliative treatment with NSAIDs, hormonal suppression with continuous oral contraceptives, and gonadotropin-releasing hormone agonists (GnRH), excision, ablation, or cystectomy, and definitive extirpating surgery such as hysterectomy or bilateral salpingo-oophorectomy.

“A lot of us are now doing a combination of medical and surgical therapies,” Dr. Lamvu said.

Which surgical technique is best for managing endometriosis remains unclear. “There have been no comparison trials,” she said. “Some experts suspect that excision may be more effective for pain management in deep lesions, but for the general population of gynecologists superficial ablation with some type of medical therapy afterwards will be less risky.”

She added that pain improvement in the postoperative period “may be best for patients who have extensive disease. There may be some correlation between the extent of disease and response to treatment.”

Pain usually recurs within a year in 40% of patients who undergo surgical therapy and within 1–2 years in 30%–40% of patients who receive medical therapy.

“This is a frustration for all of us,” said Dr. Lamvu, who is also assistant director of the Florida Hospital Family Practice Residency program. “There is no telling whether these numbers will [improve] now that we are incorporating so many different therapies for the management of pain.”

Future therapies include selective progesterone receptor modulators such as asoprisnil, which induce amenorrhea without side effects of hypoestrogenism and control uterine prostaglandins. Doses of 5, 10, or 25 mg per day may be effective in reducing pelvic pain.

The progesterone antagonist RU486 (mifepristone) also holds promise. A dose of 50 mg every day for 6 months may lead to a decrease in the number of endometriotic lesions.

“These are experimental therapies,” Dr. Lamvu emphasized. “They may not work for some patients. Most of these therapies are recommended for only 3–6 months.”

Other future therapies include selective nonsteroidal aromatase inhibitors such as anastrozole and letrozole.

“The nice thing about these is that they're heavily studied in other disease processes such as cancer, so we have a lot more data as far as long-term side-effect profile and safety profile,” she said. “In pelvic pain these have only been studied for up to 6 months.”

Dr. Lamvu said she is most optimistic about the potential for new GnRH antagonists to make a significant improvement in chronic pelvic pain associated with endometriosis.

These agents “may work faster and have fewer side effects than the GnRH agonists that we now use,” she said.

Endometriosis seen laparoscopically needs to be histologically confirmed. ©Elsevier, Katz: Comprehensive Gynecology, 5th ed. Figure 8–9. 2007

SAN DIEGO — When it comes to diagnosing endometriosis, visual inspection is not enough, Dr. Georgine Lamvu said at the annual meeting of the International Pelvic Pain Society.

“We need to be more careful to use excisional biopsies during laparoscopies and careful about the thorough evaluation of the pelvic structures, to record these so we can keep track of the infiltration, size, and distribution of the lesions,” said Dr. Lamvu of the department of obstetrics and gynecology at the Florida Hospital, Orlando.

She went on to note that not all endometriosis causes chronic pelvic pain. In one study of 15 patients with presumed endometriosis who went on to have conscious laparoscopic pain mapping, endometriotic lesions reproduced pain in 7 patients, all of whom had histologic confirmation of the diagnosis. Endometriotic lesions did not reproduce pain in eight cases.

“Seven of nine cases with histologically confirmed endometriosis mapped their pain to endometriotic lesions but none of the six cases in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to 'endometriotic' lesions,” she said. “So although it's very important to confirm [the diagnosis with] histology, we should not always assume that because you have pathology you'll have pain.”

Level A evidence suggests that endometriosis is associated with chronic pelvic pain in 50%–70% of patients. “This still does not answer the question: Is endometriosis the source of their pain?” Dr. Lamvu said. “Eighty percent of women with chronic pelvic pain also end up being diagnosed with endometriosis at some point. That does not mean that the endometriosis is the source of pain.”

Other potential causes of pelvic pain to rule out include urinary sources such as interstitial cystitis, gastrointestinal sources such as irritable bowel syndrome, and musculoskeletal trigger points.

“It's important to explain to patients with chronic pelvic pain that they may have symptomatic endometriosis or that they may have been misdiagnosed with endometriosis,” she said. “It's also important to explain to them that endometriosis can be inadequately treated and can exacerbate pain from other sources.”

The pathophysiology of endometriosis remains unclear but one concept developed in 1949 called the composite theory has gained the attention of researchers in recent years.

This theory suggests that a variety of immunologic and genetic factors may mediate endometriosis, including direct extension into myometrium and adjacent organs, exfoliation of viable endometrial cells through tubes, and implantation of these cells into the peritoneum and adjacent organs.

“There [are] a lot of convincing data that retrograde menstruation and implantation of endometrial fragments are the primary mode of developing endometriosis in the peritoneal cavity, but it's definitely not the only process,” Dr. Lamvu said. “Research is now focusing on mechanisms that are involved in the attachment and the clearance of viable endometrium from the pelvic cavity. So the focus has come to alterations in the immune system.”

Current treatment for endometriosis associated with pelvic pain includes observation with palliative treatment with NSAIDs, hormonal suppression with continuous oral contraceptives, and gonadotropin-releasing hormone agonists (GnRH), excision, ablation, or cystectomy, and definitive extirpating surgery such as hysterectomy or bilateral salpingo-oophorectomy.

“A lot of us are now doing a combination of medical and surgical therapies,” Dr. Lamvu said.

Which surgical technique is best for managing endometriosis remains unclear. “There have been no comparison trials,” she said. “Some experts suspect that excision may be more effective for pain management in deep lesions, but for the general population of gynecologists superficial ablation with some type of medical therapy afterwards will be less risky.”

She added that pain improvement in the postoperative period “may be best for patients who have extensive disease. There may be some correlation between the extent of disease and response to treatment.”

Pain usually recurs within a year in 40% of patients who undergo surgical therapy and within 1–2 years in 30%–40% of patients who receive medical therapy.

“This is a frustration for all of us,” said Dr. Lamvu, who is also assistant director of the Florida Hospital Family Practice Residency program. “There is no telling whether these numbers will [improve] now that we are incorporating so many different therapies for the management of pain.”

Future therapies include selective progesterone receptor modulators such as asoprisnil, which induce amenorrhea without side effects of hypoestrogenism and control uterine prostaglandins. Doses of 5, 10, or 25 mg per day may be effective in reducing pelvic pain.

The progesterone antagonist RU486 (mifepristone) also holds promise. A dose of 50 mg every day for 6 months may lead to a decrease in the number of endometriotic lesions.

“These are experimental therapies,” Dr. Lamvu emphasized. “They may not work for some patients. Most of these therapies are recommended for only 3–6 months.”

Other future therapies include selective nonsteroidal aromatase inhibitors such as anastrozole and letrozole.

“The nice thing about these is that they're heavily studied in other disease processes such as cancer, so we have a lot more data as far as long-term side-effect profile and safety profile,” she said. “In pelvic pain these have only been studied for up to 6 months.”

Dr. Lamvu said she is most optimistic about the potential for new GnRH antagonists to make a significant improvement in chronic pelvic pain associated with endometriosis.

These agents “may work faster and have fewer side effects than the GnRH agonists that we now use,” she said.

Endometriosis seen laparoscopically needs to be histologically confirmed. ©Elsevier, Katz: Comprehensive Gynecology, 5th ed. Figure 8–9. 2007

SAN DIEGO — When it comes to diagnosing endometriosis, visual inspection is not enough, Dr. Georgine Lamvu said at the annual meeting of the International Pelvic Pain Society.

“We need to be more careful to use excisional biopsies during laparoscopies and careful about the thorough evaluation of the pelvic structures, to record these so we can keep track of the infiltration, size, and distribution of the lesions,” said Dr. Lamvu of the department of obstetrics and gynecology at the Florida Hospital, Orlando.

She went on to note that not all endometriosis causes chronic pelvic pain. In one study of 15 patients with presumed endometriosis who went on to have conscious laparoscopic pain mapping, endometriotic lesions reproduced pain in 7 patients, all of whom had histologic confirmation of the diagnosis. Endometriotic lesions did not reproduce pain in eight cases.

“Seven of nine cases with histologically confirmed endometriosis mapped their pain to endometriotic lesions but none of the six cases in which the visual diagnosis of endometriosis was not histologically confirmed mapped their pain to 'endometriotic' lesions,” she said. “So although it's very important to confirm [the diagnosis with] histology, we should not always assume that because you have pathology you'll have pain.”

Level A evidence suggests that endometriosis is associated with chronic pelvic pain in 50%–70% of patients. “This still does not answer the question: Is endometriosis the source of their pain?” Dr. Lamvu said. “Eighty percent of women with chronic pelvic pain also end up being diagnosed with endometriosis at some point. That does not mean that the endometriosis is the source of pain.”

Other potential causes of pelvic pain to rule out include urinary sources such as interstitial cystitis, gastrointestinal sources such as irritable bowel syndrome, and musculoskeletal trigger points.

“It's important to explain to patients with chronic pelvic pain that they may have symptomatic endometriosis or that they may have been misdiagnosed with endometriosis,” she said. “It's also important to explain to them that endometriosis can be inadequately treated and can exacerbate pain from other sources.”

The pathophysiology of endometriosis remains unclear but one concept developed in 1949 called the composite theory has gained the attention of researchers in recent years.

This theory suggests that a variety of immunologic and genetic factors may mediate endometriosis, including direct extension into myometrium and adjacent organs, exfoliation of viable endometrial cells through tubes, and implantation of these cells into the peritoneum and adjacent organs.

“There [are] a lot of convincing data that retrograde menstruation and implantation of endometrial fragments are the primary mode of developing endometriosis in the peritoneal cavity, but it's definitely not the only process,” Dr. Lamvu said. “Research is now focusing on mechanisms that are involved in the attachment and the clearance of viable endometrium from the pelvic cavity. So the focus has come to alterations in the immune system.”

Current treatment for endometriosis associated with pelvic pain includes observation with palliative treatment with NSAIDs, hormonal suppression with continuous oral contraceptives, and gonadotropin-releasing hormone agonists (GnRH), excision, ablation, or cystectomy, and definitive extirpating surgery such as hysterectomy or bilateral salpingo-oophorectomy.

“A lot of us are now doing a combination of medical and surgical therapies,” Dr. Lamvu said.

Which surgical technique is best for managing endometriosis remains unclear. “There have been no comparison trials,” she said. “Some experts suspect that excision may be more effective for pain management in deep lesions, but for the general population of gynecologists superficial ablation with some type of medical therapy afterwards will be less risky.”

She added that pain improvement in the postoperative period “may be best for patients who have extensive disease. There may be some correlation between the extent of disease and response to treatment.”

Pain usually recurs within a year in 40% of patients who undergo surgical therapy and within 1–2 years in 30%–40% of patients who receive medical therapy.

“This is a frustration for all of us,” said Dr. Lamvu, who is also assistant director of the Florida Hospital Family Practice Residency program. “There is no telling whether these numbers will [improve] now that we are incorporating so many different therapies for the management of pain.”

Future therapies include selective progesterone receptor modulators such as asoprisnil, which induce amenorrhea without side effects of hypoestrogenism and control uterine prostaglandins. Doses of 5, 10, or 25 mg per day may be effective in reducing pelvic pain.

The progesterone antagonist RU486 (mifepristone) also holds promise. A dose of 50 mg every day for 6 months may lead to a decrease in the number of endometriotic lesions.

“These are experimental therapies,” Dr. Lamvu emphasized. “They may not work for some patients. Most of these therapies are recommended for only 3–6 months.”

Other future therapies include selective nonsteroidal aromatase inhibitors such as anastrozole and letrozole.

“The nice thing about these is that they're heavily studied in other disease processes such as cancer, so we have a lot more data as far as long-term side-effect profile and safety profile,” she said. “In pelvic pain these have only been studied for up to 6 months.”

Dr. Lamvu said she is most optimistic about the potential for new GnRH antagonists to make a significant improvement in chronic pelvic pain associated with endometriosis.

These agents “may work faster and have fewer side effects than the GnRH agonists that we now use,” she said.

Endometriosis seen laparoscopically needs to be histologically confirmed. ©Elsevier, Katz: Comprehensive Gynecology, 5th ed. Figure 8–9. 2007

A new Wilderness Medicine Society training program is one way for physicians with a love of the outdoors to combine that passion with their medical practice.

In July 2007, the Lawrence, Kan.-based program graduated its first 38 clinicians to become Fellows of the Academy of Wilderness Medicine (FAWM). Dr. Paul S. Auerbach, one of the society's cofounders who also completed the FAWM program, said that interest in wilderness medicine is at an all-time high, largely because of the current popularity of outdoor recreation.

“Outdoor recreation is the fastest-growing form of recreation worldwide, whether that be adventure travel or visiting foreign countries or outdoor activities like skiing, backpacking, or scuba diving,” said Dr. Auerbach, of the division of emergency medicine at Stanford (Calif.) University. “Health care providers are attracted to it because they want to be outdoors and they want to feel competent in that setting. They want to participate in these adventures.”

As described on the WMS Web site (www.wms.org

Among the first class of FAWM graduates was Dr. Luanne Freer. During a vacation one summer, Dr. Freer spotted a hospital sign while driving through Yellowstone National Park and realized that she could combine her training in emergency medicine with her love of the outdoors. She got a job working summers at the hospital, a post that “changed my life because I found that I was really able to take care of people while I was looking out the window and seeing the wilderness. Part of the excitement was not only being in the wilderness but [also] learning this whole new body of knowledge which is wilderness medicine. It's not anything that you learn in medical school. It's a lot of hands-on stuff and a lot of improvisational medicine: trying to make the best with limited resources.”

Today, the Bozeman, Mont.-based Dr. Freer works in the wilderness medicine field as the medical director for Yellowstone, where she oversees staff who treat visitors for everything from high-altitude sickness and snakebites to broken bones and wounds from grizzly bear attacks. Four years ago, she founded the first medical clinic at base camp on Mount Everest. She also runs a medical clinic on Midway Island, which is located between Japan and Hawaii.

There are other ways to combine medicine with an interest in the outdoors. During his pulmonary fellowship at the University of Washington, Seattle, internist Robert “Brownie” Schoene joined Dr. John B. West and other researchers on a trip to Mount Everest, where they studied cardiopulmonary capacity.

“That was the first point where my professional research interests overlapped with my passion for mountain climbing,” said Dr. Schoene, a pulmonary/critical care physician who now directs the internal medicine residency program at the University of California, San Diego.

His subsequent high-altitude research projects involved expeditions to Mount McKinley (also called Denali) in Alaska and to the Andes mountains in South America.

“I weave a lot of lessons from high-altitude work into the bedside teaching and care of patients,” said Dr. Schoene, an author, along with Dr. James S. Milledge and Dr. West, of “High Altitude Medicine and Physiology” (London: Hodder Arnold, 2007). “The mountains have made more difference in my life than almost anything. I couldn't imagine not having that overlap.”

Dr. Freer noted that organizers of outdoor adventures are hiring physicians or medics with specific training in wilderness medicine to accompany groups of travelers. “Ten to fifteen years ago, it used to be that taking along any doctor was good enough,” Dr. Freer said. “But expeditioners are becoming savvy to the fact that just any doctor or any nurse or any paramedic is not good enough. We are held to a standard that is being created through the WMS. You can't just show up and not have a clue about how to treat a snake bite. You need some experience with it and [have to] know what the latest recommendations are so you can give your patients the best care. If you don't have all that knowledge, not only are you not providing good care but you [also] could be held liable for not knowing.”

Dr. Auerbach considers wilderness medicine a personal avocation, but he is a noted expert, having recently produced the fifth edition of “Wilderness Medicine” (Philadelphia: Mosby, 2007), a textbook that is a bible for the field. He also writes his own blog on the topic (www.healthline.com/blogs/outdoor_health

On a recent diving trip with his son and others near La Paz, Mexico, Dr. Auerbach was stung by two Portuguese men-of-war when he neglected to cover his skin with a topical jellyfish sting inhibitor before he dove into the water.

“I didn't practice what I preached to others on the boat,” he said.

He treated the wounds with topical vinegar to take away the sting but had an itchy, painful rash “for a couple of days.”

Other situations have been more dramatic. During an expedition in Nepal, he assisted a trekker who had developed high-altitude cerebral edema. He placed her inside an inflatable body-size pressure bag known as a Gamow bag, and zipped it up. But she became claustrophobic and began to panic, so he climbed in the bag with her. “Then she vomited,” Dr. Auerbach said. “That wasn't real pleasant, but it's part of the job. She made it okay.”

Going forward, Dr. Freer said, a key challenge for the wilderness medicine field is to develop “a strong scientific body of knowledge.” Wilderness settings may not lend themselves to large controlled, randomized trials, she acknowledged, “but more research is needed. Like a lot of what we do in general medicine, sometimes what we recommend in wilderness medicine is based on what we've always done, not because it's based on controlled, scientific studies that prove a particular treatment works best.”

Dr. Auerbach agreed. “In wilderness medicine, as in all of medicine, good science trumps anecdotes,” he said. “The progress of our specialty will be measured by the quality of our research investigations.”

In Bear Country, Don't Hike Alone

Despite being warned to not hike alone through “bear alley,” a portion of Wyoming's Yellowstone National Park that many wild grizzly bears consider home, one man decided to make the trek solo.

Some people just don't listen.

“The park rangers advise people to hike in groups because when we hike in groups, we make more noise and give the bears warning that we're coming so they clear out,” recalled Dr. Freer, who was working at Lake Hospital in Yellowstone at the time, in the early 1990s. “This fellow wanted to have an experience by himself.”

He hiked about 10 miles into the backcountry and surprised a female grizzly bear with her cubs, which “is the most dangerous thing to come across,” Dr. Freer said. “They're very aggressive.”

The grizzly bear mauled the man, who had learned from park rangers to play dead in the event of a bear encounter to demonstrate that he was not a threat.

“He curled up in a ball and slept outside with the grizzly bear in the area,” Dr. Freer said.

The man survived the ordeal and hiked out the next morning. “He came to our hospital and we spent about 3 days caring for him, getting his wounds cleaned up, [and] giving him medication and rabies prophylaxis,” Dr. Freer said. “He had a good outcome.”

A new Wilderness Medicine Society training program is one way for physicians with a love of the outdoors to combine that passion with their medical practice.

In July 2007, the Lawrence, Kan.-based program graduated its first 38 clinicians to become Fellows of the Academy of Wilderness Medicine (FAWM). Dr. Paul S. Auerbach, one of the society's cofounders who also completed the FAWM program, said that interest in wilderness medicine is at an all-time high, largely because of the current popularity of outdoor recreation.

“Outdoor recreation is the fastest-growing form of recreation worldwide, whether that be adventure travel or visiting foreign countries or outdoor activities like skiing, backpacking, or scuba diving,” said Dr. Auerbach, of the division of emergency medicine at Stanford (Calif.) University. “Health care providers are attracted to it because they want to be outdoors and they want to feel competent in that setting. They want to participate in these adventures.”

As described on the WMS Web site (www.wms.org

Among the first class of FAWM graduates was Dr. Luanne Freer. During a vacation one summer, Dr. Freer spotted a hospital sign while driving through Yellowstone National Park and realized that she could combine her training in emergency medicine with her love of the outdoors. She got a job working summers at the hospital, a post that “changed my life because I found that I was really able to take care of people while I was looking out the window and seeing the wilderness. Part of the excitement was not only being in the wilderness but [also] learning this whole new body of knowledge which is wilderness medicine. It's not anything that you learn in medical school. It's a lot of hands-on stuff and a lot of improvisational medicine: trying to make the best with limited resources.”

Today, the Bozeman, Mont.-based Dr. Freer works in the wilderness medicine field as the medical director for Yellowstone, where she oversees staff who treat visitors for everything from high-altitude sickness and snakebites to broken bones and wounds from grizzly bear attacks. Four years ago, she founded the first medical clinic at base camp on Mount Everest. She also runs a medical clinic on Midway Island, which is located between Japan and Hawaii.

There are other ways to combine medicine with an interest in the outdoors. During his pulmonary fellowship at the University of Washington, Seattle, internist Robert “Brownie” Schoene joined Dr. John B. West and other researchers on a trip to Mount Everest, where they studied cardiopulmonary capacity.

“That was the first point where my professional research interests overlapped with my passion for mountain climbing,” said Dr. Schoene, a pulmonary/critical care physician who now directs the internal medicine residency program at the University of California, San Diego.

His subsequent high-altitude research projects involved expeditions to Mount McKinley (also called Denali) in Alaska and to the Andes mountains in South America.

“I weave a lot of lessons from high-altitude work into the bedside teaching and care of patients,” said Dr. Schoene, an author, along with Dr. James S. Milledge and Dr. West, of “High Altitude Medicine and Physiology” (London: Hodder Arnold, 2007). “The mountains have made more difference in my life than almost anything. I couldn't imagine not having that overlap.”

Dr. Freer noted that organizers of outdoor adventures are hiring physicians or medics with specific training in wilderness medicine to accompany groups of travelers. “Ten to fifteen years ago, it used to be that taking along any doctor was good enough,” Dr. Freer said. “But expeditioners are becoming savvy to the fact that just any doctor or any nurse or any paramedic is not good enough. We are held to a standard that is being created through the WMS. You can't just show up and not have a clue about how to treat a snake bite. You need some experience with it and [have to] know what the latest recommendations are so you can give your patients the best care. If you don't have all that knowledge, not only are you not providing good care but you [also] could be held liable for not knowing.”

Dr. Auerbach considers wilderness medicine a personal avocation, but he is a noted expert, having recently produced the fifth edition of “Wilderness Medicine” (Philadelphia: Mosby, 2007), a textbook that is a bible for the field. He also writes his own blog on the topic (www.healthline.com/blogs/outdoor_health

On a recent diving trip with his son and others near La Paz, Mexico, Dr. Auerbach was stung by two Portuguese men-of-war when he neglected to cover his skin with a topical jellyfish sting inhibitor before he dove into the water.

“I didn't practice what I preached to others on the boat,” he said.

He treated the wounds with topical vinegar to take away the sting but had an itchy, painful rash “for a couple of days.”

Other situations have been more dramatic. During an expedition in Nepal, he assisted a trekker who had developed high-altitude cerebral edema. He placed her inside an inflatable body-size pressure bag known as a Gamow bag, and zipped it up. But she became claustrophobic and began to panic, so he climbed in the bag with her. “Then she vomited,” Dr. Auerbach said. “That wasn't real pleasant, but it's part of the job. She made it okay.”

Going forward, Dr. Freer said, a key challenge for the wilderness medicine field is to develop “a strong scientific body of knowledge.” Wilderness settings may not lend themselves to large controlled, randomized trials, she acknowledged, “but more research is needed. Like a lot of what we do in general medicine, sometimes what we recommend in wilderness medicine is based on what we've always done, not because it's based on controlled, scientific studies that prove a particular treatment works best.”

Dr. Auerbach agreed. “In wilderness medicine, as in all of medicine, good science trumps anecdotes,” he said. “The progress of our specialty will be measured by the quality of our research investigations.”

In Bear Country, Don't Hike Alone

Despite being warned to not hike alone through “bear alley,” a portion of Wyoming's Yellowstone National Park that many wild grizzly bears consider home, one man decided to make the trek solo.

Some people just don't listen.

“The park rangers advise people to hike in groups because when we hike in groups, we make more noise and give the bears warning that we're coming so they clear out,” recalled Dr. Freer, who was working at Lake Hospital in Yellowstone at the time, in the early 1990s. “This fellow wanted to have an experience by himself.”

He hiked about 10 miles into the backcountry and surprised a female grizzly bear with her cubs, which “is the most dangerous thing to come across,” Dr. Freer said. “They're very aggressive.”

The grizzly bear mauled the man, who had learned from park rangers to play dead in the event of a bear encounter to demonstrate that he was not a threat.

“He curled up in a ball and slept outside with the grizzly bear in the area,” Dr. Freer said.

The man survived the ordeal and hiked out the next morning. “He came to our hospital and we spent about 3 days caring for him, getting his wounds cleaned up, [and] giving him medication and rabies prophylaxis,” Dr. Freer said. “He had a good outcome.”

A new Wilderness Medicine Society training program is one way for physicians with a love of the outdoors to combine that passion with their medical practice.

In July 2007, the Lawrence, Kan.-based program graduated its first 38 clinicians to become Fellows of the Academy of Wilderness Medicine (FAWM). Dr. Paul S. Auerbach, one of the society's cofounders who also completed the FAWM program, said that interest in wilderness medicine is at an all-time high, largely because of the current popularity of outdoor recreation.

“Outdoor recreation is the fastest-growing form of recreation worldwide, whether that be adventure travel or visiting foreign countries or outdoor activities like skiing, backpacking, or scuba diving,” said Dr. Auerbach, of the division of emergency medicine at Stanford (Calif.) University. “Health care providers are attracted to it because they want to be outdoors and they want to feel competent in that setting. They want to participate in these adventures.”

As described on the WMS Web site (www.wms.org

Among the first class of FAWM graduates was Dr. Luanne Freer. During a vacation one summer, Dr. Freer spotted a hospital sign while driving through Yellowstone National Park and realized that she could combine her training in emergency medicine with her love of the outdoors. She got a job working summers at the hospital, a post that “changed my life because I found that I was really able to take care of people while I was looking out the window and seeing the wilderness. Part of the excitement was not only being in the wilderness but [also] learning this whole new body of knowledge which is wilderness medicine. It's not anything that you learn in medical school. It's a lot of hands-on stuff and a lot of improvisational medicine: trying to make the best with limited resources.”

Today, the Bozeman, Mont.-based Dr. Freer works in the wilderness medicine field as the medical director for Yellowstone, where she oversees staff who treat visitors for everything from high-altitude sickness and snakebites to broken bones and wounds from grizzly bear attacks. Four years ago, she founded the first medical clinic at base camp on Mount Everest. She also runs a medical clinic on Midway Island, which is located between Japan and Hawaii.

There are other ways to combine medicine with an interest in the outdoors. During his pulmonary fellowship at the University of Washington, Seattle, internist Robert “Brownie” Schoene joined Dr. John B. West and other researchers on a trip to Mount Everest, where they studied cardiopulmonary capacity.

“That was the first point where my professional research interests overlapped with my passion for mountain climbing,” said Dr. Schoene, a pulmonary/critical care physician who now directs the internal medicine residency program at the University of California, San Diego.

His subsequent high-altitude research projects involved expeditions to Mount McKinley (also called Denali) in Alaska and to the Andes mountains in South America.

“I weave a lot of lessons from high-altitude work into the bedside teaching and care of patients,” said Dr. Schoene, an author, along with Dr. James S. Milledge and Dr. West, of “High Altitude Medicine and Physiology” (London: Hodder Arnold, 2007). “The mountains have made more difference in my life than almost anything. I couldn't imagine not having that overlap.”

Dr. Freer noted that organizers of outdoor adventures are hiring physicians or medics with specific training in wilderness medicine to accompany groups of travelers. “Ten to fifteen years ago, it used to be that taking along any doctor was good enough,” Dr. Freer said. “But expeditioners are becoming savvy to the fact that just any doctor or any nurse or any paramedic is not good enough. We are held to a standard that is being created through the WMS. You can't just show up and not have a clue about how to treat a snake bite. You need some experience with it and [have to] know what the latest recommendations are so you can give your patients the best care. If you don't have all that knowledge, not only are you not providing good care but you [also] could be held liable for not knowing.”

Dr. Auerbach considers wilderness medicine a personal avocation, but he is a noted expert, having recently produced the fifth edition of “Wilderness Medicine” (Philadelphia: Mosby, 2007), a textbook that is a bible for the field. He also writes his own blog on the topic (www.healthline.com/blogs/outdoor_health

On a recent diving trip with his son and others near La Paz, Mexico, Dr. Auerbach was stung by two Portuguese men-of-war when he neglected to cover his skin with a topical jellyfish sting inhibitor before he dove into the water.

“I didn't practice what I preached to others on the boat,” he said.

He treated the wounds with topical vinegar to take away the sting but had an itchy, painful rash “for a couple of days.”

Other situations have been more dramatic. During an expedition in Nepal, he assisted a trekker who had developed high-altitude cerebral edema. He placed her inside an inflatable body-size pressure bag known as a Gamow bag, and zipped it up. But she became claustrophobic and began to panic, so he climbed in the bag with her. “Then she vomited,” Dr. Auerbach said. “That wasn't real pleasant, but it's part of the job. She made it okay.”

Going forward, Dr. Freer said, a key challenge for the wilderness medicine field is to develop “a strong scientific body of knowledge.” Wilderness settings may not lend themselves to large controlled, randomized trials, she acknowledged, “but more research is needed. Like a lot of what we do in general medicine, sometimes what we recommend in wilderness medicine is based on what we've always done, not because it's based on controlled, scientific studies that prove a particular treatment works best.”

Dr. Auerbach agreed. “In wilderness medicine, as in all of medicine, good science trumps anecdotes,” he said. “The progress of our specialty will be measured by the quality of our research investigations.”

In Bear Country, Don't Hike Alone

Despite being warned to not hike alone through “bear alley,” a portion of Wyoming's Yellowstone National Park that many wild grizzly bears consider home, one man decided to make the trek solo.

Some people just don't listen.

“The park rangers advise people to hike in groups because when we hike in groups, we make more noise and give the bears warning that we're coming so they clear out,” recalled Dr. Freer, who was working at Lake Hospital in Yellowstone at the time, in the early 1990s. “This fellow wanted to have an experience by himself.”

He hiked about 10 miles into the backcountry and surprised a female grizzly bear with her cubs, which “is the most dangerous thing to come across,” Dr. Freer said. “They're very aggressive.”

The grizzly bear mauled the man, who had learned from park rangers to play dead in the event of a bear encounter to demonstrate that he was not a threat.

“He curled up in a ball and slept outside with the grizzly bear in the area,” Dr. Freer said.

The man survived the ordeal and hiked out the next morning. “He came to our hospital and we spent about 3 days caring for him, getting his wounds cleaned up, [and] giving him medication and rabies prophylaxis,” Dr. Freer said. “He had a good outcome.”

During his senior year of high school in Seattle, Wash., Dr. Kevin Ware came across a classified ad in the aviation section of a local newspaper that read: “guaranteed to solo: $99.”

He was making just $1.25 an hour as a gas station attendant in 1964 but figured he could afford flight school training. He earned his pilot's license by the time he graduated from high school.

“After that, I realized that I had a hobby that I couldn't afford,” recalled Dr. Ware, a family and emergency physician based in Seattle, who left full-time practice 10 years ago to work as a cruise ship physician and return to flying professionally. “I thought that I might as well get enough flying time and a pilot rating, so I could at least get this hobby to pay for itself.”

By the time he turned 24, he had logged more than 4,000 hours of flying time, earned a commercial pilot's license, and become a certified flight instructor. The money he made from flying clients to various locales and from teaching flight instruction helped pay his college tuition at the University of Washington, Seattle, and medical school bills at Des Moines University, in Iowa.

The summer after his first year of medical school, he got a job flying a corporate airplane for a corn seed company. He also had a stint flying Iowa's lieutenant governor during his campaign. One day, the itinerary involved flying him to Davenport in time for the evening news from the opposite end of the state. “The problem is, across Iowa in the afternoon in the summer you get a lot of thunderstorms and a lot of really rough air,” said Dr. Ware, whose father was an aircraft engineer in the Royal Air Force during World War II. “When we got to Davenport, the TV cameras were all set up for [the lieutenant governor's] arrival. He got off the airplane as green as anything.”

Dr. Ware, who owns a helicopter and a twin-engine Cessna airplane, said that the skills he learned as a pilot suited him well for a career in medicine. “Flying taught me procedural discipline and a level of self-confidence, particularly when circumstances get difficult, that is hard to obtain from any other endeavor,” he said. “Flying also involves a high level of hand/eye coordination, coupled with the ability to apply academic knowledge. All of these translate well to medicine.”

He emphasized that flying “is not inherently safe. … You can only make it safe by being very careful about what you're doing, by knowing what you're doing, and by taking information you've acquired academically and intellectually and applying it.”

Despite the inherent risks that come with flying, little rattles him. “If you do it right, you don't get scared,” he said.

He pointed out that flying has become safer and less stressful in recent years because of the advent of satellite-downloaded weather radar and GPS navigation systems. Also, annual simulator training currently is a routine requirement for professional pilots “and is a learning process medicine should copy,” he said. “If I go to a CME course in medicine, and I go to the equivalent of a CME course in aviation, the aviation CME is more effective and practical. They really do teach you how to fly those airplanes in bad situations.”

Dr. Ware noted that flying smaller aircraft enables him to see things most other people don't, such as the scores of grizzly bears he and he wife saw dotting the coast of Alaska north of Ketchikan, as well as a sizable portion of the Lewis and Clark expedition route, from the Missouri River to Oregon.

Why Not Fly the Real Thing?

Fifteen years ago, Dr. David Araujo was operating a radio-controlled glider plane with a good friend when it occurred to him: “Why not try to fly the real thing?”

While on a subsequent vacation in Oahu, Hawaii, he visited a soaring site for gliders—also known as sail planes—and took a ride.

He was hooked.

When he returned to his then-home in southern California, he took lessons at a gliding site in nearby Hemet and earned a license to pilot the craft. Nowadays, he flies once or twice a month, usually at a gliding site in Hollister, Calif., about 80 miles from his current home in northern California. He describes engineless air travel as an intellectual challenge.

“In gliding, the goal is to stay up as long as you can, whereas for people who pilot power planes, their interest is more in visiting different places,” said Dr. Araujo, who directs the family medicine residency program at Mercy Medical Center in Merced. “You have to search for forms of air lift, and you're constantly gauging how far away you are from where you're going to land versus your altitude. The other side of it is that it's just you up there all alone. You have to concentrate on what you're doing so you forget about all the other stuff: hassles, stresses, work, or whatever. You're able to put everything away and aside for a period of time. It's a good mental release and relaxation.”

Dr. Araujo belongs to a Bay Area club of pilots that owns five gliders. Monthly membership fees cover use of the craft. Other out-of-pocket costs include towing fees.

In the United States, the most common way to tow a glider is an aerotow, in which the glider is towed into the sky with a 200-foot-long rope hooked to the back of an engine-powered plane.

“You're towed up into the air with that, so you're flying in formation behind the tow plane,” he explained. “You have a release hook on the rope and you release at whatever altitude you want, based on the air conditions.”

When he's piloting a glider near Hollister, Dr. Araujo often soars with hawks and eagles. “They'll be right there in the same thermal, which is an uprising column of air,” he said.

As with other forms of flight, weather can make or break an intended gliding route. Eight years ago, Dr. Araujo was flying in Hemet when a thunderstorm cloud approached from a nearby mountain range. “I was trying to figure out: Am I going to be able to stay up and wait for it to go past, or should I try to land first?” he recalled. “I decided to land first, which probably was not the best decision. I landed right in the middle of this thunderstorm cloud coming right across the airport. It was the rockiest landing I ever had.”

To maintain his pilot status, Dr. Araujo undergoes flight review by a certified instructor every 2 years. “It's almost like recertification for a physician,” he said. “But during that time, you have to fly enough in between—at least once every 90 days—in order to remain a pilot in command. You have to do it frequently enough to remain safe.”

A high level of hand/eye coordination and the ability to apply knowledge are necessary in flying, which translates well to medicine, said Dr. Kevin Ware. KARI WARE

Risks of Flying Help Put Life in Perspective

DR. JOHN O'HANDLEY is a family physician with the Mount Carmel Family Practice Center in Columbus, Ohio.

I didn't grow up with a burning desire to fly a plane. But my teenage cousin took me flying in the late 1950s after he had gotten his license and that experience stayed in the back of my mind for several years. So when the chance arose to learn how to fly, I jumped at it.

That opportunity occurred during my first month of internship in 1972, when I was rotating in the emergency room 24 hours on and 24 hours off. Returning to my apartment for 6 hours of sleep allowed me time to enroll in a flying school at Lambert Field in St. Louis. When I found that flying in a small plane didn't bring on any nausea and the freedom of the skies was exhilarating, I was hooked. I soloed at 10 hours and had the date recorded on a torn t-shirt. By 50 hours, I had earned my private single-engine land license.

I was now allowed to fly passengers and I eagerly chose close friends. Flights to Silver Dollar City in the Ozarks; Hannibal, Mo.; Greenville, Ill.; and Columbus and Cleveland, Ohio, proved to be exciting adventures. But not all my trips ended on a high note.

When I took up my future wife for a spin on a blustery spring day, the turbulence proved to be too much for her to handle. When her tears began to flow, I knew I needed to get back to terra firma. It was the last flight she took in a single-engine plane. Another time, I landed on a grass strip in the Ozarks with two passengers and picked up a third at the field. I hadn't figured in the extra weight and just barely cleared the fence at the end of the runway. I was sweating bullets, but my passengers were oblivious to the near miss.

After residency in 1975, I chose to return to my wife's native state, Ohio, and practiced in Fairfield County. I continued to fly mostly by myself until one fateful day.

After returning from a solo trip around the area, my wife asked how much it had cost. My answer was met by, “I could have bought a place setting of china for that price.” That was essentially the end of my flying career for 20 years while my children were growing up and my wife was completing her china collection. She pointed out that it would be easier to raise four children with both spouses. I got the hint.

There have been a few snags in my late-life flying experience. A pilot friend of mine flew the Beech Musketeer that I used for most of my flights and suffered a disastrous crash with four passengers aboard while returning from Cleveland. The aircraft ran out of fuel about 10 miles from the airport, and the pilot was able to successfully land on a highway median. Unfortunately, the plane collided with an abutment during the landing, which resulted in three fatalities.

Such events do put a different slant on one's view, and I must say I am leaning more toward my wife's perspective. I now have five grandchildren and would have no problem encouraging them to take up flying. But I believe my flying days may be numbered and that more practical considerations are taking precedence. How much flying that will involve remains to be seen.

During his senior year of high school in Seattle, Wash., Dr. Kevin Ware came across a classified ad in the aviation section of a local newspaper that read: “guaranteed to solo: $99.”

He was making just $1.25 an hour as a gas station attendant in 1964 but figured he could afford flight school training. He earned his pilot's license by the time he graduated from high school.

“After that, I realized that I had a hobby that I couldn't afford,” recalled Dr. Ware, a family and emergency physician based in Seattle, who left full-time practice 10 years ago to work as a cruise ship physician and return to flying professionally. “I thought that I might as well get enough flying time and a pilot rating, so I could at least get this hobby to pay for itself.”

By the time he turned 24, he had logged more than 4,000 hours of flying time, earned a commercial pilot's license, and become a certified flight instructor. The money he made from flying clients to various locales and from teaching flight instruction helped pay his college tuition at the University of Washington, Seattle, and medical school bills at Des Moines University, in Iowa.

The summer after his first year of medical school, he got a job flying a corporate airplane for a corn seed company. He also had a stint flying Iowa's lieutenant governor during his campaign. One day, the itinerary involved flying him to Davenport in time for the evening news from the opposite end of the state. “The problem is, across Iowa in the afternoon in the summer you get a lot of thunderstorms and a lot of really rough air,” said Dr. Ware, whose father was an aircraft engineer in the Royal Air Force during World War II. “When we got to Davenport, the TV cameras were all set up for [the lieutenant governor's] arrival. He got off the airplane as green as anything.”

Dr. Ware, who owns a helicopter and a twin-engine Cessna airplane, said that the skills he learned as a pilot suited him well for a career in medicine. “Flying taught me procedural discipline and a level of self-confidence, particularly when circumstances get difficult, that is hard to obtain from any other endeavor,” he said. “Flying also involves a high level of hand/eye coordination, coupled with the ability to apply academic knowledge. All of these translate well to medicine.”

He emphasized that flying “is not inherently safe. … You can only make it safe by being very careful about what you're doing, by knowing what you're doing, and by taking information you've acquired academically and intellectually and applying it.”

Despite the inherent risks that come with flying, little rattles him. “If you do it right, you don't get scared,” he said.

He pointed out that flying has become safer and less stressful in recent years because of the advent of satellite-downloaded weather radar and GPS navigation systems. Also, annual simulator training currently is a routine requirement for professional pilots “and is a learning process medicine should copy,” he said. “If I go to a CME course in medicine, and I go to the equivalent of a CME course in aviation, the aviation CME is more effective and practical. They really do teach you how to fly those airplanes in bad situations.”

Dr. Ware noted that flying smaller aircraft enables him to see things most other people don't, such as the scores of grizzly bears he and he wife saw dotting the coast of Alaska north of Ketchikan, as well as a sizable portion of the Lewis and Clark expedition route, from the Missouri River to Oregon.

Why Not Fly the Real Thing?

Fifteen years ago, Dr. David Araujo was operating a radio-controlled glider plane with a good friend when it occurred to him: “Why not try to fly the real thing?”

While on a subsequent vacation in Oahu, Hawaii, he visited a soaring site for gliders—also known as sail planes—and took a ride.

He was hooked.

When he returned to his then-home in southern California, he took lessons at a gliding site in nearby Hemet and earned a license to pilot the craft. Nowadays, he flies once or twice a month, usually at a gliding site in Hollister, Calif., about 80 miles from his current home in northern California. He describes engineless air travel as an intellectual challenge.

“In gliding, the goal is to stay up as long as you can, whereas for people who pilot power planes, their interest is more in visiting different places,” said Dr. Araujo, who directs the family medicine residency program at Mercy Medical Center in Merced. “You have to search for forms of air lift, and you're constantly gauging how far away you are from where you're going to land versus your altitude. The other side of it is that it's just you up there all alone. You have to concentrate on what you're doing so you forget about all the other stuff: hassles, stresses, work, or whatever. You're able to put everything away and aside for a period of time. It's a good mental release and relaxation.”

Dr. Araujo belongs to a Bay Area club of pilots that owns five gliders. Monthly membership fees cover use of the craft. Other out-of-pocket costs include towing fees.

In the United States, the most common way to tow a glider is an aerotow, in which the glider is towed into the sky with a 200-foot-long rope hooked to the back of an engine-powered plane.

“You're towed up into the air with that, so you're flying in formation behind the tow plane,” he explained. “You have a release hook on the rope and you release at whatever altitude you want, based on the air conditions.”

When he's piloting a glider near Hollister, Dr. Araujo often soars with hawks and eagles. “They'll be right there in the same thermal, which is an uprising column of air,” he said.

As with other forms of flight, weather can make or break an intended gliding route. Eight years ago, Dr. Araujo was flying in Hemet when a thunderstorm cloud approached from a nearby mountain range. “I was trying to figure out: Am I going to be able to stay up and wait for it to go past, or should I try to land first?” he recalled. “I decided to land first, which probably was not the best decision. I landed right in the middle of this thunderstorm cloud coming right across the airport. It was the rockiest landing I ever had.”

To maintain his pilot status, Dr. Araujo undergoes flight review by a certified instructor every 2 years. “It's almost like recertification for a physician,” he said. “But during that time, you have to fly enough in between—at least once every 90 days—in order to remain a pilot in command. You have to do it frequently enough to remain safe.”

A high level of hand/eye coordination and the ability to apply knowledge are necessary in flying, which translates well to medicine, said Dr. Kevin Ware. KARI WARE

Risks of Flying Help Put Life in Perspective

DR. JOHN O'HANDLEY is a family physician with the Mount Carmel Family Practice Center in Columbus, Ohio.

I didn't grow up with a burning desire to fly a plane. But my teenage cousin took me flying in the late 1950s after he had gotten his license and that experience stayed in the back of my mind for several years. So when the chance arose to learn how to fly, I jumped at it.

That opportunity occurred during my first month of internship in 1972, when I was rotating in the emergency room 24 hours on and 24 hours off. Returning to my apartment for 6 hours of sleep allowed me time to enroll in a flying school at Lambert Field in St. Louis. When I found that flying in a small plane didn't bring on any nausea and the freedom of the skies was exhilarating, I was hooked. I soloed at 10 hours and had the date recorded on a torn t-shirt. By 50 hours, I had earned my private single-engine land license.

I was now allowed to fly passengers and I eagerly chose close friends. Flights to Silver Dollar City in the Ozarks; Hannibal, Mo.; Greenville, Ill.; and Columbus and Cleveland, Ohio, proved to be exciting adventures. But not all my trips ended on a high note.

When I took up my future wife for a spin on a blustery spring day, the turbulence proved to be too much for her to handle. When her tears began to flow, I knew I needed to get back to terra firma. It was the last flight she took in a single-engine plane. Another time, I landed on a grass strip in the Ozarks with two passengers and picked up a third at the field. I hadn't figured in the extra weight and just barely cleared the fence at the end of the runway. I was sweating bullets, but my passengers were oblivious to the near miss.

After residency in 1975, I chose to return to my wife's native state, Ohio, and practiced in Fairfield County. I continued to fly mostly by myself until one fateful day.

After returning from a solo trip around the area, my wife asked how much it had cost. My answer was met by, “I could have bought a place setting of china for that price.” That was essentially the end of my flying career for 20 years while my children were growing up and my wife was completing her china collection. She pointed out that it would be easier to raise four children with both spouses. I got the hint.

There have been a few snags in my late-life flying experience. A pilot friend of mine flew the Beech Musketeer that I used for most of my flights and suffered a disastrous crash with four passengers aboard while returning from Cleveland. The aircraft ran out of fuel about 10 miles from the airport, and the pilot was able to successfully land on a highway median. Unfortunately, the plane collided with an abutment during the landing, which resulted in three fatalities.

Such events do put a different slant on one's view, and I must say I am leaning more toward my wife's perspective. I now have five grandchildren and would have no problem encouraging them to take up flying. But I believe my flying days may be numbered and that more practical considerations are taking precedence. How much flying that will involve remains to be seen.

During his senior year of high school in Seattle, Wash., Dr. Kevin Ware came across a classified ad in the aviation section of a local newspaper that read: “guaranteed to solo: $99.”

He was making just $1.25 an hour as a gas station attendant in 1964 but figured he could afford flight school training. He earned his pilot's license by the time he graduated from high school.

“After that, I realized that I had a hobby that I couldn't afford,” recalled Dr. Ware, a family and emergency physician based in Seattle, who left full-time practice 10 years ago to work as a cruise ship physician and return to flying professionally. “I thought that I might as well get enough flying time and a pilot rating, so I could at least get this hobby to pay for itself.”

By the time he turned 24, he had logged more than 4,000 hours of flying time, earned a commercial pilot's license, and become a certified flight instructor. The money he made from flying clients to various locales and from teaching flight instruction helped pay his college tuition at the University of Washington, Seattle, and medical school bills at Des Moines University, in Iowa.

The summer after his first year of medical school, he got a job flying a corporate airplane for a corn seed company. He also had a stint flying Iowa's lieutenant governor during his campaign. One day, the itinerary involved flying him to Davenport in time for the evening news from the opposite end of the state. “The problem is, across Iowa in the afternoon in the summer you get a lot of thunderstorms and a lot of really rough air,” said Dr. Ware, whose father was an aircraft engineer in the Royal Air Force during World War II. “When we got to Davenport, the TV cameras were all set up for [the lieutenant governor's] arrival. He got off the airplane as green as anything.”

Dr. Ware, who owns a helicopter and a twin-engine Cessna airplane, said that the skills he learned as a pilot suited him well for a career in medicine. “Flying taught me procedural discipline and a level of self-confidence, particularly when circumstances get difficult, that is hard to obtain from any other endeavor,” he said. “Flying also involves a high level of hand/eye coordination, coupled with the ability to apply academic knowledge. All of these translate well to medicine.”

He emphasized that flying “is not inherently safe. … You can only make it safe by being very careful about what you're doing, by knowing what you're doing, and by taking information you've acquired academically and intellectually and applying it.”

Despite the inherent risks that come with flying, little rattles him. “If you do it right, you don't get scared,” he said.

He pointed out that flying has become safer and less stressful in recent years because of the advent of satellite-downloaded weather radar and GPS navigation systems. Also, annual simulator training currently is a routine requirement for professional pilots “and is a learning process medicine should copy,” he said. “If I go to a CME course in medicine, and I go to the equivalent of a CME course in aviation, the aviation CME is more effective and practical. They really do teach you how to fly those airplanes in bad situations.”

Dr. Ware noted that flying smaller aircraft enables him to see things most other people don't, such as the scores of grizzly bears he and he wife saw dotting the coast of Alaska north of Ketchikan, as well as a sizable portion of the Lewis and Clark expedition route, from the Missouri River to Oregon.

Why Not Fly the Real Thing?

Fifteen years ago, Dr. David Araujo was operating a radio-controlled glider plane with a good friend when it occurred to him: “Why not try to fly the real thing?”

While on a subsequent vacation in Oahu, Hawaii, he visited a soaring site for gliders—also known as sail planes—and took a ride.

He was hooked.

When he returned to his then-home in southern California, he took lessons at a gliding site in nearby Hemet and earned a license to pilot the craft. Nowadays, he flies once or twice a month, usually at a gliding site in Hollister, Calif., about 80 miles from his current home in northern California. He describes engineless air travel as an intellectual challenge.

“In gliding, the goal is to stay up as long as you can, whereas for people who pilot power planes, their interest is more in visiting different places,” said Dr. Araujo, who directs the family medicine residency program at Mercy Medical Center in Merced. “You have to search for forms of air lift, and you're constantly gauging how far away you are from where you're going to land versus your altitude. The other side of it is that it's just you up there all alone. You have to concentrate on what you're doing so you forget about all the other stuff: hassles, stresses, work, or whatever. You're able to put everything away and aside for a period of time. It's a good mental release and relaxation.”

Dr. Araujo belongs to a Bay Area club of pilots that owns five gliders. Monthly membership fees cover use of the craft. Other out-of-pocket costs include towing fees.

In the United States, the most common way to tow a glider is an aerotow, in which the glider is towed into the sky with a 200-foot-long rope hooked to the back of an engine-powered plane.

“You're towed up into the air with that, so you're flying in formation behind the tow plane,” he explained. “You have a release hook on the rope and you release at whatever altitude you want, based on the air conditions.”

When he's piloting a glider near Hollister, Dr. Araujo often soars with hawks and eagles. “They'll be right there in the same thermal, which is an uprising column of air,” he said.

As with other forms of flight, weather can make or break an intended gliding route. Eight years ago, Dr. Araujo was flying in Hemet when a thunderstorm cloud approached from a nearby mountain range. “I was trying to figure out: Am I going to be able to stay up and wait for it to go past, or should I try to land first?” he recalled. “I decided to land first, which probably was not the best decision. I landed right in the middle of this thunderstorm cloud coming right across the airport. It was the rockiest landing I ever had.”

To maintain his pilot status, Dr. Araujo undergoes flight review by a certified instructor every 2 years. “It's almost like recertification for a physician,” he said. “But during that time, you have to fly enough in between—at least once every 90 days—in order to remain a pilot in command. You have to do it frequently enough to remain safe.”

A high level of hand/eye coordination and the ability to apply knowledge are necessary in flying, which translates well to medicine, said Dr. Kevin Ware. KARI WARE

Risks of Flying Help Put Life in Perspective

DR. JOHN O'HANDLEY is a family physician with the Mount Carmel Family Practice Center in Columbus, Ohio.

I didn't grow up with a burning desire to fly a plane. But my teenage cousin took me flying in the late 1950s after he had gotten his license and that experience stayed in the back of my mind for several years. So when the chance arose to learn how to fly, I jumped at it.

That opportunity occurred during my first month of internship in 1972, when I was rotating in the emergency room 24 hours on and 24 hours off. Returning to my apartment for 6 hours of sleep allowed me time to enroll in a flying school at Lambert Field in St. Louis. When I found that flying in a small plane didn't bring on any nausea and the freedom of the skies was exhilarating, I was hooked. I soloed at 10 hours and had the date recorded on a torn t-shirt. By 50 hours, I had earned my private single-engine land license.

I was now allowed to fly passengers and I eagerly chose close friends. Flights to Silver Dollar City in the Ozarks; Hannibal, Mo.; Greenville, Ill.; and Columbus and Cleveland, Ohio, proved to be exciting adventures. But not all my trips ended on a high note.

When I took up my future wife for a spin on a blustery spring day, the turbulence proved to be too much for her to handle. When her tears began to flow, I knew I needed to get back to terra firma. It was the last flight she took in a single-engine plane. Another time, I landed on a grass strip in the Ozarks with two passengers and picked up a third at the field. I hadn't figured in the extra weight and just barely cleared the fence at the end of the runway. I was sweating bullets, but my passengers were oblivious to the near miss.

After residency in 1975, I chose to return to my wife's native state, Ohio, and practiced in Fairfield County. I continued to fly mostly by myself until one fateful day.

After returning from a solo trip around the area, my wife asked how much it had cost. My answer was met by, “I could have bought a place setting of china for that price.” That was essentially the end of my flying career for 20 years while my children were growing up and my wife was completing her china collection. She pointed out that it would be easier to raise four children with both spouses. I got the hint.

There have been a few snags in my late-life flying experience. A pilot friend of mine flew the Beech Musketeer that I used for most of my flights and suffered a disastrous crash with four passengers aboard while returning from Cleveland. The aircraft ran out of fuel about 10 miles from the airport, and the pilot was able to successfully land on a highway median. Unfortunately, the plane collided with an abutment during the landing, which resulted in three fatalities.

Such events do put a different slant on one's view, and I must say I am leaning more toward my wife's perspective. I now have five grandchildren and would have no problem encouraging them to take up flying. But I believe my flying days may be numbered and that more practical considerations are taking precedence. How much flying that will involve remains to be seen.

CORONADO, CALIF. — One out of six students at a Midwestern medical school reported prior use of at least one club drug, results from a survey found.

“Physicians should be cognizant, when treating medical students, physicians, or other health care workers, that we are not excluded from substance abuse,” Dr. Alex Horowitz said in an interview after presenting the study at the annual meeting of the American Academy of Addiction Psychiatry. “The same principles should be applied when assessing health care workers for substance use as when assessing the rest of the population.”

In what he said is the first study of its kind, Dr. Horowitz and his associates asked 340 students at a private Midwestern medical school to complete an anonymous survey about their use of and attitudes about club drugs. Generation I club drugs were defined as cocaine and LSD; generation II club drugs included 3,4-methylenedioxymethamphetamine (also known as ecstasy), methamphetamine, gamma hydroxybutyrate (GHB), Rohypnol, ketamine, and dextromethorphan.

Nearly half (46%) of the respondents were first-year students; 34% were second-year; and 20% were third-year.

Overall prevalence of lifetime club drug use was 17%, with ecstasy and cocaine the agents of choice (12% and 6%, respectively), said Dr. Horowitz, psychiatric unit chief of the methadone treatment program at Bellevue Hospital Center, New York. The prevalence of medical students' lifetime ecstasy use was similar to that of their peers in the general population, as reported in the National Institute on Drug Abuse's 2004 “Monitoring the Future” survey.

Compared with students aged 21–25 years, those aged 26 and older were more likely to have used the generation I drugs (cocaine, 16% vs. 4%, respectively; LSD, 14% vs. 2%). However, no relationship was found between age and use of generation II club drugs in general.

Students who reported never using club drugs perceived regular cocaine use as posing the greatest risk to health (89%), followed by ecstasy (72%). For students who reported lifetime use of at least one club drug, the perceived risk of using cocaine and ecstasy regularly was significantly lower (75% and 58%, respectively). Club drug use did not differ between men and women, but women rated them as generally more harmful than did men.

A greater number of students thought it would be necessary to revoke the licenses of physicians who were currently using generation I club drugs than those who were using generation II club drugs (27% vs. 20%, respectively).

Dr. Horowitz of the department of psychiatry at New York University acknowledged the self-reported nature of the study is a limitation. Another is that the data were collected in a classroom setting, which means participants were limited to students more likely to attend class. However, the survey was given in a class considered mandatory.

CORONADO, CALIF. — One out of six students at a Midwestern medical school reported prior use of at least one club drug, results from a survey found.

“Physicians should be cognizant, when treating medical students, physicians, or other health care workers, that we are not excluded from substance abuse,” Dr. Alex Horowitz said in an interview after presenting the study at the annual meeting of the American Academy of Addiction Psychiatry. “The same principles should be applied when assessing health care workers for substance use as when assessing the rest of the population.”

In what he said is the first study of its kind, Dr. Horowitz and his associates asked 340 students at a private Midwestern medical school to complete an anonymous survey about their use of and attitudes about club drugs. Generation I club drugs were defined as cocaine and LSD; generation II club drugs included 3,4-methylenedioxymethamphetamine (also known as ecstasy), methamphetamine, gamma hydroxybutyrate (GHB), Rohypnol, ketamine, and dextromethorphan.

Nearly half (46%) of the respondents were first-year students; 34% were second-year; and 20% were third-year.

Overall prevalence of lifetime club drug use was 17%, with ecstasy and cocaine the agents of choice (12% and 6%, respectively), said Dr. Horowitz, psychiatric unit chief of the methadone treatment program at Bellevue Hospital Center, New York. The prevalence of medical students' lifetime ecstasy use was similar to that of their peers in the general population, as reported in the National Institute on Drug Abuse's 2004 “Monitoring the Future” survey.

Compared with students aged 21–25 years, those aged 26 and older were more likely to have used the generation I drugs (cocaine, 16% vs. 4%, respectively; LSD, 14% vs. 2%). However, no relationship was found between age and use of generation II club drugs in general.

Students who reported never using club drugs perceived regular cocaine use as posing the greatest risk to health (89%), followed by ecstasy (72%). For students who reported lifetime use of at least one club drug, the perceived risk of using cocaine and ecstasy regularly was significantly lower (75% and 58%, respectively). Club drug use did not differ between men and women, but women rated them as generally more harmful than did men.

A greater number of students thought it would be necessary to revoke the licenses of physicians who were currently using generation I club drugs than those who were using generation II club drugs (27% vs. 20%, respectively).

Dr. Horowitz of the department of psychiatry at New York University acknowledged the self-reported nature of the study is a limitation. Another is that the data were collected in a classroom setting, which means participants were limited to students more likely to attend class. However, the survey was given in a class considered mandatory.

CORONADO, CALIF. — One out of six students at a Midwestern medical school reported prior use of at least one club drug, results from a survey found.

“Physicians should be cognizant, when treating medical students, physicians, or other health care workers, that we are not excluded from substance abuse,” Dr. Alex Horowitz said in an interview after presenting the study at the annual meeting of the American Academy of Addiction Psychiatry. “The same principles should be applied when assessing health care workers for substance use as when assessing the rest of the population.”

In what he said is the first study of its kind, Dr. Horowitz and his associates asked 340 students at a private Midwestern medical school to complete an anonymous survey about their use of and attitudes about club drugs. Generation I club drugs were defined as cocaine and LSD; generation II club drugs included 3,4-methylenedioxymethamphetamine (also known as ecstasy), methamphetamine, gamma hydroxybutyrate (GHB), Rohypnol, ketamine, and dextromethorphan.

Nearly half (46%) of the respondents were first-year students; 34% were second-year; and 20% were third-year.

Overall prevalence of lifetime club drug use was 17%, with ecstasy and cocaine the agents of choice (12% and 6%, respectively), said Dr. Horowitz, psychiatric unit chief of the methadone treatment program at Bellevue Hospital Center, New York. The prevalence of medical students' lifetime ecstasy use was similar to that of their peers in the general population, as reported in the National Institute on Drug Abuse's 2004 “Monitoring the Future” survey.

Compared with students aged 21–25 years, those aged 26 and older were more likely to have used the generation I drugs (cocaine, 16% vs. 4%, respectively; LSD, 14% vs. 2%). However, no relationship was found between age and use of generation II club drugs in general.

Students who reported never using club drugs perceived regular cocaine use as posing the greatest risk to health (89%), followed by ecstasy (72%). For students who reported lifetime use of at least one club drug, the perceived risk of using cocaine and ecstasy regularly was significantly lower (75% and 58%, respectively). Club drug use did not differ between men and women, but women rated them as generally more harmful than did men.

A greater number of students thought it would be necessary to revoke the licenses of physicians who were currently using generation I club drugs than those who were using generation II club drugs (27% vs. 20%, respectively).

Dr. Horowitz of the department of psychiatry at New York University acknowledged the self-reported nature of the study is a limitation. Another is that the data were collected in a classroom setting, which means participants were limited to students more likely to attend class. However, the survey was given in a class considered mandatory.

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue, he said. He added that cognitive-behavioral therapy “is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35).

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 of the participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter considers the 12-step portion of the CPH program essential. “It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using.

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue, he said. He added that cognitive-behavioral therapy “is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35).

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 of the participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter considers the 12-step portion of the CPH program essential. “It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using.

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.”

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue, he said. He added that cognitive-behavioral therapy “is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35).

The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 of the participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said. However, one complication is that physician impairment programs are responsible for serving large numbers of physicians.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Dr. Galanter considers the 12-step portion of the CPH program essential. “It's really remarkable what transformation many of these physicians experienced over the course of rehabilitation,” he said. “What we don't know is how we can compare recovery of this kind to recovery based on opioid replacement or on the variety of medications that we're going to be using.

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level. Dr. Galanter advised that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35). The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level. Dr. Galanter advised that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35). The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level. Dr. Galanter advised that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35). The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

SAN DIEGO — Consider expanding subclinical cardiovascular disease testing to include asymptomatic high-risk patient populations, Leslee J. Shaw, Ph.D., advised attendees at the annual meeting of the American Society of Nuclear Cardiology.

Referring physicians should ask themselves: In which of my appropriate patients can I identify risk of cardiovascular disease, suggested Dr. Shaw, professor of medicine at Emory University, Atlanta. “The goal is to expand cardiovascular testing to improve the detection gap. But we have to do it appropriately, without excessive cost.”

One ideal population to target with subclinical testing is the high-risk elderly. A study found that 1 in 5 people aged 65 years and older has an ankle brachial index of less than 0.9, yet only 1 in 10 peripheral artery disease patients will have classical symptoms of intermittent claudication (Atherosclerosis 2004;172:95–105). “If one relies solely on classical symptoms of intermittent claudication, you will underappreciate the prevalence of peripheral artery disease,” said Dr. Shaw, who is also an outcomes research scientist for the Emory Program in Cardiovascular Outcomes Research and Epidemiology. “So in this population of patients, perhaps ankle brachial index or some other modality may be good at identifying asymptomatic patients who are at risk of worsening outcome.”

Other populations to target include:

▸ High-risk functionally impaired patients. Patients who can't achieve 5 METs on the treadmill test “are functionally impaired and have a high risk for cardiovascular events,” she said. “We need to do a better job of not only identifying the degrees of comorbidity, but treating their comorbidities, perhaps getting them to improve their exercise abilities to lessen that risk. There [are] a lot of data showing that these patients can improve their exercise tolerance and can have an improved outcome following cardiac rehabilitation.”

▸ High-risk smokers. Smoking is a leading cause of acute coronary thrombosis. Dr. Shaw and her associates showed in a study that patients who smoke and have coronary calcification have a worsening mortality, compared with nonsmokers (Eur. Heart J. 2006;27:968–75). “Young smokers with a lot of coronary calcification have an anticipated loss in life expectancy of 4–5 years,” she said. “This is a good message for young smokers, especially patients in their 40s who have children. Five years is a lot to lose of your life.”

▸ Asymptomatic diabetics. Diabetes patients who are candidates for subclinical cardiovascular disease testing include those with poorly controlled diabetes, those who have not achieved their LDL cholesterol goal, those with multiple cardiac risk factors, and those who have had diabetes for more than 5 years.

In this population of patients, “you might want to think about assessing the baseline cardiovascular risk, consider ischemia testing in those with a high-risk scan, and look for disease progression downstream,” Dr. Shaw said. She called coronary calcification “an amazing prognostic test.” The overall rate of perfusion abnormalities is high in diabetic patients with a calcium score of 100 or higher.

▸ Patients with metabolic syndrome. The National Cholesterol Education Panel Adult Treatment Panel III defines the criteria for metabolic syndrome as three or more of the following: abdominal obesity (a waistline greater than 102 cm in men and greater than 88 cm in women); triglyceride levels of 150 mg/dL or greater; HDL cholesterol levels of less than 40 mg/dL in men and less than 50 mg/dL in women; a systolic blood pressure of 130 mm Hg or greater or a diastolic blood pressure of 85 mm Hg or greater; and a fasting glucose level of 110 mg/dL or greater.

A recent study showed that the prevalence of inducible ischemia is increased among patients with metabolic syndrome who do not have diabetes, as well as in those who have diabetes, when their calcium scores exceed 100 (Diabetes Care 2005;28:1445–50).

In these patients, “think about retesting with perfusion imaging,” Dr. Shaw advised.

▸ High-risk women. This includes those with early menopause, those with autoimmune disease, and those with polycystic ovary syndrome. All conditions confer an increased risk of coronary artery disease.

Dr. Shaw stressed that by targeting high-risk patient populations, you are testing, not screening. “In discussions with payers, tell them you are trying to identify appropriate testing candidates and minimize inappropriate testing in your testing practice.”

“The goal is to identify patients who require more intensive management and thereby decrease the detection gap of high-risk patients with a resulting … improvement in cardiovascular mortality.”

SAN DIEGO — Consider expanding subclinical cardiovascular disease testing to include asymptomatic high-risk patient populations, Leslee J. Shaw, Ph.D., advised attendees at the annual meeting of the American Society of Nuclear Cardiology.

Referring physicians should ask themselves: In which of my appropriate patients can I identify risk of cardiovascular disease, suggested Dr. Shaw, professor of medicine at Emory University, Atlanta. “The goal is to expand cardiovascular testing to improve the detection gap. But we have to do it appropriately, without excessive cost.”

One ideal population to target with subclinical testing is the high-risk elderly. A study found that 1 in 5 people aged 65 years and older has an ankle brachial index of less than 0.9, yet only 1 in 10 peripheral artery disease patients will have classical symptoms of intermittent claudication (Atherosclerosis 2004;172:95–105). “If one relies solely on classical symptoms of intermittent claudication, you will underappreciate the prevalence of peripheral artery disease,” said Dr. Shaw, who is also an outcomes research scientist for the Emory Program in Cardiovascular Outcomes Research and Epidemiology. “So in this population of patients, perhaps ankle brachial index or some other modality may be good at identifying asymptomatic patients who are at risk of worsening outcome.”

Other populations to target include:

▸ High-risk functionally impaired patients. Patients who can't achieve 5 METs on the treadmill test “are functionally impaired and have a high risk for cardiovascular events,” she said. “We need to do a better job of not only identifying the degrees of comorbidity, but treating their comorbidities, perhaps getting them to improve their exercise abilities to lessen that risk. There [are] a lot of data showing that these patients can improve their exercise tolerance and can have an improved outcome following cardiac rehabilitation.”

▸ High-risk smokers. Smoking is a leading cause of acute coronary thrombosis. Dr. Shaw and her associates showed in a study that patients who smoke and have coronary calcification have a worsening mortality, compared with nonsmokers (Eur. Heart J. 2006;27:968–75). “Young smokers with a lot of coronary calcification have an anticipated loss in life expectancy of 4–5 years,” she said. “This is a good message for young smokers, especially patients in their 40s who have children. Five years is a lot to lose of your life.”

▸ Asymptomatic diabetics. Diabetes patients who are candidates for subclinical cardiovascular disease testing include those with poorly controlled diabetes, those who have not achieved their LDL cholesterol goal, those with multiple cardiac risk factors, and those who have had diabetes for more than 5 years.

In this population of patients, “you might want to think about assessing the baseline cardiovascular risk, consider ischemia testing in those with a high-risk scan, and look for disease progression downstream,” Dr. Shaw said. She called coronary calcification “an amazing prognostic test.” The overall rate of perfusion abnormalities is high in diabetic patients with a calcium score of 100 or higher.

▸ Patients with metabolic syndrome. The National Cholesterol Education Panel Adult Treatment Panel III defines the criteria for metabolic syndrome as three or more of the following: abdominal obesity (a waistline greater than 102 cm in men and greater than 88 cm in women); triglyceride levels of 150 mg/dL or greater; HDL cholesterol levels of less than 40 mg/dL in men and less than 50 mg/dL in women; a systolic blood pressure of 130 mm Hg or greater or a diastolic blood pressure of 85 mm Hg or greater; and a fasting glucose level of 110 mg/dL or greater.

A recent study showed that the prevalence of inducible ischemia is increased among patients with metabolic syndrome who do not have diabetes, as well as in those who have diabetes, when their calcium scores exceed 100 (Diabetes Care 2005;28:1445–50).

In these patients, “think about retesting with perfusion imaging,” Dr. Shaw advised.

▸ High-risk women. This includes those with early menopause, those with autoimmune disease, and those with polycystic ovary syndrome. All conditions confer an increased risk of coronary artery disease.

Dr. Shaw stressed that by targeting high-risk patient populations, you are testing, not screening. “In discussions with payers, tell them you are trying to identify appropriate testing candidates and minimize inappropriate testing in your testing practice.”

“The goal is to identify patients who require more intensive management and thereby decrease the detection gap of high-risk patients with a resulting … improvement in cardiovascular mortality.”

SAN DIEGO — Consider expanding subclinical cardiovascular disease testing to include asymptomatic high-risk patient populations, Leslee J. Shaw, Ph.D., advised attendees at the annual meeting of the American Society of Nuclear Cardiology.

Referring physicians should ask themselves: In which of my appropriate patients can I identify risk of cardiovascular disease, suggested Dr. Shaw, professor of medicine at Emory University, Atlanta. “The goal is to expand cardiovascular testing to improve the detection gap. But we have to do it appropriately, without excessive cost.”

One ideal population to target with subclinical testing is the high-risk elderly. A study found that 1 in 5 people aged 65 years and older has an ankle brachial index of less than 0.9, yet only 1 in 10 peripheral artery disease patients will have classical symptoms of intermittent claudication (Atherosclerosis 2004;172:95–105). “If one relies solely on classical symptoms of intermittent claudication, you will underappreciate the prevalence of peripheral artery disease,” said Dr. Shaw, who is also an outcomes research scientist for the Emory Program in Cardiovascular Outcomes Research and Epidemiology. “So in this population of patients, perhaps ankle brachial index or some other modality may be good at identifying asymptomatic patients who are at risk of worsening outcome.”

Other populations to target include:

▸ High-risk functionally impaired patients. Patients who can't achieve 5 METs on the treadmill test “are functionally impaired and have a high risk for cardiovascular events,” she said. “We need to do a better job of not only identifying the degrees of comorbidity, but treating their comorbidities, perhaps getting them to improve their exercise abilities to lessen that risk. There [are] a lot of data showing that these patients can improve their exercise tolerance and can have an improved outcome following cardiac rehabilitation.”

▸ High-risk smokers. Smoking is a leading cause of acute coronary thrombosis. Dr. Shaw and her associates showed in a study that patients who smoke and have coronary calcification have a worsening mortality, compared with nonsmokers (Eur. Heart J. 2006;27:968–75). “Young smokers with a lot of coronary calcification have an anticipated loss in life expectancy of 4–5 years,” she said. “This is a good message for young smokers, especially patients in their 40s who have children. Five years is a lot to lose of your life.”

▸ Asymptomatic diabetics. Diabetes patients who are candidates for subclinical cardiovascular disease testing include those with poorly controlled diabetes, those who have not achieved their LDL cholesterol goal, those with multiple cardiac risk factors, and those who have had diabetes for more than 5 years.

In this population of patients, “you might want to think about assessing the baseline cardiovascular risk, consider ischemia testing in those with a high-risk scan, and look for disease progression downstream,” Dr. Shaw said. She called coronary calcification “an amazing prognostic test.” The overall rate of perfusion abnormalities is high in diabetic patients with a calcium score of 100 or higher.

▸ Patients with metabolic syndrome. The National Cholesterol Education Panel Adult Treatment Panel III defines the criteria for metabolic syndrome as three or more of the following: abdominal obesity (a waistline greater than 102 cm in men and greater than 88 cm in women); triglyceride levels of 150 mg/dL or greater; HDL cholesterol levels of less than 40 mg/dL in men and less than 50 mg/dL in women; a systolic blood pressure of 130 mm Hg or greater or a diastolic blood pressure of 85 mm Hg or greater; and a fasting glucose level of 110 mg/dL or greater.

A recent study showed that the prevalence of inducible ischemia is increased among patients with metabolic syndrome who do not have diabetes, as well as in those who have diabetes, when their calcium scores exceed 100 (Diabetes Care 2005;28:1445–50).

In these patients, “think about retesting with perfusion imaging,” Dr. Shaw advised.

▸ High-risk women. This includes those with early menopause, those with autoimmune disease, and those with polycystic ovary syndrome. All conditions confer an increased risk of coronary artery disease.

Dr. Shaw stressed that by targeting high-risk patient populations, you are testing, not screening. “In discussions with payers, tell them you are trying to identify appropriate testing candidates and minimize inappropriate testing in your testing practice.”

“The goal is to identify patients who require more intensive management and thereby decrease the detection gap of high-risk patients with a resulting … improvement in cardiovascular mortality.”