Doug Brunk

When Kenneth E. Bloom, M.D., sat down in front of a computer monitor and keyboard to take the first-ever pediatric dermatology board certification exam in October, he felt a sense of accomplishment before he entered a single keystroke.

After all, the test was his idea, which he first proposed at a meeting of the Society of Pediatric Dermatology in 1997.

“When I first mentioned this, the idea of physicians taking another test did not go over very well,” recalled Dr. Bloom, a dermatologist in private practice in Minneapolis. “There are a host of reasons why I think this subspecialty needed to take place. One is to recognize a true subspecialty field and to give credibility and recognition to the major advances in the care of children. Plus, while I am formally trained in both pediatrics and dermatology, there are a whole host of pediatric dermatologists who never had formal pediatrics training, who never had any true licensure or board specialty that identified them. This exam makes them unique.”

The exam is also meant to give pediatric dermatologists certain clout with managed care providers, added Elaine Siegfried, M.D., of St. Louis University. When managed care began to flourish in the 1990s, she said, “board certification became not only important for training, but it started becoming economically important. If you didn't have a board-certified specialty, then payers didn't recognize that you existed, so it wouldn't become necessary to include your services for patients.”

Today, Dr. Siegfried calls Dr. Bloom's idea for the exam visionary. But back in 1997, “most of us were busy defining diseases and taking care of sick children, and we didn't really think about what was up ahead,” said Dr. Siegfried, also in private practice in St. Louis. “Ken thought about it from a private practice perspective. He was being shut out of managed care. He had just left the university [setting], so all of these kids he was previously taking care of had limited access to care by a pediatric dermatologist.”

With help and cooperation from the American Board of Dermatology, Dr. Siegfried, as well as Ilona Frieden, M.D., of the University of California, San Francisco, and several other pediatric dermatologists—all members of the Society for Pediatric Dermatology—created a proposal that was submitted to the Committee on Certification. (SKIN & ALLERGY NEws, March 2004, p. 1).

The test marked another milestone for the American Board of Dermatology: its first computer-based exam. Minor technical glitches with some computers created a tense atmosphere early on. “There was a little more anxiety than I thought there would be,” said Dr. Siegfried, vice chair of the committee that assembled the test questions. “Even a few very experienced people who are bright and widely published seemed a little anxious.”

Of the 92 examinees, only 4 failed, for a pass rate of 96%. And 15 of the 200 items on the test were answered correctly by all examinees. An additional 44 items were answered correctly by 95%-99% of examinees.

Susan Bayliss Mallory, M.D., a member of the Society for Pediatric Dermatology since 1980, opted against taking the exam because her daughter was expecting a baby at the time. “But I think it's a great idea,” said Dr. Mallory, director of pediatric dermatology at Washington University in St. Louis. “It's probably more applicable to people coming out of training right now, as opposed to somebody like me, who's older and established in my training. I may indeed take it next time. If I take the exam, it will be because I think it is a good [way to be a] role model for the younger attendings.”

Some of her peers, she added, chose not to take the test because of its $1,600 price tag, and others wondered how it would benefit their practice. That was not the case for Seth J. Orlow, M.D., who began to be squeezed out of managed care physician panels in the late 1990s because many did not recognize pediatric dermatology as a subspecialty.

“They'd say, 'We have enough dermatologists,'” said Dr. Orlow, professor of pediatric dermatology at New York University Medical Center. “I would say to them, 'You don't have any pediatric dermatologists on your panel.' They'd say, 'There's no such thing.'”

He added that for physicians who practice in academic medical centers, the exam “adds an additional level of certification, so you can say, 'I'm actually certified in pediatric dermatology.' I think that's valuable.”

Dr. Orlow said that members of the test committee made “a real effort to be inclusive as to who got to take the exam, rather than be exclusive. It was not meant to restrict people from practicing pediatric dermatology but, rather, to add an independent measure of ability in pediatric dermatology.”

Dr. Bloom added that creation of the exam “opened the door for communications between the American Board of Pediatrics and the American Board of Dermatology to create joint training programs.”

Dr. Orlow, who was the first to complete the test—it took him 90 minutes—described the exam as a good measure of “walking-around knowledge” of pediatric dermatology. The next exam takes place in 2006. For more information, visit the American Board of Dermatology Web site, at www.abderm.org

When Kenneth E. Bloom, M.D., sat down in front of a computer monitor and keyboard to take the first-ever pediatric dermatology board certification exam in October, he felt a sense of accomplishment before he entered a single keystroke.

After all, the test was his idea, which he first proposed at a meeting of the Society of Pediatric Dermatology in 1997.

“When I first mentioned this, the idea of physicians taking another test did not go over very well,” recalled Dr. Bloom, a dermatologist in private practice in Minneapolis. “There are a host of reasons why I think this subspecialty needed to take place. One is to recognize a true subspecialty field and to give credibility and recognition to the major advances in the care of children. Plus, while I am formally trained in both pediatrics and dermatology, there are a whole host of pediatric dermatologists who never had formal pediatrics training, who never had any true licensure or board specialty that identified them. This exam makes them unique.”

The exam is also meant to give pediatric dermatologists certain clout with managed care providers, added Elaine Siegfried, M.D., of St. Louis University. When managed care began to flourish in the 1990s, she said, “board certification became not only important for training, but it started becoming economically important. If you didn't have a board-certified specialty, then payers didn't recognize that you existed, so it wouldn't become necessary to include your services for patients.”

Today, Dr. Siegfried calls Dr. Bloom's idea for the exam visionary. But back in 1997, “most of us were busy defining diseases and taking care of sick children, and we didn't really think about what was up ahead,” said Dr. Siegfried, also in private practice in St. Louis. “Ken thought about it from a private practice perspective. He was being shut out of managed care. He had just left the university [setting], so all of these kids he was previously taking care of had limited access to care by a pediatric dermatologist.”

With help and cooperation from the American Board of Dermatology, Dr. Siegfried, as well as Ilona Frieden, M.D., of the University of California, San Francisco, and several other pediatric dermatologists—all members of the Society for Pediatric Dermatology—created a proposal that was submitted to the Committee on Certification. (SKIN & ALLERGY NEws, March 2004, p. 1).

The test marked another milestone for the American Board of Dermatology: its first computer-based exam. Minor technical glitches with some computers created a tense atmosphere early on. “There was a little more anxiety than I thought there would be,” said Dr. Siegfried, vice chair of the committee that assembled the test questions. “Even a few very experienced people who are bright and widely published seemed a little anxious.”

Of the 92 examinees, only 4 failed, for a pass rate of 96%. And 15 of the 200 items on the test were answered correctly by all examinees. An additional 44 items were answered correctly by 95%-99% of examinees.

Susan Bayliss Mallory, M.D., a member of the Society for Pediatric Dermatology since 1980, opted against taking the exam because her daughter was expecting a baby at the time. “But I think it's a great idea,” said Dr. Mallory, director of pediatric dermatology at Washington University in St. Louis. “It's probably more applicable to people coming out of training right now, as opposed to somebody like me, who's older and established in my training. I may indeed take it next time. If I take the exam, it will be because I think it is a good [way to be a] role model for the younger attendings.”

Some of her peers, she added, chose not to take the test because of its $1,600 price tag, and others wondered how it would benefit their practice. That was not the case for Seth J. Orlow, M.D., who began to be squeezed out of managed care physician panels in the late 1990s because many did not recognize pediatric dermatology as a subspecialty.

“They'd say, 'We have enough dermatologists,'” said Dr. Orlow, professor of pediatric dermatology at New York University Medical Center. “I would say to them, 'You don't have any pediatric dermatologists on your panel.' They'd say, 'There's no such thing.'”

He added that for physicians who practice in academic medical centers, the exam “adds an additional level of certification, so you can say, 'I'm actually certified in pediatric dermatology.' I think that's valuable.”

Dr. Orlow said that members of the test committee made “a real effort to be inclusive as to who got to take the exam, rather than be exclusive. It was not meant to restrict people from practicing pediatric dermatology but, rather, to add an independent measure of ability in pediatric dermatology.”

Dr. Bloom added that creation of the exam “opened the door for communications between the American Board of Pediatrics and the American Board of Dermatology to create joint training programs.”

Dr. Orlow, who was the first to complete the test—it took him 90 minutes—described the exam as a good measure of “walking-around knowledge” of pediatric dermatology. The next exam takes place in 2006. For more information, visit the American Board of Dermatology Web site, at www.abderm.org

When Kenneth E. Bloom, M.D., sat down in front of a computer monitor and keyboard to take the first-ever pediatric dermatology board certification exam in October, he felt a sense of accomplishment before he entered a single keystroke.

After all, the test was his idea, which he first proposed at a meeting of the Society of Pediatric Dermatology in 1997.

“When I first mentioned this, the idea of physicians taking another test did not go over very well,” recalled Dr. Bloom, a dermatologist in private practice in Minneapolis. “There are a host of reasons why I think this subspecialty needed to take place. One is to recognize a true subspecialty field and to give credibility and recognition to the major advances in the care of children. Plus, while I am formally trained in both pediatrics and dermatology, there are a whole host of pediatric dermatologists who never had formal pediatrics training, who never had any true licensure or board specialty that identified them. This exam makes them unique.”

The exam is also meant to give pediatric dermatologists certain clout with managed care providers, added Elaine Siegfried, M.D., of St. Louis University. When managed care began to flourish in the 1990s, she said, “board certification became not only important for training, but it started becoming economically important. If you didn't have a board-certified specialty, then payers didn't recognize that you existed, so it wouldn't become necessary to include your services for patients.”

Today, Dr. Siegfried calls Dr. Bloom's idea for the exam visionary. But back in 1997, “most of us were busy defining diseases and taking care of sick children, and we didn't really think about what was up ahead,” said Dr. Siegfried, also in private practice in St. Louis. “Ken thought about it from a private practice perspective. He was being shut out of managed care. He had just left the university [setting], so all of these kids he was previously taking care of had limited access to care by a pediatric dermatologist.”

With help and cooperation from the American Board of Dermatology, Dr. Siegfried, as well as Ilona Frieden, M.D., of the University of California, San Francisco, and several other pediatric dermatologists—all members of the Society for Pediatric Dermatology—created a proposal that was submitted to the Committee on Certification. (SKIN & ALLERGY NEws, March 2004, p. 1).

The test marked another milestone for the American Board of Dermatology: its first computer-based exam. Minor technical glitches with some computers created a tense atmosphere early on. “There was a little more anxiety than I thought there would be,” said Dr. Siegfried, vice chair of the committee that assembled the test questions. “Even a few very experienced people who are bright and widely published seemed a little anxious.”

Of the 92 examinees, only 4 failed, for a pass rate of 96%. And 15 of the 200 items on the test were answered correctly by all examinees. An additional 44 items were answered correctly by 95%-99% of examinees.

Susan Bayliss Mallory, M.D., a member of the Society for Pediatric Dermatology since 1980, opted against taking the exam because her daughter was expecting a baby at the time. “But I think it's a great idea,” said Dr. Mallory, director of pediatric dermatology at Washington University in St. Louis. “It's probably more applicable to people coming out of training right now, as opposed to somebody like me, who's older and established in my training. I may indeed take it next time. If I take the exam, it will be because I think it is a good [way to be a] role model for the younger attendings.”

Some of her peers, she added, chose not to take the test because of its $1,600 price tag, and others wondered how it would benefit their practice. That was not the case for Seth J. Orlow, M.D., who began to be squeezed out of managed care physician panels in the late 1990s because many did not recognize pediatric dermatology as a subspecialty.

“They'd say, 'We have enough dermatologists,'” said Dr. Orlow, professor of pediatric dermatology at New York University Medical Center. “I would say to them, 'You don't have any pediatric dermatologists on your panel.' They'd say, 'There's no such thing.'”

He added that for physicians who practice in academic medical centers, the exam “adds an additional level of certification, so you can say, 'I'm actually certified in pediatric dermatology.' I think that's valuable.”

Dr. Orlow said that members of the test committee made “a real effort to be inclusive as to who got to take the exam, rather than be exclusive. It was not meant to restrict people from practicing pediatric dermatology but, rather, to add an independent measure of ability in pediatric dermatology.”

Dr. Bloom added that creation of the exam “opened the door for communications between the American Board of Pediatrics and the American Board of Dermatology to create joint training programs.”

Dr. Orlow, who was the first to complete the test—it took him 90 minutes—described the exam as a good measure of “walking-around knowledge” of pediatric dermatology. The next exam takes place in 2006. For more information, visit the American Board of Dermatology Web site, at www.abderm.org

Children with cystic fibrosis can acquire nonmucoid Pseudomonas aeruginosa and mucoid P. aeruginosa very early in life, and the prevalence of the mucoid form increases significantly as children age, according to results from a long-term study.

“Early prevention and detection of nonmucoid P. aeruginosa and mucoid P. aeruginosa is critical because of early acquisition and prevalence,” said Zhanhai Li, Ph.D., of the University of Wisconsin, Madison, and associates. “There is a window of opportunity for suppression and possible eradication of initial nonmucoid P. aeruginosa.”

For the study, which is called the first of its kind, the investigators prospectively evaluated 56 cystic fibrosis (CF) patients at two CF centers between April 15, 1985, and April 15, 2004 (JAMA 2005;293:581-8). Diagnoses were made through the Wisconsin CF Neonatal Screening Project. The children who participated in the study were seen every 6 weeks for the first year of life, then every 3 months for up to 16 years.

Of the 56 patients, 16 (29%) acquired nonmucoid P. aeruginosa in the first 6 months of life.

Among those who reached 16, nearly all (92%) developed mucoid P. aeruginosa. It took a median of 1 year for children to develop the nonmucoid form, compared with a median of 13 years for children to develop the mucoid form.

“Initial nonmucoid P. aeruginosa can possibly be eradicated by aggressive anti-P. aeruginosa treatment, but once mucoid P. aeruginosa is established, eradication seems impossible, and a life-threatening situation develops,” they said.

The investigators observed that relatively low antibody titers point to nonmucoid P. aeruginosa and high titers to the mucoid form.

“We also demonstrated that dramatic cough score and chest radiograph changes were associated with progressive lung infections that led to impaired pulmonary function,” Dr. Li and associates said. “Therefore, cough scores and chest radiographs may also signal nonmucoid P. aeruginosa and, especially, P. aeruginosa stages and potentially guide therapeutic decisions.”

The investigators said that the small sample of patients is a limitation of the study and that larger studies will be needed to confirm the findings.

The National Institutes of Health and the Cystic Fibrosis Foundation supported the study.

Children with cystic fibrosis can acquire nonmucoid Pseudomonas aeruginosa and mucoid P. aeruginosa very early in life, and the prevalence of the mucoid form increases significantly as children age, according to results from a long-term study.

“Early prevention and detection of nonmucoid P. aeruginosa and mucoid P. aeruginosa is critical because of early acquisition and prevalence,” said Zhanhai Li, Ph.D., of the University of Wisconsin, Madison, and associates. “There is a window of opportunity for suppression and possible eradication of initial nonmucoid P. aeruginosa.”

For the study, which is called the first of its kind, the investigators prospectively evaluated 56 cystic fibrosis (CF) patients at two CF centers between April 15, 1985, and April 15, 2004 (JAMA 2005;293:581-8). Diagnoses were made through the Wisconsin CF Neonatal Screening Project. The children who participated in the study were seen every 6 weeks for the first year of life, then every 3 months for up to 16 years.

Of the 56 patients, 16 (29%) acquired nonmucoid P. aeruginosa in the first 6 months of life.

Among those who reached 16, nearly all (92%) developed mucoid P. aeruginosa. It took a median of 1 year for children to develop the nonmucoid form, compared with a median of 13 years for children to develop the mucoid form.

“Initial nonmucoid P. aeruginosa can possibly be eradicated by aggressive anti-P. aeruginosa treatment, but once mucoid P. aeruginosa is established, eradication seems impossible, and a life-threatening situation develops,” they said.

The investigators observed that relatively low antibody titers point to nonmucoid P. aeruginosa and high titers to the mucoid form.

“We also demonstrated that dramatic cough score and chest radiograph changes were associated with progressive lung infections that led to impaired pulmonary function,” Dr. Li and associates said. “Therefore, cough scores and chest radiographs may also signal nonmucoid P. aeruginosa and, especially, P. aeruginosa stages and potentially guide therapeutic decisions.”

The investigators said that the small sample of patients is a limitation of the study and that larger studies will be needed to confirm the findings.

The National Institutes of Health and the Cystic Fibrosis Foundation supported the study.

Children with cystic fibrosis can acquire nonmucoid Pseudomonas aeruginosa and mucoid P. aeruginosa very early in life, and the prevalence of the mucoid form increases significantly as children age, according to results from a long-term study.

“Early prevention and detection of nonmucoid P. aeruginosa and mucoid P. aeruginosa is critical because of early acquisition and prevalence,” said Zhanhai Li, Ph.D., of the University of Wisconsin, Madison, and associates. “There is a window of opportunity for suppression and possible eradication of initial nonmucoid P. aeruginosa.”

For the study, which is called the first of its kind, the investigators prospectively evaluated 56 cystic fibrosis (CF) patients at two CF centers between April 15, 1985, and April 15, 2004 (JAMA 2005;293:581-8). Diagnoses were made through the Wisconsin CF Neonatal Screening Project. The children who participated in the study were seen every 6 weeks for the first year of life, then every 3 months for up to 16 years.

Of the 56 patients, 16 (29%) acquired nonmucoid P. aeruginosa in the first 6 months of life.

Among those who reached 16, nearly all (92%) developed mucoid P. aeruginosa. It took a median of 1 year for children to develop the nonmucoid form, compared with a median of 13 years for children to develop the mucoid form.

“Initial nonmucoid P. aeruginosa can possibly be eradicated by aggressive anti-P. aeruginosa treatment, but once mucoid P. aeruginosa is established, eradication seems impossible, and a life-threatening situation develops,” they said.

The investigators observed that relatively low antibody titers point to nonmucoid P. aeruginosa and high titers to the mucoid form.

“We also demonstrated that dramatic cough score and chest radiograph changes were associated with progressive lung infections that led to impaired pulmonary function,” Dr. Li and associates said. “Therefore, cough scores and chest radiographs may also signal nonmucoid P. aeruginosa and, especially, P. aeruginosa stages and potentially guide therapeutic decisions.”

The investigators said that the small sample of patients is a limitation of the study and that larger studies will be needed to confirm the findings.

The National Institutes of Health and the Cystic Fibrosis Foundation supported the study.

SAN DIEGO — Pregnant women who present with changing nevi should not be treated differently from other patients of similar age, Dina R. Massry, M.D., said at a melanoma update sponsored by the Scripps Clinic.

“Prompt biopsy is key,” said Dr. Massry, a dermatologist with the division of dermatology and cutaneous surgery at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

While it is commonly accepted that nevi enlarge and change during pregnancy and that new nevi develop, pregnant women “may get a false sense of security and disregard something that may be potentially worrisome and not get evaluated,” she noted. Pregnant women may not be aware that they should be concerned about irregular or changing moles.

Any changing mole—especially one that has become irregular or asymmetric—could be a melanoma. Synchronous and homogeneous darkening of multiple moles “is probably normal but still should be evaluated,” she said.

A delayed diagnosis of melanoma in pregnant patients illustrates that physicians should treat changing nevi exactly the same in pregnant and nonpregnant patients, and biopsy the moles promptly, Dr. Massry said.

No study has identified a difference in survival rates between pregnant patients with melanoma and nonpregnant, age-matched controls, but studies consistently show an increase in median thickness among pregnant patients with melanoma, compared with nonpregnant, age-matched controls. While a delay in melanoma diagnosis is the likely cause for this difference, Dr. Massry said there are no data to confirm or refute the possible role of growth factors that induce thicker and more rapidly growing melanomas.

In her presentation, she also addressed the following questions related to melanoma:

▸How does one approach recurrent melanoma in pregnant patients with stage II-IV disease? CT and x-ray can be used if the benefits and risks are discussed with the patient. One study supports the use of MRI in the systemic work-up (Semin. Oncol. 2000;27:623-32).

Another analysis (Curr. Opin. Oncol. 1999;11:129-31) reports that the manufacturers and suppliers of interferon have “sparse data” on pregnant patients that suggest babies delivered to mothers receiving interferon therapy have low birth weights, Dr. Massry said.

She added that dacarbazine is considered the best treatment for pregnant patients with advanced disease.

▸What is the risk to the fetus in a pregnancy complicated by melanoma? Transplacental metastases occur only in patients with hematogenous dissemination of melanoma. The incidence of maternal malignancy during pregnancy is 1 per 1,000, and melanoma accounts for 8% of all cancers during pregnancy.

“About 25% of the cancer that is metastatic to the parts of conception involve the fetus,” Dr. Massry said. “Of cases with fetal involvement, 58% or so arise via melanoma.” However, transplacental metastases “are very rare.”

At birth, she advised, “you want to do a thorough evaluation of the infant, a gross microscopic examination of the placenta, and [an examination of] the cord blood buffy coat for tumor cells.”

▸When can a woman safely become pregnant after treatment of melanoma? The commonly accepted advice for patients is to avoid conception for 2-3 years if their lesions were 1.5 mm or smaller and 5-8 years if their lesions were greater than 1.5 mm.

Part of this recommendation has to do with [when] most recurrences are likely to occur, Dr. Massry said. “But if you're talking to a 20-year-old woman versus maybe a 40-year-old woman, the recommendations may change, depending on what their sense of urgency is with regard to childbearing.”

Some investigators support the notion of individualized recommendations depending on tumor thickness, stage of diagnosis, age of the patient, and the desire of the patient to become pregnant (Cancer 2003;9:2130-3).

▸Is there a link between melanoma and use of oral contraceptives or hormone therapy? Older studies suggest that high-dose oral contraceptives increase the risk of melanoma, but newer studies that include epidemiologic analysis refute the earlier data.

A controlled study of more than 2,000 women found no relationship between the incidence of melanoma and oral contraceptive use, age at onset of use, number of years used, or proximal relationship to use (Br. J. Cancer 2002;86:1085-92).

Dr. Massry noted that there is “a paucity of information” on hormone therapy and melanoma. Some investigators maintain that there is no reason to withhold hormone therapy from a woman if it is otherwise recommended (Climacteric 2002;5:197-200).

SAN DIEGO — Pregnant women who present with changing nevi should not be treated differently from other patients of similar age, Dina R. Massry, M.D., said at a melanoma update sponsored by the Scripps Clinic.

“Prompt biopsy is key,” said Dr. Massry, a dermatologist with the division of dermatology and cutaneous surgery at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

While it is commonly accepted that nevi enlarge and change during pregnancy and that new nevi develop, pregnant women “may get a false sense of security and disregard something that may be potentially worrisome and not get evaluated,” she noted. Pregnant women may not be aware that they should be concerned about irregular or changing moles.

Any changing mole—especially one that has become irregular or asymmetric—could be a melanoma. Synchronous and homogeneous darkening of multiple moles “is probably normal but still should be evaluated,” she said.

A delayed diagnosis of melanoma in pregnant patients illustrates that physicians should treat changing nevi exactly the same in pregnant and nonpregnant patients, and biopsy the moles promptly, Dr. Massry said.

No study has identified a difference in survival rates between pregnant patients with melanoma and nonpregnant, age-matched controls, but studies consistently show an increase in median thickness among pregnant patients with melanoma, compared with nonpregnant, age-matched controls. While a delay in melanoma diagnosis is the likely cause for this difference, Dr. Massry said there are no data to confirm or refute the possible role of growth factors that induce thicker and more rapidly growing melanomas.

In her presentation, she also addressed the following questions related to melanoma:

▸How does one approach recurrent melanoma in pregnant patients with stage II-IV disease? CT and x-ray can be used if the benefits and risks are discussed with the patient. One study supports the use of MRI in the systemic work-up (Semin. Oncol. 2000;27:623-32).

Another analysis (Curr. Opin. Oncol. 1999;11:129-31) reports that the manufacturers and suppliers of interferon have “sparse data” on pregnant patients that suggest babies delivered to mothers receiving interferon therapy have low birth weights, Dr. Massry said.

She added that dacarbazine is considered the best treatment for pregnant patients with advanced disease.

▸What is the risk to the fetus in a pregnancy complicated by melanoma? Transplacental metastases occur only in patients with hematogenous dissemination of melanoma. The incidence of maternal malignancy during pregnancy is 1 per 1,000, and melanoma accounts for 8% of all cancers during pregnancy.

“About 25% of the cancer that is metastatic to the parts of conception involve the fetus,” Dr. Massry said. “Of cases with fetal involvement, 58% or so arise via melanoma.” However, transplacental metastases “are very rare.”

At birth, she advised, “you want to do a thorough evaluation of the infant, a gross microscopic examination of the placenta, and [an examination of] the cord blood buffy coat for tumor cells.”

▸When can a woman safely become pregnant after treatment of melanoma? The commonly accepted advice for patients is to avoid conception for 2-3 years if their lesions were 1.5 mm or smaller and 5-8 years if their lesions were greater than 1.5 mm.

Part of this recommendation has to do with [when] most recurrences are likely to occur, Dr. Massry said. “But if you're talking to a 20-year-old woman versus maybe a 40-year-old woman, the recommendations may change, depending on what their sense of urgency is with regard to childbearing.”

Some investigators support the notion of individualized recommendations depending on tumor thickness, stage of diagnosis, age of the patient, and the desire of the patient to become pregnant (Cancer 2003;9:2130-3).

▸Is there a link between melanoma and use of oral contraceptives or hormone therapy? Older studies suggest that high-dose oral contraceptives increase the risk of melanoma, but newer studies that include epidemiologic analysis refute the earlier data.

A controlled study of more than 2,000 women found no relationship between the incidence of melanoma and oral contraceptive use, age at onset of use, number of years used, or proximal relationship to use (Br. J. Cancer 2002;86:1085-92).

Dr. Massry noted that there is “a paucity of information” on hormone therapy and melanoma. Some investigators maintain that there is no reason to withhold hormone therapy from a woman if it is otherwise recommended (Climacteric 2002;5:197-200).

SAN DIEGO — Pregnant women who present with changing nevi should not be treated differently from other patients of similar age, Dina R. Massry, M.D., said at a melanoma update sponsored by the Scripps Clinic.

“Prompt biopsy is key,” said Dr. Massry, a dermatologist with the division of dermatology and cutaneous surgery at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

While it is commonly accepted that nevi enlarge and change during pregnancy and that new nevi develop, pregnant women “may get a false sense of security and disregard something that may be potentially worrisome and not get evaluated,” she noted. Pregnant women may not be aware that they should be concerned about irregular or changing moles.

Any changing mole—especially one that has become irregular or asymmetric—could be a melanoma. Synchronous and homogeneous darkening of multiple moles “is probably normal but still should be evaluated,” she said.

A delayed diagnosis of melanoma in pregnant patients illustrates that physicians should treat changing nevi exactly the same in pregnant and nonpregnant patients, and biopsy the moles promptly, Dr. Massry said.

No study has identified a difference in survival rates between pregnant patients with melanoma and nonpregnant, age-matched controls, but studies consistently show an increase in median thickness among pregnant patients with melanoma, compared with nonpregnant, age-matched controls. While a delay in melanoma diagnosis is the likely cause for this difference, Dr. Massry said there are no data to confirm or refute the possible role of growth factors that induce thicker and more rapidly growing melanomas.

In her presentation, she also addressed the following questions related to melanoma:

▸How does one approach recurrent melanoma in pregnant patients with stage II-IV disease? CT and x-ray can be used if the benefits and risks are discussed with the patient. One study supports the use of MRI in the systemic work-up (Semin. Oncol. 2000;27:623-32).

Another analysis (Curr. Opin. Oncol. 1999;11:129-31) reports that the manufacturers and suppliers of interferon have “sparse data” on pregnant patients that suggest babies delivered to mothers receiving interferon therapy have low birth weights, Dr. Massry said.

She added that dacarbazine is considered the best treatment for pregnant patients with advanced disease.

▸What is the risk to the fetus in a pregnancy complicated by melanoma? Transplacental metastases occur only in patients with hematogenous dissemination of melanoma. The incidence of maternal malignancy during pregnancy is 1 per 1,000, and melanoma accounts for 8% of all cancers during pregnancy.

“About 25% of the cancer that is metastatic to the parts of conception involve the fetus,” Dr. Massry said. “Of cases with fetal involvement, 58% or so arise via melanoma.” However, transplacental metastases “are very rare.”

At birth, she advised, “you want to do a thorough evaluation of the infant, a gross microscopic examination of the placenta, and [an examination of] the cord blood buffy coat for tumor cells.”

▸When can a woman safely become pregnant after treatment of melanoma? The commonly accepted advice for patients is to avoid conception for 2-3 years if their lesions were 1.5 mm or smaller and 5-8 years if their lesions were greater than 1.5 mm.

Part of this recommendation has to do with [when] most recurrences are likely to occur, Dr. Massry said. “But if you're talking to a 20-year-old woman versus maybe a 40-year-old woman, the recommendations may change, depending on what their sense of urgency is with regard to childbearing.”

Some investigators support the notion of individualized recommendations depending on tumor thickness, stage of diagnosis, age of the patient, and the desire of the patient to become pregnant (Cancer 2003;9:2130-3).

▸Is there a link between melanoma and use of oral contraceptives or hormone therapy? Older studies suggest that high-dose oral contraceptives increase the risk of melanoma, but newer studies that include epidemiologic analysis refute the earlier data.

A controlled study of more than 2,000 women found no relationship between the incidence of melanoma and oral contraceptive use, age at onset of use, number of years used, or proximal relationship to use (Br. J. Cancer 2002;86:1085-92).

Dr. Massry noted that there is “a paucity of information” on hormone therapy and melanoma. Some investigators maintain that there is no reason to withhold hormone therapy from a woman if it is otherwise recommended (Climacteric 2002;5:197-200).

SAN DIEGO — Ocular and periocular melanoma will occur in fewer than 2,900 people in the United States in 2005, Geva Mannor, M.D., said at a melanoma update sponsored by the Scripps Clinic.

Despite the rare prevalence of these lesions, it's important to understand who is at risk and when to refer to an eye specialist, said Dr. Mannor, an ophthalmologist with the La Jolla, Calif.-based Scripps Clinic.

First, any patient with atypical, familial, or unusual nevi; greater than 4 nevi; iris nevi; or a prior history of melanoma should be referred to an ophthalmologist.

Second, patients with prior eye melanoma should undergo an annual skin exam.

Third, patients with prior eye melanoma and greater than 4 atypical moles or nevi, history of early sunburn, or family or prior history of cutaneous melanoma should have more frequent skin exams, “perhaps every 3-6 months,” Dr. Mannor said.

The three main types of ocular and periocular melanoma include the following:

▸Choroidal melanoma. This is the most common form of eye melanoma. There will be an estimated 2,500 cases nationwide in 2005.

“Usually these patients are referred to retina subspecialists within ophthalmology and sometimes even ocular oncologists,” Dr. Mannor said.

Survival can be up to 89% at 5 years and 84% at 15 years, “but with a lot of new technology, we often don't have to remove the eye,” he said.

▸Lid melanoma. There will be fewer than 300 new cases of lid melanoma in 2005. This form is six times as common in whites as in blacks, and is usually in the lower or lateral lid.

Lesions on the myocutaneous lid margin are a poor prognostic sign. Another strong prognostic indicator is Breslow depth: the greater the depth, the worse the prognosis.

▸Conjunctival melanoma. There will be fewer than 70 cases of this form in 2005. Most occur on the conjunctiva behind the eyeball. The rest occur on the eyelid or in both regions. Approximately 75% will arise from primary acquired melanosis with atypia. “If the melanoma is close to the eyeball, it's a good prognosis,” Dr. Mannor commented.

Dermatologists can perform a quick exam of the eye by flipping the upper lid over a cotton swab. To look under the lower eyelid, grasp the lower eyelid and gently pull down on it.

SAN DIEGO — Ocular and periocular melanoma will occur in fewer than 2,900 people in the United States in 2005, Geva Mannor, M.D., said at a melanoma update sponsored by the Scripps Clinic.

Despite the rare prevalence of these lesions, it's important to understand who is at risk and when to refer to an eye specialist, said Dr. Mannor, an ophthalmologist with the La Jolla, Calif.-based Scripps Clinic.

First, any patient with atypical, familial, or unusual nevi; greater than 4 nevi; iris nevi; or a prior history of melanoma should be referred to an ophthalmologist.

Second, patients with prior eye melanoma should undergo an annual skin exam.

Third, patients with prior eye melanoma and greater than 4 atypical moles or nevi, history of early sunburn, or family or prior history of cutaneous melanoma should have more frequent skin exams, “perhaps every 3-6 months,” Dr. Mannor said.

The three main types of ocular and periocular melanoma include the following:

▸Choroidal melanoma. This is the most common form of eye melanoma. There will be an estimated 2,500 cases nationwide in 2005.

“Usually these patients are referred to retina subspecialists within ophthalmology and sometimes even ocular oncologists,” Dr. Mannor said.

Survival can be up to 89% at 5 years and 84% at 15 years, “but with a lot of new technology, we often don't have to remove the eye,” he said.

▸Lid melanoma. There will be fewer than 300 new cases of lid melanoma in 2005. This form is six times as common in whites as in blacks, and is usually in the lower or lateral lid.

Lesions on the myocutaneous lid margin are a poor prognostic sign. Another strong prognostic indicator is Breslow depth: the greater the depth, the worse the prognosis.

▸Conjunctival melanoma. There will be fewer than 70 cases of this form in 2005. Most occur on the conjunctiva behind the eyeball. The rest occur on the eyelid or in both regions. Approximately 75% will arise from primary acquired melanosis with atypia. “If the melanoma is close to the eyeball, it's a good prognosis,” Dr. Mannor commented.

Dermatologists can perform a quick exam of the eye by flipping the upper lid over a cotton swab. To look under the lower eyelid, grasp the lower eyelid and gently pull down on it.

SAN DIEGO — Ocular and periocular melanoma will occur in fewer than 2,900 people in the United States in 2005, Geva Mannor, M.D., said at a melanoma update sponsored by the Scripps Clinic.

Despite the rare prevalence of these lesions, it's important to understand who is at risk and when to refer to an eye specialist, said Dr. Mannor, an ophthalmologist with the La Jolla, Calif.-based Scripps Clinic.

First, any patient with atypical, familial, or unusual nevi; greater than 4 nevi; iris nevi; or a prior history of melanoma should be referred to an ophthalmologist.

Second, patients with prior eye melanoma should undergo an annual skin exam.

Third, patients with prior eye melanoma and greater than 4 atypical moles or nevi, history of early sunburn, or family or prior history of cutaneous melanoma should have more frequent skin exams, “perhaps every 3-6 months,” Dr. Mannor said.

The three main types of ocular and periocular melanoma include the following:

▸Choroidal melanoma. This is the most common form of eye melanoma. There will be an estimated 2,500 cases nationwide in 2005.

“Usually these patients are referred to retina subspecialists within ophthalmology and sometimes even ocular oncologists,” Dr. Mannor said.

Survival can be up to 89% at 5 years and 84% at 15 years, “but with a lot of new technology, we often don't have to remove the eye,” he said.

▸Lid melanoma. There will be fewer than 300 new cases of lid melanoma in 2005. This form is six times as common in whites as in blacks, and is usually in the lower or lateral lid.

Lesions on the myocutaneous lid margin are a poor prognostic sign. Another strong prognostic indicator is Breslow depth: the greater the depth, the worse the prognosis.

▸Conjunctival melanoma. There will be fewer than 70 cases of this form in 2005. Most occur on the conjunctiva behind the eyeball. The rest occur on the eyelid or in both regions. Approximately 75% will arise from primary acquired melanosis with atypia. “If the melanoma is close to the eyeball, it's a good prognosis,” Dr. Mannor commented.

Dermatologists can perform a quick exam of the eye by flipping the upper lid over a cotton swab. To look under the lower eyelid, grasp the lower eyelid and gently pull down on it.

SAN DIEGO — No matter what sun protection factor sunscreen you recommend, remember that the SPF system has its limitations, Shanna Meads, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

For one thing, SPF measures only UVB protection, not protection from UVA rays, said Dr. Meads, a dermatologist and Mohs fellow at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

Also, SPF is measured and classified under controlled laboratory conditions, “and most people don't live in a laboratory setting,” she said.

And finally, consumers must follow directions for proper sunscreen use. “You have to apply at least 30 g to cover the entire body,” she said. “You have to apply it 20 minutes prior to sun exposure and reapply every 60-90 minutes. Most people don't follow these directions and may never achieve the SPF that's been achieved in a laboratory setting.”

She recommended the following products to use in conjunction with proper sunscreen application:

▸Sun protective clothing. UV protection factor (UPF), a rating similar to SPF, measures the efficacy of these clothes. Factors increasing UV protection in these products include tighter weave, dark color, heavier fabric, and less stretch. These clothes are generally are made of wool, polyester, and/or acrylic, and can be expensive.

▸Laundry. Sun Guard, manufactured by Rit, contains Tinosorb, a fabric brightener that penetrates fabric fibers and blocks UV rays. Patients can add it to their regular wash load. The maker says it provides protection for 20 washings.

SAN DIEGO — No matter what sun protection factor sunscreen you recommend, remember that the SPF system has its limitations, Shanna Meads, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

For one thing, SPF measures only UVB protection, not protection from UVA rays, said Dr. Meads, a dermatologist and Mohs fellow at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

Also, SPF is measured and classified under controlled laboratory conditions, “and most people don't live in a laboratory setting,” she said.

And finally, consumers must follow directions for proper sunscreen use. “You have to apply at least 30 g to cover the entire body,” she said. “You have to apply it 20 minutes prior to sun exposure and reapply every 60-90 minutes. Most people don't follow these directions and may never achieve the SPF that's been achieved in a laboratory setting.”

She recommended the following products to use in conjunction with proper sunscreen application:

▸Sun protective clothing. UV protection factor (UPF), a rating similar to SPF, measures the efficacy of these clothes. Factors increasing UV protection in these products include tighter weave, dark color, heavier fabric, and less stretch. These clothes are generally are made of wool, polyester, and/or acrylic, and can be expensive.

▸Laundry. Sun Guard, manufactured by Rit, contains Tinosorb, a fabric brightener that penetrates fabric fibers and blocks UV rays. Patients can add it to their regular wash load. The maker says it provides protection for 20 washings.

SAN DIEGO — No matter what sun protection factor sunscreen you recommend, remember that the SPF system has its limitations, Shanna Meads, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

For one thing, SPF measures only UVB protection, not protection from UVA rays, said Dr. Meads, a dermatologist and Mohs fellow at the Scripps Clinic-Torrey Pines, La Jolla, Calif.

Also, SPF is measured and classified under controlled laboratory conditions, “and most people don't live in a laboratory setting,” she said.

And finally, consumers must follow directions for proper sunscreen use. “You have to apply at least 30 g to cover the entire body,” she said. “You have to apply it 20 minutes prior to sun exposure and reapply every 60-90 minutes. Most people don't follow these directions and may never achieve the SPF that's been achieved in a laboratory setting.”

She recommended the following products to use in conjunction with proper sunscreen application:

▸Sun protective clothing. UV protection factor (UPF), a rating similar to SPF, measures the efficacy of these clothes. Factors increasing UV protection in these products include tighter weave, dark color, heavier fabric, and less stretch. These clothes are generally are made of wool, polyester, and/or acrylic, and can be expensive.

▸Laundry. Sun Guard, manufactured by Rit, contains Tinosorb, a fabric brightener that penetrates fabric fibers and blocks UV rays. Patients can add it to their regular wash load. The maker says it provides protection for 20 washings.

SAN DIEGO — Over the next 15 years, 5-year survivors of melanoma have a 91.5% chance of having achieved cure, Duane C. Whitaker, M.D., reported at a melanoma update sponsored by the Scripps Clinic.

“Stated another way, all comers with an invasive melanoma—regardless of stage—who reach 5-year survival have a 91%-92% odds of surviving another 15 years,” said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. “So we can say that in 2005, 5-year survival is nearly equivalent to cure.”

The figures come from an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. His study revealed that 5-year survival rates of all invasive melanoma cases between 1975 and 1996 increased about 10%, from 82.1% to 91.9%.

“We believe there is earlier recognition and treatment of most cancers [today] because of better patient education, good physician monitoring, and so forth,” he said.

The finding is important because most melanoma patients want to know their odds of surviving. “To have the word melanoma used in relation to you is a major event in your life,” he noted. “From a patient standpoint, at least until they're able to put it in some perspective and talk with all their family and friends, even in situ melanoma has a big impact. It's our role to help patients adjust and fit [this diagnosis] into the scheme of their life.”

Dr. Whitaker uses a compressed form of the American Joint Committee on Cancer's melanoma staging classification to stage disease in his patients. In this system, stage I comprises all invasive melanomas up to 2.0 mm. Stage II comprises all melanomas of any thickness greater than 2.0 mm (in the absence of known metastases). Stage III comprises all single site, regional nodal disease, and stage IV comprises all visceral or distant nodal, skin, and soft tissue disease.

According to the latest SEER data, 5-year melanoma survival rates stand as follows: 88%-100% for stage I disease; 79% for depths up to 4.0 mm in patients with stage II disease and 67% for those of all greater depths; 27%-69% for patients with stage III disease; and 20% or less for those with stage IV disease.

In 2004, there were 55,000 new cases of invasive melanoma in the United States and 41,000 cases of in situ melanoma. “Therefore, there are about 100,000 cases which require a procedure every year,” Dr. Whitaker said. “There's a lot of work out there to be done.”

Invasive melanoma accounts for 4% of all newly diagnosed cancers in the United States per year and 1.4% of cancer-related deaths per year.

When patients ask Dr. Whitaker what caused their melanoma, he lists the culprits attributed to all forms of cancer: the environment, senescence, trauma, and genetics. “I say to patients, 'One thing you can affect is protection from sun exposure.'”

He added that when celebrities with melanoma are profiled in the media, “those voices are heard by the public. I am amazed by patients who tell me what they know about changing moles that are dark in color, and so forth.”

SAN DIEGO — Over the next 15 years, 5-year survivors of melanoma have a 91.5% chance of having achieved cure, Duane C. Whitaker, M.D., reported at a melanoma update sponsored by the Scripps Clinic.

“Stated another way, all comers with an invasive melanoma—regardless of stage—who reach 5-year survival have a 91%-92% odds of surviving another 15 years,” said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. “So we can say that in 2005, 5-year survival is nearly equivalent to cure.”

The figures come from an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. His study revealed that 5-year survival rates of all invasive melanoma cases between 1975 and 1996 increased about 10%, from 82.1% to 91.9%.

“We believe there is earlier recognition and treatment of most cancers [today] because of better patient education, good physician monitoring, and so forth,” he said.

The finding is important because most melanoma patients want to know their odds of surviving. “To have the word melanoma used in relation to you is a major event in your life,” he noted. “From a patient standpoint, at least until they're able to put it in some perspective and talk with all their family and friends, even in situ melanoma has a big impact. It's our role to help patients adjust and fit [this diagnosis] into the scheme of their life.”

Dr. Whitaker uses a compressed form of the American Joint Committee on Cancer's melanoma staging classification to stage disease in his patients. In this system, stage I comprises all invasive melanomas up to 2.0 mm. Stage II comprises all melanomas of any thickness greater than 2.0 mm (in the absence of known metastases). Stage III comprises all single site, regional nodal disease, and stage IV comprises all visceral or distant nodal, skin, and soft tissue disease.

According to the latest SEER data, 5-year melanoma survival rates stand as follows: 88%-100% for stage I disease; 79% for depths up to 4.0 mm in patients with stage II disease and 67% for those of all greater depths; 27%-69% for patients with stage III disease; and 20% or less for those with stage IV disease.

In 2004, there were 55,000 new cases of invasive melanoma in the United States and 41,000 cases of in situ melanoma. “Therefore, there are about 100,000 cases which require a procedure every year,” Dr. Whitaker said. “There's a lot of work out there to be done.”

Invasive melanoma accounts for 4% of all newly diagnosed cancers in the United States per year and 1.4% of cancer-related deaths per year.

When patients ask Dr. Whitaker what caused their melanoma, he lists the culprits attributed to all forms of cancer: the environment, senescence, trauma, and genetics. “I say to patients, 'One thing you can affect is protection from sun exposure.'”

He added that when celebrities with melanoma are profiled in the media, “those voices are heard by the public. I am amazed by patients who tell me what they know about changing moles that are dark in color, and so forth.”

SAN DIEGO — Over the next 15 years, 5-year survivors of melanoma have a 91.5% chance of having achieved cure, Duane C. Whitaker, M.D., reported at a melanoma update sponsored by the Scripps Clinic.

“Stated another way, all comers with an invasive melanoma—regardless of stage—who reach 5-year survival have a 91%-92% odds of surviving another 15 years,” said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. “So we can say that in 2005, 5-year survival is nearly equivalent to cure.”

The figures come from an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. His study revealed that 5-year survival rates of all invasive melanoma cases between 1975 and 1996 increased about 10%, from 82.1% to 91.9%.

“We believe there is earlier recognition and treatment of most cancers [today] because of better patient education, good physician monitoring, and so forth,” he said.

The finding is important because most melanoma patients want to know their odds of surviving. “To have the word melanoma used in relation to you is a major event in your life,” he noted. “From a patient standpoint, at least until they're able to put it in some perspective and talk with all their family and friends, even in situ melanoma has a big impact. It's our role to help patients adjust and fit [this diagnosis] into the scheme of their life.”

Dr. Whitaker uses a compressed form of the American Joint Committee on Cancer's melanoma staging classification to stage disease in his patients. In this system, stage I comprises all invasive melanomas up to 2.0 mm. Stage II comprises all melanomas of any thickness greater than 2.0 mm (in the absence of known metastases). Stage III comprises all single site, regional nodal disease, and stage IV comprises all visceral or distant nodal, skin, and soft tissue disease.

According to the latest SEER data, 5-year melanoma survival rates stand as follows: 88%-100% for stage I disease; 79% for depths up to 4.0 mm in patients with stage II disease and 67% for those of all greater depths; 27%-69% for patients with stage III disease; and 20% or less for those with stage IV disease.

In 2004, there were 55,000 new cases of invasive melanoma in the United States and 41,000 cases of in situ melanoma. “Therefore, there are about 100,000 cases which require a procedure every year,” Dr. Whitaker said. “There's a lot of work out there to be done.”

Invasive melanoma accounts for 4% of all newly diagnosed cancers in the United States per year and 1.4% of cancer-related deaths per year.

When patients ask Dr. Whitaker what caused their melanoma, he lists the culprits attributed to all forms of cancer: the environment, senescence, trauma, and genetics. “I say to patients, 'One thing you can affect is protection from sun exposure.'”

He added that when celebrities with melanoma are profiled in the media, “those voices are heard by the public. I am amazed by patients who tell me what they know about changing moles that are dark in color, and so forth.”

Brooke Jackson, M.D., describes herself as a “late bloomer” to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

“The ad said, 'We'll train you to run a marathon,'” Dr. Jackson recalled. “I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles.”

Only 6 months later, she found herself at the starting line of her first marathon, “wondering what I had gotten myself into,” she said. “I had such a good time doing it that I went back the next year.”

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. “A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles,” she said. “I joined that group. That's how I met my husband.” She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is a “great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else.”

The clinical benefits of even moderate exercise–like a brisk walk–are well known, but few physicians make concerted efforts to incorporate it into their daily routine, said Tedd Mitchell, M.D.

He described the fitness levels and habits of physicians, priests, preachers, and rabbis as “abysmal” compared with that of the general population because of the service-related nature of their work. In those professions, “it's all about everyone else, not about you,” noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise “is because inconsistency is built into your schedule,” he said. “You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition.”

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the “FIT” principle of aerobic training. “F” stands for frequency of exercise sessions; “I” stands for intensity of the exercise, and “T” stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports.

“Think of exercise as another medication,” he said. “If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week.”

Once you establish the frequency, the next most important variable is the length of time you exercise. “Thirty minutes is great,” he said. “You can walk for 30 minutes or jog for 20.”

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. “Physicians tend to work out infrequently and hard,” Dr. Mitchell said. “That formula is backward for the benefits, but it's just right for pulling hamstrings.”

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, “because you can control the morning schedule better than you can control anything else,” Dr. Mitchell said.

“Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done,” he said.

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. “I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m.” said Dr. Horbach, a urogynecologist in private practice in Annandale, Va.

But not everyone's an early bird. Larry Wagman, M.D., used to run every morning for 45 minutes before starting his workday as a surgeon. The grind grew on him, so he switched to working out at a local health club at the end of his workday, said Dr. Wagman, chairman of the division of surgery at the City of Hope National Medical Center in Duarte, Calif.

▸ Keep it simple and practical. “You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there,” Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months.

“There's a shower in the office, too, so it makes it harder to come up with excuses” for not using the room, Dr. Olson said.

He added that his office, house, and nearest golf club are within 1.5 miles of one another, “so I can play six holes at dusk and be home for dinner, and it's very convenient,” he said. “To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient.”

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. “Running is one of the things that you can do anywhere, so there's no excuse,” Dr. Jackson said. “It doesn't take a lot of time. All you need is a pair of shoes.”

▸ Keep it short. Physicians tend to embrace the notion of “all or none” or “no pain, no gain,” Dr. Mitchell said. “If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it,” he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. “Keep a workweek mind-set,” Dr. Mitchell advised.

“For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'”

Planning and Problem Solving Are Key

The skinny on exercise boils down to this:

If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

“I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem solving,” said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of Active Living Every Day: 20 Weeks to Lifelong Vitality (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: “What's my schedule tomorrow?” and “When do I have time to fit in my exercise?”

“I always start with my personal assumption that I'm going to get some exercise tomorrow,” Mr. Blair said. “Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime.”

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

“Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation,” he said. “I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in.”

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, “I vow to be active nearly every day.”

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

” 'Most' means 5 days, so 30 minutes of walking 5 days a week,” Dr. Blair said. “'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks.”

Brooke Jackson, M.D., describes herself as a “late bloomer” to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

“The ad said, 'We'll train you to run a marathon,'” Dr. Jackson recalled. “I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles.”

Only 6 months later, she found herself at the starting line of her first marathon, “wondering what I had gotten myself into,” she said. “I had such a good time doing it that I went back the next year.”

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. “A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles,” she said. “I joined that group. That's how I met my husband.” She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is a “great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else.”

The clinical benefits of even moderate exercise–like a brisk walk–are well known, but few physicians make concerted efforts to incorporate it into their daily routine, said Tedd Mitchell, M.D.

He described the fitness levels and habits of physicians, priests, preachers, and rabbis as “abysmal” compared with that of the general population because of the service-related nature of their work. In those professions, “it's all about everyone else, not about you,” noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise “is because inconsistency is built into your schedule,” he said. “You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition.”

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the “FIT” principle of aerobic training. “F” stands for frequency of exercise sessions; “I” stands for intensity of the exercise, and “T” stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports.

“Think of exercise as another medication,” he said. “If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week.”

Once you establish the frequency, the next most important variable is the length of time you exercise. “Thirty minutes is great,” he said. “You can walk for 30 minutes or jog for 20.”

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. “Physicians tend to work out infrequently and hard,” Dr. Mitchell said. “That formula is backward for the benefits, but it's just right for pulling hamstrings.”

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, “because you can control the morning schedule better than you can control anything else,” Dr. Mitchell said.

“Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done,” he said.

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. “I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m.” said Dr. Horbach, a urogynecologist in private practice in Annandale, Va.

But not everyone's an early bird. Larry Wagman, M.D., used to run every morning for 45 minutes before starting his workday as a surgeon. The grind grew on him, so he switched to working out at a local health club at the end of his workday, said Dr. Wagman, chairman of the division of surgery at the City of Hope National Medical Center in Duarte, Calif.

▸ Keep it simple and practical. “You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there,” Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months.

“There's a shower in the office, too, so it makes it harder to come up with excuses” for not using the room, Dr. Olson said.

He added that his office, house, and nearest golf club are within 1.5 miles of one another, “so I can play six holes at dusk and be home for dinner, and it's very convenient,” he said. “To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient.”

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. “Running is one of the things that you can do anywhere, so there's no excuse,” Dr. Jackson said. “It doesn't take a lot of time. All you need is a pair of shoes.”

▸ Keep it short. Physicians tend to embrace the notion of “all or none” or “no pain, no gain,” Dr. Mitchell said. “If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it,” he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. “Keep a workweek mind-set,” Dr. Mitchell advised.

“For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'”

Planning and Problem Solving Are Key

The skinny on exercise boils down to this:

If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

“I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem solving,” said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of Active Living Every Day: 20 Weeks to Lifelong Vitality (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: “What's my schedule tomorrow?” and “When do I have time to fit in my exercise?”

“I always start with my personal assumption that I'm going to get some exercise tomorrow,” Mr. Blair said. “Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime.”

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

“Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation,” he said. “I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in.”

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, “I vow to be active nearly every day.”

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

” 'Most' means 5 days, so 30 minutes of walking 5 days a week,” Dr. Blair said. “'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks.”

Brooke Jackson, M.D., describes herself as a “late bloomer” to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

“The ad said, 'We'll train you to run a marathon,'” Dr. Jackson recalled. “I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles.”

Only 6 months later, she found herself at the starting line of her first marathon, “wondering what I had gotten myself into,” she said. “I had such a good time doing it that I went back the next year.”

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. “A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles,” she said. “I joined that group. That's how I met my husband.” She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is a “great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else.”

The clinical benefits of even moderate exercise–like a brisk walk–are well known, but few physicians make concerted efforts to incorporate it into their daily routine, said Tedd Mitchell, M.D.

He described the fitness levels and habits of physicians, priests, preachers, and rabbis as “abysmal” compared with that of the general population because of the service-related nature of their work. In those professions, “it's all about everyone else, not about you,” noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise “is because inconsistency is built into your schedule,” he said. “You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition.”

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the “FIT” principle of aerobic training. “F” stands for frequency of exercise sessions; “I” stands for intensity of the exercise, and “T” stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports.

“Think of exercise as another medication,” he said. “If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week.”

Once you establish the frequency, the next most important variable is the length of time you exercise. “Thirty minutes is great,” he said. “You can walk for 30 minutes or jog for 20.”

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. “Physicians tend to work out infrequently and hard,” Dr. Mitchell said. “That formula is backward for the benefits, but it's just right for pulling hamstrings.”

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, “because you can control the morning schedule better than you can control anything else,” Dr. Mitchell said.

“Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done,” he said.

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. “I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m.” said Dr. Horbach, a urogynecologist in private practice in Annandale, Va.

But not everyone's an early bird. Larry Wagman, M.D., used to run every morning for 45 minutes before starting his workday as a surgeon. The grind grew on him, so he switched to working out at a local health club at the end of his workday, said Dr. Wagman, chairman of the division of surgery at the City of Hope National Medical Center in Duarte, Calif.

▸ Keep it simple and practical. “You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there,” Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months.

“There's a shower in the office, too, so it makes it harder to come up with excuses” for not using the room, Dr. Olson said.

He added that his office, house, and nearest golf club are within 1.5 miles of one another, “so I can play six holes at dusk and be home for dinner, and it's very convenient,” he said. “To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient.”

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. “Running is one of the things that you can do anywhere, so there's no excuse,” Dr. Jackson said. “It doesn't take a lot of time. All you need is a pair of shoes.”

▸ Keep it short. Physicians tend to embrace the notion of “all or none” or “no pain, no gain,” Dr. Mitchell said. “If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it,” he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. “Keep a workweek mind-set,” Dr. Mitchell advised.

“For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'”

Planning and Problem Solving Are Key

The skinny on exercise boils down to this:

If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

“I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem solving,” said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of Active Living Every Day: 20 Weeks to Lifelong Vitality (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: “What's my schedule tomorrow?” and “When do I have time to fit in my exercise?”

“I always start with my personal assumption that I'm going to get some exercise tomorrow,” Mr. Blair said. “Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime.”

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

“Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation,” he said. “I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in.”

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, “I vow to be active nearly every day.”

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

” 'Most' means 5 days, so 30 minutes of walking 5 days a week,” Dr. Blair said. “'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks.”

LA JOLLA, CALIF. — The first step in advising patients who may want to try complementary and alternative medicine therapies is to ask them a simple question: “Have you used, or considered using, any other therapy for your [chief complaint]?” David M. Eisenberg, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

If your patient responds, “I'm interested in therapies like [acupuncture, massage, etc.],” tell him or her, “I have the time.”

Those four words “are rarely spoken in a doctor's office,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.

“Those are the four most powerful words you can say if you want a direct answer. I challenge you to try it.”

Some of the meeting attendees laughed out loud at the challenge.

“I'm not kidding,” he countered. “When you do it, they will talk to you. If you don't, they may or may not. It's all about your body language.”

Before you offer specific advice, consider the following questions:

▸ Has the patient's conventional diagnostic work-up been complete?

▸ If so, what is the diagnosis?

▸ What are the conventional treatment options? Have they all been tried?

▸ What are the risks of the conventional treatment options?

▸ What are the risks of the CAM options?

Once you address these questions, identify a key symptom and ask the patient to keep a symptom diary on a scale of 0-10, with 0 meaning there is no symptom. (For more details on the symptom diary, see Ann. Intern. Med. 1997;127:61-9).

“I tell patients to put up a piece of paper where they brush their teeth at night and put a number down for how bad the symptom was that day, whether it's abdominal pain, headache, anxiety, you name it,” Dr. Eisenberg said at the meeting, which was cosponsored by the University of California, San Diego.

Have the patient “keep the diary for a week or two, or a month if it's a monthly symptom. Then discuss with the patient the therapy that you're suggesting or they're asking about,” he said.

Review the safety of the CAM therapy, formulate a plan, and ask the patient to maintain the symptom diary.

“Make the patient the pilot and you become the copilot,” he said. “It's their data with their symptoms.”

If you refer for CAM, see the patient after the initial visit to the CAM provider and review that person's recommendation. “This is the thumbs-up, thumbs-down conversation that we don't have with patients often enough,” he said.

“Physicians who practice this way will be in much higher demand in the marketplace, because [patients] will be able to have an honest conversation with an educated clinician who does care about CAM and does understand the literature,” he explained.

If the CAM therapy works, “then it feels like you participated with them in this exploratory journey,” Dr. Eisenberg said.

“It's about shared decision making. The patient feels listened to [and] safe, and the patient-physician relationship is tested,” he said.

If the CAM therapy fails, patients, “are still very grateful for the opportunity, and you can go back together to square one and ask, 'What can we try now?'” he said.

LA JOLLA, CALIF. — The first step in advising patients who may want to try complementary and alternative medicine therapies is to ask them a simple question: “Have you used, or considered using, any other therapy for your [chief complaint]?” David M. Eisenberg, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

If your patient responds, “I'm interested in therapies like [acupuncture, massage, etc.],” tell him or her, “I have the time.”

Those four words “are rarely spoken in a doctor's office,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.

“Those are the four most powerful words you can say if you want a direct answer. I challenge you to try it.”

Some of the meeting attendees laughed out loud at the challenge.

“I'm not kidding,” he countered. “When you do it, they will talk to you. If you don't, they may or may not. It's all about your body language.”

Before you offer specific advice, consider the following questions:

▸ Has the patient's conventional diagnostic work-up been complete?

▸ If so, what is the diagnosis?

▸ What are the conventional treatment options? Have they all been tried?

▸ What are the risks of the conventional treatment options?

▸ What are the risks of the CAM options?

Once you address these questions, identify a key symptom and ask the patient to keep a symptom diary on a scale of 0-10, with 0 meaning there is no symptom. (For more details on the symptom diary, see Ann. Intern. Med. 1997;127:61-9).

“I tell patients to put up a piece of paper where they brush their teeth at night and put a number down for how bad the symptom was that day, whether it's abdominal pain, headache, anxiety, you name it,” Dr. Eisenberg said at the meeting, which was cosponsored by the University of California, San Diego.

Have the patient “keep the diary for a week or two, or a month if it's a monthly symptom. Then discuss with the patient the therapy that you're suggesting or they're asking about,” he said.

Review the safety of the CAM therapy, formulate a plan, and ask the patient to maintain the symptom diary.

“Make the patient the pilot and you become the copilot,” he said. “It's their data with their symptoms.”

If you refer for CAM, see the patient after the initial visit to the CAM provider and review that person's recommendation. “This is the thumbs-up, thumbs-down conversation that we don't have with patients often enough,” he said.

“Physicians who practice this way will be in much higher demand in the marketplace, because [patients] will be able to have an honest conversation with an educated clinician who does care about CAM and does understand the literature,” he explained.

If the CAM therapy works, “then it feels like you participated with them in this exploratory journey,” Dr. Eisenberg said.

“It's about shared decision making. The patient feels listened to [and] safe, and the patient-physician relationship is tested,” he said.

If the CAM therapy fails, patients, “are still very grateful for the opportunity, and you can go back together to square one and ask, 'What can we try now?'” he said.

LA JOLLA, CALIF. — The first step in advising patients who may want to try complementary and alternative medicine therapies is to ask them a simple question: “Have you used, or considered using, any other therapy for your [chief complaint]?” David M. Eisenberg, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

If your patient responds, “I'm interested in therapies like [acupuncture, massage, etc.],” tell him or her, “I have the time.”

Those four words “are rarely spoken in a doctor's office,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.

“Those are the four most powerful words you can say if you want a direct answer. I challenge you to try it.”

Some of the meeting attendees laughed out loud at the challenge.

“I'm not kidding,” he countered. “When you do it, they will talk to you. If you don't, they may or may not. It's all about your body language.”

Before you offer specific advice, consider the following questions:

▸ Has the patient's conventional diagnostic work-up been complete?

▸ If so, what is the diagnosis?

▸ What are the conventional treatment options? Have they all been tried?

▸ What are the risks of the conventional treatment options?

▸ What are the risks of the CAM options?

Once you address these questions, identify a key symptom and ask the patient to keep a symptom diary on a scale of 0-10, with 0 meaning there is no symptom. (For more details on the symptom diary, see Ann. Intern. Med. 1997;127:61-9).

“I tell patients to put up a piece of paper where they brush their teeth at night and put a number down for how bad the symptom was that day, whether it's abdominal pain, headache, anxiety, you name it,” Dr. Eisenberg said at the meeting, which was cosponsored by the University of California, San Diego.

Have the patient “keep the diary for a week or two, or a month if it's a monthly symptom. Then discuss with the patient the therapy that you're suggesting or they're asking about,” he said.

Review the safety of the CAM therapy, formulate a plan, and ask the patient to maintain the symptom diary.

“Make the patient the pilot and you become the copilot,” he said. “It's their data with their symptoms.”

If you refer for CAM, see the patient after the initial visit to the CAM provider and review that person's recommendation. “This is the thumbs-up, thumbs-down conversation that we don't have with patients often enough,” he said.

“Physicians who practice this way will be in much higher demand in the marketplace, because [patients] will be able to have an honest conversation with an educated clinician who does care about CAM and does understand the literature,” he explained.

If the CAM therapy works, “then it feels like you participated with them in this exploratory journey,” Dr. Eisenberg said.

“It's about shared decision making. The patient feels listened to [and] safe, and the patient-physician relationship is tested,” he said.

If the CAM therapy fails, patients, “are still very grateful for the opportunity, and you can go back together to square one and ask, 'What can we try now?'” he said.

LA JOLLA, CALIF. — When physicians refer patients to providers of complementary and alternative medicine, they should keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D., (Ann. Intern. Med. 2002;136:596-603) include the following:

1 Determine the clinical risk level. Physicians should decide whether to:

▸ Recommend, yet continue to monitor, the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and actively discourage use of the therapy.

2 Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies for the Osher Institute at Harvard Medical School in Boston.

“By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach,” he said.

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation.

“You could say this is a bit too conservative, like having suspenders and a belt,” he commented at the meeting, which was cosponsored by the University of California, San Diego. “But I think this is the best advice.”

3 Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

4 Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions.

That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the physician's risk of being sued for malpractice.

“Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

5 Familiarize yourself with the providers to whom you refer. Physicians should ask themselves if they would refer a friend to this person. “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by the relevant state regulatory board. “You have to check the regulations and scope of practice,” he said.

“From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it,” Dr. Eisenberg said.

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

PIThe referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

PIThe referring provider knew or should have known that the referred-to provider was incompetent.

PIThe referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation or because there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted.

“Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved,” he said.

LA JOLLA, CALIF. — When physicians refer patients to providers of complementary and alternative medicine, they should keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D., (Ann. Intern. Med. 2002;136:596-603) include the following:

1 Determine the clinical risk level. Physicians should decide whether to:

▸ Recommend, yet continue to monitor, the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and actively discourage use of the therapy.

2 Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies for the Osher Institute at Harvard Medical School in Boston.

“By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach,” he said.

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation.

“You could say this is a bit too conservative, like having suspenders and a belt,” he commented at the meeting, which was cosponsored by the University of California, San Diego. “But I think this is the best advice.”

3 Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

4 Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions.

That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the physician's risk of being sued for malpractice.

“Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

5 Familiarize yourself with the providers to whom you refer. Physicians should ask themselves if they would refer a friend to this person. “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by the relevant state regulatory board. “You have to check the regulations and scope of practice,” he said.

“From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it,” Dr. Eisenberg said.

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

PIThe referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

PIThe referring provider knew or should have known that the referred-to provider was incompetent.

PIThe referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation or because there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted.

“Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved,” he said.

LA JOLLA, CALIF. — When physicians refer patients to providers of complementary and alternative medicine, they should keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D., (Ann. Intern. Med. 2002;136:596-603) include the following:

1 Determine the clinical risk level. Physicians should decide whether to:

▸ Recommend, yet continue to monitor, the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and actively discourage use of the therapy.

2 Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies for the Osher Institute at Harvard Medical School in Boston.

“By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach,” he said.

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation.

“You could say this is a bit too conservative, like having suspenders and a belt,” he commented at the meeting, which was cosponsored by the University of California, San Diego. “But I think this is the best advice.”

3 Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

4 Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions.

That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the physician's risk of being sued for malpractice.

“Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

5 Familiarize yourself with the providers to whom you refer. Physicians should ask themselves if they would refer a friend to this person. “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by the relevant state regulatory board. “You have to check the regulations and scope of practice,” he said.

“From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it,” Dr. Eisenberg said.

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

PIThe referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

PIThe referring provider knew or should have known that the referred-to provider was incompetent.

PIThe referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation or because there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted.

“Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved,” he said.

SAN DIEGO — There is no one technique or strategy that will protect you from the risk of physical attacks in your workplace by patients or coworkers, Donna Pence declared at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.

“There is nothing about who and what you are that makes you immune from people intent on doing bad things,” said Ms. Pence, training coordinator for San Diego State University's Public Child Welfare Training Academy. “Not looks, not money, not profession, not uniform, not where you live, not how religious you are, or how good you are.”

The best self-protection involves a combination of factors, including being aware of your capabilities, your environment, your habits, realistic hazards, and your options should a violent episode occur.

She offered the following tips:

▸ Do some self-reflection. What is your history of violence and anger and your response to it? Have you been in situations where you felt threatened, and now you feel hypervigilant? Your personal history of violence “will affect your response to situations,” said Ms. Pence, who spent 25 years as a special agent with the Tennessee Bureau of Investigation. “It will impact the lens through which you view [someone's] behavior. That can be good, but it also could lead you to jump the gun and have a perception of violence and danger when it doesn't really exist.”

▸ Make an effort to understand your colleagues' attitudes about personal safety and anger in the workplace. Are you allowed to talk about it? Are you encouraged to talk about it? “Is there a forum where you can ventilate about any anxieties you have about a client, or any anger you may have toward the client?” Ms. Pence asked. “Because if you're angry and they're angry, that's not a real healthy combination.”

Also, ask yourself, are there people in the office who can hear you if you yell for help? Is there an emergency buzzer nearby? If somebody enters the office and a buzzer goes off, do we have a plan on what to do?

▸ Think twice before visiting a patient in his or her home. Look at prior referrals. Consult with social workers or other physicians to see if the patient has a history of violent behavior. “If I have somebody who's been arrested for drugs, weapons, domestic violence, or child abuse, I'm going to think twice before going out to their turf by myself,” she said.

To protect against workplace violence and abuse, Ms. Pence recommended working on “target hardening.” Target hardening is a military term that refers to the notion that you are the person you are trying to make most safe. “Until you recognize your personal, physical, mental, and environmental culpabilities and the possibility of victimization and do what you can realistically to reduce these, you're not a hard target,” she explained.

This means:

▸ You must be aware.

▸ You must think in a different way. For example, “Don't walk down a sidewalk that has doors on one side and bushes on the other,” she advised. Also, when you approach a parking lot, don't skirt the edge of it. Rather, “walk toward the middle of the parking lot and look to the left and right.”

▸ You must act in a different way. “The way you walk, look, and carry yourself makes a difference in the degree of vulnerability that is ascribed to you by someone looking to attack,” Ms. Pence said. “Look confident, look aware, and be in the present.”

▸ You must recognize your personal vulnerabilities. Ask yourself, how could I defend myself in the event of a personal attack? “For example, I'm not a long distance runner,” Ms. Pence said. “I don't aspire to be a runner. That's a realistic assessment of my physical abilities. If there are areas where you have a deficit, ask, what can I do to enhance my abilities? Maybe it's learning some form of self-protection or learning verbal de-escalation techniques.”

SAN DIEGO — There is no one technique or strategy that will protect you from the risk of physical attacks in your workplace by patients or coworkers, Donna Pence declared at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.

“There is nothing about who and what you are that makes you immune from people intent on doing bad things,” said Ms. Pence, training coordinator for San Diego State University's Public Child Welfare Training Academy. “Not looks, not money, not profession, not uniform, not where you live, not how religious you are, or how good you are.”

The best self-protection involves a combination of factors, including being aware of your capabilities, your environment, your habits, realistic hazards, and your options should a violent episode occur.

She offered the following tips:

▸ Do some self-reflection. What is your history of violence and anger and your response to it? Have you been in situations where you felt threatened, and now you feel hypervigilant? Your personal history of violence “will affect your response to situations,” said Ms. Pence, who spent 25 years as a special agent with the Tennessee Bureau of Investigation. “It will impact the lens through which you view [someone's] behavior. That can be good, but it also could lead you to jump the gun and have a perception of violence and danger when it doesn't really exist.”

▸ Make an effort to understand your colleagues' attitudes about personal safety and anger in the workplace. Are you allowed to talk about it? Are you encouraged to talk about it? “Is there a forum where you can ventilate about any anxieties you have about a client, or any anger you may have toward the client?” Ms. Pence asked. “Because if you're angry and they're angry, that's not a real healthy combination.”

Also, ask yourself, are there people in the office who can hear you if you yell for help? Is there an emergency buzzer nearby? If somebody enters the office and a buzzer goes off, do we have a plan on what to do?

▸ Think twice before visiting a patient in his or her home. Look at prior referrals. Consult with social workers or other physicians to see if the patient has a history of violent behavior. “If I have somebody who's been arrested for drugs, weapons, domestic violence, or child abuse, I'm going to think twice before going out to their turf by myself,” she said.

To protect against workplace violence and abuse, Ms. Pence recommended working on “target hardening.” Target hardening is a military term that refers to the notion that you are the person you are trying to make most safe. “Until you recognize your personal, physical, mental, and environmental culpabilities and the possibility of victimization and do what you can realistically to reduce these, you're not a hard target,” she explained.

This means:

▸ You must be aware.

▸ You must think in a different way. For example, “Don't walk down a sidewalk that has doors on one side and bushes on the other,” she advised. Also, when you approach a parking lot, don't skirt the edge of it. Rather, “walk toward the middle of the parking lot and look to the left and right.”

▸ You must act in a different way. “The way you walk, look, and carry yourself makes a difference in the degree of vulnerability that is ascribed to you by someone looking to attack,” Ms. Pence said. “Look confident, look aware, and be in the present.”

▸ You must recognize your personal vulnerabilities. Ask yourself, how could I defend myself in the event of a personal attack? “For example, I'm not a long distance runner,” Ms. Pence said. “I don't aspire to be a runner. That's a realistic assessment of my physical abilities. If there are areas where you have a deficit, ask, what can I do to enhance my abilities? Maybe it's learning some form of self-protection or learning verbal de-escalation techniques.”

SAN DIEGO — There is no one technique or strategy that will protect you from the risk of physical attacks in your workplace by patients or coworkers, Donna Pence declared at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.

“There is nothing about who and what you are that makes you immune from people intent on doing bad things,” said Ms. Pence, training coordinator for San Diego State University's Public Child Welfare Training Academy. “Not looks, not money, not profession, not uniform, not where you live, not how religious you are, or how good you are.”

The best self-protection involves a combination of factors, including being aware of your capabilities, your environment, your habits, realistic hazards, and your options should a violent episode occur.

She offered the following tips:

▸ Do some self-reflection. What is your history of violence and anger and your response to it? Have you been in situations where you felt threatened, and now you feel hypervigilant? Your personal history of violence “will affect your response to situations,” said Ms. Pence, who spent 25 years as a special agent with the Tennessee Bureau of Investigation. “It will impact the lens through which you view [someone's] behavior. That can be good, but it also could lead you to jump the gun and have a perception of violence and danger when it doesn't really exist.”

▸ Make an effort to understand your colleagues' attitudes about personal safety and anger in the workplace. Are you allowed to talk about it? Are you encouraged to talk about it? “Is there a forum where you can ventilate about any anxieties you have about a client, or any anger you may have toward the client?” Ms. Pence asked. “Because if you're angry and they're angry, that's not a real healthy combination.”

Also, ask yourself, are there people in the office who can hear you if you yell for help? Is there an emergency buzzer nearby? If somebody enters the office and a buzzer goes off, do we have a plan on what to do?

▸ Think twice before visiting a patient in his or her home. Look at prior referrals. Consult with social workers or other physicians to see if the patient has a history of violent behavior. “If I have somebody who's been arrested for drugs, weapons, domestic violence, or child abuse, I'm going to think twice before going out to their turf by myself,” she said.

To protect against workplace violence and abuse, Ms. Pence recommended working on “target hardening.” Target hardening is a military term that refers to the notion that you are the person you are trying to make most safe. “Until you recognize your personal, physical, mental, and environmental culpabilities and the possibility of victimization and do what you can realistically to reduce these, you're not a hard target,” she explained.

This means:

▸ You must be aware.

▸ You must think in a different way. For example, “Don't walk down a sidewalk that has doors on one side and bushes on the other,” she advised. Also, when you approach a parking lot, don't skirt the edge of it. Rather, “walk toward the middle of the parking lot and look to the left and right.”

▸ You must act in a different way. “The way you walk, look, and carry yourself makes a difference in the degree of vulnerability that is ascribed to you by someone looking to attack,” Ms. Pence said. “Look confident, look aware, and be in the present.”

▸ You must recognize your personal vulnerabilities. Ask yourself, how could I defend myself in the event of a personal attack? “For example, I'm not a long distance runner,” Ms. Pence said. “I don't aspire to be a runner. That's a realistic assessment of my physical abilities. If there are areas where you have a deficit, ask, what can I do to enhance my abilities? Maybe it's learning some form of self-protection or learning verbal de-escalation techniques.”