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Physician value thyself!
The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.
Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.
The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.1
Physicians are also reputed to be possessing dominant leadership styles and seen as bossy and disruptive. Hence, we are made to have frequent training in how to ameliorate our disruptive behavior tendencies. Again, this may be true in a few cases. However, while reports mention how many people witness such unacceptable behavior, there is no valid data about the incidence in practicing physicians. Research also does not support the view that physicians have dominant and aggressive personalities leading to such behavior.
One of the leading interpersonal skills model is Social Styles. We happen to teach this to our faculty at the Ohio State Medical Center’s Faculty Leadership Institute. Turns out that physicians and nurses are almost equally placed into the four quadrants of leadership styles: driving, expressive, amiable, and analytical. I found similar findings in our society members participating in a leadership session I moderated. Indeed, we rank very high on “versatility,” a measure that enables us to adapt our behaviors to fit with our patients and coworkers.
Reported burnout rates of 50% in physicians may or may not be accurate, but burnout is real and so is depression and so are physician suicides. I have witnessed six physician suicides in my career thus far. Teaching resilience, celebrating doctor’s day, and giving out a few awards are all interventions after the fact. Preventive measures like employers and hospitals prioritizing removing daily obstacles eliminating meaningless work, providing more resources to deal with EMRs, and making our lives easier at work, so we can get to our loved ones sooner would help.
Physicians have been largely excluded themselves from participating in the health care debate. We want to see empirical evidence before we sign on to every new proposed care model. Otherwise, we cling on to the status quo and therefore, decision makers tend to leave us out. More important, value-based payment models have not thus far led to reduction in the cost of health care. Despite poor engagement scores at major health systems, physicians are “managed” and sidelined, and mandates are “done to them, not with them.”
In my 40-year career, our devaluation has been a slow and painful process. It started with being called a “provider.” This devalues me. Call me by what I am and do. Physician. Doctor. That is what our patients call us. But, we have been pushed to acquiesce. So, why do physicians undervalue themselves and are unable to be confident of their value to employers and hospital executives?
Some have theorized that physicians have low self-esteem and that denial and rationalization are simply defense mechanisms. The low self-esteem is traced back to medical student days and considered “posttraumatic” disorder. In one study of 189 medical students, 50% reported a decrease in their self-esteem/confidence. The students blamed their residents and attendings for this reaction. Some degree of intimidation may continue into training and employment where it may be part of the culture. We need to change this cycle and treat our students, residents, and mentees with respect as future peers.
Another aspect is related to our own well-being. Most physicians value their patient’s health more than their own. That concept is drilled into us throughout our life. Our spouses complain that we care more about our patients than we do for our families. We often ignore warning signs of serious issues in our own health, always downplaying textbook symptoms of burnout, depression, and even MI. Being too busy is a badge of honor to indicate how successful and wanted we are. This also needs to change.
Sheryl Sandberg in her book “Lean in” discusses the “tiara syndrome,” mainly referring to women. I would suggest that this applies to a lot of physicians, both men and women. Physicians tend to keep their heads down, work hard, and expect someone to come compliment them and place a “tiara” over their head. We may be wary of being called “self-promoters.” Sometimes it is cultural baggage for immigrant physicians who are taught to not brag about their accomplishments. It may behoove us to judiciously make peers and leadership aware of our positive activities in and outside the health system.
Some see physicians not as “pillars of any community,” but as “technicians on an assembly line” or “pawns in a money-making game for hospital administrators.” This degree of pessimism among physicians in surveys is well known but there is good news.
In a 2016 survey based upon responses by 17,236 physicians, 63% were pessimistic or very pessimistic about the medical profession, down from 77% in 2012.2 In another poll, medical doctors were rated as having very high or high ratings of honesty and ethical standards by 65%, higher than all except nurses, military officers, and grade school teachers.3 When the health care debate was at its peak in 2009, a public poll on who they trusted to recommend the right thing for reforming the healthcare system placed physicians at the very top (73%)ahead of health care professors, researchers, hospitals, the President, and politicians. Gallup surveyed 7,000 physicians about engagement in four hierarchical levels: Confidence, Integrity, Pride and Passion. Physicians scored highly on the Pride items in the survey (feel proud to work and being treated with respect).4 In other words, if we are treated well, we feel proud to tell others where we work.
Finally, like many I may consider myself an expert in all sorts of things not relevant to practicing medicine. Yet, I respectfully suggest we stay away from political hot potatoes like nuclear disarmament, gun control, climate change, immigration, and other controversial issues because they distract us from our primary mission. I would hate to see us viewed like Hollywood.
References
1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html
2. www.medpagetoday.com/primarycare/generalprimarycare/60446
3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/
4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx
Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.
The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.
Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.
The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.1
Physicians are also reputed to be possessing dominant leadership styles and seen as bossy and disruptive. Hence, we are made to have frequent training in how to ameliorate our disruptive behavior tendencies. Again, this may be true in a few cases. However, while reports mention how many people witness such unacceptable behavior, there is no valid data about the incidence in practicing physicians. Research also does not support the view that physicians have dominant and aggressive personalities leading to such behavior.
One of the leading interpersonal skills model is Social Styles. We happen to teach this to our faculty at the Ohio State Medical Center’s Faculty Leadership Institute. Turns out that physicians and nurses are almost equally placed into the four quadrants of leadership styles: driving, expressive, amiable, and analytical. I found similar findings in our society members participating in a leadership session I moderated. Indeed, we rank very high on “versatility,” a measure that enables us to adapt our behaviors to fit with our patients and coworkers.
Reported burnout rates of 50% in physicians may or may not be accurate, but burnout is real and so is depression and so are physician suicides. I have witnessed six physician suicides in my career thus far. Teaching resilience, celebrating doctor’s day, and giving out a few awards are all interventions after the fact. Preventive measures like employers and hospitals prioritizing removing daily obstacles eliminating meaningless work, providing more resources to deal with EMRs, and making our lives easier at work, so we can get to our loved ones sooner would help.
Physicians have been largely excluded themselves from participating in the health care debate. We want to see empirical evidence before we sign on to every new proposed care model. Otherwise, we cling on to the status quo and therefore, decision makers tend to leave us out. More important, value-based payment models have not thus far led to reduction in the cost of health care. Despite poor engagement scores at major health systems, physicians are “managed” and sidelined, and mandates are “done to them, not with them.”
In my 40-year career, our devaluation has been a slow and painful process. It started with being called a “provider.” This devalues me. Call me by what I am and do. Physician. Doctor. That is what our patients call us. But, we have been pushed to acquiesce. So, why do physicians undervalue themselves and are unable to be confident of their value to employers and hospital executives?
Some have theorized that physicians have low self-esteem and that denial and rationalization are simply defense mechanisms. The low self-esteem is traced back to medical student days and considered “posttraumatic” disorder. In one study of 189 medical students, 50% reported a decrease in their self-esteem/confidence. The students blamed their residents and attendings for this reaction. Some degree of intimidation may continue into training and employment where it may be part of the culture. We need to change this cycle and treat our students, residents, and mentees with respect as future peers.
Another aspect is related to our own well-being. Most physicians value their patient’s health more than their own. That concept is drilled into us throughout our life. Our spouses complain that we care more about our patients than we do for our families. We often ignore warning signs of serious issues in our own health, always downplaying textbook symptoms of burnout, depression, and even MI. Being too busy is a badge of honor to indicate how successful and wanted we are. This also needs to change.
Sheryl Sandberg in her book “Lean in” discusses the “tiara syndrome,” mainly referring to women. I would suggest that this applies to a lot of physicians, both men and women. Physicians tend to keep their heads down, work hard, and expect someone to come compliment them and place a “tiara” over their head. We may be wary of being called “self-promoters.” Sometimes it is cultural baggage for immigrant physicians who are taught to not brag about their accomplishments. It may behoove us to judiciously make peers and leadership aware of our positive activities in and outside the health system.
Some see physicians not as “pillars of any community,” but as “technicians on an assembly line” or “pawns in a money-making game for hospital administrators.” This degree of pessimism among physicians in surveys is well known but there is good news.
In a 2016 survey based upon responses by 17,236 physicians, 63% were pessimistic or very pessimistic about the medical profession, down from 77% in 2012.2 In another poll, medical doctors were rated as having very high or high ratings of honesty and ethical standards by 65%, higher than all except nurses, military officers, and grade school teachers.3 When the health care debate was at its peak in 2009, a public poll on who they trusted to recommend the right thing for reforming the healthcare system placed physicians at the very top (73%)ahead of health care professors, researchers, hospitals, the President, and politicians. Gallup surveyed 7,000 physicians about engagement in four hierarchical levels: Confidence, Integrity, Pride and Passion. Physicians scored highly on the Pride items in the survey (feel proud to work and being treated with respect).4 In other words, if we are treated well, we feel proud to tell others where we work.
Finally, like many I may consider myself an expert in all sorts of things not relevant to practicing medicine. Yet, I respectfully suggest we stay away from political hot potatoes like nuclear disarmament, gun control, climate change, immigration, and other controversial issues because they distract us from our primary mission. I would hate to see us viewed like Hollywood.
References
1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html
2. www.medpagetoday.com/primarycare/generalprimarycare/60446
3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/
4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx
Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.
The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.
Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.
The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.1
Physicians are also reputed to be possessing dominant leadership styles and seen as bossy and disruptive. Hence, we are made to have frequent training in how to ameliorate our disruptive behavior tendencies. Again, this may be true in a few cases. However, while reports mention how many people witness such unacceptable behavior, there is no valid data about the incidence in practicing physicians. Research also does not support the view that physicians have dominant and aggressive personalities leading to such behavior.
One of the leading interpersonal skills model is Social Styles. We happen to teach this to our faculty at the Ohio State Medical Center’s Faculty Leadership Institute. Turns out that physicians and nurses are almost equally placed into the four quadrants of leadership styles: driving, expressive, amiable, and analytical. I found similar findings in our society members participating in a leadership session I moderated. Indeed, we rank very high on “versatility,” a measure that enables us to adapt our behaviors to fit with our patients and coworkers.
Reported burnout rates of 50% in physicians may or may not be accurate, but burnout is real and so is depression and so are physician suicides. I have witnessed six physician suicides in my career thus far. Teaching resilience, celebrating doctor’s day, and giving out a few awards are all interventions after the fact. Preventive measures like employers and hospitals prioritizing removing daily obstacles eliminating meaningless work, providing more resources to deal with EMRs, and making our lives easier at work, so we can get to our loved ones sooner would help.
Physicians have been largely excluded themselves from participating in the health care debate. We want to see empirical evidence before we sign on to every new proposed care model. Otherwise, we cling on to the status quo and therefore, decision makers tend to leave us out. More important, value-based payment models have not thus far led to reduction in the cost of health care. Despite poor engagement scores at major health systems, physicians are “managed” and sidelined, and mandates are “done to them, not with them.”
In my 40-year career, our devaluation has been a slow and painful process. It started with being called a “provider.” This devalues me. Call me by what I am and do. Physician. Doctor. That is what our patients call us. But, we have been pushed to acquiesce. So, why do physicians undervalue themselves and are unable to be confident of their value to employers and hospital executives?
Some have theorized that physicians have low self-esteem and that denial and rationalization are simply defense mechanisms. The low self-esteem is traced back to medical student days and considered “posttraumatic” disorder. In one study of 189 medical students, 50% reported a decrease in their self-esteem/confidence. The students blamed their residents and attendings for this reaction. Some degree of intimidation may continue into training and employment where it may be part of the culture. We need to change this cycle and treat our students, residents, and mentees with respect as future peers.
Another aspect is related to our own well-being. Most physicians value their patient’s health more than their own. That concept is drilled into us throughout our life. Our spouses complain that we care more about our patients than we do for our families. We often ignore warning signs of serious issues in our own health, always downplaying textbook symptoms of burnout, depression, and even MI. Being too busy is a badge of honor to indicate how successful and wanted we are. This also needs to change.
Sheryl Sandberg in her book “Lean in” discusses the “tiara syndrome,” mainly referring to women. I would suggest that this applies to a lot of physicians, both men and women. Physicians tend to keep their heads down, work hard, and expect someone to come compliment them and place a “tiara” over their head. We may be wary of being called “self-promoters.” Sometimes it is cultural baggage for immigrant physicians who are taught to not brag about their accomplishments. It may behoove us to judiciously make peers and leadership aware of our positive activities in and outside the health system.
Some see physicians not as “pillars of any community,” but as “technicians on an assembly line” or “pawns in a money-making game for hospital administrators.” This degree of pessimism among physicians in surveys is well known but there is good news.
In a 2016 survey based upon responses by 17,236 physicians, 63% were pessimistic or very pessimistic about the medical profession, down from 77% in 2012.2 In another poll, medical doctors were rated as having very high or high ratings of honesty and ethical standards by 65%, higher than all except nurses, military officers, and grade school teachers.3 When the health care debate was at its peak in 2009, a public poll on who they trusted to recommend the right thing for reforming the healthcare system placed physicians at the very top (73%)ahead of health care professors, researchers, hospitals, the President, and politicians. Gallup surveyed 7,000 physicians about engagement in four hierarchical levels: Confidence, Integrity, Pride and Passion. Physicians scored highly on the Pride items in the survey (feel proud to work and being treated with respect).4 In other words, if we are treated well, we feel proud to tell others where we work.
Finally, like many I may consider myself an expert in all sorts of things not relevant to practicing medicine. Yet, I respectfully suggest we stay away from political hot potatoes like nuclear disarmament, gun control, climate change, immigration, and other controversial issues because they distract us from our primary mission. I would hate to see us viewed like Hollywood.
References
1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html
2. www.medpagetoday.com/primarycare/generalprimarycare/60446
3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/
4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx
Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.
January 2019 Question 2
A 54-year-old woman presents for management of moderately severe ileocolonic Crohn’s disease. She has a strong family history of multiple sclerosis and recently noted some tingling in her toes for which she is undergoing neurologic evaluation. She has had two small basal cell carcinomas removed from her cheek in the last year. She received the BCG vaccine as a child and had a positive PPD skin test within the last year. Laboratory evaluation reveals HBsAg negative, anti-HBs positive, and anti-HBc positive; JC virus antibody is positive.
DDSEP quick quiz December question 2
A 54-year-old woman presents for management of moderately severe ileocolonic Crohn’s disease. She has a strong family history of multiple sclerosis and recently noted some tingling in her toes for which she is undergoing neurologic evaluation. She has had two small basal cell carcinomas removed from her cheek in the last year. She received the BCG vaccine as a child and had a positive PPD skin test within the last year. Laboratory evaluation reveals HBsAg negative, anti-HBs positive, and anti-HBc positive; JC virus antibody is positive.
January 2019 Question 1
A 31-year-old man is seen for a 1-week history of epigastric pain and scleral icterus. One month earlier, he developed diarrhea and fatigue, which has continued to persist. He denies any prior medical problems, though he admits he has not seen a doctor in years. He is currently visiting family in the United States, but he resides in South Africa. His laboratory tests are as follows: total bilirubin, 3.5 mg/dL; direct bilirubin, 2.9 mg/dL; alkaline phosphatase, 720 U/L; ALT, 105 U/L; AST, 117 U/L; albumin, 2.1 g/dL; INR, 1.2; HIV viral load 450,000 copies/mL, CD4 count, 25 cells/mm3. An abdominal ultrasound shows intra- and extrahepatic ductal dilation and an ERCP shows strictured intrahepatic ducts with papillary stenosis.
Guidelines on Integrating New Migraine Treatments
In order to provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults, a recent position statement released by the American Headache Society updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. In addition, expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.
The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows:
- Use evidence‐based treatments when possible and appropriate.
- Start with a low dose and titrate slowly; newer injectable treatments may work faster and may not need titration.
- Reach a therapeutic dose if possible.
- Allow for an adequate treatment trial duration.
- Establish expectations of therapeutic response and adverse events and maximize adherence.
The principles of acute treatment include:
- Use evidence‐based treatments when possible and appropriate.
- Treat early after the onset of a migraine attack.
- Choose a non-oral route of administration for selected patients.
- Account for tolerability and safety issues.
- Consider self‐administered rescue treatments.
- Avoid overuse of acute medications.
American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. [Published online ahead of print December 10, 2018]. Headache. doi:10.1111/head.13456.
In order to provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults, a recent position statement released by the American Headache Society updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. In addition, expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.
The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows:
- Use evidence‐based treatments when possible and appropriate.
- Start with a low dose and titrate slowly; newer injectable treatments may work faster and may not need titration.
- Reach a therapeutic dose if possible.
- Allow for an adequate treatment trial duration.
- Establish expectations of therapeutic response and adverse events and maximize adherence.
The principles of acute treatment include:
- Use evidence‐based treatments when possible and appropriate.
- Treat early after the onset of a migraine attack.
- Choose a non-oral route of administration for selected patients.
- Account for tolerability and safety issues.
- Consider self‐administered rescue treatments.
- Avoid overuse of acute medications.
American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. [Published online ahead of print December 10, 2018]. Headache. doi:10.1111/head.13456.
In order to provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults, a recent position statement released by the American Headache Society updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. In addition, expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.
The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows:
- Use evidence‐based treatments when possible and appropriate.
- Start with a low dose and titrate slowly; newer injectable treatments may work faster and may not need titration.
- Reach a therapeutic dose if possible.
- Allow for an adequate treatment trial duration.
- Establish expectations of therapeutic response and adverse events and maximize adherence.
The principles of acute treatment include:
- Use evidence‐based treatments when possible and appropriate.
- Treat early after the onset of a migraine attack.
- Choose a non-oral route of administration for selected patients.
- Account for tolerability and safety issues.
- Consider self‐administered rescue treatments.
- Avoid overuse of acute medications.
American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. [Published online ahead of print December 10, 2018]. Headache. doi:10.1111/head.13456.
Migraine with Visual Aura a Risk Factor for AF
Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:
- Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
- Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
- After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.
Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.
Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:
- Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
- Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
- After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.
Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.
Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:
- Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
- Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
- After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.
Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.
Women with Migraine Have Lower T2D Risk
Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:
- From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
- Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
- During 10 years of follow-up, 2372 incident T2D cases occurred.
- A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).
Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.
Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:
- From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
- Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
- During 10 years of follow-up, 2372 incident T2D cases occurred.
- A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).
Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.
Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:
- From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
- Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
- During 10 years of follow-up, 2372 incident T2D cases occurred.
- A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).
Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.
Back pain criteria perform well in patients with active axial psoriatic arthritis
A back pain screening questionnaire developed for ankylosing spondylitis performs well for identifying the subset of axial psoriatic arthritis patients who have active symptoms, according to researchers.
The inflammatory back pain criteria didn’t perform as well when patients with established disease but no symptoms were included, though using a lower cutoff point for the questionnaire improved its sensitivity, the researchers reported in the Annals of the Rheumatic Diseases.
Previous investigations showed that the inflammatory back pain criteria, as defined by the Assessment of Spondyloarthritis International Society (ASAS), had low sensitivity and high specificity for axial involvement in psoriatic arthritis.
Those earlier studies may have registered suboptimal performance of the inflammatory back pain criteria by not distinguishing between patients with axial disease in remission and those with active symptoms, according to Muhammad Haroon, PhD, of the division of rheumatology at University Hospital Kerry in Tralee, Ireland, and his coinvestigators.
The present study, which they said represents a much larger cohort than earlier investigations, included 406 patients with psoriatic arthritis, about one-quarter of whom had rheumatologist-diagnosed axial psoriatic arthritis. The mean age of the axial psoriatic arthritis patients was 51 years and 53% were male.
The researchers found that the inflammatory back pain criteria had poor sensitivity but good specificity at 59% and 84%, respectively, in patients with established axial psoriatic arthritis, defined as axial disease regardless of whether it was active or in remission.
By contrast, the criteria had good sensitivity and good specificity at 82% and 88%, respectively, in patients who had active axial psoriatic arthritis, according to the investigators.
The standard cutoff points used by the ASAS inflammatory back pain criteria may be too high for screening for early disease or for evaluating patients already receiving systemic therapies for psoriatic disease, the investigators said.
Looking at a lower cutoff point of three of five ASAS criteria, sensitivity was “quite high” for detecting established axial psoriatic arthritis, they said, increasing from 59% to 84%, while specificity remained relatively high, decreasing from 84% to 80%.
“We suggest that the standard cutoffs for this questionnaire be used for patients with active axial psoriatic arthritis, and the lower cutoffs should be used among patients with established axial psoriatic arthritis, where patients can potentially be in remission or partial remission,” they wrote in their report.
These findings could have important implications for the use of this screening tool in patients with psoriatic arthritis; however, more research is needed to validate the observations, the researchers cautioned.
Dr. Haroon reported competing interests related to AbbVie, Pfizer, and Celgene.
SOURCE: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.
A back pain screening questionnaire developed for ankylosing spondylitis performs well for identifying the subset of axial psoriatic arthritis patients who have active symptoms, according to researchers.
The inflammatory back pain criteria didn’t perform as well when patients with established disease but no symptoms were included, though using a lower cutoff point for the questionnaire improved its sensitivity, the researchers reported in the Annals of the Rheumatic Diseases.
Previous investigations showed that the inflammatory back pain criteria, as defined by the Assessment of Spondyloarthritis International Society (ASAS), had low sensitivity and high specificity for axial involvement in psoriatic arthritis.
Those earlier studies may have registered suboptimal performance of the inflammatory back pain criteria by not distinguishing between patients with axial disease in remission and those with active symptoms, according to Muhammad Haroon, PhD, of the division of rheumatology at University Hospital Kerry in Tralee, Ireland, and his coinvestigators.
The present study, which they said represents a much larger cohort than earlier investigations, included 406 patients with psoriatic arthritis, about one-quarter of whom had rheumatologist-diagnosed axial psoriatic arthritis. The mean age of the axial psoriatic arthritis patients was 51 years and 53% were male.
The researchers found that the inflammatory back pain criteria had poor sensitivity but good specificity at 59% and 84%, respectively, in patients with established axial psoriatic arthritis, defined as axial disease regardless of whether it was active or in remission.
By contrast, the criteria had good sensitivity and good specificity at 82% and 88%, respectively, in patients who had active axial psoriatic arthritis, according to the investigators.
The standard cutoff points used by the ASAS inflammatory back pain criteria may be too high for screening for early disease or for evaluating patients already receiving systemic therapies for psoriatic disease, the investigators said.
Looking at a lower cutoff point of three of five ASAS criteria, sensitivity was “quite high” for detecting established axial psoriatic arthritis, they said, increasing from 59% to 84%, while specificity remained relatively high, decreasing from 84% to 80%.
“We suggest that the standard cutoffs for this questionnaire be used for patients with active axial psoriatic arthritis, and the lower cutoffs should be used among patients with established axial psoriatic arthritis, where patients can potentially be in remission or partial remission,” they wrote in their report.
These findings could have important implications for the use of this screening tool in patients with psoriatic arthritis; however, more research is needed to validate the observations, the researchers cautioned.
Dr. Haroon reported competing interests related to AbbVie, Pfizer, and Celgene.
SOURCE: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.
A back pain screening questionnaire developed for ankylosing spondylitis performs well for identifying the subset of axial psoriatic arthritis patients who have active symptoms, according to researchers.
The inflammatory back pain criteria didn’t perform as well when patients with established disease but no symptoms were included, though using a lower cutoff point for the questionnaire improved its sensitivity, the researchers reported in the Annals of the Rheumatic Diseases.
Previous investigations showed that the inflammatory back pain criteria, as defined by the Assessment of Spondyloarthritis International Society (ASAS), had low sensitivity and high specificity for axial involvement in psoriatic arthritis.
Those earlier studies may have registered suboptimal performance of the inflammatory back pain criteria by not distinguishing between patients with axial disease in remission and those with active symptoms, according to Muhammad Haroon, PhD, of the division of rheumatology at University Hospital Kerry in Tralee, Ireland, and his coinvestigators.
The present study, which they said represents a much larger cohort than earlier investigations, included 406 patients with psoriatic arthritis, about one-quarter of whom had rheumatologist-diagnosed axial psoriatic arthritis. The mean age of the axial psoriatic arthritis patients was 51 years and 53% were male.
The researchers found that the inflammatory back pain criteria had poor sensitivity but good specificity at 59% and 84%, respectively, in patients with established axial psoriatic arthritis, defined as axial disease regardless of whether it was active or in remission.
By contrast, the criteria had good sensitivity and good specificity at 82% and 88%, respectively, in patients who had active axial psoriatic arthritis, according to the investigators.
The standard cutoff points used by the ASAS inflammatory back pain criteria may be too high for screening for early disease or for evaluating patients already receiving systemic therapies for psoriatic disease, the investigators said.
Looking at a lower cutoff point of three of five ASAS criteria, sensitivity was “quite high” for detecting established axial psoriatic arthritis, they said, increasing from 59% to 84%, while specificity remained relatively high, decreasing from 84% to 80%.
“We suggest that the standard cutoffs for this questionnaire be used for patients with active axial psoriatic arthritis, and the lower cutoffs should be used among patients with established axial psoriatic arthritis, where patients can potentially be in remission or partial remission,” they wrote in their report.
These findings could have important implications for the use of this screening tool in patients with psoriatic arthritis; however, more research is needed to validate the observations, the researchers cautioned.
Dr. Haroon reported competing interests related to AbbVie, Pfizer, and Celgene.
SOURCE: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.
FROM ANNALS OF THE RHEUMATIC DISEASES
Key clinical point: An inflammatory back pain screening questionnaire, developed for ankylosing spondylitis, performed well in identifying axial psoriatic arthritis in patients with active symptoms.
Major finding: The tool performed suboptimally when patients without active symptoms were included, but had good sensitivity (82%) and specificity (88%) in patients with active axial psoriatic arthritis.
Study details: A study including more than 400 patients with psoriatic arthritis.
Disclosures: The corresponding author reported competing interests related to AbbVie, Pfizer, and Celgene.
Source: Haroon M et al. Ann Rheum Dis. 2018 Dec 14. doi: 10.1136/annrheumdis-2018-214583.
Continuous certification – Not just one more hoop to jump through
Maintenance of Certification (MOC) is an American Board of Medical Specialties (ABMS) requirement for their 24 member boards. The MOC process has received much criticism, especially in recent years. To date, a 5-hour exam at a secure testing center every 10 years covering comprehensive vascular surgery knowledge has been the routine. This requirement had the surgeon take off a day from work for the exam, in addition to the time it took to prepare. Burnout, at least in part, is related to the sheer volume of busywork not directly relevant to being a practicing surgeon.
The American Board of Surgery is sensitive to both the relevance of MOC and needs of the diplomate, and is striving to make appropriate changes. Diplomates were surveyed regarding MOC and the accompanying exam in both 2016 and 2017. Using this input, the development of the 10-year exam format was studied carefully by the board directors and executive staff, all of whom are active in the clinical practice of surgery, and a new process now known as Continuous Certification was introduced. The intent of the new Continuous Certification Assessment (to replace the every-10-year MOC exam) is to be an activity that is convenient, timely, and more reflective of the surgeon’s daily practice. The assessment is to be done every 2 years and is online, open book, and taken at a place of the examinee’s choosing, such as the home or in the office. Another key feature of the continuous certification process is that the total number of CME required is decreased and the self-assessment requirement is eliminated.
In November 2018, I took the first General Surgery Continuous Certification Assessment. There was approximately a 2-month window to register, and online registration was simple, taking only about 15 minutes to complete. All the references were listed on the ABS website and the vast majority were open access and directly linked to the article. For those articles that were not open access, there was a link to the PubMed abstract. I downloaded all of the articles (actually this part my assistant did) and requested five articles from the library. I did not review the articles in advance, but used them when going sequentially through the assessment questions. Depending on the article, I read it or looked up the specific aspect I was looking for. I worked on the test three different times – at the airport during a long layover, at home, and at my office. After answering each question, I received feedback on what was the correct answer and a one-paragraph explanation which I read completely. After completing all 40 questions, each question for which I had an incorrect answer (not more than one or two of course, Ha!) was shown again with the opportunity to answer the question. The total time took me was about 4.5 hours. All in all, it was a good experience, and I learned something.
The general surgery assessment is modular. Twenty questions (half) were core surgery topics, and the other twenty questions came from one of four specialty modules of the examinee’s choice – breast, abdomen, alimentary tract, or comprehensive general surgery. I took the core and the abdomen modules. The core topics were, for the most part, areas that a surgeon who does patient care would find relevant (for example, perioperative management of a patient on corticosteroids, postoperative delirium, and prophylaxis for venous thromboembolism).
A couple of other details should be mentioned about this new process. From the time of initiation of the assessment, there are 2 weeks allocated for completion. One needs 80% correct to pass. If the examinee receives less than 80% but higher than 40% on the first assessment attempt, he/she will have a second attempt to answer the questions that were incorrect on the first try. If a cumulative score of less than 80% is achieved after the second attempt, a grace year will be provided, which is an extension of certification for 1 year with the opportunity to take the next year’s assessment. If after the grace year (four attempts) the diplomate is unsuccessful, then a secure exam is required to regain certification.
Overall, there has been much positive feedback. Of the 2,164 diplomates taking the Continuous Certification Assessment, only 21 were unsuccessful. Therefore, the pass rate was over 99% for the inaugural year. The average examinee took just over 3 hours to complete the assessment.
In 2018, the 10-year recertification examination in vascular surgery with 10 years of credit was given for the last time. The Vascular Surgery Continuous Certification Assessment is in preparation now and will roll out in the fall of 2019. It will follow a format similar to general surgery with 40 questions on a number of topics in vascular surgery. However, the vascular surgery assessment will not be modular. This activity will incorporate general knowledge (for example, from consensus guidelines), as well as late breaking trials. So far, this process looks to be a better one, as well as more efficient and relevant for the busy surgeon.
Dr. Gahtan is professor and chief, division of vascular surgery and endovascular services, State University of New York Upstate Medical University, Syracuse.
Maintenance of Certification (MOC) is an American Board of Medical Specialties (ABMS) requirement for their 24 member boards. The MOC process has received much criticism, especially in recent years. To date, a 5-hour exam at a secure testing center every 10 years covering comprehensive vascular surgery knowledge has been the routine. This requirement had the surgeon take off a day from work for the exam, in addition to the time it took to prepare. Burnout, at least in part, is related to the sheer volume of busywork not directly relevant to being a practicing surgeon.
The American Board of Surgery is sensitive to both the relevance of MOC and needs of the diplomate, and is striving to make appropriate changes. Diplomates were surveyed regarding MOC and the accompanying exam in both 2016 and 2017. Using this input, the development of the 10-year exam format was studied carefully by the board directors and executive staff, all of whom are active in the clinical practice of surgery, and a new process now known as Continuous Certification was introduced. The intent of the new Continuous Certification Assessment (to replace the every-10-year MOC exam) is to be an activity that is convenient, timely, and more reflective of the surgeon’s daily practice. The assessment is to be done every 2 years and is online, open book, and taken at a place of the examinee’s choosing, such as the home or in the office. Another key feature of the continuous certification process is that the total number of CME required is decreased and the self-assessment requirement is eliminated.
In November 2018, I took the first General Surgery Continuous Certification Assessment. There was approximately a 2-month window to register, and online registration was simple, taking only about 15 minutes to complete. All the references were listed on the ABS website and the vast majority were open access and directly linked to the article. For those articles that were not open access, there was a link to the PubMed abstract. I downloaded all of the articles (actually this part my assistant did) and requested five articles from the library. I did not review the articles in advance, but used them when going sequentially through the assessment questions. Depending on the article, I read it or looked up the specific aspect I was looking for. I worked on the test three different times – at the airport during a long layover, at home, and at my office. After answering each question, I received feedback on what was the correct answer and a one-paragraph explanation which I read completely. After completing all 40 questions, each question for which I had an incorrect answer (not more than one or two of course, Ha!) was shown again with the opportunity to answer the question. The total time took me was about 4.5 hours. All in all, it was a good experience, and I learned something.
The general surgery assessment is modular. Twenty questions (half) were core surgery topics, and the other twenty questions came from one of four specialty modules of the examinee’s choice – breast, abdomen, alimentary tract, or comprehensive general surgery. I took the core and the abdomen modules. The core topics were, for the most part, areas that a surgeon who does patient care would find relevant (for example, perioperative management of a patient on corticosteroids, postoperative delirium, and prophylaxis for venous thromboembolism).
A couple of other details should be mentioned about this new process. From the time of initiation of the assessment, there are 2 weeks allocated for completion. One needs 80% correct to pass. If the examinee receives less than 80% but higher than 40% on the first assessment attempt, he/she will have a second attempt to answer the questions that were incorrect on the first try. If a cumulative score of less than 80% is achieved after the second attempt, a grace year will be provided, which is an extension of certification for 1 year with the opportunity to take the next year’s assessment. If after the grace year (four attempts) the diplomate is unsuccessful, then a secure exam is required to regain certification.
Overall, there has been much positive feedback. Of the 2,164 diplomates taking the Continuous Certification Assessment, only 21 were unsuccessful. Therefore, the pass rate was over 99% for the inaugural year. The average examinee took just over 3 hours to complete the assessment.
In 2018, the 10-year recertification examination in vascular surgery with 10 years of credit was given for the last time. The Vascular Surgery Continuous Certification Assessment is in preparation now and will roll out in the fall of 2019. It will follow a format similar to general surgery with 40 questions on a number of topics in vascular surgery. However, the vascular surgery assessment will not be modular. This activity will incorporate general knowledge (for example, from consensus guidelines), as well as late breaking trials. So far, this process looks to be a better one, as well as more efficient and relevant for the busy surgeon.
Dr. Gahtan is professor and chief, division of vascular surgery and endovascular services, State University of New York Upstate Medical University, Syracuse.
Maintenance of Certification (MOC) is an American Board of Medical Specialties (ABMS) requirement for their 24 member boards. The MOC process has received much criticism, especially in recent years. To date, a 5-hour exam at a secure testing center every 10 years covering comprehensive vascular surgery knowledge has been the routine. This requirement had the surgeon take off a day from work for the exam, in addition to the time it took to prepare. Burnout, at least in part, is related to the sheer volume of busywork not directly relevant to being a practicing surgeon.
The American Board of Surgery is sensitive to both the relevance of MOC and needs of the diplomate, and is striving to make appropriate changes. Diplomates were surveyed regarding MOC and the accompanying exam in both 2016 and 2017. Using this input, the development of the 10-year exam format was studied carefully by the board directors and executive staff, all of whom are active in the clinical practice of surgery, and a new process now known as Continuous Certification was introduced. The intent of the new Continuous Certification Assessment (to replace the every-10-year MOC exam) is to be an activity that is convenient, timely, and more reflective of the surgeon’s daily practice. The assessment is to be done every 2 years and is online, open book, and taken at a place of the examinee’s choosing, such as the home or in the office. Another key feature of the continuous certification process is that the total number of CME required is decreased and the self-assessment requirement is eliminated.
In November 2018, I took the first General Surgery Continuous Certification Assessment. There was approximately a 2-month window to register, and online registration was simple, taking only about 15 minutes to complete. All the references were listed on the ABS website and the vast majority were open access and directly linked to the article. For those articles that were not open access, there was a link to the PubMed abstract. I downloaded all of the articles (actually this part my assistant did) and requested five articles from the library. I did not review the articles in advance, but used them when going sequentially through the assessment questions. Depending on the article, I read it or looked up the specific aspect I was looking for. I worked on the test three different times – at the airport during a long layover, at home, and at my office. After answering each question, I received feedback on what was the correct answer and a one-paragraph explanation which I read completely. After completing all 40 questions, each question for which I had an incorrect answer (not more than one or two of course, Ha!) was shown again with the opportunity to answer the question. The total time took me was about 4.5 hours. All in all, it was a good experience, and I learned something.
The general surgery assessment is modular. Twenty questions (half) were core surgery topics, and the other twenty questions came from one of four specialty modules of the examinee’s choice – breast, abdomen, alimentary tract, or comprehensive general surgery. I took the core and the abdomen modules. The core topics were, for the most part, areas that a surgeon who does patient care would find relevant (for example, perioperative management of a patient on corticosteroids, postoperative delirium, and prophylaxis for venous thromboembolism).
A couple of other details should be mentioned about this new process. From the time of initiation of the assessment, there are 2 weeks allocated for completion. One needs 80% correct to pass. If the examinee receives less than 80% but higher than 40% on the first assessment attempt, he/she will have a second attempt to answer the questions that were incorrect on the first try. If a cumulative score of less than 80% is achieved after the second attempt, a grace year will be provided, which is an extension of certification for 1 year with the opportunity to take the next year’s assessment. If after the grace year (four attempts) the diplomate is unsuccessful, then a secure exam is required to regain certification.
Overall, there has been much positive feedback. Of the 2,164 diplomates taking the Continuous Certification Assessment, only 21 were unsuccessful. Therefore, the pass rate was over 99% for the inaugural year. The average examinee took just over 3 hours to complete the assessment.
In 2018, the 10-year recertification examination in vascular surgery with 10 years of credit was given for the last time. The Vascular Surgery Continuous Certification Assessment is in preparation now and will roll out in the fall of 2019. It will follow a format similar to general surgery with 40 questions on a number of topics in vascular surgery. However, the vascular surgery assessment will not be modular. This activity will incorporate general knowledge (for example, from consensus guidelines), as well as late breaking trials. So far, this process looks to be a better one, as well as more efficient and relevant for the busy surgeon.
Dr. Gahtan is professor and chief, division of vascular surgery and endovascular services, State University of New York Upstate Medical University, Syracuse.
Knee and elbow rejuvenation
The cosmetic industry improves techniques for tightening faces, hands, necks, and decolletes; meanwhile, sagging elbows and knees, once ignored, also are a visible sign of aging. Modifying techniques commonly used for the face and neck can yield significant improvements in the elbows and knees. The elbows and knees naturally have looser skin to allow for joint movement; over time, the skin over these joints is exposed to sun damage, friction, and recurrent extension and flexion, which cause skin laxity and aging.
A combination approach addressing skin texture, collagen damage, rhytides, and fat deposition is the most effective method for knee and elbow rejuvenation.
For knees and elbows with loose skin and rhytides, in-office noninvasive and minimally invasive radio-frequency and light energy treatments are helpful in increasing collagen production and tissue tightening. Similarly, microfocused ultrasound has been shown to be a safe and effective skin tightening treatment for the knees. In comparison to the face, however, the skin around the elbows and knees can be thinner and has fewer sebaceous glands. Caution should be used particularly with minimally invasive radio-frequency techniques in order to protect the epidermal skin. Often, treatments have to be repeated to give optimal results, which are not apparent until 3-6 months after the initial procedure.
For knee skin with severe laxity, a comprehensive approach using polydioxanone (PDO) or poly-l-lactic acid (PLLA) threads in both the upper thighs and circumferentially around the knees provides collagen production and tightening of the loose skin. Treatment of the upper thighs is essential in providing a vector that lifts the skin of the knees. Treatments can be repeated, with results seen after 90 days. Thread lifts of the knees and thighs are highly effective, noninvasive procedures with little to no downtime and can be used for severe skin laxity, wrinkling, and thinning of the knee skin.
Loose, roughened knee and elbow skin can also be treated with nonablative factional resurfacing, radio-frequency microneedling, or a series of monthly treatments with PLLA and hyaluronic acid fillers injected in the superficial to mid-dermis. Both fractional resurfacing and dermal filler injections help stimulate collagen production and improve both fine rhytides and dermatoheliosis.
Adipose tissue around the knees can be treated with monthly deoxycholic acid injections (for a video of this procedure, go to https://drive.google.com/file/d/1rhw-nESy15AoDhKUrc25DDjKEun7RL4i/view). The volume of injection, however, is significantly higher than that recommended in the submental area. Two to four times the volume is needed per knee over a series of 3-6 treatments, depending on the amount of fat in the knees.
Cryolipolysis is also an effective option for fat pockets around the knees; however, in my experience, it can be difficult to fit the applicators onto the area of concern appropriately unless smaller applicators are applied.
With the increasing demand for body rejuvenation techniques, providers are adapting techniques used for the face and neck to lift, tighten, thin, and sculpt the knees and elbows. A combination approach using lasers, ultrasound, fillers, threads, and cryolipolysis can be effective for these areas. Results are obtainable when repeat treatments are performed; however, one must be patient because results are not seen for 6 months or more.
Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Macedo O. et al. J Am Acad Dermatol. 2014;70(Suppl 1), Abstract P800, page AB193.
The cosmetic industry improves techniques for tightening faces, hands, necks, and decolletes; meanwhile, sagging elbows and knees, once ignored, also are a visible sign of aging. Modifying techniques commonly used for the face and neck can yield significant improvements in the elbows and knees. The elbows and knees naturally have looser skin to allow for joint movement; over time, the skin over these joints is exposed to sun damage, friction, and recurrent extension and flexion, which cause skin laxity and aging.
A combination approach addressing skin texture, collagen damage, rhytides, and fat deposition is the most effective method for knee and elbow rejuvenation.
For knees and elbows with loose skin and rhytides, in-office noninvasive and minimally invasive radio-frequency and light energy treatments are helpful in increasing collagen production and tissue tightening. Similarly, microfocused ultrasound has been shown to be a safe and effective skin tightening treatment for the knees. In comparison to the face, however, the skin around the elbows and knees can be thinner and has fewer sebaceous glands. Caution should be used particularly with minimally invasive radio-frequency techniques in order to protect the epidermal skin. Often, treatments have to be repeated to give optimal results, which are not apparent until 3-6 months after the initial procedure.
For knee skin with severe laxity, a comprehensive approach using polydioxanone (PDO) or poly-l-lactic acid (PLLA) threads in both the upper thighs and circumferentially around the knees provides collagen production and tightening of the loose skin. Treatment of the upper thighs is essential in providing a vector that lifts the skin of the knees. Treatments can be repeated, with results seen after 90 days. Thread lifts of the knees and thighs are highly effective, noninvasive procedures with little to no downtime and can be used for severe skin laxity, wrinkling, and thinning of the knee skin.
Loose, roughened knee and elbow skin can also be treated with nonablative factional resurfacing, radio-frequency microneedling, or a series of monthly treatments with PLLA and hyaluronic acid fillers injected in the superficial to mid-dermis. Both fractional resurfacing and dermal filler injections help stimulate collagen production and improve both fine rhytides and dermatoheliosis.
Adipose tissue around the knees can be treated with monthly deoxycholic acid injections (for a video of this procedure, go to https://drive.google.com/file/d/1rhw-nESy15AoDhKUrc25DDjKEun7RL4i/view). The volume of injection, however, is significantly higher than that recommended in the submental area. Two to four times the volume is needed per knee over a series of 3-6 treatments, depending on the amount of fat in the knees.
Cryolipolysis is also an effective option for fat pockets around the knees; however, in my experience, it can be difficult to fit the applicators onto the area of concern appropriately unless smaller applicators are applied.
With the increasing demand for body rejuvenation techniques, providers are adapting techniques used for the face and neck to lift, tighten, thin, and sculpt the knees and elbows. A combination approach using lasers, ultrasound, fillers, threads, and cryolipolysis can be effective for these areas. Results are obtainable when repeat treatments are performed; however, one must be patient because results are not seen for 6 months or more.
Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Macedo O. et al. J Am Acad Dermatol. 2014;70(Suppl 1), Abstract P800, page AB193.
The cosmetic industry improves techniques for tightening faces, hands, necks, and decolletes; meanwhile, sagging elbows and knees, once ignored, also are a visible sign of aging. Modifying techniques commonly used for the face and neck can yield significant improvements in the elbows and knees. The elbows and knees naturally have looser skin to allow for joint movement; over time, the skin over these joints is exposed to sun damage, friction, and recurrent extension and flexion, which cause skin laxity and aging.
A combination approach addressing skin texture, collagen damage, rhytides, and fat deposition is the most effective method for knee and elbow rejuvenation.
For knees and elbows with loose skin and rhytides, in-office noninvasive and minimally invasive radio-frequency and light energy treatments are helpful in increasing collagen production and tissue tightening. Similarly, microfocused ultrasound has been shown to be a safe and effective skin tightening treatment for the knees. In comparison to the face, however, the skin around the elbows and knees can be thinner and has fewer sebaceous glands. Caution should be used particularly with minimally invasive radio-frequency techniques in order to protect the epidermal skin. Often, treatments have to be repeated to give optimal results, which are not apparent until 3-6 months after the initial procedure.
For knee skin with severe laxity, a comprehensive approach using polydioxanone (PDO) or poly-l-lactic acid (PLLA) threads in both the upper thighs and circumferentially around the knees provides collagen production and tightening of the loose skin. Treatment of the upper thighs is essential in providing a vector that lifts the skin of the knees. Treatments can be repeated, with results seen after 90 days. Thread lifts of the knees and thighs are highly effective, noninvasive procedures with little to no downtime and can be used for severe skin laxity, wrinkling, and thinning of the knee skin.
Loose, roughened knee and elbow skin can also be treated with nonablative factional resurfacing, radio-frequency microneedling, or a series of monthly treatments with PLLA and hyaluronic acid fillers injected in the superficial to mid-dermis. Both fractional resurfacing and dermal filler injections help stimulate collagen production and improve both fine rhytides and dermatoheliosis.
Adipose tissue around the knees can be treated with monthly deoxycholic acid injections (for a video of this procedure, go to https://drive.google.com/file/d/1rhw-nESy15AoDhKUrc25DDjKEun7RL4i/view). The volume of injection, however, is significantly higher than that recommended in the submental area. Two to four times the volume is needed per knee over a series of 3-6 treatments, depending on the amount of fat in the knees.
Cryolipolysis is also an effective option for fat pockets around the knees; however, in my experience, it can be difficult to fit the applicators onto the area of concern appropriately unless smaller applicators are applied.
With the increasing demand for body rejuvenation techniques, providers are adapting techniques used for the face and neck to lift, tighten, thin, and sculpt the knees and elbows. A combination approach using lasers, ultrasound, fillers, threads, and cryolipolysis can be effective for these areas. Results are obtainable when repeat treatments are performed; however, one must be patient because results are not seen for 6 months or more.
Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Macedo O. et al. J Am Acad Dermatol. 2014;70(Suppl 1), Abstract P800, page AB193.