Commentary

The last decade has been a period of advancement for the lesbian, gay, bisexual, and transgender (LGBT) community for legal protections and visibility. Although the journey to acceptance and equality is far from over, this progress has appropriately extended to medical academia as physicians search for ways to become more inclusive and effective care providers for their LGBT patients.¹ In a recent cross-sectional study, Ginsberg et al² examined the role for dermatologists in the care of transgender patients. The investigators concluded that dermatologists should play a larger role in a transgender patient’s physical transformation.² It is our opinion that dermatologists need to be comfortable building rapport with LGBT patients and to become attuned to their specific needs to provide effective care.

When forging a relationship with an LGBT patient, assumptions can damage rapport. Two assumptions that should be avoided include presuming heterosexuality or, on the other hand, assuming risk for disease based on known LGBT status. A dermatologist who takes a cursory sexual history, or none at all, assuming his/her patient is heterosexual creates an environment in which a nonheterosexual patient feels uncomfortable being honest and open. Although there is enough literature to support the claim that some sexual minority groups have increased risk for sexually transmitted infections (STIs),³ it is dangerous to assume a patient’s risk based solely on sexual orientation. An abstinent patient or a patient in a long-term, monogamous, same-sex relationship, for instance, may feel stereotyped by a dermatologist who wants to screen him/her for an STI. The best step in building a therapeutic relationship is to cast out these assumptions and allow LGBT patients to be open about themselves and their sexual practices. Sexual histories should be asked in nonjudgmental ways that are related to the health of the patient, leading to relevant and useful information for their care. For example, ask patients, “Do you have sex with men, women, or both?” This question should be delivered in a matter-of-fact tone, which conveys to the patient that the provider merely wants an answer to guide patient care.

Dermatologists can tailor their encounters to the specific needs of sexual minority patients. The medical literature is rich with examples of conditions that occur at greater frequency in specific sexual minority groups. Sexually transmitted infections, particularly human immunodeficiency virus, are important causes of morbidity and mortality among sexual minorities, especially men who have sex with men (MSM).^3,4 Anal and penile human papillomavirus (HPV) infection and HPV-associated anal carcinoma risk are increased in MSM.^5,6 The literature has remained inconclusive on the use of anal Papanicolaou tests for diagnosis; however, dermatologists have a duty to at least examine the perianal and genital area of any patient at risk for HPV-related disease or STIs.^7,8 For younger patients, the HPV vaccine can help prevent certain types of HPV infection and likely reduce a patient’s risk for condyloma acuminatum and other sequelae of the virus. Guidelines have been expanded to include men aged 13 to 21 years and up to 26 years.⁹ More research is needed to determine if detection and prevention of these types of HPV infection using the vaccine in MSM actually leads to a decreased incidence of anal carcinoma.

Certain LGBT groups may benefit from a dermatologist’s care outside the realm of infectious diseases. One study found that increased indoor tanning use in MSM correlated with increased risk for nonmelanoma skin cancer.¹⁰ Lesbians have been found to be less likely to pursue preventative health examinations in general, including skin checks.¹¹ Finally, transgender patients can utilize dermatologists for help with transformative procedures and side effects of hormonal treatment such as androgenic acne.^1,4

Cutaneous and beyond, the future of LGBT health care in the United States is affected by the institutions that train future physicians. There is a trend toward incorporating formal LGBT curricula into medical schools and academic centers.¹² The Penn Medicine Program for LGBT Health (Philadelphia, Pennsylvania) is a pilot program geared toward both educating future clinicians and providing equal and unbiased care to LGBT patients.¹² Programs such as this one give rise to a new generation of physicians who feel comfortable and aware of the needs of their LGBT patients.

In a time when LGBT patients are becoming more comfortable claiming their sexual and gender identities openly, there is a need for dermatologists to provide individualized unbiased care, which can best be achieved by building rapport through assumption-free history taking, performing thorough physical examinations that include the genital and perianal area, and passing these good practices on to trainees.

The last decade has been a period of advancement for the lesbian, gay, bisexual, and transgender (LGBT) community for legal protections and visibility. Although the journey to acceptance and equality is far from over, this progress has appropriately extended to medical academia as physicians search for ways to become more inclusive and effective care providers for their LGBT patients.¹ In a recent cross-sectional study, Ginsberg et al² examined the role for dermatologists in the care of transgender patients. The investigators concluded that dermatologists should play a larger role in a transgender patient’s physical transformation.² It is our opinion that dermatologists need to be comfortable building rapport with LGBT patients and to become attuned to their specific needs to provide effective care.

When forging a relationship with an LGBT patient, assumptions can damage rapport. Two assumptions that should be avoided include presuming heterosexuality or, on the other hand, assuming risk for disease based on known LGBT status. A dermatologist who takes a cursory sexual history, or none at all, assuming his/her patient is heterosexual creates an environment in which a nonheterosexual patient feels uncomfortable being honest and open. Although there is enough literature to support the claim that some sexual minority groups have increased risk for sexually transmitted infections (STIs),³ it is dangerous to assume a patient’s risk based solely on sexual orientation. An abstinent patient or a patient in a long-term, monogamous, same-sex relationship, for instance, may feel stereotyped by a dermatologist who wants to screen him/her for an STI. The best step in building a therapeutic relationship is to cast out these assumptions and allow LGBT patients to be open about themselves and their sexual practices. Sexual histories should be asked in nonjudgmental ways that are related to the health of the patient, leading to relevant and useful information for their care. For example, ask patients, “Do you have sex with men, women, or both?” This question should be delivered in a matter-of-fact tone, which conveys to the patient that the provider merely wants an answer to guide patient care.

Dermatologists can tailor their encounters to the specific needs of sexual minority patients. The medical literature is rich with examples of conditions that occur at greater frequency in specific sexual minority groups. Sexually transmitted infections, particularly human immunodeficiency virus, are important causes of morbidity and mortality among sexual minorities, especially men who have sex with men (MSM).^3,4 Anal and penile human papillomavirus (HPV) infection and HPV-associated anal carcinoma risk are increased in MSM.^5,6 The literature has remained inconclusive on the use of anal Papanicolaou tests for diagnosis; however, dermatologists have a duty to at least examine the perianal and genital area of any patient at risk for HPV-related disease or STIs.^7,8 For younger patients, the HPV vaccine can help prevent certain types of HPV infection and likely reduce a patient’s risk for condyloma acuminatum and other sequelae of the virus. Guidelines have been expanded to include men aged 13 to 21 years and up to 26 years.⁹ More research is needed to determine if detection and prevention of these types of HPV infection using the vaccine in MSM actually leads to a decreased incidence of anal carcinoma.

Certain LGBT groups may benefit from a dermatologist’s care outside the realm of infectious diseases. One study found that increased indoor tanning use in MSM correlated with increased risk for nonmelanoma skin cancer.¹⁰ Lesbians have been found to be less likely to pursue preventative health examinations in general, including skin checks.¹¹ Finally, transgender patients can utilize dermatologists for help with transformative procedures and side effects of hormonal treatment such as androgenic acne.^1,4

Cutaneous and beyond, the future of LGBT health care in the United States is affected by the institutions that train future physicians. There is a trend toward incorporating formal LGBT curricula into medical schools and academic centers.¹² The Penn Medicine Program for LGBT Health (Philadelphia, Pennsylvania) is a pilot program geared toward both educating future clinicians and providing equal and unbiased care to LGBT patients.¹² Programs such as this one give rise to a new generation of physicians who feel comfortable and aware of the needs of their LGBT patients.

In a time when LGBT patients are becoming more comfortable claiming their sexual and gender identities openly, there is a need for dermatologists to provide individualized unbiased care, which can best be achieved by building rapport through assumption-free history taking, performing thorough physical examinations that include the genital and perianal area, and passing these good practices on to trainees.

The last decade has been a period of advancement for the lesbian, gay, bisexual, and transgender (LGBT) community for legal protections and visibility. Although the journey to acceptance and equality is far from over, this progress has appropriately extended to medical academia as physicians search for ways to become more inclusive and effective care providers for their LGBT patients.¹ In a recent cross-sectional study, Ginsberg et al² examined the role for dermatologists in the care of transgender patients. The investigators concluded that dermatologists should play a larger role in a transgender patient’s physical transformation.² It is our opinion that dermatologists need to be comfortable building rapport with LGBT patients and to become attuned to their specific needs to provide effective care.

When forging a relationship with an LGBT patient, assumptions can damage rapport. Two assumptions that should be avoided include presuming heterosexuality or, on the other hand, assuming risk for disease based on known LGBT status. A dermatologist who takes a cursory sexual history, or none at all, assuming his/her patient is heterosexual creates an environment in which a nonheterosexual patient feels uncomfortable being honest and open. Although there is enough literature to support the claim that some sexual minority groups have increased risk for sexually transmitted infections (STIs),³ it is dangerous to assume a patient’s risk based solely on sexual orientation. An abstinent patient or a patient in a long-term, monogamous, same-sex relationship, for instance, may feel stereotyped by a dermatologist who wants to screen him/her for an STI. The best step in building a therapeutic relationship is to cast out these assumptions and allow LGBT patients to be open about themselves and their sexual practices. Sexual histories should be asked in nonjudgmental ways that are related to the health of the patient, leading to relevant and useful information for their care. For example, ask patients, “Do you have sex with men, women, or both?” This question should be delivered in a matter-of-fact tone, which conveys to the patient that the provider merely wants an answer to guide patient care.

Dermatologists can tailor their encounters to the specific needs of sexual minority patients. The medical literature is rich with examples of conditions that occur at greater frequency in specific sexual minority groups. Sexually transmitted infections, particularly human immunodeficiency virus, are important causes of morbidity and mortality among sexual minorities, especially men who have sex with men (MSM).^3,4 Anal and penile human papillomavirus (HPV) infection and HPV-associated anal carcinoma risk are increased in MSM.^5,6 The literature has remained inconclusive on the use of anal Papanicolaou tests for diagnosis; however, dermatologists have a duty to at least examine the perianal and genital area of any patient at risk for HPV-related disease or STIs.^7,8 For younger patients, the HPV vaccine can help prevent certain types of HPV infection and likely reduce a patient’s risk for condyloma acuminatum and other sequelae of the virus. Guidelines have been expanded to include men aged 13 to 21 years and up to 26 years.⁹ More research is needed to determine if detection and prevention of these types of HPV infection using the vaccine in MSM actually leads to a decreased incidence of anal carcinoma.

Certain LGBT groups may benefit from a dermatologist’s care outside the realm of infectious diseases. One study found that increased indoor tanning use in MSM correlated with increased risk for nonmelanoma skin cancer.¹⁰ Lesbians have been found to be less likely to pursue preventative health examinations in general, including skin checks.¹¹ Finally, transgender patients can utilize dermatologists for help with transformative procedures and side effects of hormonal treatment such as androgenic acne.^1,4

Cutaneous and beyond, the future of LGBT health care in the United States is affected by the institutions that train future physicians. There is a trend toward incorporating formal LGBT curricula into medical schools and academic centers.¹² The Penn Medicine Program for LGBT Health (Philadelphia, Pennsylvania) is a pilot program geared toward both educating future clinicians and providing equal and unbiased care to LGBT patients.¹² Programs such as this one give rise to a new generation of physicians who feel comfortable and aware of the needs of their LGBT patients.

In a time when LGBT patients are becoming more comfortable claiming their sexual and gender identities openly, there is a need for dermatologists to provide individualized unbiased care, which can best be achieved by building rapport through assumption-free history taking, performing thorough physical examinations that include the genital and perianal area, and passing these good practices on to trainees.

Cervical dysplasia is a condition commonly encountered by the gynecologist. It is either treated (with excision or ablation) or monitored, depending on the lesion grade, cytologic history, medical history, and reproductive goals. Cervical dysplasia commonly arises in women of reproductive age. Therefore, consider reproductive effects when deciding whether to treat or monitor, as well as when choosing the treatment modality.

Background

Approximately two-thirds of human papillomavirus infections resolve within a year, and more than 90% resolve within 2 years. Similarly, low-grade cervical intraepithelial neoplasia (CIN 1) lesions frequently resolve. High-grade (CIN 2 and CIN 3) lesions regress less commonly, with 5% and 12%-40% progressing to invasive cancer, respectively. Therefore, treatment is typically recommended.

Obstetric implications

Potential obstetric risks of treatment for CIN include infertility, spontaneous abortion, preterm premature rupture of membranes (PPROM), preterm delivery, and perinatal/neonatal mortality. These risks are discussed individually below. Mechanisms that have been suggested for such complications include decreased cervical mucous, cervical scarring impeding conception or dilation, loss of cervical volume, collagen breakdown, and immunologic processes due to decreased physical defenses or microbiome shifts.

Fertility

Studies have shown that treatment does not appear to impede conception. The overall pregnancy rate is higher among treated women than untreated women. Pregnancy rates are not different among women intending to conceive or among women attempting conception for more than 12 months, with the caveat being that these studies are heterogenous.^2,3

Miscarriage

No difference has been observed in total (less than 24 weeks) miscarriage rate or first trimester (less than 12 weeks) miscarriage rate among treated and untreated women. However, the second trimester miscarriage rate is significantly higher among treated women (risk ratio, 2.60).² This risk is most notable following laser conization or LEEP.⁴ There may also be an association between ablation and pregnancy loss.

Preterm birth and PPROM

Several studies and meta-analyses show an association between preterm birth and treatment for CIN using LEEP or CKC. There is an increased risk of severe preterm delivery (relative risk, 2.78), extreme preterm delivery (relative risk, 5.33), and low birth weight (relative risk, 2.86) with CKC.⁵ LEEP is associated with the same outcomes, albeit the risk is lower than with CKC.⁶ The risk of preterm birth is even lower for ablation.⁷

Other complications

Ectopic pregnancy and termination rates may be higher in treated women, compared with untreated women.² However, there does not appear to be an increased risk for perinatal/neonatal mortality, cesarean section, or neonatal intensive care unit admission among women treated with excisional procedures.⁶

Pointers for practice

• Due to the potential for adverse obstetric complications following excisional procedures for cervical dysplasia, gynecologists should closely adhere to the American Society for Colposcopy and Cervical Pathology guidelines when determining the appropriateness of dysplasia interventions. The decision to treat, versus monitor, dysplasia in a woman who plans future childbearing should be made with the patient after thorough discussion of the risks and benefits of each path.
• Women younger than age 30 years should not be screened for high-risk human papillomavirus because of both its high incidence and its high rate of spontaneous resolution.
• For reproductive-aged women with CIN 2 and adequate colposcopy, the American Society for Colposcopy and Cervical Pathology supports either monitoring with cytology and colposcopy every 6 months for a year or excisional treatment. However, women with CIN 3, inadequate colposcopy, prior cervical cancer, diethylstilbestrol exposure, or decreased immunity should undergo excisional treatment.
• When selecting an excisional method (LEEP or CKC), surgeons should choose the most appropriate technique for the patient’s pathology but should acknowledge the observed higher rates of PPROM, preterm birth, and low-birth-weight infants among those receiving CKC, and tailor the size of the excision to the specific lesion.
• Consider recommending a 12-month interval between treatment and pregnancy to ensure resolution of high-grade dysplasia. Furthermore, obstetric risk may be increased within 12 months following treatment.

Dr. Robbins is a resident in the department of obstetrics and gynecology at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC, Chapel Hill. They reported having no relevant financial disclosures.

References

1. Am J Obstet Gynecol. 2011 Jul;205(1):19-27.

2. Cochrane Database Syst Rev. 2015 Sep 29;(9):CD008478.

3. BMJ. 2014 Oct 28;349:g6192.

4. Obstet Gynecol. 2016 Dec;128(6):1265-73.

5. BMJ. 2008 Sep 18;337:a1284.

6. Arch Gynecol Obstet. 2014 Jan;289(1):85-99.

7. BJOG. 2011 Aug;118(9):1031-41.

8. Obstet Gynecol. 2013 May;121(5):1063-8.

9. Lancet. 2006 Feb 11;367(9509):489-98.

10. Gynecol Obstet Invest. 2014;77(4):240-4.

Cervical dysplasia is a condition commonly encountered by the gynecologist. It is either treated (with excision or ablation) or monitored, depending on the lesion grade, cytologic history, medical history, and reproductive goals. Cervical dysplasia commonly arises in women of reproductive age. Therefore, consider reproductive effects when deciding whether to treat or monitor, as well as when choosing the treatment modality.

Background

Approximately two-thirds of human papillomavirus infections resolve within a year, and more than 90% resolve within 2 years. Similarly, low-grade cervical intraepithelial neoplasia (CIN 1) lesions frequently resolve. High-grade (CIN 2 and CIN 3) lesions regress less commonly, with 5% and 12%-40% progressing to invasive cancer, respectively. Therefore, treatment is typically recommended.

Obstetric implications

Potential obstetric risks of treatment for CIN include infertility, spontaneous abortion, preterm premature rupture of membranes (PPROM), preterm delivery, and perinatal/neonatal mortality. These risks are discussed individually below. Mechanisms that have been suggested for such complications include decreased cervical mucous, cervical scarring impeding conception or dilation, loss of cervical volume, collagen breakdown, and immunologic processes due to decreased physical defenses or microbiome shifts.

Fertility

Studies have shown that treatment does not appear to impede conception. The overall pregnancy rate is higher among treated women than untreated women. Pregnancy rates are not different among women intending to conceive or among women attempting conception for more than 12 months, with the caveat being that these studies are heterogenous.^2,3

Miscarriage

No difference has been observed in total (less than 24 weeks) miscarriage rate or first trimester (less than 12 weeks) miscarriage rate among treated and untreated women. However, the second trimester miscarriage rate is significantly higher among treated women (risk ratio, 2.60).² This risk is most notable following laser conization or LEEP.⁴ There may also be an association between ablation and pregnancy loss.

Preterm birth and PPROM

Several studies and meta-analyses show an association between preterm birth and treatment for CIN using LEEP or CKC. There is an increased risk of severe preterm delivery (relative risk, 2.78), extreme preterm delivery (relative risk, 5.33), and low birth weight (relative risk, 2.86) with CKC.⁵ LEEP is associated with the same outcomes, albeit the risk is lower than with CKC.⁶ The risk of preterm birth is even lower for ablation.⁷

Other complications

Ectopic pregnancy and termination rates may be higher in treated women, compared with untreated women.² However, there does not appear to be an increased risk for perinatal/neonatal mortality, cesarean section, or neonatal intensive care unit admission among women treated with excisional procedures.⁶

Pointers for practice

• Due to the potential for adverse obstetric complications following excisional procedures for cervical dysplasia, gynecologists should closely adhere to the American Society for Colposcopy and Cervical Pathology guidelines when determining the appropriateness of dysplasia interventions. The decision to treat, versus monitor, dysplasia in a woman who plans future childbearing should be made with the patient after thorough discussion of the risks and benefits of each path.
• Women younger than age 30 years should not be screened for high-risk human papillomavirus because of both its high incidence and its high rate of spontaneous resolution.
• For reproductive-aged women with CIN 2 and adequate colposcopy, the American Society for Colposcopy and Cervical Pathology supports either monitoring with cytology and colposcopy every 6 months for a year or excisional treatment. However, women with CIN 3, inadequate colposcopy, prior cervical cancer, diethylstilbestrol exposure, or decreased immunity should undergo excisional treatment.
• When selecting an excisional method (LEEP or CKC), surgeons should choose the most appropriate technique for the patient’s pathology but should acknowledge the observed higher rates of PPROM, preterm birth, and low-birth-weight infants among those receiving CKC, and tailor the size of the excision to the specific lesion.
• Consider recommending a 12-month interval between treatment and pregnancy to ensure resolution of high-grade dysplasia. Furthermore, obstetric risk may be increased within 12 months following treatment.

Dr. Robbins is a resident in the department of obstetrics and gynecology at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC, Chapel Hill. They reported having no relevant financial disclosures.

References

1. Am J Obstet Gynecol. 2011 Jul;205(1):19-27.

2. Cochrane Database Syst Rev. 2015 Sep 29;(9):CD008478.

3. BMJ. 2014 Oct 28;349:g6192.

4. Obstet Gynecol. 2016 Dec;128(6):1265-73.

5. BMJ. 2008 Sep 18;337:a1284.

6. Arch Gynecol Obstet. 2014 Jan;289(1):85-99.

7. BJOG. 2011 Aug;118(9):1031-41.

8. Obstet Gynecol. 2013 May;121(5):1063-8.

9. Lancet. 2006 Feb 11;367(9509):489-98.

10. Gynecol Obstet Invest. 2014;77(4):240-4.

Cervical dysplasia is a condition commonly encountered by the gynecologist. It is either treated (with excision or ablation) or monitored, depending on the lesion grade, cytologic history, medical history, and reproductive goals. Cervical dysplasia commonly arises in women of reproductive age. Therefore, consider reproductive effects when deciding whether to treat or monitor, as well as when choosing the treatment modality.

Background

Approximately two-thirds of human papillomavirus infections resolve within a year, and more than 90% resolve within 2 years. Similarly, low-grade cervical intraepithelial neoplasia (CIN 1) lesions frequently resolve. High-grade (CIN 2 and CIN 3) lesions regress less commonly, with 5% and 12%-40% progressing to invasive cancer, respectively. Therefore, treatment is typically recommended.

Obstetric implications

Potential obstetric risks of treatment for CIN include infertility, spontaneous abortion, preterm premature rupture of membranes (PPROM), preterm delivery, and perinatal/neonatal mortality. These risks are discussed individually below. Mechanisms that have been suggested for such complications include decreased cervical mucous, cervical scarring impeding conception or dilation, loss of cervical volume, collagen breakdown, and immunologic processes due to decreased physical defenses or microbiome shifts.

Fertility

Studies have shown that treatment does not appear to impede conception. The overall pregnancy rate is higher among treated women than untreated women. Pregnancy rates are not different among women intending to conceive or among women attempting conception for more than 12 months, with the caveat being that these studies are heterogenous.^2,3

Miscarriage

No difference has been observed in total (less than 24 weeks) miscarriage rate or first trimester (less than 12 weeks) miscarriage rate among treated and untreated women. However, the second trimester miscarriage rate is significantly higher among treated women (risk ratio, 2.60).² This risk is most notable following laser conization or LEEP.⁴ There may also be an association between ablation and pregnancy loss.

Preterm birth and PPROM

Several studies and meta-analyses show an association between preterm birth and treatment for CIN using LEEP or CKC. There is an increased risk of severe preterm delivery (relative risk, 2.78), extreme preterm delivery (relative risk, 5.33), and low birth weight (relative risk, 2.86) with CKC.⁵ LEEP is associated with the same outcomes, albeit the risk is lower than with CKC.⁶ The risk of preterm birth is even lower for ablation.⁷

Other complications

Ectopic pregnancy and termination rates may be higher in treated women, compared with untreated women.² However, there does not appear to be an increased risk for perinatal/neonatal mortality, cesarean section, or neonatal intensive care unit admission among women treated with excisional procedures.⁶

Pointers for practice

• Due to the potential for adverse obstetric complications following excisional procedures for cervical dysplasia, gynecologists should closely adhere to the American Society for Colposcopy and Cervical Pathology guidelines when determining the appropriateness of dysplasia interventions. The decision to treat, versus monitor, dysplasia in a woman who plans future childbearing should be made with the patient after thorough discussion of the risks and benefits of each path.
• Women younger than age 30 years should not be screened for high-risk human papillomavirus because of both its high incidence and its high rate of spontaneous resolution.
• For reproductive-aged women with CIN 2 and adequate colposcopy, the American Society for Colposcopy and Cervical Pathology supports either monitoring with cytology and colposcopy every 6 months for a year or excisional treatment. However, women with CIN 3, inadequate colposcopy, prior cervical cancer, diethylstilbestrol exposure, or decreased immunity should undergo excisional treatment.
• When selecting an excisional method (LEEP or CKC), surgeons should choose the most appropriate technique for the patient’s pathology but should acknowledge the observed higher rates of PPROM, preterm birth, and low-birth-weight infants among those receiving CKC, and tailor the size of the excision to the specific lesion.
• Consider recommending a 12-month interval between treatment and pregnancy to ensure resolution of high-grade dysplasia. Furthermore, obstetric risk may be increased within 12 months following treatment.

Dr. Robbins is a resident in the department of obstetrics and gynecology at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at UNC, Chapel Hill. They reported having no relevant financial disclosures.

References

1. Am J Obstet Gynecol. 2011 Jul;205(1):19-27.

2. Cochrane Database Syst Rev. 2015 Sep 29;(9):CD008478.

3. BMJ. 2014 Oct 28;349:g6192.

4. Obstet Gynecol. 2016 Dec;128(6):1265-73.

5. BMJ. 2008 Sep 18;337:a1284.

6. Arch Gynecol Obstet. 2014 Jan;289(1):85-99.

7. BJOG. 2011 Aug;118(9):1031-41.

8. Obstet Gynecol. 2013 May;121(5):1063-8.

9. Lancet. 2006 Feb 11;367(9509):489-98.

10. Gynecol Obstet Invest. 2014;77(4):240-4.

Mentorship, whether through a formal or informal system, plays a significant role in a professional’s life; it fosters the development of professional expertise and is associated with increased job satisfaction. An effective mentor guides a less-experienced colleague by modeling positive behaviors and building trust, while being cognizant that his or her role is to be dependable, engaged, authentic, and attuned to the needs of the mentee. You can probably name one of your mentors off the top of your head right now!

The original “mentor” was a character of that name in Homer’s epic poem The Odyssey, but the word is now used to refer to a trusted advisor, friend, teacher, or wise person. In the story, Mentor served as a friend and advocate to Telemachus, the son of the king of Ithaca, while his father, Odysseus, was away fighting in the Trojan War. In 1699, the novel The Adventures of Telemachus portrayed Mentor as Telemachus’ tutor, and he became the hero of the story.^1,2

History holds many examples of mentoring relationships: Socrates and Plato, Haydn and Beethoven, and Freud and Jung. Modern-day duos include Kobe Bryant and Shaquille O’Neal, Kirk and Spock, and—dare I say it?—Brady and Belichick. During the Middle Ages, mentorship—particularly in medicine and nursing—was practiced via apprenticeship, which incorporated support, guidance, socialization, well-being, empowerment, education, and career progression.³

Throughout my career as a PA, I have been fortunate to be guided by competent and willing mentors. What have they had in common? For starters, an internal desire (sometimes called generosity of spirit) to mentor and a commitment to my growth and development as their mentee. Successful professional mentors must also possess the necessary knowledge to help effectively develop their mentee’s skills. Discussions with my colleagues and previous mentors inspired the following compilation of the essential responsibilities and traits of a mentor.

Initiating new ideas. A main aspect of a mentor’s role involves assisting in acquiring the confidence and tools to function and excel in our competitive professional world.^4-6 In the early 1970s, when I was a young PA, a wonderful physician and friend, Dr. Burton Brasher, took me under his wing and exemplified what it means to be a clinician. I learned from him that it was also my obligation to mentor others, and I have tried to do this frequently in my four decades as a PA. Through his example, I was shown the importance of cultivating emotional intelligence and sensitivity while still providing an honest assessment of strengths and weaknesses. Here was a physician who was unencumbered by ego. We met often to discuss the care of both of our patients.

Staying the course. In 1995, I mentored James Cannon—a young financial comptroller who desperately wanted to be a PA. I’ve (hopefully) helped him navigate PA school, our mutual time in the military, his time in academia, and his introduction to professional volunteer work. In each stage of his career, we had lengthy conversations about the pros and cons of his decisions. Now, 22 years later, he has become my mentor; he has matured in the profession and is at the forefront of taking it to the next level. It is now very common for me to call on him for his advice as I move into the home stretch of my career. A few years ago, he became a trustee of our university and his skills have advanced the success of our programs. Indeed, the student becomes the teacher.

Networking and articulating cultural norms. Dave Mittman, the co-founder and original publisher of Clinician Reviews, had the experience of hiring his very close friend and PA school classmate, Tom Yackeren. In 1985, Dave was publisher of Physician Assistant Journal (at that time, the official journal of the AAPA). Dave and Tom were business partners and relied on each other’s skills to grow their business. They shared trust, friendship, and a mutual knowledge of professional “culture.” They understood each other and how they could each contribute to their success. Their partnership maintained a complementary balance, each of them able to play to his strengths with the support and encouragement of the other. Tom has since used his knowledge and experience to mentor others.

Demonstrating honesty, integrity, and enthusiasm. Marie-Eileen Onieal, our NP editor-in-chief, grew up in a household where her father was a firefighter and union organizer. He taught her the value of always paying it forward. While she has mentored many people in her career, she fondly remembers mentoring Lori Fritz through her transition into academia—what Marie-Eileen calls “the precarious journey of an educator.” When she met Lori, she says, they just “clicked,” and that bond has survived to this day. Lori is now an established academician, mentoring new students and professionals, and modeling her experience with Marie-Eileen’s involvement in the profession.

These are examples of when it works. But what happens when the relationship doesn’t “click”? Unfortunately, not all mentorships are fruitful. When mentor and mentee clash, it is paramount to acknowledge that the relationship is not working and to back away appropriately, without regard to ego. No one benefits when the parties are at odds—and this may explain why some of the greatest partnerships form organically.

Above all, in order for a mentorship to be prosperous, mentors must express compassion and remain genuine throughout all interactions with their mentee. It is a long-term commitment. Without this generosity of spirit, the influence and benefit of a professional mentor would be lost. If you have other ideas about what makes a great mentor, or how to foster a more satisfying mentor/mentee relationship, please share them with me at PAEditor@frontlinemedcom.com.

Mentorship, whether through a formal or informal system, plays a significant role in a professional’s life; it fosters the development of professional expertise and is associated with increased job satisfaction. An effective mentor guides a less-experienced colleague by modeling positive behaviors and building trust, while being cognizant that his or her role is to be dependable, engaged, authentic, and attuned to the needs of the mentee. You can probably name one of your mentors off the top of your head right now!

The original “mentor” was a character of that name in Homer’s epic poem The Odyssey, but the word is now used to refer to a trusted advisor, friend, teacher, or wise person. In the story, Mentor served as a friend and advocate to Telemachus, the son of the king of Ithaca, while his father, Odysseus, was away fighting in the Trojan War. In 1699, the novel The Adventures of Telemachus portrayed Mentor as Telemachus’ tutor, and he became the hero of the story.^1,2

History holds many examples of mentoring relationships: Socrates and Plato, Haydn and Beethoven, and Freud and Jung. Modern-day duos include Kobe Bryant and Shaquille O’Neal, Kirk and Spock, and—dare I say it?—Brady and Belichick. During the Middle Ages, mentorship—particularly in medicine and nursing—was practiced via apprenticeship, which incorporated support, guidance, socialization, well-being, empowerment, education, and career progression.³

Throughout my career as a PA, I have been fortunate to be guided by competent and willing mentors. What have they had in common? For starters, an internal desire (sometimes called generosity of spirit) to mentor and a commitment to my growth and development as their mentee. Successful professional mentors must also possess the necessary knowledge to help effectively develop their mentee’s skills. Discussions with my colleagues and previous mentors inspired the following compilation of the essential responsibilities and traits of a mentor.

Initiating new ideas. A main aspect of a mentor’s role involves assisting in acquiring the confidence and tools to function and excel in our competitive professional world.^4-6 In the early 1970s, when I was a young PA, a wonderful physician and friend, Dr. Burton Brasher, took me under his wing and exemplified what it means to be a clinician. I learned from him that it was also my obligation to mentor others, and I have tried to do this frequently in my four decades as a PA. Through his example, I was shown the importance of cultivating emotional intelligence and sensitivity while still providing an honest assessment of strengths and weaknesses. Here was a physician who was unencumbered by ego. We met often to discuss the care of both of our patients.

Staying the course. In 1995, I mentored James Cannon—a young financial comptroller who desperately wanted to be a PA. I’ve (hopefully) helped him navigate PA school, our mutual time in the military, his time in academia, and his introduction to professional volunteer work. In each stage of his career, we had lengthy conversations about the pros and cons of his decisions. Now, 22 years later, he has become my mentor; he has matured in the profession and is at the forefront of taking it to the next level. It is now very common for me to call on him for his advice as I move into the home stretch of my career. A few years ago, he became a trustee of our university and his skills have advanced the success of our programs. Indeed, the student becomes the teacher.

Networking and articulating cultural norms. Dave Mittman, the co-founder and original publisher of Clinician Reviews, had the experience of hiring his very close friend and PA school classmate, Tom Yackeren. In 1985, Dave was publisher of Physician Assistant Journal (at that time, the official journal of the AAPA). Dave and Tom were business partners and relied on each other’s skills to grow their business. They shared trust, friendship, and a mutual knowledge of professional “culture.” They understood each other and how they could each contribute to their success. Their partnership maintained a complementary balance, each of them able to play to his strengths with the support and encouragement of the other. Tom has since used his knowledge and experience to mentor others.

Demonstrating honesty, integrity, and enthusiasm. Marie-Eileen Onieal, our NP editor-in-chief, grew up in a household where her father was a firefighter and union organizer. He taught her the value of always paying it forward. While she has mentored many people in her career, she fondly remembers mentoring Lori Fritz through her transition into academia—what Marie-Eileen calls “the precarious journey of an educator.” When she met Lori, she says, they just “clicked,” and that bond has survived to this day. Lori is now an established academician, mentoring new students and professionals, and modeling her experience with Marie-Eileen’s involvement in the profession.

These are examples of when it works. But what happens when the relationship doesn’t “click”? Unfortunately, not all mentorships are fruitful. When mentor and mentee clash, it is paramount to acknowledge that the relationship is not working and to back away appropriately, without regard to ego. No one benefits when the parties are at odds—and this may explain why some of the greatest partnerships form organically.

Above all, in order for a mentorship to be prosperous, mentors must express compassion and remain genuine throughout all interactions with their mentee. It is a long-term commitment. Without this generosity of spirit, the influence and benefit of a professional mentor would be lost. If you have other ideas about what makes a great mentor, or how to foster a more satisfying mentor/mentee relationship, please share them with me at PAEditor@frontlinemedcom.com.

Mentorship, whether through a formal or informal system, plays a significant role in a professional’s life; it fosters the development of professional expertise and is associated with increased job satisfaction. An effective mentor guides a less-experienced colleague by modeling positive behaviors and building trust, while being cognizant that his or her role is to be dependable, engaged, authentic, and attuned to the needs of the mentee. You can probably name one of your mentors off the top of your head right now!

The original “mentor” was a character of that name in Homer’s epic poem The Odyssey, but the word is now used to refer to a trusted advisor, friend, teacher, or wise person. In the story, Mentor served as a friend and advocate to Telemachus, the son of the king of Ithaca, while his father, Odysseus, was away fighting in the Trojan War. In 1699, the novel The Adventures of Telemachus portrayed Mentor as Telemachus’ tutor, and he became the hero of the story.^1,2

History holds many examples of mentoring relationships: Socrates and Plato, Haydn and Beethoven, and Freud and Jung. Modern-day duos include Kobe Bryant and Shaquille O’Neal, Kirk and Spock, and—dare I say it?—Brady and Belichick. During the Middle Ages, mentorship—particularly in medicine and nursing—was practiced via apprenticeship, which incorporated support, guidance, socialization, well-being, empowerment, education, and career progression.³

Throughout my career as a PA, I have been fortunate to be guided by competent and willing mentors. What have they had in common? For starters, an internal desire (sometimes called generosity of spirit) to mentor and a commitment to my growth and development as their mentee. Successful professional mentors must also possess the necessary knowledge to help effectively develop their mentee’s skills. Discussions with my colleagues and previous mentors inspired the following compilation of the essential responsibilities and traits of a mentor.

Initiating new ideas. A main aspect of a mentor’s role involves assisting in acquiring the confidence and tools to function and excel in our competitive professional world.^4-6 In the early 1970s, when I was a young PA, a wonderful physician and friend, Dr. Burton Brasher, took me under his wing and exemplified what it means to be a clinician. I learned from him that it was also my obligation to mentor others, and I have tried to do this frequently in my four decades as a PA. Through his example, I was shown the importance of cultivating emotional intelligence and sensitivity while still providing an honest assessment of strengths and weaknesses. Here was a physician who was unencumbered by ego. We met often to discuss the care of both of our patients.

Staying the course. In 1995, I mentored James Cannon—a young financial comptroller who desperately wanted to be a PA. I’ve (hopefully) helped him navigate PA school, our mutual time in the military, his time in academia, and his introduction to professional volunteer work. In each stage of his career, we had lengthy conversations about the pros and cons of his decisions. Now, 22 years later, he has become my mentor; he has matured in the profession and is at the forefront of taking it to the next level. It is now very common for me to call on him for his advice as I move into the home stretch of my career. A few years ago, he became a trustee of our university and his skills have advanced the success of our programs. Indeed, the student becomes the teacher.

Networking and articulating cultural norms. Dave Mittman, the co-founder and original publisher of Clinician Reviews, had the experience of hiring his very close friend and PA school classmate, Tom Yackeren. In 1985, Dave was publisher of Physician Assistant Journal (at that time, the official journal of the AAPA). Dave and Tom were business partners and relied on each other’s skills to grow their business. They shared trust, friendship, and a mutual knowledge of professional “culture.” They understood each other and how they could each contribute to their success. Their partnership maintained a complementary balance, each of them able to play to his strengths with the support and encouragement of the other. Tom has since used his knowledge and experience to mentor others.

Demonstrating honesty, integrity, and enthusiasm. Marie-Eileen Onieal, our NP editor-in-chief, grew up in a household where her father was a firefighter and union organizer. He taught her the value of always paying it forward. While she has mentored many people in her career, she fondly remembers mentoring Lori Fritz through her transition into academia—what Marie-Eileen calls “the precarious journey of an educator.” When she met Lori, she says, they just “clicked,” and that bond has survived to this day. Lori is now an established academician, mentoring new students and professionals, and modeling her experience with Marie-Eileen’s involvement in the profession.

These are examples of when it works. But what happens when the relationship doesn’t “click”? Unfortunately, not all mentorships are fruitful. When mentor and mentee clash, it is paramount to acknowledge that the relationship is not working and to back away appropriately, without regard to ego. No one benefits when the parties are at odds—and this may explain why some of the greatest partnerships form organically.

Above all, in order for a mentorship to be prosperous, mentors must express compassion and remain genuine throughout all interactions with their mentee. It is a long-term commitment. Without this generosity of spirit, the influence and benefit of a professional mentor would be lost. If you have other ideas about what makes a great mentor, or how to foster a more satisfying mentor/mentee relationship, please share them with me at PAEditor@frontlinemedcom.com.

In this month’s issue of The Journal of Family Practice, we are pleased to launch a new department called “Behavioral Health Consult.” This bimonthly column will feature behavioral and mental health topics such as depression, anxiety, obesity, and substance abuse.

Drawn from real patient encounters. As you read the inaugural item on depression, written by Michael Maksimowski, MD, and Michael Raddock, MD, you'll notice that the article starts with a brief case report. Cases will play an important role in this column and will either describe a single patient whom the author(s) cared for or be an amalgam of several (as was the case this month).

Practical and to the point. We have asked the authors, who are family physicians (FPs) and psychiatrists or psychologists who work closely with FPs, to provide a concentrated and practical summary of the elements of diagnosis and treatment that are most important and pertinent to primary care clinicians.

The column will address topics like depression and substance abuse.

Addressing an overwhelming need. The need for FPs and other primary care clinicians to stay current on the management of mental and behavioral health issues is obvious. Mood and anxiety disorders (eg, depression, anxiety, panic disorder, agoraphobia) affect almost 30% of the US adult population¹ and many of these patients are seen at least initially by their primary care physicians. According to the Centers for Disease Control and Prevention, 4 health risk behaviors—tobacco use, poor nutrition, excess alcohol consumption, and insufficient exercise—cause much of the illness, suffering, and early death related to chronic diseases and conditions.² My personal experience in our urban Chicago clinic definitely supports these statistics.

No lack of research. I teach several evidence-based medicine courses each year that focus on the review of recent randomized trials and meta-analyses that are important for FPs to know about. Every year, one of my talks is about either mental health or behavioral health research. Every year I wonder whether there will be enough new research to report on, and every year, I find that there is an abundance of research that helps us to better manage these common problems. “Behavioral Health Consult” is this journal’s way of helping to keep you current and informed.

In an effort to make this addition as useful to you as possible, please feel free to email me at jfp.eic@gmail.com with suggestions for topics you would like to see in “Behavioral Health Consult.” We look forward to your reactions—and your comments.

In this month’s issue of The Journal of Family Practice, we are pleased to launch a new department called “Behavioral Health Consult.” This bimonthly column will feature behavioral and mental health topics such as depression, anxiety, obesity, and substance abuse.

Drawn from real patient encounters. As you read the inaugural item on depression, written by Michael Maksimowski, MD, and Michael Raddock, MD, you'll notice that the article starts with a brief case report. Cases will play an important role in this column and will either describe a single patient whom the author(s) cared for or be an amalgam of several (as was the case this month).

Practical and to the point. We have asked the authors, who are family physicians (FPs) and psychiatrists or psychologists who work closely with FPs, to provide a concentrated and practical summary of the elements of diagnosis and treatment that are most important and pertinent to primary care clinicians.

The column will address topics like depression and substance abuse.

Addressing an overwhelming need. The need for FPs and other primary care clinicians to stay current on the management of mental and behavioral health issues is obvious. Mood and anxiety disorders (eg, depression, anxiety, panic disorder, agoraphobia) affect almost 30% of the US adult population¹ and many of these patients are seen at least initially by their primary care physicians. According to the Centers for Disease Control and Prevention, 4 health risk behaviors—tobacco use, poor nutrition, excess alcohol consumption, and insufficient exercise—cause much of the illness, suffering, and early death related to chronic diseases and conditions.² My personal experience in our urban Chicago clinic definitely supports these statistics.

No lack of research. I teach several evidence-based medicine courses each year that focus on the review of recent randomized trials and meta-analyses that are important for FPs to know about. Every year, one of my talks is about either mental health or behavioral health research. Every year I wonder whether there will be enough new research to report on, and every year, I find that there is an abundance of research that helps us to better manage these common problems. “Behavioral Health Consult” is this journal’s way of helping to keep you current and informed.

In an effort to make this addition as useful to you as possible, please feel free to email me at jfp.eic@gmail.com with suggestions for topics you would like to see in “Behavioral Health Consult.” We look forward to your reactions—and your comments.

In this month’s issue of The Journal of Family Practice, we are pleased to launch a new department called “Behavioral Health Consult.” This bimonthly column will feature behavioral and mental health topics such as depression, anxiety, obesity, and substance abuse.

Drawn from real patient encounters. As you read the inaugural item on depression, written by Michael Maksimowski, MD, and Michael Raddock, MD, you'll notice that the article starts with a brief case report. Cases will play an important role in this column and will either describe a single patient whom the author(s) cared for or be an amalgam of several (as was the case this month).

Practical and to the point. We have asked the authors, who are family physicians (FPs) and psychiatrists or psychologists who work closely with FPs, to provide a concentrated and practical summary of the elements of diagnosis and treatment that are most important and pertinent to primary care clinicians.

The column will address topics like depression and substance abuse.

Addressing an overwhelming need. The need for FPs and other primary care clinicians to stay current on the management of mental and behavioral health issues is obvious. Mood and anxiety disorders (eg, depression, anxiety, panic disorder, agoraphobia) affect almost 30% of the US adult population¹ and many of these patients are seen at least initially by their primary care physicians. According to the Centers for Disease Control and Prevention, 4 health risk behaviors—tobacco use, poor nutrition, excess alcohol consumption, and insufficient exercise—cause much of the illness, suffering, and early death related to chronic diseases and conditions.² My personal experience in our urban Chicago clinic definitely supports these statistics.

No lack of research. I teach several evidence-based medicine courses each year that focus on the review of recent randomized trials and meta-analyses that are important for FPs to know about. Every year, one of my talks is about either mental health or behavioral health research. Every year I wonder whether there will be enough new research to report on, and every year, I find that there is an abundance of research that helps us to better manage these common problems. “Behavioral Health Consult” is this journal’s way of helping to keep you current and informed.

In an effort to make this addition as useful to you as possible, please feel free to email me at jfp.eic@gmail.com with suggestions for topics you would like to see in “Behavioral Health Consult.” We look forward to your reactions—and your comments.

I read the article, “What family physicians can do to combat bullying” (J Fam Pract. 2017;66:82-89) and Dr. Hickner’s editorial, “It’s time to screen for bullying” (J Fam Pract. 2017;66:66) with great interest. I’m a bullying prevention researcher and the creator of a new bullying prevention program, CirclePoint, which is being piloted in Boston Public Schools. I’m also a featured speaker on bullying in the Massachusetts General Hospital’s life skills after-school program that runs in a dozen area schools.

My work in schools has taught me that as important as it is to identify bullying problems, it is equally important for doctors to know how to counsel patients and caregivers on how to resolve these problems.

Identifying bullying without providing further guidance can actually do more harm than good, both to the child’s health and to the child-physician relationship.

Children often don’t tell adults they are being bullied because the actions that adults take—while well-intended—can sometimes make the situation worse. Further, some caregivers may actually blame the child for being bullied. And a doctor who simply identifies the problem and leaves the next steps to an ill-informed caregiver may lose the patient’s trust.

Also worth noting: Some children who are bullied may not have a clear understanding of what the term “bullying” means. I strongly suggest asking patients about how others are treating them and if anyone is making them upset. Questions about behaviors and feelings are more effective at identifying a bullying problem than questions that use the term “bullying.”

Our program has a free resource that was developed for educators, but can easily be used by physicians to counsel patients and caregivers. It’s designed to convey recommended actions for both the student and caregiver in a matter of minutes.

Doctors who identify a bullying problem bear a responsibility to counsel both the patient and caregiver(s) on what bullying is, why it happens, and, most critically, recommended actions to take to effectively resolve the problem.

Ari Magnusson
Charlestown, Mass

I read the article, “What family physicians can do to combat bullying” (J Fam Pract. 2017;66:82-89) and Dr. Hickner’s editorial, “It’s time to screen for bullying” (J Fam Pract. 2017;66:66) with great interest. I’m a bullying prevention researcher and the creator of a new bullying prevention program, CirclePoint, which is being piloted in Boston Public Schools. I’m also a featured speaker on bullying in the Massachusetts General Hospital’s life skills after-school program that runs in a dozen area schools.

My work in schools has taught me that as important as it is to identify bullying problems, it is equally important for doctors to know how to counsel patients and caregivers on how to resolve these problems.

Identifying bullying without providing further guidance can actually do more harm than good, both to the child’s health and to the child-physician relationship.

Children often don’t tell adults they are being bullied because the actions that adults take—while well-intended—can sometimes make the situation worse. Further, some caregivers may actually blame the child for being bullied. And a doctor who simply identifies the problem and leaves the next steps to an ill-informed caregiver may lose the patient’s trust.

Also worth noting: Some children who are bullied may not have a clear understanding of what the term “bullying” means. I strongly suggest asking patients about how others are treating them and if anyone is making them upset. Questions about behaviors and feelings are more effective at identifying a bullying problem than questions that use the term “bullying.”

Our program has a free resource that was developed for educators, but can easily be used by physicians to counsel patients and caregivers. It’s designed to convey recommended actions for both the student and caregiver in a matter of minutes.

Doctors who identify a bullying problem bear a responsibility to counsel both the patient and caregiver(s) on what bullying is, why it happens, and, most critically, recommended actions to take to effectively resolve the problem.

Ari Magnusson
Charlestown, Mass

I read the article, “What family physicians can do to combat bullying” (J Fam Pract. 2017;66:82-89) and Dr. Hickner’s editorial, “It’s time to screen for bullying” (J Fam Pract. 2017;66:66) with great interest. I’m a bullying prevention researcher and the creator of a new bullying prevention program, CirclePoint, which is being piloted in Boston Public Schools. I’m also a featured speaker on bullying in the Massachusetts General Hospital’s life skills after-school program that runs in a dozen area schools.

My work in schools has taught me that as important as it is to identify bullying problems, it is equally important for doctors to know how to counsel patients and caregivers on how to resolve these problems.

Identifying bullying without providing further guidance can actually do more harm than good, both to the child’s health and to the child-physician relationship.

Children often don’t tell adults they are being bullied because the actions that adults take—while well-intended—can sometimes make the situation worse. Further, some caregivers may actually blame the child for being bullied. And a doctor who simply identifies the problem and leaves the next steps to an ill-informed caregiver may lose the patient’s trust.

Also worth noting: Some children who are bullied may not have a clear understanding of what the term “bullying” means. I strongly suggest asking patients about how others are treating them and if anyone is making them upset. Questions about behaviors and feelings are more effective at identifying a bullying problem than questions that use the term “bullying.”

Our program has a free resource that was developed for educators, but can easily be used by physicians to counsel patients and caregivers. It’s designed to convey recommended actions for both the student and caregiver in a matter of minutes.

Doctors who identify a bullying problem bear a responsibility to counsel both the patient and caregiver(s) on what bullying is, why it happens, and, most critically, recommended actions to take to effectively resolve the problem.

Ari Magnusson
Charlestown, Mass

In a recent letter to the editor on the role of auscultation and echocardiography, “Point-of-care ultrasound: It’s no replacement for the stethoscope” (J Fam Pract. 2016;65:734), Dr. Fredricks claimed that “doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.” His citation for this claim was a review article from more than 20 years ago that offered no evidence in support of the superiority of auscultation over echocardiography to characterize murmurs.¹ The review did acknowledge the limitations and variability between examiners.

The notion that physical examination is superior to echocardiography is appealing, but likely incorrect. A study of medical students with basic training in echocardiography showed that they were able to characterize murmurs more accurately with point-of-care ultrasound than experienced cardiologists auscultating the murmur.²

The existence of a better test does not obviate the role of the physical examination, but it does highlight the need to understand its limits. Like an ultrasound study, physical examination maneuvers are tests, with sensitivities and specificities. We should approach them as such, and not romanticize their performance.

David Mackenzie, MD
Portland, Me

In a recent letter to the editor on the role of auscultation and echocardiography, “Point-of-care ultrasound: It’s no replacement for the stethoscope” (J Fam Pract. 2016;65:734), Dr. Fredricks claimed that “doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.” His citation for this claim was a review article from more than 20 years ago that offered no evidence in support of the superiority of auscultation over echocardiography to characterize murmurs.¹ The review did acknowledge the limitations and variability between examiners.

The notion that physical examination is superior to echocardiography is appealing, but likely incorrect. A study of medical students with basic training in echocardiography showed that they were able to characterize murmurs more accurately with point-of-care ultrasound than experienced cardiologists auscultating the murmur.²

The existence of a better test does not obviate the role of the physical examination, but it does highlight the need to understand its limits. Like an ultrasound study, physical examination maneuvers are tests, with sensitivities and specificities. We should approach them as such, and not romanticize their performance.

David Mackenzie, MD
Portland, Me

In a recent letter to the editor on the role of auscultation and echocardiography, “Point-of-care ultrasound: It’s no replacement for the stethoscope” (J Fam Pract. 2016;65:734), Dr. Fredricks claimed that “doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.” His citation for this claim was a review article from more than 20 years ago that offered no evidence in support of the superiority of auscultation over echocardiography to characterize murmurs.¹ The review did acknowledge the limitations and variability between examiners.

The notion that physical examination is superior to echocardiography is appealing, but likely incorrect. A study of medical students with basic training in echocardiography showed that they were able to characterize murmurs more accurately with point-of-care ultrasound than experienced cardiologists auscultating the murmur.²

The existence of a better test does not obviate the role of the physical examination, but it does highlight the need to understand its limits. Like an ultrasound study, physical examination maneuvers are tests, with sensitivities and specificities. We should approach them as such, and not romanticize their performance.

David Mackenzie, MD
Portland, Me

Thank you for stating that ARNPs “do not need physician endorsement for the advanced component” of their practice. ARNPs need to be responsible for themselves. In California, NPs are given a certificate, not a license, and operate under the rules of the state board of nursing and the board of business and professional codes. We must act in a prudent and competent manner. I think this has been demonstrated where full practice authority is in force.

The American Medical Association (AMA) and American Academy of Family Physicians (AAFP), which still want “supervision, collaboration, or participating” designations for PAs and NPs, have tripped on their own stethoscopes on this issue. In trying to suppress advanced practice providers, they have helped create a provider shortage. Many NPs will not work in a state that has practice limitations.

In Humboldt County, California, family practice doctors are so overworked due to provider shortages that they are leaving the area. Enter locum tenens to fill the gap. But at a point, there is no benefit to being in such demand. The cost of health care has risen, and patients are unhappy with the care they receive. New patients cannot see doctors in a timely manner; when they are finally seen, they have a few minutes to share their concerns with the provider, who rarely sits down or looks away from the computer screen to make eye contact with them.

We are already seeing the push for advanced education for our NPs and PAs. We have witnessed the changeover to NP programs that culminate in a doctorate (not a master’s) degree. By 2021, PA programs will be required to be master’s level; although the process has started, there are still a few holdouts. But I consider Washington State to be a front-runner in this area.

This, for me, is the area we need to address: degree designation and equivalency. Rather than give “diplomat” or similar status to someone whose base degree is an associate’s, a better idea—and one more palatable to AMA and AAFP—might be to bring everyone to at least a master’s level. For example, the Academy of Integrative Pain Management (AIPM) gives “Fellow” designation to those with master’s preparation who successfully pass AIPM’s examination, and “Diplomat” status to doctorate-prepared practitioners who have also passed the exam.

At the end of the day, many patients prefer to see a PA or NP rather than a medical doctor. Yes, patients care about credentials—but they care more about their provider being respectful, listening, remembering their history, connecting the history from their previous provider, and offering the proper treatment for the correct diagnosis.

Jan Morgan, MS, ARNP
Fellow, Academy of Integrative Pain Management
Eureka, California

Thank you for stating that ARNPs “do not need physician endorsement for the advanced component” of their practice. ARNPs need to be responsible for themselves. In California, NPs are given a certificate, not a license, and operate under the rules of the state board of nursing and the board of business and professional codes. We must act in a prudent and competent manner. I think this has been demonstrated where full practice authority is in force.

The American Medical Association (AMA) and American Academy of Family Physicians (AAFP), which still want “supervision, collaboration, or participating” designations for PAs and NPs, have tripped on their own stethoscopes on this issue. In trying to suppress advanced practice providers, they have helped create a provider shortage. Many NPs will not work in a state that has practice limitations.

In Humboldt County, California, family practice doctors are so overworked due to provider shortages that they are leaving the area. Enter locum tenens to fill the gap. But at a point, there is no benefit to being in such demand. The cost of health care has risen, and patients are unhappy with the care they receive. New patients cannot see doctors in a timely manner; when they are finally seen, they have a few minutes to share their concerns with the provider, who rarely sits down or looks away from the computer screen to make eye contact with them.

We are already seeing the push for advanced education for our NPs and PAs. We have witnessed the changeover to NP programs that culminate in a doctorate (not a master’s) degree. By 2021, PA programs will be required to be master’s level; although the process has started, there are still a few holdouts. But I consider Washington State to be a front-runner in this area.

This, for me, is the area we need to address: degree designation and equivalency. Rather than give “diplomat” or similar status to someone whose base degree is an associate’s, a better idea—and one more palatable to AMA and AAFP—might be to bring everyone to at least a master’s level. For example, the Academy of Integrative Pain Management (AIPM) gives “Fellow” designation to those with master’s preparation who successfully pass AIPM’s examination, and “Diplomat” status to doctorate-prepared practitioners who have also passed the exam.

At the end of the day, many patients prefer to see a PA or NP rather than a medical doctor. Yes, patients care about credentials—but they care more about their provider being respectful, listening, remembering their history, connecting the history from their previous provider, and offering the proper treatment for the correct diagnosis.

Jan Morgan, MS, ARNP
Fellow, Academy of Integrative Pain Management
Eureka, California

Thank you for stating that ARNPs “do not need physician endorsement for the advanced component” of their practice. ARNPs need to be responsible for themselves. In California, NPs are given a certificate, not a license, and operate under the rules of the state board of nursing and the board of business and professional codes. We must act in a prudent and competent manner. I think this has been demonstrated where full practice authority is in force.

The American Medical Association (AMA) and American Academy of Family Physicians (AAFP), which still want “supervision, collaboration, or participating” designations for PAs and NPs, have tripped on their own stethoscopes on this issue. In trying to suppress advanced practice providers, they have helped create a provider shortage. Many NPs will not work in a state that has practice limitations.

In Humboldt County, California, family practice doctors are so overworked due to provider shortages that they are leaving the area. Enter locum tenens to fill the gap. But at a point, there is no benefit to being in such demand. The cost of health care has risen, and patients are unhappy with the care they receive. New patients cannot see doctors in a timely manner; when they are finally seen, they have a few minutes to share their concerns with the provider, who rarely sits down or looks away from the computer screen to make eye contact with them.

We are already seeing the push for advanced education for our NPs and PAs. We have witnessed the changeover to NP programs that culminate in a doctorate (not a master’s) degree. By 2021, PA programs will be required to be master’s level; although the process has started, there are still a few holdouts. But I consider Washington State to be a front-runner in this area.

This, for me, is the area we need to address: degree designation and equivalency. Rather than give “diplomat” or similar status to someone whose base degree is an associate’s, a better idea—and one more palatable to AMA and AAFP—might be to bring everyone to at least a master’s level. For example, the Academy of Integrative Pain Management (AIPM) gives “Fellow” designation to those with master’s preparation who successfully pass AIPM’s examination, and “Diplomat” status to doctorate-prepared practitioners who have also passed the exam.

At the end of the day, many patients prefer to see a PA or NP rather than a medical doctor. Yes, patients care about credentials—but they care more about their provider being respectful, listening, remembering their history, connecting the history from their previous provider, and offering the proper treatment for the correct diagnosis.

Jan Morgan, MS, ARNP
Fellow, Academy of Integrative Pain Management
Eureka, California

Thank you for your thoughtful commentary on the pertinent topic of full practice authority for PAs (2017;27[2]:12-14). In more than 30 years as a PA, I have rarely regretted my career choice. In 1982, when I was planning my career path, I chose to become a PA instead of an NP because I didn’t want to further my nursing training (I was already an LPN) to advance my practice, and my impression was that PAs and NPs were equivalent in the workforce. This perception held true until the past few years; I have lost job opportunities specifically because the employer didn’t want to deal with the administrative details of PA supervisory requirements here in Colorado. I find this frustrating, as well as perplexing.

Although I’ve become more comfortable with autonomy throughout my years of practice, I’ve always reserved the right to consult when necessary and appropriate, based on my own judgment and comfort level. I certainly wouldn’t mind more relaxed supervision, but I wouldn’t want to be cut entirely loose, either. On the other hand, I resent being ineligible for job opportunities simply for administrative reasons. While this is surely misguided on the part of the employers, it is a reality that practition­ers encounter.

I learned recently—to my astonishment—that my NP colleagues pay about a tenth of what I do for malpractice insurance. Apparently the underwriters (and/or the plaintiffs) haven’t caught up with the nuances of responsibility and autonomy! From my perspective, PAs and NPs have more in common in the practice setting than NPs and RNs do. The fact that NPs are governed by nursing boards and insured as nurses is more an antiquated accident than a reflection of function in the workforce.

Ideally, there should be a governing body dedicated to the entire spectrum of nonphysician providers who are qualified to diagnose, treat, and prescribe. Since that is not likely to happen, it is our responsibility as PAs to match NPs in the marketplace while maintaining our integrity as providers.

Elizabeth Upper, PA-C
Denver, Colorado

Thank you for your thoughtful commentary on the pertinent topic of full practice authority for PAs (2017;27[2]:12-14). In more than 30 years as a PA, I have rarely regretted my career choice. In 1982, when I was planning my career path, I chose to become a PA instead of an NP because I didn’t want to further my nursing training (I was already an LPN) to advance my practice, and my impression was that PAs and NPs were equivalent in the workforce. This perception held true until the past few years; I have lost job opportunities specifically because the employer didn’t want to deal with the administrative details of PA supervisory requirements here in Colorado. I find this frustrating, as well as perplexing.

Although I’ve become more comfortable with autonomy throughout my years of practice, I’ve always reserved the right to consult when necessary and appropriate, based on my own judgment and comfort level. I certainly wouldn’t mind more relaxed supervision, but I wouldn’t want to be cut entirely loose, either. On the other hand, I resent being ineligible for job opportunities simply for administrative reasons. While this is surely misguided on the part of the employers, it is a reality that practition­ers encounter.

I learned recently—to my astonishment—that my NP colleagues pay about a tenth of what I do for malpractice insurance. Apparently the underwriters (and/or the plaintiffs) haven’t caught up with the nuances of responsibility and autonomy! From my perspective, PAs and NPs have more in common in the practice setting than NPs and RNs do. The fact that NPs are governed by nursing boards and insured as nurses is more an antiquated accident than a reflection of function in the workforce.

Ideally, there should be a governing body dedicated to the entire spectrum of nonphysician providers who are qualified to diagnose, treat, and prescribe. Since that is not likely to happen, it is our responsibility as PAs to match NPs in the marketplace while maintaining our integrity as providers.

Elizabeth Upper, PA-C
Denver, Colorado

Thank you for your thoughtful commentary on the pertinent topic of full practice authority for PAs (2017;27[2]:12-14). In more than 30 years as a PA, I have rarely regretted my career choice. In 1982, when I was planning my career path, I chose to become a PA instead of an NP because I didn’t want to further my nursing training (I was already an LPN) to advance my practice, and my impression was that PAs and NPs were equivalent in the workforce. This perception held true until the past few years; I have lost job opportunities specifically because the employer didn’t want to deal with the administrative details of PA supervisory requirements here in Colorado. I find this frustrating, as well as perplexing.

Although I’ve become more comfortable with autonomy throughout my years of practice, I’ve always reserved the right to consult when necessary and appropriate, based on my own judgment and comfort level. I certainly wouldn’t mind more relaxed supervision, but I wouldn’t want to be cut entirely loose, either. On the other hand, I resent being ineligible for job opportunities simply for administrative reasons. While this is surely misguided on the part of the employers, it is a reality that practition­ers encounter.

I learned recently—to my astonishment—that my NP colleagues pay about a tenth of what I do for malpractice insurance. Apparently the underwriters (and/or the plaintiffs) haven’t caught up with the nuances of responsibility and autonomy! From my perspective, PAs and NPs have more in common in the practice setting than NPs and RNs do. The fact that NPs are governed by nursing boards and insured as nurses is more an antiquated accident than a reflection of function in the workforce.

Ideally, there should be a governing body dedicated to the entire spectrum of nonphysician providers who are qualified to diagnose, treat, and prescribe. Since that is not likely to happen, it is our responsibility as PAs to match NPs in the marketplace while maintaining our integrity as providers.

Elizabeth Upper, PA-C
Denver, Colorado

I recently had the good fortune to read a commentary written by Dr. Peter Angelos in ACS Surgery News entitled, The Right Choice? Surgeons, confidence, and humility (2017, February, p. 11). The essay touches on the philosophy, psychology, and attitudes that surgeons adopt and express in their daily interactions with the public.

The article refers to “the balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications.” This is a critically important struggle in the mind of the surgeon. I would like to propose an exercise to bolster self-esteem in the psyche of the surgeon, particularly in the formative stages of one’s career, without fostering false or pathological bravado.

Dr. Chuback is a vascular surgeon in private practice in Paramus, N.J.

I recently had the good fortune to read a commentary written by Dr. Peter Angelos in ACS Surgery News entitled, The Right Choice? Surgeons, confidence, and humility (2017, February, p. 11). The essay touches on the philosophy, psychology, and attitudes that surgeons adopt and express in their daily interactions with the public.

The article refers to “the balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications.” This is a critically important struggle in the mind of the surgeon. I would like to propose an exercise to bolster self-esteem in the psyche of the surgeon, particularly in the formative stages of one’s career, without fostering false or pathological bravado.

Dr. Chuback is a vascular surgeon in private practice in Paramus, N.J.

I recently had the good fortune to read a commentary written by Dr. Peter Angelos in ACS Surgery News entitled, The Right Choice? Surgeons, confidence, and humility (2017, February, p. 11). The essay touches on the philosophy, psychology, and attitudes that surgeons adopt and express in their daily interactions with the public.

The article refers to “the balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications.” This is a critically important struggle in the mind of the surgeon. I would like to propose an exercise to bolster self-esteem in the psyche of the surgeon, particularly in the formative stages of one’s career, without fostering false or pathological bravado.

Dr. Chuback is a vascular surgeon in private practice in Paramus, N.J.

Sports and sports figures provide both a welcome relief from the stress of dealing with life and death in the ED and memorable ways of characterizing serious health care issues. When the Institute of Medicine issued its 2006 report “Hospital-Based Emergency Care: At the Breaking Point,” we thought that a quote about a popular restaurant by the late, great New York Yankees catcher Yogi Berra better described the severely overcrowded EDs and ambulance diversion: “Nobody goes there anymore—it’s too crowded.”

In late winter and early spring of this year, after vigorous attempts to repeal/revise the 2010 Affordable Care Act (ACA), a replacement bill was withdrawn immediately prior to a Congressional vote on March 24 due to a lack of support. Seven years earlier, when President Obama also seemed to have little chance of getting the ACA through Congress, we thought that there would be “many more balks before the president and Congress finally pitched a viable health care package to the nation.” Only a month later, however, with the ACA now the law, we suggested that our erroneous prediction was similar to that of “a father who convinces his son to leave for the parking lot during the bottom of the ninth inning of a 3-0 game only to hear the roar of the crowd from the exit ramp as the rookie batter hits a grand-slam home run to win the game.”

In June 2012, when the Supreme Court ruled on the constitutionality of the ACA, many reporters quickly read the Court’s rejection of the first two arguments defending the ACA, and rushed to report that it was dead, without considering that the government had “one more out to go…[the one] casting ACA as a tax—considered to be the weakest player in the lineup—[which] managed to score the winning run to uphold ACA. Game over. Final score: ACA wins 5 to 4.”

But with the 2017 baseball season finally underway, it is a recent football game that provides the perfect paradigm for emergency medicine (EM) and emergency physicians (EPs). The New England Patriots were slight favorites to win Super Bowl 51 over the Atlanta Falcons on February 5,and the first quarter ended with no score. But by halftime, Atlanta was leading 21-3. In 50 years of Super Bowls, no team had ever overcome more than a 10-point deficit to win the game, and with a little over 8 minutes left in the third quarter, the deficit had widened even further to 28-3. Then the Patriots began to turn things around. Though the Patriots never led during regulation play, and no Super Bowl had ever gone into overtime, the fourth quarter ended in a 28-28 tie, and the Patriots went on to win 34-28 in overtime.

Coming out of the locker room to play the second half of that game in front of over 111 million viewers must have been a daunting experience for the Patriots, but no more so than the experience depicted in EP/cinematographer Ryan McGarry’s award-winning documentary “Code Black,” in which he shows young EM residents walking through a packed waiting room to begin their shift, realizing that in the next 12 hours, they could never treat all of the ill patients waiting to be seen. But the young residents proceeded to treat one patient after another without ever giving up or losing their idealism, until in the end, they, too, had won the game against all odds.

Many patients arrive in EDs so ill that there is no reasonable expectation any intervention can save them, but we nevertheless try and sometimes succeed in doing the seemingly impossible. It is the type of medicine we have chosen to devote our careers to, and we are no less heroes than were the Patriots on February 5, 2017. Each time we go out to “play ball” in our overcrowded EDs, it is worth remembering another famous Yogi Berra quote: “It ain’t over till it’s over.” 

Sports and sports figures provide both a welcome relief from the stress of dealing with life and death in the ED and memorable ways of characterizing serious health care issues. When the Institute of Medicine issued its 2006 report “Hospital-Based Emergency Care: At the Breaking Point,” we thought that a quote about a popular restaurant by the late, great New York Yankees catcher Yogi Berra better described the severely overcrowded EDs and ambulance diversion: “Nobody goes there anymore—it’s too crowded.”

In late winter and early spring of this year, after vigorous attempts to repeal/revise the 2010 Affordable Care Act (ACA), a replacement bill was withdrawn immediately prior to a Congressional vote on March 24 due to a lack of support. Seven years earlier, when President Obama also seemed to have little chance of getting the ACA through Congress, we thought that there would be “many more balks before the president and Congress finally pitched a viable health care package to the nation.” Only a month later, however, with the ACA now the law, we suggested that our erroneous prediction was similar to that of “a father who convinces his son to leave for the parking lot during the bottom of the ninth inning of a 3-0 game only to hear the roar of the crowd from the exit ramp as the rookie batter hits a grand-slam home run to win the game.”

In June 2012, when the Supreme Court ruled on the constitutionality of the ACA, many reporters quickly read the Court’s rejection of the first two arguments defending the ACA, and rushed to report that it was dead, without considering that the government had “one more out to go…[the one] casting ACA as a tax—considered to be the weakest player in the lineup—[which] managed to score the winning run to uphold ACA. Game over. Final score: ACA wins 5 to 4.”

But with the 2017 baseball season finally underway, it is a recent football game that provides the perfect paradigm for emergency medicine (EM) and emergency physicians (EPs). The New England Patriots were slight favorites to win Super Bowl 51 over the Atlanta Falcons on February 5,and the first quarter ended with no score. But by halftime, Atlanta was leading 21-3. In 50 years of Super Bowls, no team had ever overcome more than a 10-point deficit to win the game, and with a little over 8 minutes left in the third quarter, the deficit had widened even further to 28-3. Then the Patriots began to turn things around. Though the Patriots never led during regulation play, and no Super Bowl had ever gone into overtime, the fourth quarter ended in a 28-28 tie, and the Patriots went on to win 34-28 in overtime.

Coming out of the locker room to play the second half of that game in front of over 111 million viewers must have been a daunting experience for the Patriots, but no more so than the experience depicted in EP/cinematographer Ryan McGarry’s award-winning documentary “Code Black,” in which he shows young EM residents walking through a packed waiting room to begin their shift, realizing that in the next 12 hours, they could never treat all of the ill patients waiting to be seen. But the young residents proceeded to treat one patient after another without ever giving up or losing their idealism, until in the end, they, too, had won the game against all odds.

Many patients arrive in EDs so ill that there is no reasonable expectation any intervention can save them, but we nevertheless try and sometimes succeed in doing the seemingly impossible. It is the type of medicine we have chosen to devote our careers to, and we are no less heroes than were the Patriots on February 5, 2017. Each time we go out to “play ball” in our overcrowded EDs, it is worth remembering another famous Yogi Berra quote: “It ain’t over till it’s over.” 

Sports and sports figures provide both a welcome relief from the stress of dealing with life and death in the ED and memorable ways of characterizing serious health care issues. When the Institute of Medicine issued its 2006 report “Hospital-Based Emergency Care: At the Breaking Point,” we thought that a quote about a popular restaurant by the late, great New York Yankees catcher Yogi Berra better described the severely overcrowded EDs and ambulance diversion: “Nobody goes there anymore—it’s too crowded.”

In late winter and early spring of this year, after vigorous attempts to repeal/revise the 2010 Affordable Care Act (ACA), a replacement bill was withdrawn immediately prior to a Congressional vote on March 24 due to a lack of support. Seven years earlier, when President Obama also seemed to have little chance of getting the ACA through Congress, we thought that there would be “many more balks before the president and Congress finally pitched a viable health care package to the nation.” Only a month later, however, with the ACA now the law, we suggested that our erroneous prediction was similar to that of “a father who convinces his son to leave for the parking lot during the bottom of the ninth inning of a 3-0 game only to hear the roar of the crowd from the exit ramp as the rookie batter hits a grand-slam home run to win the game.”

In June 2012, when the Supreme Court ruled on the constitutionality of the ACA, many reporters quickly read the Court’s rejection of the first two arguments defending the ACA, and rushed to report that it was dead, without considering that the government had “one more out to go…[the one] casting ACA as a tax—considered to be the weakest player in the lineup—[which] managed to score the winning run to uphold ACA. Game over. Final score: ACA wins 5 to 4.”

But with the 2017 baseball season finally underway, it is a recent football game that provides the perfect paradigm for emergency medicine (EM) and emergency physicians (EPs). The New England Patriots were slight favorites to win Super Bowl 51 over the Atlanta Falcons on February 5,and the first quarter ended with no score. But by halftime, Atlanta was leading 21-3. In 50 years of Super Bowls, no team had ever overcome more than a 10-point deficit to win the game, and with a little over 8 minutes left in the third quarter, the deficit had widened even further to 28-3. Then the Patriots began to turn things around. Though the Patriots never led during regulation play, and no Super Bowl had ever gone into overtime, the fourth quarter ended in a 28-28 tie, and the Patriots went on to win 34-28 in overtime.

Coming out of the locker room to play the second half of that game in front of over 111 million viewers must have been a daunting experience for the Patriots, but no more so than the experience depicted in EP/cinematographer Ryan McGarry’s award-winning documentary “Code Black,” in which he shows young EM residents walking through a packed waiting room to begin their shift, realizing that in the next 12 hours, they could never treat all of the ill patients waiting to be seen. But the young residents proceeded to treat one patient after another without ever giving up or losing their idealism, until in the end, they, too, had won the game against all odds.

Many patients arrive in EDs so ill that there is no reasonable expectation any intervention can save them, but we nevertheless try and sometimes succeed in doing the seemingly impossible. It is the type of medicine we have chosen to devote our careers to, and we are no less heroes than were the Patriots on February 5, 2017. Each time we go out to “play ball” in our overcrowded EDs, it is worth remembering another famous Yogi Berra quote: “It ain’t over till it’s over.”