Commentary

Breast cancer is the most common cancer in women and ranks second, after lung cancer, as a cause of cancer-related death in women.

In the United States alone, an estimated 231,840 women will be diagnosed with breast cancer in 2015. Largely as a result of screening mammography and early detection, associated mortality has been steadily declining since 1990. Still, the American Cancer Society has estimated that 40,290 U.S. women will die of breast cancer in 2015.

Specific recommendations for breast cancer screening vary significantly between two major guidelines: the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). In 2003, the ACS recommended annual screening with mammography for women beginning at age 40, stopping only when a woman’s health would preclude her from cancer treatment. Furthermore, the ACS recommended a clinical breast examination (CBE) at least every 3 years for women in their 20s and 30s and then annually starting at age 40. Current USPSTF guidelines recommend mammograms biennially from age 50 to age 74, finding insufficient evidence to recommend CBE.

Gaps between these two organizations are shrinking, however, as the ACS released its new 2015 guidelines, updating the 2003 recommendations for breast cancer screening for women at average risk. The ACS defined average risk broadly: women without a personal history of breast cancer, a confirmed or suspected genetic mutation known to increase risk of breast cancer (e.g., BRCA), or a history of previous radiotherapy to the chest at a young age. These guidelines include the following recommendations:

1. Women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years. (Strong Recommendation)

1a. Women aged 45-54 years should be screening annually. (Qualified Recommendation)

1b. Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. (Qualified Recommendation)

1c. Women should have the opportunity to begin annual screening between the ages of 40 and 44 years. (Qualified Recommendation)

2. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer. (Qualified Recommendation)

3. The ACS does not recommend CBE for breast cancer screening among average-risk women at any age. (Qualified Recommendation)

These new guidelines bring the USPSTF and ACS recommendation closer to one another; they provide a clear step toward consensus. Both guidelines now agree that for average-risk women who are younger than 45 years, the harms of screening mammography likely outweigh the benefits. They are also consistent in their position that for women older than 55 years, biennial mammography is likely to provide the best balance of benefits to harms. Finally, they both recommend decisions to be individualized to reflect a woman’s preferences and her underlying risk of breast cancer.

Differences between the two guidelines originate from several methodological decisions made by the group responsible for the new ACS guidelines. In addition to randomized controlled trials and mathematic modeling, the group reviewed and utilized results from recent observational studies. The group also decided to analyze the benefits and harms of mammography using 5-year age groups, rather than the conventional 10 years. Also, it assessed annual vs. biennial screening, finding that the proportion of tumors that were stage IIB or higher and larger than 15 mm was greater for premenopausal women undergoing biennial screening but not for postmenopausal women.

Several messages are worth emphasizing as clinicians continue to review these new guidelines and decide whether or not to incorporate them into practice. First, thanks to breakthroughs in breast cancer treatment, the majority of women who are diagnosed with breast cancer will do well regardless of whether their cancer was found by mammography. Evidence from randomized trials of women in their 40s and 50s suggests that screening mammography only decreases breast cancer mortality by approximately 15%. Thus, about 85% of women in their 40s and 50s who die of breast cancer would have died regardless of mammography screening. Furthermore, because of the low risk of breast cancer for women in their 40s, this relative benefit of 15% translates to a small absolute benefit of around 5 of 10,000 women likely to have a breast cancer death prevented by mammography. Obviously the absolute benefit is higher for women with an increased risk of breast cancer, highlighting the importance of identifying higher-risk women. The lifetime risk of dying from breast cancer with no screening is 2.7%. Using the screening guidelines of the USPSTF that risk decreases to 2% with a total of 13 mammograms by 74 years of age. Using the new screening guidelines from the ACS, the calculated risk of dying from breast cancer is 1.8%-1.9% with 20 mammograms by 74 years of age. This is a significant departure from the 35 mammograms that were recommended by the older 2003 ACS guidelines.

Bottom line

The American Cancer Society has released a 2015 update to its breast cancer screening guidelines for women at average risk. The new guidelines recommend against clinical breast exams and in favor of annual mammograms between ages 45 and 54 years, followed by biennial mammograms starting at age 55 years and ending when life expectancy is less than 10 years. These guidelines also allow for patient preference or clinical judgment to opt in for annual mammography from 40 to 44 years of age and to continue with annual screening beyond age 55.

References

1. Keating NL, Pace LE. New guidelines for breast cancer screening in U.S. women. JAMA. 2015;314(15)1658.

2. Kerlikowske K. Progress toward consensus on breast cancer screening guidelines and reducing screening harms. JAMA Intern Med. 2015 Oct 20. doi:10.1001/jamainternmed.2015.6466.

3. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast cancer screening for women at average risk. JAMA. 2015;314(15):1599-614. doi:10/1001/jama.2015.12783.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lyons is a third-year resident in the program.

Breast cancer is the most common cancer in women and ranks second, after lung cancer, as a cause of cancer-related death in women.

In the United States alone, an estimated 231,840 women will be diagnosed with breast cancer in 2015. Largely as a result of screening mammography and early detection, associated mortality has been steadily declining since 1990. Still, the American Cancer Society has estimated that 40,290 U.S. women will die of breast cancer in 2015.

Specific recommendations for breast cancer screening vary significantly between two major guidelines: the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). In 2003, the ACS recommended annual screening with mammography for women beginning at age 40, stopping only when a woman’s health would preclude her from cancer treatment. Furthermore, the ACS recommended a clinical breast examination (CBE) at least every 3 years for women in their 20s and 30s and then annually starting at age 40. Current USPSTF guidelines recommend mammograms biennially from age 50 to age 74, finding insufficient evidence to recommend CBE.

Gaps between these two organizations are shrinking, however, as the ACS released its new 2015 guidelines, updating the 2003 recommendations for breast cancer screening for women at average risk. The ACS defined average risk broadly: women without a personal history of breast cancer, a confirmed or suspected genetic mutation known to increase risk of breast cancer (e.g., BRCA), or a history of previous radiotherapy to the chest at a young age. These guidelines include the following recommendations:

1. Women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years. (Strong Recommendation)

1a. Women aged 45-54 years should be screening annually. (Qualified Recommendation)

1b. Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. (Qualified Recommendation)

1c. Women should have the opportunity to begin annual screening between the ages of 40 and 44 years. (Qualified Recommendation)

2. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer. (Qualified Recommendation)

3. The ACS does not recommend CBE for breast cancer screening among average-risk women at any age. (Qualified Recommendation)

These new guidelines bring the USPSTF and ACS recommendation closer to one another; they provide a clear step toward consensus. Both guidelines now agree that for average-risk women who are younger than 45 years, the harms of screening mammography likely outweigh the benefits. They are also consistent in their position that for women older than 55 years, biennial mammography is likely to provide the best balance of benefits to harms. Finally, they both recommend decisions to be individualized to reflect a woman’s preferences and her underlying risk of breast cancer.

Differences between the two guidelines originate from several methodological decisions made by the group responsible for the new ACS guidelines. In addition to randomized controlled trials and mathematic modeling, the group reviewed and utilized results from recent observational studies. The group also decided to analyze the benefits and harms of mammography using 5-year age groups, rather than the conventional 10 years. Also, it assessed annual vs. biennial screening, finding that the proportion of tumors that were stage IIB or higher and larger than 15 mm was greater for premenopausal women undergoing biennial screening but not for postmenopausal women.

Several messages are worth emphasizing as clinicians continue to review these new guidelines and decide whether or not to incorporate them into practice. First, thanks to breakthroughs in breast cancer treatment, the majority of women who are diagnosed with breast cancer will do well regardless of whether their cancer was found by mammography. Evidence from randomized trials of women in their 40s and 50s suggests that screening mammography only decreases breast cancer mortality by approximately 15%. Thus, about 85% of women in their 40s and 50s who die of breast cancer would have died regardless of mammography screening. Furthermore, because of the low risk of breast cancer for women in their 40s, this relative benefit of 15% translates to a small absolute benefit of around 5 of 10,000 women likely to have a breast cancer death prevented by mammography. Obviously the absolute benefit is higher for women with an increased risk of breast cancer, highlighting the importance of identifying higher-risk women. The lifetime risk of dying from breast cancer with no screening is 2.7%. Using the screening guidelines of the USPSTF that risk decreases to 2% with a total of 13 mammograms by 74 years of age. Using the new screening guidelines from the ACS, the calculated risk of dying from breast cancer is 1.8%-1.9% with 20 mammograms by 74 years of age. This is a significant departure from the 35 mammograms that were recommended by the older 2003 ACS guidelines.

Bottom line

The American Cancer Society has released a 2015 update to its breast cancer screening guidelines for women at average risk. The new guidelines recommend against clinical breast exams and in favor of annual mammograms between ages 45 and 54 years, followed by biennial mammograms starting at age 55 years and ending when life expectancy is less than 10 years. These guidelines also allow for patient preference or clinical judgment to opt in for annual mammography from 40 to 44 years of age and to continue with annual screening beyond age 55.

References

1. Keating NL, Pace LE. New guidelines for breast cancer screening in U.S. women. JAMA. 2015;314(15)1658.

2. Kerlikowske K. Progress toward consensus on breast cancer screening guidelines and reducing screening harms. JAMA Intern Med. 2015 Oct 20. doi:10.1001/jamainternmed.2015.6466.

3. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast cancer screening for women at average risk. JAMA. 2015;314(15):1599-614. doi:10/1001/jama.2015.12783.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lyons is a third-year resident in the program.

Breast cancer is the most common cancer in women and ranks second, after lung cancer, as a cause of cancer-related death in women.

In the United States alone, an estimated 231,840 women will be diagnosed with breast cancer in 2015. Largely as a result of screening mammography and early detection, associated mortality has been steadily declining since 1990. Still, the American Cancer Society has estimated that 40,290 U.S. women will die of breast cancer in 2015.

Specific recommendations for breast cancer screening vary significantly between two major guidelines: the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). In 2003, the ACS recommended annual screening with mammography for women beginning at age 40, stopping only when a woman’s health would preclude her from cancer treatment. Furthermore, the ACS recommended a clinical breast examination (CBE) at least every 3 years for women in their 20s and 30s and then annually starting at age 40. Current USPSTF guidelines recommend mammograms biennially from age 50 to age 74, finding insufficient evidence to recommend CBE.

Gaps between these two organizations are shrinking, however, as the ACS released its new 2015 guidelines, updating the 2003 recommendations for breast cancer screening for women at average risk. The ACS defined average risk broadly: women without a personal history of breast cancer, a confirmed or suspected genetic mutation known to increase risk of breast cancer (e.g., BRCA), or a history of previous radiotherapy to the chest at a young age. These guidelines include the following recommendations:

1. Women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years. (Strong Recommendation)

1a. Women aged 45-54 years should be screening annually. (Qualified Recommendation)

1b. Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. (Qualified Recommendation)

1c. Women should have the opportunity to begin annual screening between the ages of 40 and 44 years. (Qualified Recommendation)

2. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer. (Qualified Recommendation)

3. The ACS does not recommend CBE for breast cancer screening among average-risk women at any age. (Qualified Recommendation)

These new guidelines bring the USPSTF and ACS recommendation closer to one another; they provide a clear step toward consensus. Both guidelines now agree that for average-risk women who are younger than 45 years, the harms of screening mammography likely outweigh the benefits. They are also consistent in their position that for women older than 55 years, biennial mammography is likely to provide the best balance of benefits to harms. Finally, they both recommend decisions to be individualized to reflect a woman’s preferences and her underlying risk of breast cancer.

Differences between the two guidelines originate from several methodological decisions made by the group responsible for the new ACS guidelines. In addition to randomized controlled trials and mathematic modeling, the group reviewed and utilized results from recent observational studies. The group also decided to analyze the benefits and harms of mammography using 5-year age groups, rather than the conventional 10 years. Also, it assessed annual vs. biennial screening, finding that the proportion of tumors that were stage IIB or higher and larger than 15 mm was greater for premenopausal women undergoing biennial screening but not for postmenopausal women.

Several messages are worth emphasizing as clinicians continue to review these new guidelines and decide whether or not to incorporate them into practice. First, thanks to breakthroughs in breast cancer treatment, the majority of women who are diagnosed with breast cancer will do well regardless of whether their cancer was found by mammography. Evidence from randomized trials of women in their 40s and 50s suggests that screening mammography only decreases breast cancer mortality by approximately 15%. Thus, about 85% of women in their 40s and 50s who die of breast cancer would have died regardless of mammography screening. Furthermore, because of the low risk of breast cancer for women in their 40s, this relative benefit of 15% translates to a small absolute benefit of around 5 of 10,000 women likely to have a breast cancer death prevented by mammography. Obviously the absolute benefit is higher for women with an increased risk of breast cancer, highlighting the importance of identifying higher-risk women. The lifetime risk of dying from breast cancer with no screening is 2.7%. Using the screening guidelines of the USPSTF that risk decreases to 2% with a total of 13 mammograms by 74 years of age. Using the new screening guidelines from the ACS, the calculated risk of dying from breast cancer is 1.8%-1.9% with 20 mammograms by 74 years of age. This is a significant departure from the 35 mammograms that were recommended by the older 2003 ACS guidelines.

Bottom line

The American Cancer Society has released a 2015 update to its breast cancer screening guidelines for women at average risk. The new guidelines recommend against clinical breast exams and in favor of annual mammograms between ages 45 and 54 years, followed by biennial mammograms starting at age 55 years and ending when life expectancy is less than 10 years. These guidelines also allow for patient preference or clinical judgment to opt in for annual mammography from 40 to 44 years of age and to continue with annual screening beyond age 55.

References

1. Keating NL, Pace LE. New guidelines for breast cancer screening in U.S. women. JAMA. 2015;314(15)1658.

2. Kerlikowske K. Progress toward consensus on breast cancer screening guidelines and reducing screening harms. JAMA Intern Med. 2015 Oct 20. doi:10.1001/jamainternmed.2015.6466.

3. Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast cancer screening for women at average risk. JAMA. 2015;314(15):1599-614. doi:10/1001/jama.2015.12783.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Lyons is a third-year resident in the program.

As the year comes to an end, I have decided – after 9 years of writing for Pediatric News – to bring my column to a close. It has been a great joy to be a part of the pediatric community in this way, and I have been grateful for those of you who approach me at meetings, saying, “Hey, I recognize you – I really like your column!” or tell me you appreciated a particular topic or piece of advice.

As I reflected on the columns I have written, I realized there were two themes that repeatedly emerged as most meaningful to me. While these thoughts are nothing new, I thought they would be a fitting way to sum up my writings over the years.

First, and most important, is that patients and families are the best partners we have in the care we give. When we take the time to listen to them, involve them in decision making and think past what we see on the surface, kids are healthier. This is just as true for preventative “well-baby” care as it is for acute and specialty care. Understanding a family’s priorities, values, and the context in which they live is just as important as our medical knowledge and skills when taking care of patients. Pediatricians are expert at bringing all of these things together, grounded in the best and most up-to-date evidence available, and in doing so elevate the care of children.

Which leads me to the second theme – pediatricians are a strong and important voice for children, and it is important for us to learn to lead. Through our work, we have a window into the lives of children, both when they are healthy and when they are sick. That is a great privilege but also a great responsibility. We see the things that work well in our systems and the things that do not. We see the amazing things children are capable of, but also troubling and pervasive inequities in care, access, and education. We see children who aren’t having their basic needs met – things like food, shelter, and a safe place to play. We see how these inequities impact health and wellness – both now and as children grow into adults. These observations, and the things we learn by caring for children and families day in and day out, can be translated into action. For each of us that will mean something different, but it is imperative that we develop our talents as advocates and leaders so that we can catalyze change. Our best hope for making things better is if we each do our part to create solutions. And when that happens, children – a lot of children – are healthier.

Since I began my first column 9 years ago, a lot has changed for me, and I suspect for many of you. When I first began writing, my now tall, confident tween (who already wears the same shoe size as me!) was barely walking. Thank you to all who have listened and encouraged me along the way – it has been a fun journey, and I’ve appreciated your time.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, both in Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and immediate past president of the District of Columbia chapter of the American Academy of Pediatrics.

As the year comes to an end, I have decided – after 9 years of writing for Pediatric News – to bring my column to a close. It has been a great joy to be a part of the pediatric community in this way, and I have been grateful for those of you who approach me at meetings, saying, “Hey, I recognize you – I really like your column!” or tell me you appreciated a particular topic or piece of advice.

As I reflected on the columns I have written, I realized there were two themes that repeatedly emerged as most meaningful to me. While these thoughts are nothing new, I thought they would be a fitting way to sum up my writings over the years.

First, and most important, is that patients and families are the best partners we have in the care we give. When we take the time to listen to them, involve them in decision making and think past what we see on the surface, kids are healthier. This is just as true for preventative “well-baby” care as it is for acute and specialty care. Understanding a family’s priorities, values, and the context in which they live is just as important as our medical knowledge and skills when taking care of patients. Pediatricians are expert at bringing all of these things together, grounded in the best and most up-to-date evidence available, and in doing so elevate the care of children.

Which leads me to the second theme – pediatricians are a strong and important voice for children, and it is important for us to learn to lead. Through our work, we have a window into the lives of children, both when they are healthy and when they are sick. That is a great privilege but also a great responsibility. We see the things that work well in our systems and the things that do not. We see the amazing things children are capable of, but also troubling and pervasive inequities in care, access, and education. We see children who aren’t having their basic needs met – things like food, shelter, and a safe place to play. We see how these inequities impact health and wellness – both now and as children grow into adults. These observations, and the things we learn by caring for children and families day in and day out, can be translated into action. For each of us that will mean something different, but it is imperative that we develop our talents as advocates and leaders so that we can catalyze change. Our best hope for making things better is if we each do our part to create solutions. And when that happens, children – a lot of children – are healthier.

Since I began my first column 9 years ago, a lot has changed for me, and I suspect for many of you. When I first began writing, my now tall, confident tween (who already wears the same shoe size as me!) was barely walking. Thank you to all who have listened and encouraged me along the way – it has been a fun journey, and I’ve appreciated your time.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, both in Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and immediate past president of the District of Columbia chapter of the American Academy of Pediatrics.

As the year comes to an end, I have decided – after 9 years of writing for Pediatric News – to bring my column to a close. It has been a great joy to be a part of the pediatric community in this way, and I have been grateful for those of you who approach me at meetings, saying, “Hey, I recognize you – I really like your column!” or tell me you appreciated a particular topic or piece of advice.

As I reflected on the columns I have written, I realized there were two themes that repeatedly emerged as most meaningful to me. While these thoughts are nothing new, I thought they would be a fitting way to sum up my writings over the years.

First, and most important, is that patients and families are the best partners we have in the care we give. When we take the time to listen to them, involve them in decision making and think past what we see on the surface, kids are healthier. This is just as true for preventative “well-baby” care as it is for acute and specialty care. Understanding a family’s priorities, values, and the context in which they live is just as important as our medical knowledge and skills when taking care of patients. Pediatricians are expert at bringing all of these things together, grounded in the best and most up-to-date evidence available, and in doing so elevate the care of children.

Which leads me to the second theme – pediatricians are a strong and important voice for children, and it is important for us to learn to lead. Through our work, we have a window into the lives of children, both when they are healthy and when they are sick. That is a great privilege but also a great responsibility. We see the things that work well in our systems and the things that do not. We see the amazing things children are capable of, but also troubling and pervasive inequities in care, access, and education. We see children who aren’t having their basic needs met – things like food, shelter, and a safe place to play. We see how these inequities impact health and wellness – both now and as children grow into adults. These observations, and the things we learn by caring for children and families day in and day out, can be translated into action. For each of us that will mean something different, but it is imperative that we develop our talents as advocates and leaders so that we can catalyze change. Our best hope for making things better is if we each do our part to create solutions. And when that happens, children – a lot of children – are healthier.

Since I began my first column 9 years ago, a lot has changed for me, and I suspect for many of you. When I first began writing, my now tall, confident tween (who already wears the same shoe size as me!) was barely walking. Thank you to all who have listened and encouraged me along the way – it has been a fun journey, and I’ve appreciated your time.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, both in Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and immediate past president of the District of Columbia chapter of the American Academy of Pediatrics.

Fifth grade is a wonderful school year and fifth graders are interesting, enthusiastic, and busy people, but conflicts can arise amidst their many activities. We discovered that our fifth grader could not finish his homework, play on 3 sports teams, take bass lessons (and practice), join the city chorus, play outside with his friends, walk his dog, spend quality time with his parents, and do his chores—much less eat and sleep. Choices needed to be made. Unfortunately, in our community dropping out of the premier soccer club probably limits future possibilities in the sport; nevertheless, it would entail 6 to 8 hours of game and practice time per week (plus travel), as well as multiple 3-day tournaments. Therefore our son dropped soccer, as we decided the best strategy for our fifth grader to develop and mature was to do his personal best at his schoolwork while also exploring a greater variety of less intensive extracurricular experiences.

Most dermatologists appropriately adopt a different strategy during medical school and dermatology training. An intensive, single-minded focus gets us through hours in the anatomy laboratory, the first difficult clinical rotations, sleepless nights, grand rounds quizzing, and board examinations. Completion of our training does not, however, signal that development and maturation are complete; rather, we must then choose among a new set of options, such as the basic questions of whether to practice in an academic setting or group or solo practice and whether to emphasize a subspecialty. These choices involve some mutually exclusive options and exist in a milieu of adult (ie, nonacademic) dilemmas concerning family life, community and spiritual life, avocations, exercise regimens, housing and material goods, and other routine aspects of life. The professional options that are available may be limited by the lack of community opportunities, geographic need, or job availability in a preferred location or institution.

So how do dermatologists manage to start their careers, then develop and maintain them? A best practice is to be both introspective as well as aware of our external environments. Good questions to ask ourselves periodically (having different answers at different stages is highly recommended!) include: What are my core values and what do I want to accomplish? Pay attention to your gut. When do you lose track of time and what makes you want to scream in frustration? Regularly take an inventory of your strengths and find opportunities to acquire the competencies that can take you to the next level. What skill do I need to finesse and how do I finesse it? Do an external scan and understand limiting factors such as geographic saturation in your desired practice type or the lack of appropriate collaborators in your preferred area of interest. Search out people who are doing what you’d like to do and then identify their paths and what you can use from their experiences to help with your career development.

Once you have identified a few professional goals to pursue, utilize all the resources you can find. You might find helpful seminars at an academic institution or at conferences. Do you want to become the regional expert in sarcoidosis? Check out what has been written and find other experts in the subject and where they are speaking. Many organizations have practice management or leadership development courses and seminars. There also are books for everything—those that I have found most useful include Douglas Stone’s Difficult Conversations: How to Discuss What Matters Most¹ and William L. Fisher and Roger Ury’s classic, Getting to Yes: Negotiating Agreement Without Giving In.² Have to give a talk? There is a PowerPoint 2016 for Dummies.³ The same series also includes a book on the Microsoft^® Excel spreadsheet. Also check out my all-time favorite—Brian Tracy’s Eat That Frog! 21 Ways to Stop Procrastinating and Get More Done in Less Time.⁴

It is important to experiment with different professional experiences and have an open mind when a new activity presents itself. Look for opportunities for new side ventures or interesting projects that will not take up much time so you can continue to do your best at your daily work. When I was a senior resident, a dermatologist from Maine asked me if I would help him find a dermatologist who would work regularly at a rural clinic in the northern part of the state. My answer was, why not me? For 8 years I worked in that clinic once to twice per month, seeing as many patients as I could for 8 to 12 hours a day on Friday, Saturday, and Sunday, and then returning to Boston, Massachusetts, for my normal work week. I even took my 2 youngest children (who were born during that time) with me and found a family there who took excellent care of them while I worked. It ended up being one of the most important experiences, both intellectually and emotionally, of my professional career. I learned how to diagnose difficult and complex dermatology problems by myself in an environment with few resources (the closest dermatologist was 150 miles away), how to use primary care providers to manage patients remotely, how to set up a clinic and manage staff (I hired other part-time staff to help me), and how to lead an effort that I felt passionate about. I sometimes even took on residents, which helped me finesse my teaching and supervision style.

Unlike the achievement of becoming a board-certified dermatologist, a dermatology career does not develop in a straight line, and rarely at a steady pace. It seems to me that a shift from a single-minded focus during residency to the fifth-grade strategy of doing our personal best at the main tasks of everyday work as well as participating in a variety of other experiences successfully develops a career that encompasses excellence, enthusiasm, and the fulfillment of personal needs along with those of our practice or institution. When we do our personal best on the day-to-day matters, people will be beating down the doors to offer other valuable experiences. To paraphrase an old truism, if you want something done well, find a busy person who does other things well. Some of the experiences presented to us may question our basic assumptions and redirect our careers; others will fizzle out, but not before they garner self-confidence or even indirectly lead to something more substantial in our careers. Sometimes all that an experience teaches us is that we do not want to continue down that path.

Career development is a dynamic process. Strive for excellence in everything that you do, keep your eyes open for broadening experiences, and maintain your fifth-grade enthusiasm! I am not sure what I will be doing in 5 years, but I hope it will be fresh, varied, and exciting. Do dermatology careers develop through a focused plan or serendipity? At my mature age, with a well-developed career, my answer is mostly serendipity.

Fifth grade is a wonderful school year and fifth graders are interesting, enthusiastic, and busy people, but conflicts can arise amidst their many activities. We discovered that our fifth grader could not finish his homework, play on 3 sports teams, take bass lessons (and practice), join the city chorus, play outside with his friends, walk his dog, spend quality time with his parents, and do his chores—much less eat and sleep. Choices needed to be made. Unfortunately, in our community dropping out of the premier soccer club probably limits future possibilities in the sport; nevertheless, it would entail 6 to 8 hours of game and practice time per week (plus travel), as well as multiple 3-day tournaments. Therefore our son dropped soccer, as we decided the best strategy for our fifth grader to develop and mature was to do his personal best at his schoolwork while also exploring a greater variety of less intensive extracurricular experiences.

Most dermatologists appropriately adopt a different strategy during medical school and dermatology training. An intensive, single-minded focus gets us through hours in the anatomy laboratory, the first difficult clinical rotations, sleepless nights, grand rounds quizzing, and board examinations. Completion of our training does not, however, signal that development and maturation are complete; rather, we must then choose among a new set of options, such as the basic questions of whether to practice in an academic setting or group or solo practice and whether to emphasize a subspecialty. These choices involve some mutually exclusive options and exist in a milieu of adult (ie, nonacademic) dilemmas concerning family life, community and spiritual life, avocations, exercise regimens, housing and material goods, and other routine aspects of life. The professional options that are available may be limited by the lack of community opportunities, geographic need, or job availability in a preferred location or institution.

So how do dermatologists manage to start their careers, then develop and maintain them? A best practice is to be both introspective as well as aware of our external environments. Good questions to ask ourselves periodically (having different answers at different stages is highly recommended!) include: What are my core values and what do I want to accomplish? Pay attention to your gut. When do you lose track of time and what makes you want to scream in frustration? Regularly take an inventory of your strengths and find opportunities to acquire the competencies that can take you to the next level. What skill do I need to finesse and how do I finesse it? Do an external scan and understand limiting factors such as geographic saturation in your desired practice type or the lack of appropriate collaborators in your preferred area of interest. Search out people who are doing what you’d like to do and then identify their paths and what you can use from their experiences to help with your career development.

Once you have identified a few professional goals to pursue, utilize all the resources you can find. You might find helpful seminars at an academic institution or at conferences. Do you want to become the regional expert in sarcoidosis? Check out what has been written and find other experts in the subject and where they are speaking. Many organizations have practice management or leadership development courses and seminars. There also are books for everything—those that I have found most useful include Douglas Stone’s Difficult Conversations: How to Discuss What Matters Most¹ and William L. Fisher and Roger Ury’s classic, Getting to Yes: Negotiating Agreement Without Giving In.² Have to give a talk? There is a PowerPoint 2016 for Dummies.³ The same series also includes a book on the Microsoft^® Excel spreadsheet. Also check out my all-time favorite—Brian Tracy’s Eat That Frog! 21 Ways to Stop Procrastinating and Get More Done in Less Time.⁴

It is important to experiment with different professional experiences and have an open mind when a new activity presents itself. Look for opportunities for new side ventures or interesting projects that will not take up much time so you can continue to do your best at your daily work. When I was a senior resident, a dermatologist from Maine asked me if I would help him find a dermatologist who would work regularly at a rural clinic in the northern part of the state. My answer was, why not me? For 8 years I worked in that clinic once to twice per month, seeing as many patients as I could for 8 to 12 hours a day on Friday, Saturday, and Sunday, and then returning to Boston, Massachusetts, for my normal work week. I even took my 2 youngest children (who were born during that time) with me and found a family there who took excellent care of them while I worked. It ended up being one of the most important experiences, both intellectually and emotionally, of my professional career. I learned how to diagnose difficult and complex dermatology problems by myself in an environment with few resources (the closest dermatologist was 150 miles away), how to use primary care providers to manage patients remotely, how to set up a clinic and manage staff (I hired other part-time staff to help me), and how to lead an effort that I felt passionate about. I sometimes even took on residents, which helped me finesse my teaching and supervision style.

Unlike the achievement of becoming a board-certified dermatologist, a dermatology career does not develop in a straight line, and rarely at a steady pace. It seems to me that a shift from a single-minded focus during residency to the fifth-grade strategy of doing our personal best at the main tasks of everyday work as well as participating in a variety of other experiences successfully develops a career that encompasses excellence, enthusiasm, and the fulfillment of personal needs along with those of our practice or institution. When we do our personal best on the day-to-day matters, people will be beating down the doors to offer other valuable experiences. To paraphrase an old truism, if you want something done well, find a busy person who does other things well. Some of the experiences presented to us may question our basic assumptions and redirect our careers; others will fizzle out, but not before they garner self-confidence or even indirectly lead to something more substantial in our careers. Sometimes all that an experience teaches us is that we do not want to continue down that path.

Career development is a dynamic process. Strive for excellence in everything that you do, keep your eyes open for broadening experiences, and maintain your fifth-grade enthusiasm! I am not sure what I will be doing in 5 years, but I hope it will be fresh, varied, and exciting. Do dermatology careers develop through a focused plan or serendipity? At my mature age, with a well-developed career, my answer is mostly serendipity.

Fifth grade is a wonderful school year and fifth graders are interesting, enthusiastic, and busy people, but conflicts can arise amidst their many activities. We discovered that our fifth grader could not finish his homework, play on 3 sports teams, take bass lessons (and practice), join the city chorus, play outside with his friends, walk his dog, spend quality time with his parents, and do his chores—much less eat and sleep. Choices needed to be made. Unfortunately, in our community dropping out of the premier soccer club probably limits future possibilities in the sport; nevertheless, it would entail 6 to 8 hours of game and practice time per week (plus travel), as well as multiple 3-day tournaments. Therefore our son dropped soccer, as we decided the best strategy for our fifth grader to develop and mature was to do his personal best at his schoolwork while also exploring a greater variety of less intensive extracurricular experiences.

Most dermatologists appropriately adopt a different strategy during medical school and dermatology training. An intensive, single-minded focus gets us through hours in the anatomy laboratory, the first difficult clinical rotations, sleepless nights, grand rounds quizzing, and board examinations. Completion of our training does not, however, signal that development and maturation are complete; rather, we must then choose among a new set of options, such as the basic questions of whether to practice in an academic setting or group or solo practice and whether to emphasize a subspecialty. These choices involve some mutually exclusive options and exist in a milieu of adult (ie, nonacademic) dilemmas concerning family life, community and spiritual life, avocations, exercise regimens, housing and material goods, and other routine aspects of life. The professional options that are available may be limited by the lack of community opportunities, geographic need, or job availability in a preferred location or institution.

So how do dermatologists manage to start their careers, then develop and maintain them? A best practice is to be both introspective as well as aware of our external environments. Good questions to ask ourselves periodically (having different answers at different stages is highly recommended!) include: What are my core values and what do I want to accomplish? Pay attention to your gut. When do you lose track of time and what makes you want to scream in frustration? Regularly take an inventory of your strengths and find opportunities to acquire the competencies that can take you to the next level. What skill do I need to finesse and how do I finesse it? Do an external scan and understand limiting factors such as geographic saturation in your desired practice type or the lack of appropriate collaborators in your preferred area of interest. Search out people who are doing what you’d like to do and then identify their paths and what you can use from their experiences to help with your career development.

Once you have identified a few professional goals to pursue, utilize all the resources you can find. You might find helpful seminars at an academic institution or at conferences. Do you want to become the regional expert in sarcoidosis? Check out what has been written and find other experts in the subject and where they are speaking. Many organizations have practice management or leadership development courses and seminars. There also are books for everything—those that I have found most useful include Douglas Stone’s Difficult Conversations: How to Discuss What Matters Most¹ and William L. Fisher and Roger Ury’s classic, Getting to Yes: Negotiating Agreement Without Giving In.² Have to give a talk? There is a PowerPoint 2016 for Dummies.³ The same series also includes a book on the Microsoft^® Excel spreadsheet. Also check out my all-time favorite—Brian Tracy’s Eat That Frog! 21 Ways to Stop Procrastinating and Get More Done in Less Time.⁴

It is important to experiment with different professional experiences and have an open mind when a new activity presents itself. Look for opportunities for new side ventures or interesting projects that will not take up much time so you can continue to do your best at your daily work. When I was a senior resident, a dermatologist from Maine asked me if I would help him find a dermatologist who would work regularly at a rural clinic in the northern part of the state. My answer was, why not me? For 8 years I worked in that clinic once to twice per month, seeing as many patients as I could for 8 to 12 hours a day on Friday, Saturday, and Sunday, and then returning to Boston, Massachusetts, for my normal work week. I even took my 2 youngest children (who were born during that time) with me and found a family there who took excellent care of them while I worked. It ended up being one of the most important experiences, both intellectually and emotionally, of my professional career. I learned how to diagnose difficult and complex dermatology problems by myself in an environment with few resources (the closest dermatologist was 150 miles away), how to use primary care providers to manage patients remotely, how to set up a clinic and manage staff (I hired other part-time staff to help me), and how to lead an effort that I felt passionate about. I sometimes even took on residents, which helped me finesse my teaching and supervision style.

Unlike the achievement of becoming a board-certified dermatologist, a dermatology career does not develop in a straight line, and rarely at a steady pace. It seems to me that a shift from a single-minded focus during residency to the fifth-grade strategy of doing our personal best at the main tasks of everyday work as well as participating in a variety of other experiences successfully develops a career that encompasses excellence, enthusiasm, and the fulfillment of personal needs along with those of our practice or institution. When we do our personal best on the day-to-day matters, people will be beating down the doors to offer other valuable experiences. To paraphrase an old truism, if you want something done well, find a busy person who does other things well. Some of the experiences presented to us may question our basic assumptions and redirect our careers; others will fizzle out, but not before they garner self-confidence or even indirectly lead to something more substantial in our careers. Sometimes all that an experience teaches us is that we do not want to continue down that path.

Career development is a dynamic process. Strive for excellence in everything that you do, keep your eyes open for broadening experiences, and maintain your fifth-grade enthusiasm! I am not sure what I will be doing in 5 years, but I hope it will be fresh, varied, and exciting. Do dermatology careers develop through a focused plan or serendipity? At my mature age, with a well-developed career, my answer is mostly serendipity.

Staphylococcus aureus (S aureus) is a common cause of infection within the hospital and in the community.¹ Treatment is based on the organism’s susceptibility to methicillin and is referred to as either MRSA (methicillin-resistant S aureus) or MSSA (methicillin-susceptible 
S aureus). As antibiotic resistance has evolved, patients with S aureus (especially MRSA) infections have become more difficult to treat. Susceptibility testing guides treatment of these infections and determines the minimum inhibitory concentration (MIC) for each antibiotic. A MIC is the minimum concentration of an antibiotic that will inhibit the visible growth of the organism after incubation.

Related: Experts Debate Infection Control Merits of ‘Bare Beneath the Elbows’

Vancomycin has remained the mainstay for treatment of patients with MRSA infections. An increasing number of infections with high documented MICs to vancomycin are raising concern that resistance may be developing. Clinical controversy exists within the infectious disease community as to whether vancomycin is less effective against S aureus infections with a vancomycin MIC of ≥ 2 µg/mL, contributing to poor patient outcomes.²

The Clinical and Laboratory Standards Institute (CLSI) lowered the breakpoint for vancomycin in 2006 from > 4 µg/mL to > 2 µg/mL.³ Breakpoints delineate MIC values that are considered susceptible, nonsusceptible, or resistant to an antibiotic. The CLSI breakpoint change points to an increase in vancomycin resistance and supports the need for further discussion and insight.

A 2012 meta-analysis was conducted to determine whether an association exists between S aureus infections with vancomycin MIC values ≥ 2 µg/mL and the effectiveness of the therapy.² Twenty-two studies were included with a primary outcome of 30-day mortality. A review of MRSA data revealed a statistically significant association between high vancomycin MICs (≥ 1.5 µg/mL) and increased mortality (P < .01), regardless of the source of infection. When limiting the data to Etest (bioMérieux, Marcy L’Etoile, France) MIC testing for MRSA bloodstream infections (BSIs), a vancomycin MIC ≥ 1.5 µg/mL was not associated with increased mortality (P = .08). Comparing data for MIC ≥ 2 µg/mL and ≤ 1.5 µg/mL, found that MICs ≥ 2 µg/mL were associated with increased mortality (P < .01). Analysis of the 11 studies that included data on treatment failure concluded that S aureus infections with a vancomycin MIC ≥ 1.5 µg/mL were associated with an increased risk of treatment failure in both MSSA and MRSA infections (P < .01) and that treatment failure was more likely in MRSA BSIs than in non-BSIs (P < .01).Evidence to support a possible correlation between high S aureus vancomycin MICs and poor patient outcomes came from a 2013 meta-analysis.³ The specific aim of this study was to examine the correlations between vancomycin MIC, patient mortality, and treatment failure. A MIC ≥ 1.5 µg/mL and ≥ 1.0 µg/mL were used to classify MICs as high when determined by Etest and broth microdilution (BMD), respectively. Analysis revealed an association between high vancomycin MICs and increased risk of treatment failure (relative risk [RR] 1.40, 95% confidence interval [CI] 1.15-1.71) and overall mortality (RR 1.42, 95% CI 1.08-1.87). Similarly, a sensitivity analysis on S aureus BSIs with high vancomycin MICs revealed an increased risk of mortality (RR 1.46, 95% CI 1.06-2.01) and treatment failure (RR 1.37, 95% CI 1.09-1.73).

Related: The Importance of an Antimicrobial Stewardship Program

The most recent meta-analysis (published in 2014) included patients with S aureus bacteremia and evaluated the association of high S aureus vancomycin MIC with an increased risk of mortality.⁴ A high MIC was defined as ≥ 1.5 µg/mL by Etest and ≥ 2.0 µg/mL by BMD. The analysis of 38 studies found a nonstatistically significant difference in mortality risk (P = .43). Further analysis was performed to determine whether the vancomycin MIC cutoff plays a role in increased mortality. No statistically significant difference in mortality was found when using a vancomycin MIC ≥ 1.5 µg/mL, ≥ 2.0 µg/mL, ≥ 4.0 µg/mL, or ≥ 8.0 µg/mL. The authors argued that their differing conclusions from other meta-analyses may be due to the inclusion of only bacteremias rather than all infection types, and although there was not a statistically significant difference, increased risk of mortality could not be excluded.

Related: Results Mixed in Hospital Efforts to Tackle Antimicrobial Resistance

Although conclusions of published meta-analyses differ, the results highlight the necessity of using clinical judgment in treating patients with S aureus infections with high MIC values and to consider the primary source and severity of infection. A confounding factor to direct comparison of the literature is the variations based on the method of MIC determination and testing (Etest vs BMD).

Additionally, all 3 studies addressed the importance of considering clinical patient factors that may lead to poorer prognosis as well as the difficultly in achieving necessary vancomycin levels with limited toxicity. The risk of increased mortality in patients with high vancomycin MICs cannot be ruled out at this time. Therefore, additional patient factors as well as the potential toxicities that may result from vancomycin therapy should be considered when using vancomycin in treating patients with S aureus infections.

Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Staphylococcus aureus (S aureus) is a common cause of infection within the hospital and in the community.¹ Treatment is based on the organism’s susceptibility to methicillin and is referred to as either MRSA (methicillin-resistant S aureus) or MSSA (methicillin-susceptible 
S aureus). As antibiotic resistance has evolved, patients with S aureus (especially MRSA) infections have become more difficult to treat. Susceptibility testing guides treatment of these infections and determines the minimum inhibitory concentration (MIC) for each antibiotic. A MIC is the minimum concentration of an antibiotic that will inhibit the visible growth of the organism after incubation.

Related: Experts Debate Infection Control Merits of ‘Bare Beneath the Elbows’

Vancomycin has remained the mainstay for treatment of patients with MRSA infections. An increasing number of infections with high documented MICs to vancomycin are raising concern that resistance may be developing. Clinical controversy exists within the infectious disease community as to whether vancomycin is less effective against S aureus infections with a vancomycin MIC of ≥ 2 µg/mL, contributing to poor patient outcomes.²

The Clinical and Laboratory Standards Institute (CLSI) lowered the breakpoint for vancomycin in 2006 from > 4 µg/mL to > 2 µg/mL.³ Breakpoints delineate MIC values that are considered susceptible, nonsusceptible, or resistant to an antibiotic. The CLSI breakpoint change points to an increase in vancomycin resistance and supports the need for further discussion and insight.

A 2012 meta-analysis was conducted to determine whether an association exists between S aureus infections with vancomycin MIC values ≥ 2 µg/mL and the effectiveness of the therapy.² Twenty-two studies were included with a primary outcome of 30-day mortality. A review of MRSA data revealed a statistically significant association between high vancomycin MICs (≥ 1.5 µg/mL) and increased mortality (P < .01), regardless of the source of infection. When limiting the data to Etest (bioMérieux, Marcy L’Etoile, France) MIC testing for MRSA bloodstream infections (BSIs), a vancomycin MIC ≥ 1.5 µg/mL was not associated with increased mortality (P = .08). Comparing data for MIC ≥ 2 µg/mL and ≤ 1.5 µg/mL, found that MICs ≥ 2 µg/mL were associated with increased mortality (P < .01). Analysis of the 11 studies that included data on treatment failure concluded that S aureus infections with a vancomycin MIC ≥ 1.5 µg/mL were associated with an increased risk of treatment failure in both MSSA and MRSA infections (P < .01) and that treatment failure was more likely in MRSA BSIs than in non-BSIs (P < .01).Evidence to support a possible correlation between high S aureus vancomycin MICs and poor patient outcomes came from a 2013 meta-analysis.³ The specific aim of this study was to examine the correlations between vancomycin MIC, patient mortality, and treatment failure. A MIC ≥ 1.5 µg/mL and ≥ 1.0 µg/mL were used to classify MICs as high when determined by Etest and broth microdilution (BMD), respectively. Analysis revealed an association between high vancomycin MICs and increased risk of treatment failure (relative risk [RR] 1.40, 95% confidence interval [CI] 1.15-1.71) and overall mortality (RR 1.42, 95% CI 1.08-1.87). Similarly, a sensitivity analysis on S aureus BSIs with high vancomycin MICs revealed an increased risk of mortality (RR 1.46, 95% CI 1.06-2.01) and treatment failure (RR 1.37, 95% CI 1.09-1.73).

Related: The Importance of an Antimicrobial Stewardship Program

The most recent meta-analysis (published in 2014) included patients with S aureus bacteremia and evaluated the association of high S aureus vancomycin MIC with an increased risk of mortality.⁴ A high MIC was defined as ≥ 1.5 µg/mL by Etest and ≥ 2.0 µg/mL by BMD. The analysis of 38 studies found a nonstatistically significant difference in mortality risk (P = .43). Further analysis was performed to determine whether the vancomycin MIC cutoff plays a role in increased mortality. No statistically significant difference in mortality was found when using a vancomycin MIC ≥ 1.5 µg/mL, ≥ 2.0 µg/mL, ≥ 4.0 µg/mL, or ≥ 8.0 µg/mL. The authors argued that their differing conclusions from other meta-analyses may be due to the inclusion of only bacteremias rather than all infection types, and although there was not a statistically significant difference, increased risk of mortality could not be excluded.

Related: Results Mixed in Hospital Efforts to Tackle Antimicrobial Resistance

Although conclusions of published meta-analyses differ, the results highlight the necessity of using clinical judgment in treating patients with S aureus infections with high MIC values and to consider the primary source and severity of infection. A confounding factor to direct comparison of the literature is the variations based on the method of MIC determination and testing (Etest vs BMD).

Additionally, all 3 studies addressed the importance of considering clinical patient factors that may lead to poorer prognosis as well as the difficultly in achieving necessary vancomycin levels with limited toxicity. The risk of increased mortality in patients with high vancomycin MICs cannot be ruled out at this time. Therefore, additional patient factors as well as the potential toxicities that may result from vancomycin therapy should be considered when using vancomycin in treating patients with S aureus infections.

Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Staphylococcus aureus (S aureus) is a common cause of infection within the hospital and in the community.¹ Treatment is based on the organism’s susceptibility to methicillin and is referred to as either MRSA (methicillin-resistant S aureus) or MSSA (methicillin-susceptible 
S aureus). As antibiotic resistance has evolved, patients with S aureus (especially MRSA) infections have become more difficult to treat. Susceptibility testing guides treatment of these infections and determines the minimum inhibitory concentration (MIC) for each antibiotic. A MIC is the minimum concentration of an antibiotic that will inhibit the visible growth of the organism after incubation.

Related: Experts Debate Infection Control Merits of ‘Bare Beneath the Elbows’

Vancomycin has remained the mainstay for treatment of patients with MRSA infections. An increasing number of infections with high documented MICs to vancomycin are raising concern that resistance may be developing. Clinical controversy exists within the infectious disease community as to whether vancomycin is less effective against S aureus infections with a vancomycin MIC of ≥ 2 µg/mL, contributing to poor patient outcomes.²

The Clinical and Laboratory Standards Institute (CLSI) lowered the breakpoint for vancomycin in 2006 from > 4 µg/mL to > 2 µg/mL.³ Breakpoints delineate MIC values that are considered susceptible, nonsusceptible, or resistant to an antibiotic. The CLSI breakpoint change points to an increase in vancomycin resistance and supports the need for further discussion and insight.

A 2012 meta-analysis was conducted to determine whether an association exists between S aureus infections with vancomycin MIC values ≥ 2 µg/mL and the effectiveness of the therapy.² Twenty-two studies were included with a primary outcome of 30-day mortality. A review of MRSA data revealed a statistically significant association between high vancomycin MICs (≥ 1.5 µg/mL) and increased mortality (P < .01), regardless of the source of infection. When limiting the data to Etest (bioMérieux, Marcy L’Etoile, France) MIC testing for MRSA bloodstream infections (BSIs), a vancomycin MIC ≥ 1.5 µg/mL was not associated with increased mortality (P = .08). Comparing data for MIC ≥ 2 µg/mL and ≤ 1.5 µg/mL, found that MICs ≥ 2 µg/mL were associated with increased mortality (P < .01). Analysis of the 11 studies that included data on treatment failure concluded that S aureus infections with a vancomycin MIC ≥ 1.5 µg/mL were associated with an increased risk of treatment failure in both MSSA and MRSA infections (P < .01) and that treatment failure was more likely in MRSA BSIs than in non-BSIs (P < .01).Evidence to support a possible correlation between high S aureus vancomycin MICs and poor patient outcomes came from a 2013 meta-analysis.³ The specific aim of this study was to examine the correlations between vancomycin MIC, patient mortality, and treatment failure. A MIC ≥ 1.5 µg/mL and ≥ 1.0 µg/mL were used to classify MICs as high when determined by Etest and broth microdilution (BMD), respectively. Analysis revealed an association between high vancomycin MICs and increased risk of treatment failure (relative risk [RR] 1.40, 95% confidence interval [CI] 1.15-1.71) and overall mortality (RR 1.42, 95% CI 1.08-1.87). Similarly, a sensitivity analysis on S aureus BSIs with high vancomycin MICs revealed an increased risk of mortality (RR 1.46, 95% CI 1.06-2.01) and treatment failure (RR 1.37, 95% CI 1.09-1.73).

Related: The Importance of an Antimicrobial Stewardship Program

The most recent meta-analysis (published in 2014) included patients with S aureus bacteremia and evaluated the association of high S aureus vancomycin MIC with an increased risk of mortality.⁴ A high MIC was defined as ≥ 1.5 µg/mL by Etest and ≥ 2.0 µg/mL by BMD. The analysis of 38 studies found a nonstatistically significant difference in mortality risk (P = .43). Further analysis was performed to determine whether the vancomycin MIC cutoff plays a role in increased mortality. No statistically significant difference in mortality was found when using a vancomycin MIC ≥ 1.5 µg/mL, ≥ 2.0 µg/mL, ≥ 4.0 µg/mL, or ≥ 8.0 µg/mL. The authors argued that their differing conclusions from other meta-analyses may be due to the inclusion of only bacteremias rather than all infection types, and although there was not a statistically significant difference, increased risk of mortality could not be excluded.

Related: Results Mixed in Hospital Efforts to Tackle Antimicrobial Resistance

Although conclusions of published meta-analyses differ, the results highlight the necessity of using clinical judgment in treating patients with S aureus infections with high MIC values and to consider the primary source and severity of infection. A confounding factor to direct comparison of the literature is the variations based on the method of MIC determination and testing (Etest vs BMD).

Additionally, all 3 studies addressed the importance of considering clinical patient factors that may lead to poorer prognosis as well as the difficultly in achieving necessary vancomycin levels with limited toxicity. The risk of increased mortality in patients with high vancomycin MICs cannot be ruled out at this time. Therefore, additional patient factors as well as the potential toxicities that may result from vancomycin therapy should be considered when using vancomycin in treating patients with S aureus infections.

Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Over the last 2 decades, the medical community has accumulated more information regarding fetal exposure to selective serotonin reuptake inhibitors than almost any medicine that women take during pregnancy.

Data on the risks for major congenital malformations and even specific malformations, such as cardiac defects, are so vast that they can be confusing for clinicians and researchers alike to digest. Yet the consensus among experts in reproductive safety is that the risk of teratogenesis following fetal exposure to SSRIs is small in terms of absolute risks (N Engl J Med. 2007;356:2732-3.).

But women and their partners are worried about more than the risk of malformations. They also are concerned about how fetal exposure to SSRIs will impact long-term neurobehavioral sequelae. It turns out that is a much more challenging question, and the data available to inform our answers still are relatively sparse.

Research gaps

There have been several reports in the literature that suggest there are modest effects on motor function in children whose mothers used SSRIs during pregnancy, but these reports have not been particularly systematic and have excluded some relevant variables, such as the presence or absence of a psychiatric disorder during pregnancy.

In what is considered a seminal examination of this topic performed more than a decade ago, Dr. Irena Nulman and her colleagues at the Motherisk program in Toronto demonstrated the importance of accounting for postpartum maternal depression and mood. Among a group of children exposed to fluoxetine (Prozac) or tricyclic antidepressants throughout pregnancy, there were no differences in IQ or language development, compared with unexposed children between 15 and 71 months of age. However, children with lower cognitive and language achievement were more likely to have mothers with higher ratings of postpartum mood disturbance (Am J Psychiatry. 2002 Nov;159[11]:1889-95.).

The charge to the field is to tackle this next clinical research frontier: the longer-term effects of fetal exposure to antidepressants and maternal psychiatric illness. Only by factoring in both of these important variables will we be able to get a true model of risk for this very critical issue of longer-term behavioral function.

Recently, researchers attempted to look at this question using data from the Norwegian Mother and Child Cohort study, a large population-based, prospective pregnancy cohort study. Children were assessed at age 3 years and motor development was assessed by maternal reports of fine and gross motor development using items from the Ages and Stages Questionnaire (ASQ). Maternal ASQ scores were compared with data from another Norwegian study in which clinicians assessed motor development using the gross and fine motor Mullen Scales of Early Learning (MSEL).

The strength of the study is that it included a very large number of children – more than 50,000 – although it is noteworthy that only a small percentage of women actually used SSRIs during pregnancy. A total of 381 women reported the use of SSRIs during pregnancy, with about half of the women reporting prolonged use (defined as exposure at two points of observation in the study).

Creatas Images

The findings are noteworthy. The study showed that children with prolonged SSRI exposure were more likely to exhibit delays in fine motor development, compared with children with no fetal exposure to SSRIs (odds ratio, 1.42; 95% confidence interval, 1.07-1.87). The association persisted even after adjusting for symptoms of anxiety and depression before and during pregnancy. The severity of maternal depression provided only a partial explanation for the association, and depression after pregnancy appeared to have no impact on the estimated effect of SSRIs during pregnancy (BJOG. 2015 Sep 15. doi: 10.1111/1471-0528.13582).

Personal medicine

So how does the clinician translate these findings into practice? While the study indicates that prolonged prenatal exposure to SSRIs was associated with delayed motor development at age 3 years, the association was very weak, and only a few children had clinically significant impairment in motor development. The finding should be reassuring to many women who are faced with this decision.

The researchers should be commended for trying to at least begin to tackle this critical frontier with respect to the risk-benefit decision in using these medicines during pregnancy. The problem is that in the absence of robust data quantifying the exposure to maternal psychiatric illness, the quality of the data still is somewhat limited.

So far the data indicate that there is not a major signal for neurobehavioral dysregulation associated with fetal exposure to SSRIs. That being said, to adequately answer the question for the field it will be important to conduct a single, prospective study where we can accurately quantify exposure to medicine and exposure to maternal psychiatric illness during pregnancy. That type of study will allow us to assess the relative exposures and come up with a much more refined risk estimate. We also will be able to fold in a critical piece – the role of genomics.

Genomics will play a significant role in determining risk because vulnerability to potential disruption in central nervous system development may be a factor in determining the development of the brain in utero. We know, for example, that prenatal stress affects neuromodulation in the brain, and that vulnerability to disruption will be variable from patient to patient. Prospective studies where we not only quantify what medicines women are taking and the severity of psychiatric illness, but also vulnerability to central nervous system disruption, if any, at the level of the genome will be a critical missing piece for future investigators.

Even similar exposure to medicine and psychiatric disorders may have variable effects on the developing brain. If we can identify that variability at the level of the genome, then we will be able to create a refined model of risk that will dictate personalized medicine with respect to reproductive psychopharmacology.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, email him at obnews@frontlinemedcom.com.

Over the last 2 decades, the medical community has accumulated more information regarding fetal exposure to selective serotonin reuptake inhibitors than almost any medicine that women take during pregnancy.

Data on the risks for major congenital malformations and even specific malformations, such as cardiac defects, are so vast that they can be confusing for clinicians and researchers alike to digest. Yet the consensus among experts in reproductive safety is that the risk of teratogenesis following fetal exposure to SSRIs is small in terms of absolute risks (N Engl J Med. 2007;356:2732-3.).

But women and their partners are worried about more than the risk of malformations. They also are concerned about how fetal exposure to SSRIs will impact long-term neurobehavioral sequelae. It turns out that is a much more challenging question, and the data available to inform our answers still are relatively sparse.

Research gaps

There have been several reports in the literature that suggest there are modest effects on motor function in children whose mothers used SSRIs during pregnancy, but these reports have not been particularly systematic and have excluded some relevant variables, such as the presence or absence of a psychiatric disorder during pregnancy.

In what is considered a seminal examination of this topic performed more than a decade ago, Dr. Irena Nulman and her colleagues at the Motherisk program in Toronto demonstrated the importance of accounting for postpartum maternal depression and mood. Among a group of children exposed to fluoxetine (Prozac) or tricyclic antidepressants throughout pregnancy, there were no differences in IQ or language development, compared with unexposed children between 15 and 71 months of age. However, children with lower cognitive and language achievement were more likely to have mothers with higher ratings of postpartum mood disturbance (Am J Psychiatry. 2002 Nov;159[11]:1889-95.).

The charge to the field is to tackle this next clinical research frontier: the longer-term effects of fetal exposure to antidepressants and maternal psychiatric illness. Only by factoring in both of these important variables will we be able to get a true model of risk for this very critical issue of longer-term behavioral function.

Recently, researchers attempted to look at this question using data from the Norwegian Mother and Child Cohort study, a large population-based, prospective pregnancy cohort study. Children were assessed at age 3 years and motor development was assessed by maternal reports of fine and gross motor development using items from the Ages and Stages Questionnaire (ASQ). Maternal ASQ scores were compared with data from another Norwegian study in which clinicians assessed motor development using the gross and fine motor Mullen Scales of Early Learning (MSEL).

The strength of the study is that it included a very large number of children – more than 50,000 – although it is noteworthy that only a small percentage of women actually used SSRIs during pregnancy. A total of 381 women reported the use of SSRIs during pregnancy, with about half of the women reporting prolonged use (defined as exposure at two points of observation in the study).

Creatas Images

The findings are noteworthy. The study showed that children with prolonged SSRI exposure were more likely to exhibit delays in fine motor development, compared with children with no fetal exposure to SSRIs (odds ratio, 1.42; 95% confidence interval, 1.07-1.87). The association persisted even after adjusting for symptoms of anxiety and depression before and during pregnancy. The severity of maternal depression provided only a partial explanation for the association, and depression after pregnancy appeared to have no impact on the estimated effect of SSRIs during pregnancy (BJOG. 2015 Sep 15. doi: 10.1111/1471-0528.13582).

Personal medicine

So how does the clinician translate these findings into practice? While the study indicates that prolonged prenatal exposure to SSRIs was associated with delayed motor development at age 3 years, the association was very weak, and only a few children had clinically significant impairment in motor development. The finding should be reassuring to many women who are faced with this decision.

The researchers should be commended for trying to at least begin to tackle this critical frontier with respect to the risk-benefit decision in using these medicines during pregnancy. The problem is that in the absence of robust data quantifying the exposure to maternal psychiatric illness, the quality of the data still is somewhat limited.

So far the data indicate that there is not a major signal for neurobehavioral dysregulation associated with fetal exposure to SSRIs. That being said, to adequately answer the question for the field it will be important to conduct a single, prospective study where we can accurately quantify exposure to medicine and exposure to maternal psychiatric illness during pregnancy. That type of study will allow us to assess the relative exposures and come up with a much more refined risk estimate. We also will be able to fold in a critical piece – the role of genomics.

Genomics will play a significant role in determining risk because vulnerability to potential disruption in central nervous system development may be a factor in determining the development of the brain in utero. We know, for example, that prenatal stress affects neuromodulation in the brain, and that vulnerability to disruption will be variable from patient to patient. Prospective studies where we not only quantify what medicines women are taking and the severity of psychiatric illness, but also vulnerability to central nervous system disruption, if any, at the level of the genome will be a critical missing piece for future investigators.

Even similar exposure to medicine and psychiatric disorders may have variable effects on the developing brain. If we can identify that variability at the level of the genome, then we will be able to create a refined model of risk that will dictate personalized medicine with respect to reproductive psychopharmacology.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, email him at obnews@frontlinemedcom.com.

Over the last 2 decades, the medical community has accumulated more information regarding fetal exposure to selective serotonin reuptake inhibitors than almost any medicine that women take during pregnancy.

Data on the risks for major congenital malformations and even specific malformations, such as cardiac defects, are so vast that they can be confusing for clinicians and researchers alike to digest. Yet the consensus among experts in reproductive safety is that the risk of teratogenesis following fetal exposure to SSRIs is small in terms of absolute risks (N Engl J Med. 2007;356:2732-3.).

But women and their partners are worried about more than the risk of malformations. They also are concerned about how fetal exposure to SSRIs will impact long-term neurobehavioral sequelae. It turns out that is a much more challenging question, and the data available to inform our answers still are relatively sparse.

Research gaps

There have been several reports in the literature that suggest there are modest effects on motor function in children whose mothers used SSRIs during pregnancy, but these reports have not been particularly systematic and have excluded some relevant variables, such as the presence or absence of a psychiatric disorder during pregnancy.

In what is considered a seminal examination of this topic performed more than a decade ago, Dr. Irena Nulman and her colleagues at the Motherisk program in Toronto demonstrated the importance of accounting for postpartum maternal depression and mood. Among a group of children exposed to fluoxetine (Prozac) or tricyclic antidepressants throughout pregnancy, there were no differences in IQ or language development, compared with unexposed children between 15 and 71 months of age. However, children with lower cognitive and language achievement were more likely to have mothers with higher ratings of postpartum mood disturbance (Am J Psychiatry. 2002 Nov;159[11]:1889-95.).

The charge to the field is to tackle this next clinical research frontier: the longer-term effects of fetal exposure to antidepressants and maternal psychiatric illness. Only by factoring in both of these important variables will we be able to get a true model of risk for this very critical issue of longer-term behavioral function.

Recently, researchers attempted to look at this question using data from the Norwegian Mother and Child Cohort study, a large population-based, prospective pregnancy cohort study. Children were assessed at age 3 years and motor development was assessed by maternal reports of fine and gross motor development using items from the Ages and Stages Questionnaire (ASQ). Maternal ASQ scores were compared with data from another Norwegian study in which clinicians assessed motor development using the gross and fine motor Mullen Scales of Early Learning (MSEL).

The strength of the study is that it included a very large number of children – more than 50,000 – although it is noteworthy that only a small percentage of women actually used SSRIs during pregnancy. A total of 381 women reported the use of SSRIs during pregnancy, with about half of the women reporting prolonged use (defined as exposure at two points of observation in the study).

Creatas Images

The findings are noteworthy. The study showed that children with prolonged SSRI exposure were more likely to exhibit delays in fine motor development, compared with children with no fetal exposure to SSRIs (odds ratio, 1.42; 95% confidence interval, 1.07-1.87). The association persisted even after adjusting for symptoms of anxiety and depression before and during pregnancy. The severity of maternal depression provided only a partial explanation for the association, and depression after pregnancy appeared to have no impact on the estimated effect of SSRIs during pregnancy (BJOG. 2015 Sep 15. doi: 10.1111/1471-0528.13582).

Personal medicine

So how does the clinician translate these findings into practice? While the study indicates that prolonged prenatal exposure to SSRIs was associated with delayed motor development at age 3 years, the association was very weak, and only a few children had clinically significant impairment in motor development. The finding should be reassuring to many women who are faced with this decision.

The researchers should be commended for trying to at least begin to tackle this critical frontier with respect to the risk-benefit decision in using these medicines during pregnancy. The problem is that in the absence of robust data quantifying the exposure to maternal psychiatric illness, the quality of the data still is somewhat limited.

So far the data indicate that there is not a major signal for neurobehavioral dysregulation associated with fetal exposure to SSRIs. That being said, to adequately answer the question for the field it will be important to conduct a single, prospective study where we can accurately quantify exposure to medicine and exposure to maternal psychiatric illness during pregnancy. That type of study will allow us to assess the relative exposures and come up with a much more refined risk estimate. We also will be able to fold in a critical piece – the role of genomics.

Genomics will play a significant role in determining risk because vulnerability to potential disruption in central nervous system development may be a factor in determining the development of the brain in utero. We know, for example, that prenatal stress affects neuromodulation in the brain, and that vulnerability to disruption will be variable from patient to patient. Prospective studies where we not only quantify what medicines women are taking and the severity of psychiatric illness, but also vulnerability to central nervous system disruption, if any, at the level of the genome will be a critical missing piece for future investigators.

Even similar exposure to medicine and psychiatric disorders may have variable effects on the developing brain. If we can identify that variability at the level of the genome, then we will be able to create a refined model of risk that will dictate personalized medicine with respect to reproductive psychopharmacology.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, email him at obnews@frontlinemedcom.com.

In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

In this month’s Vascular Specialist, there are two letters to the editor that seem to imply a division in the SVS membership. The letters indirectly suggest that the SVS comprises two camps, on the one hand, academics, and on the other, community-based physicians. Further, although the majority of the membership comprises primarily of nonacademic surgeons, the leadership is, and will remain, predominantly composed of University-employed physicians. Implicit also is that there may not be a common agenda.

However, many questions come to mind: Are we truly a house divided? If so, how did this come about? Do community and academic surgeons indeed have different concerns that split us into camps? If so, how can we come together because the aphorism “United we stand, divided we fall” will have critical implications for the future of our specialty.

Dennis Gable writes that “the SVS is often (and historically) thought of as a society reserved for academic surgeons” because it is regarded solely as a vehicle to arrange a national academic meeting (the VAM). However, he counters that incorrect assessment by describing many fundamentally important roles that the SVS plays in the daily lives of practicing vascular surgeons. He encourages members to go online (at www.vascularweb.org) and see for themselves all that the SVS is doing for vascular surgery, vascular surgeons and their patients. The Society’s strong advocacy efforts on reimbursement issues, for example, have prevented millions of dollars in payment cuts, something hugely important to members in community practice.

However, many older surgeons will recall a period when only a select few could join the Society for Vascular Surgery as it was then constituted. Entry was reserved for nationally recognized researchers or those with an extensive list of publications. At that time, it was even difficult to become a member of the International Society for Cardiovascular Surgery. Community surgeons who had limited or few current publications were almost totally excluded. That was the impetus for community surgeons to form the Society for Clinical Vascular Surgery. However, some years back the SVS expanded beyond just the meeting and sought to be inclusive rather than restrictive. Membership is now virtually guaranteed to all board-certified vascular surgeons in good standing. Even members of allied health groups such as nurse practitioners and physician assistants are encouraged to become affiliate members. The SVS inspires female and minority medical students to become vascular surgeons and future members.

Further, 7 years ago, current President Bruce Perler, then chair of the Clinical Practice Council, initiated the Community Practice Advisory Committee in an effort to address the concerns of community members. I had the privilege of being its first chairperson. The current chairperson of that committee, Richard Lynn, now serves on the Board of the Society. Additionally, the SVS has made a concerted effort to add community surgeons to all of its committees.

Even the annual meeting has increasingly added multiple sessions addressing topics of interest to community surgeons. As attendance at these session proves, academic and employed physicians have found them to be equally informative. This is the result of the changing economic and health care environment that has blurred the lines between academic and nonacademic practices. Is there, then, any real division that separates the university surgeon from his or her community counterpart? Personally I believe there is none. If there is, it is simply a historical memory that has failed to disappear when confronted with the reality of the present.

However, Carlo Dall’Olmo and Dennis Gable, community surgeons who have been very active in SVS leadership positions (Carlo as Chair of the PAC and Dennis as Membership Chair), both recognize the absence of community surgeons on the SVS Executive Committee. Does this imply a conspiracy? Of course not! Rather, it is a result of the many factors briefly outlined in their letters. I have had the benefit of discussions with both men, as well as current and past SVS Presidents, so perhaps I can paraphrase their thoughts on this issue.

Carlo suggests that it is a result of a governance structure that rewards leadership positions based not only on service to the Society but also on academic achievements. He, as well as many others, suggests that our leaders should be elected, based not only on their publications and research, but also they must have proven dedication to the Society as well as providing a manifesto or platform explaining their goals for its future. Indeed, most if not all current and past executive members have been some of the most prolific researchers and have also effectively served on multiple committees over many years. If not for their hard work (unpaid and purely voluntary), our Society would never be in the viable situation it is now. We certainly owe a great deal of gratitude to the many academics who have so effectively stewarded our organization.

Some also have questioned whether busy community practice surgeons will be equally able to comply with the time-consuming demands of the Executive Committee. The presidency is almost a full-time position, yet it remains unpaid. Accordingly, a private-practice surgeon will need the backing of his or her partners or sufficient finances to counter the loss of income. Academic surgeons also have busy lives running departments, lecturing students, and operating on the most-challenging cases. Surely then, if candidates have proven themselves through years of conscientious labor on SVS committees, the manner of their employment or source of income should not influence their electability.

Dennis also explains that many private practice surgeons have a laissez-faire attitude leaving the multitude of committee appointments to these dedicated academic surgeons. On the contrary, I have spoken with numerous community surgeons who claim to have volunteered for committee or leadership positions and have not yet been appointed. Perhaps it is a self-fulfilling situation. The composition of the SVS Nominating Committee, which proposes the slate for SVS officers, originally comprised the immediate past, current, and future presidents. The composition was changed several years ago and now includes the two immediate past presidents, a representative from the affiliated vascular societies, a representative from the SVS Councils, and recently, an at-large member elected by the SVS membership. The objective was to encourage participation from someone, possibly a community practice surgeon, who had the support of the general membership.

However, it is problematic for community surgeons to gain sufficient exposure or national recognition to be elected unless they publish and lecture prolifically. Since the nominating committee has always consisted of academic surgeons, it could be argued that they would necessarily favor academics. On the other hand, such favoritism may be based simply on the fact that they are more familiar with one another. It is conceivable that as more community surgeons prove their organizational skills by serving on various committees, some will become well known and electable. As yet, the current pool of eligible community surgeons is small, whereas there are many academic surgeons clearly deserving of appointment.

Interestingly, there are now academic members of the current Executive Committee who were formerly in private practice or are currently in situations that can be regarded as both academic and community based. This suggests that the lines between academic and community practice have blurred sufficiently enough that we should no longer consider ourselves as belonging to different camps. Also, for the last 3 years, I have been a guest at the SVS Board of Directors meetings, where I have witnessed intense deliberation on multiple issues of equal concern to both academic and private surgeons. In fact, some current leaders are so certain that we are all the same that they question whether the addition of community surgeons will add new insights that might modify the daily function and future agenda of the SVS.

Consistent with the necessity for full disclosure, I am a community-practice surgeon, although I was in full-time academics for the first 6 years of my practice and now hold a position as a clinical professor at Florida State University Medical School in Tallahassee. With this background, I suggest that negating the value of community input is an incorrect concept. Private practice has many challenges, which include diverse issues such as maintaining IT departments, staffing, electronic medical records, Stark issues, malpractice insurance requirements, PQRS requirements, contract issues, partnership contracts, and competition with other specialists and hospital groups. Even current training paradigms are affecting private practitioners. Accordingly, it is imperative that their concerns are heard at the highest level. Perhaps, too, having community-practice representation on the Executive would be seen as a positive impetus to encourage more unaffiliated community doctors to join the Society.In September, Pope Francis visited America. During his speech to the United Nations, he made the following statement: “The contemporary world, with its open wounds which affect so many of our brothers and sisters, commands that we confront every form of polarization which would divide it into these two camps.”

Vascular surgeons and the Society for Vascular Surgery would do well to heed his words.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.