Commentary

White tea, like green tea, is derived from the plant Camellia sinensis, a member of the Theaceae family and the source of all the globally popular “true tea” beverages.

Of the four main true teas, green and white are unfermented (white is the least processed), black tea is fermented, and oolong tea is semifermented.^1,2,3 White tea actually comes from the tips of the green tea leaves or leaves that have not yet fully opened, with buds covered by fine white hair. As a commodity, white tea is more expensive than green tea because it is more difficult to obtain. EGCG [(-)epigallocatechin-3-O-gallate], the most abundant and biologically active polyphenolic catechin found in green tea, is also the constituent in white tea that accounts for its antioxidant properties.^4,5 Indeed, white tea is included in topical products for its antioxidant as well as antiseptic activity, and is considered a more potent antioxidant additive medium than green tea.^6,1

As an ingredient in a combination formula

White tea is included in the dietary supplement Imedeen Prime Renewal, along with fish protein polysaccharides, vitamins C and E, zinc, and extracts from soy, grape seed, chamomile, and tomato.

In 2006, Skovgaard et al. conducted a 6-month, double-blind, placebo-controlled randomized study on 80 healthy postmenopausal women (38 in the treatment group, 42 in the placebo group completed the study) to determine antiaging effects on the skin. Subjects took 2 tablets of the supplement or placebo twice daily. Clinical, photo, and ultrasound evaluations showed significantly greater improvements in the treatment group, compared with the placebo group, in the face (forehead, periocular, and perioral wrinkles; mottled pigmentation, laxity, sagging, dark circles under the eyes; and overall appearance), hands, and décolletage.⁷

Antioxidant and antiaging activity

In 2009, Thring et al. studied the antiaging and antioxidant characteristics of 23 plant extracts (from 21 species) by considering antielastase and anticollagenase activities. White tea was found to exhibit the greatest inhibitory activity against both elastase and collagenase, greater than burdock root and angelica in terms of antielastase activity, and greater than green tea, rose tincture, and lavender in relation to anticollagenase activity. The Trolox equivalent antioxidant capacity assay also showed that white tea displayed the highest antioxidant activity. The investigators noted the very high phenolic content of white tea in characterizing its potent inhibitory activity against enzymes that accelerate cutaneous aging.⁶

Earlier in 2009, Camouse et al. examined skin samples from volunteers or skin explants treated with topical white or green tea after ultraviolet exposure to ascertain that the antioxidant could prevent simulated solar radiation–induced damage to DNA and Langerhans cells. They noted that each product displayed a sun protection factor of 1, suggesting that the photoprotection conferred was not due to direct UV absorption. Both forms of topically applied tea extracts were equally effective and judged by the researchers to be potential photoprotective agents when used along with other substantiated approaches to skin protection. These findings provided the first reported evidence of topically applied white tea preventing UV-induced immunosuppression. The researchers further suggested that the color of white tea might render it more cosmetically desirable than green tea.⁸

It should be noted that a systematic review performed by Hunt et al. in 2010 of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and AMED (Allied and Complementary Medicine Database) databases up to 2009 identified 11 randomized clinical or controlled clinical trials evaluating the effectiveness of botanical extracts for diminishing wrinkling and other signs of cutaneous aging. No significant reductions in wrinkling were associated with the use of green tea or Vitaphenol (a combination of green and white teas, mangosteen, and pomegranate extract). The authors noted, however, that all of the trials that they identified were characterized by poor methodologic quality.⁹

Thring et al. conducted an in vitro study in 2011 to evaluate the antioxidant and anti-inflammatory activity of white tea, rose, and witch hazel extracts in primary human skin fibroblasts. The investigators measured significant anticollagenase, antielastase, and antioxidant activities for the white tea extracts, which also spurred a significant reduction in the interleukin-8 amount synthesized by fibroblasts, compared with controls. They concluded that white tea (as well as the other extracts) yielded a protective effect on fibroblasts against damage induced by hydrogen peroxide exposure.¹⁰

In 2014, Azman et al. used the spin trap method and electron paramagnetic resonance (EPR) spectroscopy to show that among white tea constituents, EGCG and epicatechin-3-gallate (ECG) exhibit the greatest antiradical activity against the methoxy radical.¹

Conclusion

Tea is one of the most popular beverages in the world and is touted for its antioxidant and anticancer properties. While the ingredients of green tea polyphenols have inspired a spate of recent research, much is yet to be learned about the potential health benefits of white tea, which is even less processed. Some evidence appears to suggest that white tea may be shown to be more effective overall, and in the dermatologic realm, than green tea. I look forward to seeing more research.

References

1. J Agric Food Chem. 2014;62(1):5743-8.

2. Dermatol Surg. 2005;31(7 Pt 2):873-80.

3. Oxid Med Cell Longev. 2012:2012:560682.

4. Mol Cell Biochem. 2000;206(1-2):125-32.

5. Free Radic Biol Med. 1999;26(11-12):1427-35.

6. BMC Complement Altern Med. 2009;9:27.

7. Eur J Clin Nutr. 2006;60(10):1201-6.

8. Exp Dermatol. 2009;18(6):522-6.

9. Drugs Aging. 2010;27(12):973-85.

10. J Inflamm (Lond). 2011;8(1):27).

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

White tea, like green tea, is derived from the plant Camellia sinensis, a member of the Theaceae family and the source of all the globally popular “true tea” beverages.

Of the four main true teas, green and white are unfermented (white is the least processed), black tea is fermented, and oolong tea is semifermented.^1,2,3 White tea actually comes from the tips of the green tea leaves or leaves that have not yet fully opened, with buds covered by fine white hair. As a commodity, white tea is more expensive than green tea because it is more difficult to obtain. EGCG [(-)epigallocatechin-3-O-gallate], the most abundant and biologically active polyphenolic catechin found in green tea, is also the constituent in white tea that accounts for its antioxidant properties.^4,5 Indeed, white tea is included in topical products for its antioxidant as well as antiseptic activity, and is considered a more potent antioxidant additive medium than green tea.^6,1

As an ingredient in a combination formula

White tea is included in the dietary supplement Imedeen Prime Renewal, along with fish protein polysaccharides, vitamins C and E, zinc, and extracts from soy, grape seed, chamomile, and tomato.

In 2006, Skovgaard et al. conducted a 6-month, double-blind, placebo-controlled randomized study on 80 healthy postmenopausal women (38 in the treatment group, 42 in the placebo group completed the study) to determine antiaging effects on the skin. Subjects took 2 tablets of the supplement or placebo twice daily. Clinical, photo, and ultrasound evaluations showed significantly greater improvements in the treatment group, compared with the placebo group, in the face (forehead, periocular, and perioral wrinkles; mottled pigmentation, laxity, sagging, dark circles under the eyes; and overall appearance), hands, and décolletage.⁷

Antioxidant and antiaging activity

In 2009, Thring et al. studied the antiaging and antioxidant characteristics of 23 plant extracts (from 21 species) by considering antielastase and anticollagenase activities. White tea was found to exhibit the greatest inhibitory activity against both elastase and collagenase, greater than burdock root and angelica in terms of antielastase activity, and greater than green tea, rose tincture, and lavender in relation to anticollagenase activity. The Trolox equivalent antioxidant capacity assay also showed that white tea displayed the highest antioxidant activity. The investigators noted the very high phenolic content of white tea in characterizing its potent inhibitory activity against enzymes that accelerate cutaneous aging.⁶

Earlier in 2009, Camouse et al. examined skin samples from volunteers or skin explants treated with topical white or green tea after ultraviolet exposure to ascertain that the antioxidant could prevent simulated solar radiation–induced damage to DNA and Langerhans cells. They noted that each product displayed a sun protection factor of 1, suggesting that the photoprotection conferred was not due to direct UV absorption. Both forms of topically applied tea extracts were equally effective and judged by the researchers to be potential photoprotective agents when used along with other substantiated approaches to skin protection. These findings provided the first reported evidence of topically applied white tea preventing UV-induced immunosuppression. The researchers further suggested that the color of white tea might render it more cosmetically desirable than green tea.⁸

It should be noted that a systematic review performed by Hunt et al. in 2010 of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and AMED (Allied and Complementary Medicine Database) databases up to 2009 identified 11 randomized clinical or controlled clinical trials evaluating the effectiveness of botanical extracts for diminishing wrinkling and other signs of cutaneous aging. No significant reductions in wrinkling were associated with the use of green tea or Vitaphenol (a combination of green and white teas, mangosteen, and pomegranate extract). The authors noted, however, that all of the trials that they identified were characterized by poor methodologic quality.⁹

Thring et al. conducted an in vitro study in 2011 to evaluate the antioxidant and anti-inflammatory activity of white tea, rose, and witch hazel extracts in primary human skin fibroblasts. The investigators measured significant anticollagenase, antielastase, and antioxidant activities for the white tea extracts, which also spurred a significant reduction in the interleukin-8 amount synthesized by fibroblasts, compared with controls. They concluded that white tea (as well as the other extracts) yielded a protective effect on fibroblasts against damage induced by hydrogen peroxide exposure.¹⁰

In 2014, Azman et al. used the spin trap method and electron paramagnetic resonance (EPR) spectroscopy to show that among white tea constituents, EGCG and epicatechin-3-gallate (ECG) exhibit the greatest antiradical activity against the methoxy radical.¹

Conclusion

Tea is one of the most popular beverages in the world and is touted for its antioxidant and anticancer properties. While the ingredients of green tea polyphenols have inspired a spate of recent research, much is yet to be learned about the potential health benefits of white tea, which is even less processed. Some evidence appears to suggest that white tea may be shown to be more effective overall, and in the dermatologic realm, than green tea. I look forward to seeing more research.

References

1. J Agric Food Chem. 2014;62(1):5743-8.

2. Dermatol Surg. 2005;31(7 Pt 2):873-80.

3. Oxid Med Cell Longev. 2012:2012:560682.

4. Mol Cell Biochem. 2000;206(1-2):125-32.

5. Free Radic Biol Med. 1999;26(11-12):1427-35.

6. BMC Complement Altern Med. 2009;9:27.

7. Eur J Clin Nutr. 2006;60(10):1201-6.

8. Exp Dermatol. 2009;18(6):522-6.

9. Drugs Aging. 2010;27(12):973-85.

10. J Inflamm (Lond). 2011;8(1):27).

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

White tea, like green tea, is derived from the plant Camellia sinensis, a member of the Theaceae family and the source of all the globally popular “true tea” beverages.

Of the four main true teas, green and white are unfermented (white is the least processed), black tea is fermented, and oolong tea is semifermented.^1,2,3 White tea actually comes from the tips of the green tea leaves or leaves that have not yet fully opened, with buds covered by fine white hair. As a commodity, white tea is more expensive than green tea because it is more difficult to obtain. EGCG [(-)epigallocatechin-3-O-gallate], the most abundant and biologically active polyphenolic catechin found in green tea, is also the constituent in white tea that accounts for its antioxidant properties.^4,5 Indeed, white tea is included in topical products for its antioxidant as well as antiseptic activity, and is considered a more potent antioxidant additive medium than green tea.^6,1

As an ingredient in a combination formula

White tea is included in the dietary supplement Imedeen Prime Renewal, along with fish protein polysaccharides, vitamins C and E, zinc, and extracts from soy, grape seed, chamomile, and tomato.

In 2006, Skovgaard et al. conducted a 6-month, double-blind, placebo-controlled randomized study on 80 healthy postmenopausal women (38 in the treatment group, 42 in the placebo group completed the study) to determine antiaging effects on the skin. Subjects took 2 tablets of the supplement or placebo twice daily. Clinical, photo, and ultrasound evaluations showed significantly greater improvements in the treatment group, compared with the placebo group, in the face (forehead, periocular, and perioral wrinkles; mottled pigmentation, laxity, sagging, dark circles under the eyes; and overall appearance), hands, and décolletage.⁷

Antioxidant and antiaging activity

In 2009, Thring et al. studied the antiaging and antioxidant characteristics of 23 plant extracts (from 21 species) by considering antielastase and anticollagenase activities. White tea was found to exhibit the greatest inhibitory activity against both elastase and collagenase, greater than burdock root and angelica in terms of antielastase activity, and greater than green tea, rose tincture, and lavender in relation to anticollagenase activity. The Trolox equivalent antioxidant capacity assay also showed that white tea displayed the highest antioxidant activity. The investigators noted the very high phenolic content of white tea in characterizing its potent inhibitory activity against enzymes that accelerate cutaneous aging.⁶

Earlier in 2009, Camouse et al. examined skin samples from volunteers or skin explants treated with topical white or green tea after ultraviolet exposure to ascertain that the antioxidant could prevent simulated solar radiation–induced damage to DNA and Langerhans cells. They noted that each product displayed a sun protection factor of 1, suggesting that the photoprotection conferred was not due to direct UV absorption. Both forms of topically applied tea extracts were equally effective and judged by the researchers to be potential photoprotective agents when used along with other substantiated approaches to skin protection. These findings provided the first reported evidence of topically applied white tea preventing UV-induced immunosuppression. The researchers further suggested that the color of white tea might render it more cosmetically desirable than green tea.⁸

It should be noted that a systematic review performed by Hunt et al. in 2010 of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and AMED (Allied and Complementary Medicine Database) databases up to 2009 identified 11 randomized clinical or controlled clinical trials evaluating the effectiveness of botanical extracts for diminishing wrinkling and other signs of cutaneous aging. No significant reductions in wrinkling were associated with the use of green tea or Vitaphenol (a combination of green and white teas, mangosteen, and pomegranate extract). The authors noted, however, that all of the trials that they identified were characterized by poor methodologic quality.⁹

Thring et al. conducted an in vitro study in 2011 to evaluate the antioxidant and anti-inflammatory activity of white tea, rose, and witch hazel extracts in primary human skin fibroblasts. The investigators measured significant anticollagenase, antielastase, and antioxidant activities for the white tea extracts, which also spurred a significant reduction in the interleukin-8 amount synthesized by fibroblasts, compared with controls. They concluded that white tea (as well as the other extracts) yielded a protective effect on fibroblasts against damage induced by hydrogen peroxide exposure.¹⁰

In 2014, Azman et al. used the spin trap method and electron paramagnetic resonance (EPR) spectroscopy to show that among white tea constituents, EGCG and epicatechin-3-gallate (ECG) exhibit the greatest antiradical activity against the methoxy radical.¹

Conclusion

Tea is one of the most popular beverages in the world and is touted for its antioxidant and anticancer properties. While the ingredients of green tea polyphenols have inspired a spate of recent research, much is yet to be learned about the potential health benefits of white tea, which is even less processed. Some evidence appears to suggest that white tea may be shown to be more effective overall, and in the dermatologic realm, than green tea. I look forward to seeing more research.

References

1. J Agric Food Chem. 2014;62(1):5743-8.

2. Dermatol Surg. 2005;31(7 Pt 2):873-80.

3. Oxid Med Cell Longev. 2012:2012:560682.

4. Mol Cell Biochem. 2000;206(1-2):125-32.

5. Free Radic Biol Med. 1999;26(11-12):1427-35.

6. BMC Complement Altern Med. 2009;9:27.

7. Eur J Clin Nutr. 2006;60(10):1201-6.

8. Exp Dermatol. 2009;18(6):522-6.

9. Drugs Aging. 2010;27(12):973-85.

10. J Inflamm (Lond). 2011;8(1):27).

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at dermnews@frontlinemedcom.com.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at dermnews@frontlinemedcom.com.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at dermnews@frontlinemedcom.com.

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

What Matters prides itself on reviewing the literature and presenting thoughtful commentary on articles that are relevant and applicable to the practicing clinician. We separate the wheat from the chaff. We are not, however, above taking on attention-grabbing articles.

Over the years, this column has reported on various methods to facilitate the expulsion of kidney stones, including tamsulosin, phosphodiesterase type 5 (PDE5) inhibitors, and steroids. But this one called out for our assessment: sex to expel kidney stones. Erroneously perceived prurient interests must be forgiven.

Dr. Omer Gokhan Doluoglu of the Clinic of Ankara (Turkey) Training and Research Hospital and colleagues conducted a randomized trial evaluating the effectiveness of sexual intercourse, tamsulosin, or standard medical therapy for kidney stone expulsion (Urology. 2015;86[1]:19-24). Potential subjects were eligible for inclusion if they had radiopaque distal ureteral stones. Subjects were excluded if the stones were larger than 6 mm.

Subjects were randomized to encouragement to have sexual intercourse at least three times per week, tamsulosin 0.4 mg/day, or symptomatic therapy alone. All patients received an antispasmodic and an anti-inflammatory, and were told to drink 2 L of water per day. Sexual intercourse and masturbation were prohibited in groups 2 and 3 during the treatment period, which lasted 4 weeks.

Ninety patients were randomized to the three groups. The mean stone size was 4.7-5.0 mm and not significantly different between the groups.

At 2 weeks, 83.9% (26 of 31) of the patients in the intercourse group, 47.6% (10 of 21) in the tamsulosin group, and 34.8% (8 of 23) passed the stones (P = .001). There was no difference between the groups at 4 weeks. Mean expulsion times were 10 days, 16.6 days, and 18 days, respectively (P = .0001).

The study’s authors propose that nitrous oxide is operant here by causing ureteric relaxation when released to create penile tumescence and during sexual activity. Because masturbation could achieve the same effect, patients in the other groups were told they could not. How effective this instruction was in the current study is unknown, because only “sexual intercourses” were collected on follow-up.

The random-envelope method used is less than ideal, and no data were reported on differences in the number of sexual experiences between groups. If we assume for a moment that a real effect exists, one is left wondering if more would be better. Does the requirement of a partner decrease the likelihood of more frequent stone-expelling sexual experiences? If our patients do not have sexual partners, do we not share these data with them?

And if we use PDE5 inhibitors and encourage sexual activity, do we … kill two birds with one stone?

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

What Matters prides itself on reviewing the literature and presenting thoughtful commentary on articles that are relevant and applicable to the practicing clinician. We separate the wheat from the chaff. We are not, however, above taking on attention-grabbing articles.

Over the years, this column has reported on various methods to facilitate the expulsion of kidney stones, including tamsulosin, phosphodiesterase type 5 (PDE5) inhibitors, and steroids. But this one called out for our assessment: sex to expel kidney stones. Erroneously perceived prurient interests must be forgiven.

Dr. Omer Gokhan Doluoglu of the Clinic of Ankara (Turkey) Training and Research Hospital and colleagues conducted a randomized trial evaluating the effectiveness of sexual intercourse, tamsulosin, or standard medical therapy for kidney stone expulsion (Urology. 2015;86[1]:19-24). Potential subjects were eligible for inclusion if they had radiopaque distal ureteral stones. Subjects were excluded if the stones were larger than 6 mm.

Subjects were randomized to encouragement to have sexual intercourse at least three times per week, tamsulosin 0.4 mg/day, or symptomatic therapy alone. All patients received an antispasmodic and an anti-inflammatory, and were told to drink 2 L of water per day. Sexual intercourse and masturbation were prohibited in groups 2 and 3 during the treatment period, which lasted 4 weeks.

Ninety patients were randomized to the three groups. The mean stone size was 4.7-5.0 mm and not significantly different between the groups.

At 2 weeks, 83.9% (26 of 31) of the patients in the intercourse group, 47.6% (10 of 21) in the tamsulosin group, and 34.8% (8 of 23) passed the stones (P = .001). There was no difference between the groups at 4 weeks. Mean expulsion times were 10 days, 16.6 days, and 18 days, respectively (P = .0001).

The study’s authors propose that nitrous oxide is operant here by causing ureteric relaxation when released to create penile tumescence and during sexual activity. Because masturbation could achieve the same effect, patients in the other groups were told they could not. How effective this instruction was in the current study is unknown, because only “sexual intercourses” were collected on follow-up.

The random-envelope method used is less than ideal, and no data were reported on differences in the number of sexual experiences between groups. If we assume for a moment that a real effect exists, one is left wondering if more would be better. Does the requirement of a partner decrease the likelihood of more frequent stone-expelling sexual experiences? If our patients do not have sexual partners, do we not share these data with them?

And if we use PDE5 inhibitors and encourage sexual activity, do we … kill two birds with one stone?

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

What Matters prides itself on reviewing the literature and presenting thoughtful commentary on articles that are relevant and applicable to the practicing clinician. We separate the wheat from the chaff. We are not, however, above taking on attention-grabbing articles.

Over the years, this column has reported on various methods to facilitate the expulsion of kidney stones, including tamsulosin, phosphodiesterase type 5 (PDE5) inhibitors, and steroids. But this one called out for our assessment: sex to expel kidney stones. Erroneously perceived prurient interests must be forgiven.

Dr. Omer Gokhan Doluoglu of the Clinic of Ankara (Turkey) Training and Research Hospital and colleagues conducted a randomized trial evaluating the effectiveness of sexual intercourse, tamsulosin, or standard medical therapy for kidney stone expulsion (Urology. 2015;86[1]:19-24). Potential subjects were eligible for inclusion if they had radiopaque distal ureteral stones. Subjects were excluded if the stones were larger than 6 mm.

Subjects were randomized to encouragement to have sexual intercourse at least three times per week, tamsulosin 0.4 mg/day, or symptomatic therapy alone. All patients received an antispasmodic and an anti-inflammatory, and were told to drink 2 L of water per day. Sexual intercourse and masturbation were prohibited in groups 2 and 3 during the treatment period, which lasted 4 weeks.

Ninety patients were randomized to the three groups. The mean stone size was 4.7-5.0 mm and not significantly different between the groups.

At 2 weeks, 83.9% (26 of 31) of the patients in the intercourse group, 47.6% (10 of 21) in the tamsulosin group, and 34.8% (8 of 23) passed the stones (P = .001). There was no difference between the groups at 4 weeks. Mean expulsion times were 10 days, 16.6 days, and 18 days, respectively (P = .0001).

The study’s authors propose that nitrous oxide is operant here by causing ureteric relaxation when released to create penile tumescence and during sexual activity. Because masturbation could achieve the same effect, patients in the other groups were told they could not. How effective this instruction was in the current study is unknown, because only “sexual intercourses” were collected on follow-up.

The random-envelope method used is less than ideal, and no data were reported on differences in the number of sexual experiences between groups. If we assume for a moment that a real effect exists, one is left wondering if more would be better. Does the requirement of a partner decrease the likelihood of more frequent stone-expelling sexual experiences? If our patients do not have sexual partners, do we not share these data with them?

And if we use PDE5 inhibitors and encourage sexual activity, do we … kill two birds with one stone?

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

How often do you encounter phantom appointments?

What are phantom appointments? They’re patient visits that are nowhere on your schedule.

I’m not talking about someone who shows up on the wrong day or time. That’s at least partially understandable. I’m talking about people who you have no record of but say they have an appointment.

The first impression is to assume they’re scheduled with someone else in the building or another neurologist in my area, but they’ll often pull out a crumpled sheet of paper with my name and address on it, and a time circled.

Where on Earth do these people come from? I have no clue. When asked who made the appointment, it’s always “They made it for me,” or “They told me to be here.” It’s never clear who “they” are. These folks almost never can give you the name of their referring doctor, or who they spoke to. I’m a pretty small office here, just me and my secretary, so there aren’t many people here to talk to.

These aren’t common, maybe a handful per year, but generally unpleasant when they occur. If they happen to show up when I’ve got a gap in the schedule, I’ll try to see them, but the majority end up being turned away. We always offer to make an appointment for them, but most leave, usually angry.

I suspect some were referred for cognitive issues, which partially explains the confusion. Others may be doing it intentionally, hoping that they’ll be seen. (I suspect these are the minority.) Misinterpreted information from other offices likely plays a big part. Perhaps they were given my name and info by another office and told to make an appointment. Somehow, a time for something else got mixed in on the same sheet … and they show up here.

Although they are a minor annoyance on the scale of daily office goings-on, these patients are still a problem. Most are angry and frustrated, as they want to see me. Some are willing to schedule an appointment, but most aren’t. The awkward situation interrupts the routine flow of check-ins and phone calls, and it certainly isn’t something anyone waiting in the lobby wants to overhear. Oftentimes, I have to go up front to handle it, taking me away from a patient. In cases when the patient was referred by another doctor, they might call that office to complain.

It’s a losing situation for all involved. I wish there was some way to prevent them, but their uncertain nature makes it impossible.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you encounter phantom appointments?

What are phantom appointments? They’re patient visits that are nowhere on your schedule.

I’m not talking about someone who shows up on the wrong day or time. That’s at least partially understandable. I’m talking about people who you have no record of but say they have an appointment.

The first impression is to assume they’re scheduled with someone else in the building or another neurologist in my area, but they’ll often pull out a crumpled sheet of paper with my name and address on it, and a time circled.

Where on Earth do these people come from? I have no clue. When asked who made the appointment, it’s always “They made it for me,” or “They told me to be here.” It’s never clear who “they” are. These folks almost never can give you the name of their referring doctor, or who they spoke to. I’m a pretty small office here, just me and my secretary, so there aren’t many people here to talk to.

These aren’t common, maybe a handful per year, but generally unpleasant when they occur. If they happen to show up when I’ve got a gap in the schedule, I’ll try to see them, but the majority end up being turned away. We always offer to make an appointment for them, but most leave, usually angry.

I suspect some were referred for cognitive issues, which partially explains the confusion. Others may be doing it intentionally, hoping that they’ll be seen. (I suspect these are the minority.) Misinterpreted information from other offices likely plays a big part. Perhaps they were given my name and info by another office and told to make an appointment. Somehow, a time for something else got mixed in on the same sheet … and they show up here.

Although they are a minor annoyance on the scale of daily office goings-on, these patients are still a problem. Most are angry and frustrated, as they want to see me. Some are willing to schedule an appointment, but most aren’t. The awkward situation interrupts the routine flow of check-ins and phone calls, and it certainly isn’t something anyone waiting in the lobby wants to overhear. Oftentimes, I have to go up front to handle it, taking me away from a patient. In cases when the patient was referred by another doctor, they might call that office to complain.

It’s a losing situation for all involved. I wish there was some way to prevent them, but their uncertain nature makes it impossible.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often do you encounter phantom appointments?

What are phantom appointments? They’re patient visits that are nowhere on your schedule.

I’m not talking about someone who shows up on the wrong day or time. That’s at least partially understandable. I’m talking about people who you have no record of but say they have an appointment.

The first impression is to assume they’re scheduled with someone else in the building or another neurologist in my area, but they’ll often pull out a crumpled sheet of paper with my name and address on it, and a time circled.

Where on Earth do these people come from? I have no clue. When asked who made the appointment, it’s always “They made it for me,” or “They told me to be here.” It’s never clear who “they” are. These folks almost never can give you the name of their referring doctor, or who they spoke to. I’m a pretty small office here, just me and my secretary, so there aren’t many people here to talk to.

These aren’t common, maybe a handful per year, but generally unpleasant when they occur. If they happen to show up when I’ve got a gap in the schedule, I’ll try to see them, but the majority end up being turned away. We always offer to make an appointment for them, but most leave, usually angry.

I suspect some were referred for cognitive issues, which partially explains the confusion. Others may be doing it intentionally, hoping that they’ll be seen. (I suspect these are the minority.) Misinterpreted information from other offices likely plays a big part. Perhaps they were given my name and info by another office and told to make an appointment. Somehow, a time for something else got mixed in on the same sheet … and they show up here.

Although they are a minor annoyance on the scale of daily office goings-on, these patients are still a problem. Most are angry and frustrated, as they want to see me. Some are willing to schedule an appointment, but most aren’t. The awkward situation interrupts the routine flow of check-ins and phone calls, and it certainly isn’t something anyone waiting in the lobby wants to overhear. Oftentimes, I have to go up front to handle it, taking me away from a patient. In cases when the patient was referred by another doctor, they might call that office to complain.

It’s a losing situation for all involved. I wish there was some way to prevent them, but their uncertain nature makes it impossible.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My residency program was fantastic. There were about 40 residents in my intern year and more than 100 residents in all. You were never alone. The atmosphere was congenial. You sat at the nurses’ station for hours charting away, but you interacted with co-residents, fellows, attendings, and residents from other specialties. Residency was tough, but it was easy to make friends with people sharing the experience.

I was unprepared for how different fellowship would be. I expected to be milling about in the wards, getting to know fellows in other specialties. Instead, I spent all of my time in the rheumatology office seeing patients or fulfilling research or teaching or conference obligations. I had a great relationship with my co-fellows, but there were only four of us and we each had different schedules. It felt surprisingly isolating.

The isolation led to another, more insidious change: I started forgetting internal medicine. Right out of residency, you think you know most everything there is to know. After all, you did just run an ICU by yourself and you just passed the internal medicine boards. You are eager to put that behind you, and you channel all your efforts into learning rheumatology.

But with each passing day that you are not called on to identify a murmur, feel a spleen tip, or treat a patient with diabetes, your ability to do those things diminishes. My world has shrunk significantly in ways I do not care to admit. I have never been as familiar with the nail-seeking properties of my rheumatology hammer as I am now. That’s fine until you consider that metabolic problems, infections, and malignancies can all masquerade as rheumatologic conditions.

When I realized that my IM skills were vanishing, I resolved to reverse the isolation. It helps that I belong to a fantastic community of physicians who welcomed me into their tribe. I started attending the weekly IM grand rounds and morbidity and mortality conferences. I am giddy with the excitement of being immersed in internal medicine once again and grateful to receive the collected wisdom of the brilliant people that surround me.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My residency program was fantastic. There were about 40 residents in my intern year and more than 100 residents in all. You were never alone. The atmosphere was congenial. You sat at the nurses’ station for hours charting away, but you interacted with co-residents, fellows, attendings, and residents from other specialties. Residency was tough, but it was easy to make friends with people sharing the experience.

I was unprepared for how different fellowship would be. I expected to be milling about in the wards, getting to know fellows in other specialties. Instead, I spent all of my time in the rheumatology office seeing patients or fulfilling research or teaching or conference obligations. I had a great relationship with my co-fellows, but there were only four of us and we each had different schedules. It felt surprisingly isolating.

The isolation led to another, more insidious change: I started forgetting internal medicine. Right out of residency, you think you know most everything there is to know. After all, you did just run an ICU by yourself and you just passed the internal medicine boards. You are eager to put that behind you, and you channel all your efforts into learning rheumatology.

But with each passing day that you are not called on to identify a murmur, feel a spleen tip, or treat a patient with diabetes, your ability to do those things diminishes. My world has shrunk significantly in ways I do not care to admit. I have never been as familiar with the nail-seeking properties of my rheumatology hammer as I am now. That’s fine until you consider that metabolic problems, infections, and malignancies can all masquerade as rheumatologic conditions.

When I realized that my IM skills were vanishing, I resolved to reverse the isolation. It helps that I belong to a fantastic community of physicians who welcomed me into their tribe. I started attending the weekly IM grand rounds and morbidity and mortality conferences. I am giddy with the excitement of being immersed in internal medicine once again and grateful to receive the collected wisdom of the brilliant people that surround me.

Dr. Chan practices rheumatology in Pawtucket, R.I.

My residency program was fantastic. There were about 40 residents in my intern year and more than 100 residents in all. You were never alone. The atmosphere was congenial. You sat at the nurses’ station for hours charting away, but you interacted with co-residents, fellows, attendings, and residents from other specialties. Residency was tough, but it was easy to make friends with people sharing the experience.

I was unprepared for how different fellowship would be. I expected to be milling about in the wards, getting to know fellows in other specialties. Instead, I spent all of my time in the rheumatology office seeing patients or fulfilling research or teaching or conference obligations. I had a great relationship with my co-fellows, but there were only four of us and we each had different schedules. It felt surprisingly isolating.

The isolation led to another, more insidious change: I started forgetting internal medicine. Right out of residency, you think you know most everything there is to know. After all, you did just run an ICU by yourself and you just passed the internal medicine boards. You are eager to put that behind you, and you channel all your efforts into learning rheumatology.

But with each passing day that you are not called on to identify a murmur, feel a spleen tip, or treat a patient with diabetes, your ability to do those things diminishes. My world has shrunk significantly in ways I do not care to admit. I have never been as familiar with the nail-seeking properties of my rheumatology hammer as I am now. That’s fine until you consider that metabolic problems, infections, and malignancies can all masquerade as rheumatologic conditions.

When I realized that my IM skills were vanishing, I resolved to reverse the isolation. It helps that I belong to a fantastic community of physicians who welcomed me into their tribe. I started attending the weekly IM grand rounds and morbidity and mortality conferences. I am giddy with the excitement of being immersed in internal medicine once again and grateful to receive the collected wisdom of the brilliant people that surround me.

Dr. Chan practices rheumatology in Pawtucket, R.I.

The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.

Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.

This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.

Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.

The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.

In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.

One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.

Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.

This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.

Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.

The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.

In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.

One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.

Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.

This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.

Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.

The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.

In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.

One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Peering out from 28 floors above the busy, early morning streets of downtown Chicago, I was entranced by the view. The rising sun in the east created a shimmering, iridescent play of light on the waters of Lake Michigan that extended as far as the eye could see. The room I was in also commanded my attention. Several rows of desks, each with a computer screen, faced a single elevated line of chairs for the leaders of the deliberations that were about to take place. Above this row on the front wall of this imposing room is emblazoned the seal of our College with its mission statement, “The ACS is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment,” to remind those in the room of the ultimate purpose in serving this professional organization. So the Regents room and view appeared to me, a newcomer to these meetings of the leadership of the American College of Surgeons.

I hope I can convince you in the paragraphs that follow that this mission and its execution by Regents, Governors, and Fellows of the ACS, are every bit as noble as the architecture of the room and the view it affords.

I have been a Fellow of the American College of Surgeons since 1980. My membership in this extraordinary association has provided me many benefits and numerous opportunities. In the early years, I significantly expanded the knowledge base I had gained in residency by attending every fall Clinical Congress and consuming as many educational offerings as time would permit during this nearly week-long learning marathon. After a few years, I was granted the privilege of being on the instructor end of several of these educational exchanges. At that time in my career, it appeared to me that the ACS’s main and almost sole purpose was to provide continuing education for surgeons who attended the annual Clinical Congress. I have subsequently found that it is so much more.

In 2005, I was invited to represent one of my specialist surgical societies as a Governor. During my 6-year term, I came to realize that the key purpose of the Board of Governors (BOG) is to provide an effective communication conduit between the Fellows and the sole policy-making body of the ACS, the Board of Regents (BOR). In recent years, most of the Regents have attended the annual BOG meeting in order to facilitate this interaction.

In 2012, I was elected First Vice-President of the ACS. Now as an officer of the College, I was invited for 2 years to attend all BOR meetings and to be in the mainstream of all communications relating to strategy and policy. These opportunities provided me with an intimate, inside look at how this large organization of nearly 80,000 members functions to serve the entire surgical profession including each of its many specialties. What I learned about the internal workings of the leadership and those who dedicate their time to this work has reinforced my own commitment to the ACS. It is a remarkable organization.

This brings us back to the well-designed and impressive Regents’ room high above Chicago. The hum of numerous disjointed conversations ceased as the Chair of the ACS Board of Regents called the June 2012 meeting to order. My attention is now focused on the proceedings rather than on the beauty of Lake Michigan below. Although every surgical specialty is represented among the 22 Regents, all discussion was invariably directed toward the betterment of the surgical profession as a whole rather than about any specific specialty’s interests.

The Regents are dedicated servants of the ACS. In addition to three one-and-a-half day meetings annually, each of which requires hours of reading in preparation, most of the Regents serve on at least two committees of the Board. Regents are nominated by Fellows, advisory councils, and committees, and are elected by the much larger BOG which represents every state and Canadian province, several countries, and many surgery specialist societies. In addition to assuring that all surgical specialties are represented, bylaws of the ACS state that the President of the ACS and two Canadian Fellows must be among the BOR membership. Based on my 2-year experience, the BOG has exhibited considerable wisdom in their choice of Regents.

The officers of the ACS (President-Elect, First and Second Vice-Presidents and Vice-Presidents-Elect, Secretary, Treasurer), and the officers of the BOG (Chair, Vice-Chair, and Secretary/Treasurer) attend all BOR meetings and serve in an advisory capacity. Also in attendance and providing essential input are executive members of the ACS staff and, representing the younger ACS membership, the chairs of the Resident Associates Society (RAS) and the Young Fellows Association (YAF). Although only Regents can vote and are therefore responsible for establishing ACS policy, I discovered they welcome participation from all in attendance. I always felt that my contributions and those of other non-voting attendees were thoughtfully and carefully considered.

Much of the preparatory work for BOR meetings is done in the committees that meet just prior to the full Board meeting. I had the pleasure of being on the Honors Committee that selects Honorary Fellows of the ACS from regions throughout the world and selects Fellows for special awards such as the Distinguished Service Award, and on the Members Services Liaison Committee that concentrates on expanding ACS membership and on more fully informing the Fellows of BOR activities. Among several other important committees are the Central Judiciary Committee that is responsible for disciplining Fellows who breach the ethical standards of our College and the Finance Committee that assures responsible fiscal stewardship of the ACS. Deliberations of all of the committees are brought before the full Board for final approval

Although the BOR has been the policy-making body since the founding of the ACS 102 years ago, the structure of our society has evolved considerably, especially during the past 2 decades. The ACS is organized around five major Divisions: Advocacy and Health Policy, Education, Integrated Communications, Member Services, and Research and Optimal Patient Care. The Directors of these Divisions report on a regular basis to the BOR to keep the Regents’ knowledge up-to-date and to assist them in determining the strategic direction of the ACS. Much of the discussion, modifications, and innovations center around these Divisions, also represented as pillars in the recent BOG re-organization. I trust you are aware of the many achievements that have resulted: NSQIP, legislative elimination of the flawed Sustainable Growth Rate (SGR) formula, reorganization of the Clinical Congress, and a re-emphasis on global surgery and the Operation Giving Back Program to name but a few.

Finally, a key role of the BOR is to select the Executive Director of the ACS who manages the day-to-day operations of the College with the Board’s strategic guidance. The ACS has been blessed with a number of excellent Directors, none more visionary and competent than the present Director, David Hoyt, MD, FACS, who is 1 year into his second 5-year term.

I hope that this discussion provides you with a better understanding of the role and functioning of the BOR and the College of which you are a member. The grandeur of the BOR room appropriately parallels the excellence of what takes place within it.

Take time to visit the next time you are in Chicago. I am certain the ACS staff would be pleased and proud to meet you, show you around, and have you experience what I have tried to describe in this brief discourse.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Peering out from 28 floors above the busy, early morning streets of downtown Chicago, I was entranced by the view. The rising sun in the east created a shimmering, iridescent play of light on the waters of Lake Michigan that extended as far as the eye could see. The room I was in also commanded my attention. Several rows of desks, each with a computer screen, faced a single elevated line of chairs for the leaders of the deliberations that were about to take place. Above this row on the front wall of this imposing room is emblazoned the seal of our College with its mission statement, “The ACS is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment,” to remind those in the room of the ultimate purpose in serving this professional organization. So the Regents room and view appeared to me, a newcomer to these meetings of the leadership of the American College of Surgeons.

I hope I can convince you in the paragraphs that follow that this mission and its execution by Regents, Governors, and Fellows of the ACS, are every bit as noble as the architecture of the room and the view it affords.

I have been a Fellow of the American College of Surgeons since 1980. My membership in this extraordinary association has provided me many benefits and numerous opportunities. In the early years, I significantly expanded the knowledge base I had gained in residency by attending every fall Clinical Congress and consuming as many educational offerings as time would permit during this nearly week-long learning marathon. After a few years, I was granted the privilege of being on the instructor end of several of these educational exchanges. At that time in my career, it appeared to me that the ACS’s main and almost sole purpose was to provide continuing education for surgeons who attended the annual Clinical Congress. I have subsequently found that it is so much more.

In 2005, I was invited to represent one of my specialist surgical societies as a Governor. During my 6-year term, I came to realize that the key purpose of the Board of Governors (BOG) is to provide an effective communication conduit between the Fellows and the sole policy-making body of the ACS, the Board of Regents (BOR). In recent years, most of the Regents have attended the annual BOG meeting in order to facilitate this interaction.

In 2012, I was elected First Vice-President of the ACS. Now as an officer of the College, I was invited for 2 years to attend all BOR meetings and to be in the mainstream of all communications relating to strategy and policy. These opportunities provided me with an intimate, inside look at how this large organization of nearly 80,000 members functions to serve the entire surgical profession including each of its many specialties. What I learned about the internal workings of the leadership and those who dedicate their time to this work has reinforced my own commitment to the ACS. It is a remarkable organization.

This brings us back to the well-designed and impressive Regents’ room high above Chicago. The hum of numerous disjointed conversations ceased as the Chair of the ACS Board of Regents called the June 2012 meeting to order. My attention is now focused on the proceedings rather than on the beauty of Lake Michigan below. Although every surgical specialty is represented among the 22 Regents, all discussion was invariably directed toward the betterment of the surgical profession as a whole rather than about any specific specialty’s interests.

The Regents are dedicated servants of the ACS. In addition to three one-and-a-half day meetings annually, each of which requires hours of reading in preparation, most of the Regents serve on at least two committees of the Board. Regents are nominated by Fellows, advisory councils, and committees, and are elected by the much larger BOG which represents every state and Canadian province, several countries, and many surgery specialist societies. In addition to assuring that all surgical specialties are represented, bylaws of the ACS state that the President of the ACS and two Canadian Fellows must be among the BOR membership. Based on my 2-year experience, the BOG has exhibited considerable wisdom in their choice of Regents.

The officers of the ACS (President-Elect, First and Second Vice-Presidents and Vice-Presidents-Elect, Secretary, Treasurer), and the officers of the BOG (Chair, Vice-Chair, and Secretary/Treasurer) attend all BOR meetings and serve in an advisory capacity. Also in attendance and providing essential input are executive members of the ACS staff and, representing the younger ACS membership, the chairs of the Resident Associates Society (RAS) and the Young Fellows Association (YAF). Although only Regents can vote and are therefore responsible for establishing ACS policy, I discovered they welcome participation from all in attendance. I always felt that my contributions and those of other non-voting attendees were thoughtfully and carefully considered.

Much of the preparatory work for BOR meetings is done in the committees that meet just prior to the full Board meeting. I had the pleasure of being on the Honors Committee that selects Honorary Fellows of the ACS from regions throughout the world and selects Fellows for special awards such as the Distinguished Service Award, and on the Members Services Liaison Committee that concentrates on expanding ACS membership and on more fully informing the Fellows of BOR activities. Among several other important committees are the Central Judiciary Committee that is responsible for disciplining Fellows who breach the ethical standards of our College and the Finance Committee that assures responsible fiscal stewardship of the ACS. Deliberations of all of the committees are brought before the full Board for final approval

Although the BOR has been the policy-making body since the founding of the ACS 102 years ago, the structure of our society has evolved considerably, especially during the past 2 decades. The ACS is organized around five major Divisions: Advocacy and Health Policy, Education, Integrated Communications, Member Services, and Research and Optimal Patient Care. The Directors of these Divisions report on a regular basis to the BOR to keep the Regents’ knowledge up-to-date and to assist them in determining the strategic direction of the ACS. Much of the discussion, modifications, and innovations center around these Divisions, also represented as pillars in the recent BOG re-organization. I trust you are aware of the many achievements that have resulted: NSQIP, legislative elimination of the flawed Sustainable Growth Rate (SGR) formula, reorganization of the Clinical Congress, and a re-emphasis on global surgery and the Operation Giving Back Program to name but a few.

Finally, a key role of the BOR is to select the Executive Director of the ACS who manages the day-to-day operations of the College with the Board’s strategic guidance. The ACS has been blessed with a number of excellent Directors, none more visionary and competent than the present Director, David Hoyt, MD, FACS, who is 1 year into his second 5-year term.

I hope that this discussion provides you with a better understanding of the role and functioning of the BOR and the College of which you are a member. The grandeur of the BOR room appropriately parallels the excellence of what takes place within it.

Take time to visit the next time you are in Chicago. I am certain the ACS staff would be pleased and proud to meet you, show you around, and have you experience what I have tried to describe in this brief discourse.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Peering out from 28 floors above the busy, early morning streets of downtown Chicago, I was entranced by the view. The rising sun in the east created a shimmering, iridescent play of light on the waters of Lake Michigan that extended as far as the eye could see. The room I was in also commanded my attention. Several rows of desks, each with a computer screen, faced a single elevated line of chairs for the leaders of the deliberations that were about to take place. Above this row on the front wall of this imposing room is emblazoned the seal of our College with its mission statement, “The ACS is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment,” to remind those in the room of the ultimate purpose in serving this professional organization. So the Regents room and view appeared to me, a newcomer to these meetings of the leadership of the American College of Surgeons.

I hope I can convince you in the paragraphs that follow that this mission and its execution by Regents, Governors, and Fellows of the ACS, are every bit as noble as the architecture of the room and the view it affords.

I have been a Fellow of the American College of Surgeons since 1980. My membership in this extraordinary association has provided me many benefits and numerous opportunities. In the early years, I significantly expanded the knowledge base I had gained in residency by attending every fall Clinical Congress and consuming as many educational offerings as time would permit during this nearly week-long learning marathon. After a few years, I was granted the privilege of being on the instructor end of several of these educational exchanges. At that time in my career, it appeared to me that the ACS’s main and almost sole purpose was to provide continuing education for surgeons who attended the annual Clinical Congress. I have subsequently found that it is so much more.

In 2005, I was invited to represent one of my specialist surgical societies as a Governor. During my 6-year term, I came to realize that the key purpose of the Board of Governors (BOG) is to provide an effective communication conduit between the Fellows and the sole policy-making body of the ACS, the Board of Regents (BOR). In recent years, most of the Regents have attended the annual BOG meeting in order to facilitate this interaction.

In 2012, I was elected First Vice-President of the ACS. Now as an officer of the College, I was invited for 2 years to attend all BOR meetings and to be in the mainstream of all communications relating to strategy and policy. These opportunities provided me with an intimate, inside look at how this large organization of nearly 80,000 members functions to serve the entire surgical profession including each of its many specialties. What I learned about the internal workings of the leadership and those who dedicate their time to this work has reinforced my own commitment to the ACS. It is a remarkable organization.

This brings us back to the well-designed and impressive Regents’ room high above Chicago. The hum of numerous disjointed conversations ceased as the Chair of the ACS Board of Regents called the June 2012 meeting to order. My attention is now focused on the proceedings rather than on the beauty of Lake Michigan below. Although every surgical specialty is represented among the 22 Regents, all discussion was invariably directed toward the betterment of the surgical profession as a whole rather than about any specific specialty’s interests.

The Regents are dedicated servants of the ACS. In addition to three one-and-a-half day meetings annually, each of which requires hours of reading in preparation, most of the Regents serve on at least two committees of the Board. Regents are nominated by Fellows, advisory councils, and committees, and are elected by the much larger BOG which represents every state and Canadian province, several countries, and many surgery specialist societies. In addition to assuring that all surgical specialties are represented, bylaws of the ACS state that the President of the ACS and two Canadian Fellows must be among the BOR membership. Based on my 2-year experience, the BOG has exhibited considerable wisdom in their choice of Regents.

The officers of the ACS (President-Elect, First and Second Vice-Presidents and Vice-Presidents-Elect, Secretary, Treasurer), and the officers of the BOG (Chair, Vice-Chair, and Secretary/Treasurer) attend all BOR meetings and serve in an advisory capacity. Also in attendance and providing essential input are executive members of the ACS staff and, representing the younger ACS membership, the chairs of the Resident Associates Society (RAS) and the Young Fellows Association (YAF). Although only Regents can vote and are therefore responsible for establishing ACS policy, I discovered they welcome participation from all in attendance. I always felt that my contributions and those of other non-voting attendees were thoughtfully and carefully considered.

Much of the preparatory work for BOR meetings is done in the committees that meet just prior to the full Board meeting. I had the pleasure of being on the Honors Committee that selects Honorary Fellows of the ACS from regions throughout the world and selects Fellows for special awards such as the Distinguished Service Award, and on the Members Services Liaison Committee that concentrates on expanding ACS membership and on more fully informing the Fellows of BOR activities. Among several other important committees are the Central Judiciary Committee that is responsible for disciplining Fellows who breach the ethical standards of our College and the Finance Committee that assures responsible fiscal stewardship of the ACS. Deliberations of all of the committees are brought before the full Board for final approval

Although the BOR has been the policy-making body since the founding of the ACS 102 years ago, the structure of our society has evolved considerably, especially during the past 2 decades. The ACS is organized around five major Divisions: Advocacy and Health Policy, Education, Integrated Communications, Member Services, and Research and Optimal Patient Care. The Directors of these Divisions report on a regular basis to the BOR to keep the Regents’ knowledge up-to-date and to assist them in determining the strategic direction of the ACS. Much of the discussion, modifications, and innovations center around these Divisions, also represented as pillars in the recent BOG re-organization. I trust you are aware of the many achievements that have resulted: NSQIP, legislative elimination of the flawed Sustainable Growth Rate (SGR) formula, reorganization of the Clinical Congress, and a re-emphasis on global surgery and the Operation Giving Back Program to name but a few.

Finally, a key role of the BOR is to select the Executive Director of the ACS who manages the day-to-day operations of the College with the Board’s strategic guidance. The ACS has been blessed with a number of excellent Directors, none more visionary and competent than the present Director, David Hoyt, MD, FACS, who is 1 year into his second 5-year term.

I hope that this discussion provides you with a better understanding of the role and functioning of the BOR and the College of which you are a member. The grandeur of the BOR room appropriately parallels the excellence of what takes place within it.

Take time to visit the next time you are in Chicago. I am certain the ACS staff would be pleased and proud to meet you, show you around, and have you experience what I have tried to describe in this brief discourse.

Dr. Rikkers is Editor in Chief of ACS Surgery News.