Commentary

“Alien Physician” – thus am I ordained by the document that allows me to train in America. I am the International Medical Graduate. This is my story.

I came from poverty and hardship. In other cases, I came from wealth and privilege. Regardless, I clawed my way over staggering numbers of competitors to earn my shot at a medical education. Back home, I was top of my class, fresh out of medical school. In other cases, I was a respected practitioner with a wealth of experience. Now I am a blank slate.

I am here because I heard of a place where questions were encouraged and boundaries pushed. Or I am here because I learned of the American dream. They told me I would be judged for my merit here and nothing else. I have escaped persecution, war, nepotism, or perhaps just a bogged-down system to get here.

Although I have taken the same tests as you, my resume comes with an asterisk. I have had to prove myself by rising to a standard higher than that expected of my peers. Much of my time and peace of mind are consumed jumping through bureaucratic hoops in order to continue my stay. For every one of me you see, there is at least one more who was forced to give up on his or her dream midway.

Know this, however – I appreciate working in a system where the team is greater than the individual, where no job is menial, where the ability to make choices about your health is yours alone, to be shared should you need to.

Know that I am good company, although my jokes sometimes fall flat in the space between our two cultures. Learning new things about your country and its people makes me feel young again.

Know that I have a keen appreciation of how important cultural nuance is to the doctor-patient relationship, even if I come across as ignorant. I have gained this understanding not by reading about it in a book, but by living it.

Know that nothing is more important to me than the health of my patients, and that my being a foreigner does not mean your child will receive anything less than my very best.

Most importantly, know that I feel blessed to be here. While my journey is still uphill, I have no regrets. If I were not made of hard stuff, I would not be here. Although I may grumble, I shall endeavor to accept my lot with grace and humility in the knowledge that I have earned the right to practice the subject that I love and the cognizance that not everyone would open their arms to outsiders the way you have. It has meant the world to me. Working with you has opened my eyes to things I did not see before and has inspired me to be a better doctor. I hope in some small way my presence here affords you that same inspiration.

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, N.H. when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del.

“Alien Physician” – thus am I ordained by the document that allows me to train in America. I am the International Medical Graduate. This is my story.

I came from poverty and hardship. In other cases, I came from wealth and privilege. Regardless, I clawed my way over staggering numbers of competitors to earn my shot at a medical education. Back home, I was top of my class, fresh out of medical school. In other cases, I was a respected practitioner with a wealth of experience. Now I am a blank slate.

I am here because I heard of a place where questions were encouraged and boundaries pushed. Or I am here because I learned of the American dream. They told me I would be judged for my merit here and nothing else. I have escaped persecution, war, nepotism, or perhaps just a bogged-down system to get here.

Although I have taken the same tests as you, my resume comes with an asterisk. I have had to prove myself by rising to a standard higher than that expected of my peers. Much of my time and peace of mind are consumed jumping through bureaucratic hoops in order to continue my stay. For every one of me you see, there is at least one more who was forced to give up on his or her dream midway.

Know this, however – I appreciate working in a system where the team is greater than the individual, where no job is menial, where the ability to make choices about your health is yours alone, to be shared should you need to.

Know that I am good company, although my jokes sometimes fall flat in the space between our two cultures. Learning new things about your country and its people makes me feel young again.

Know that I have a keen appreciation of how important cultural nuance is to the doctor-patient relationship, even if I come across as ignorant. I have gained this understanding not by reading about it in a book, but by living it.

Know that nothing is more important to me than the health of my patients, and that my being a foreigner does not mean your child will receive anything less than my very best.

Most importantly, know that I feel blessed to be here. While my journey is still uphill, I have no regrets. If I were not made of hard stuff, I would not be here. Although I may grumble, I shall endeavor to accept my lot with grace and humility in the knowledge that I have earned the right to practice the subject that I love and the cognizance that not everyone would open their arms to outsiders the way you have. It has meant the world to me. Working with you has opened my eyes to things I did not see before and has inspired me to be a better doctor. I hope in some small way my presence here affords you that same inspiration.

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, N.H. when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del.

“Alien Physician” – thus am I ordained by the document that allows me to train in America. I am the International Medical Graduate. This is my story.

I came from poverty and hardship. In other cases, I came from wealth and privilege. Regardless, I clawed my way over staggering numbers of competitors to earn my shot at a medical education. Back home, I was top of my class, fresh out of medical school. In other cases, I was a respected practitioner with a wealth of experience. Now I am a blank slate.

I am here because I heard of a place where questions were encouraged and boundaries pushed. Or I am here because I learned of the American dream. They told me I would be judged for my merit here and nothing else. I have escaped persecution, war, nepotism, or perhaps just a bogged-down system to get here.

Although I have taken the same tests as you, my resume comes with an asterisk. I have had to prove myself by rising to a standard higher than that expected of my peers. Much of my time and peace of mind are consumed jumping through bureaucratic hoops in order to continue my stay. For every one of me you see, there is at least one more who was forced to give up on his or her dream midway.

Know this, however – I appreciate working in a system where the team is greater than the individual, where no job is menial, where the ability to make choices about your health is yours alone, to be shared should you need to.

Know that I am good company, although my jokes sometimes fall flat in the space between our two cultures. Learning new things about your country and its people makes me feel young again.

Know that I have a keen appreciation of how important cultural nuance is to the doctor-patient relationship, even if I come across as ignorant. I have gained this understanding not by reading about it in a book, but by living it.

Know that nothing is more important to me than the health of my patients, and that my being a foreigner does not mean your child will receive anything less than my very best.

Most importantly, know that I feel blessed to be here. While my journey is still uphill, I have no regrets. If I were not made of hard stuff, I would not be here. Although I may grumble, I shall endeavor to accept my lot with grace and humility in the knowledge that I have earned the right to practice the subject that I love and the cognizance that not everyone would open their arms to outsiders the way you have. It has meant the world to me. Working with you has opened my eyes to things I did not see before and has inspired me to be a better doctor. I hope in some small way my presence here affords you that same inspiration.

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, N.H. when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del.

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

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

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

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

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

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

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at dermnews@frontlinemedcom.com.

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at dermnews@frontlinemedcom.com.

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at dermnews@frontlinemedcom.com.

I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.

That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.

One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.

Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.

In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.

All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”

Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.

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

I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.

That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.

One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.

Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.

In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.

All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”

Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.

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

I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.

That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.

One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.

Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.

In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.

All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”

Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.

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

The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).

In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).

Potential cutaneous benefits

Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).

Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).

©Ls9907/Thinkstockphotos.com

In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).

A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).

Conclusion

The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.

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.

The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).

In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).

Potential cutaneous benefits

Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).

Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).

©Ls9907/Thinkstockphotos.com

In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).

A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).

Conclusion

The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.

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.

The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).

In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).

Potential cutaneous benefits

Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).

Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).

©Ls9907/Thinkstockphotos.com

In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).

A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).

Conclusion

The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.

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.

Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.

“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”

We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.

This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.

If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:

•  It can grow and become painful.

•  It can stay the same for years, never bother you, and go away.

•  New ones can appear elsewhere on the sole.

•  It can disappear tomorrow afternoon.

Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.

There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.

That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.

Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”

It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.

I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.

Well, sometimes maybe. Just not this time.

Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”

What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.

I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.

In other words, eczema has no butt. So you can’t kick it.

The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.

The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?

No, actually it sometimes isn’t.

We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.

Or that there are indeed butts, big and small. But not everything has one to kick.

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.

Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.

“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”

We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.

This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.

If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:

•  It can grow and become painful.

•  It can stay the same for years, never bother you, and go away.

•  New ones can appear elsewhere on the sole.

•  It can disappear tomorrow afternoon.

Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.

There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.

That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.

Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”

It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.

I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.

Well, sometimes maybe. Just not this time.

Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”

What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.

I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.

In other words, eczema has no butt. So you can’t kick it.

The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.

The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?

No, actually it sometimes isn’t.

We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.

Or that there are indeed butts, big and small. But not everything has one to kick.

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.

Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.

“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”

We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.

This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.

If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:

•  It can grow and become painful.

•  It can stay the same for years, never bother you, and go away.

•  New ones can appear elsewhere on the sole.

•  It can disappear tomorrow afternoon.

Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.

There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.

That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.

Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”

It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.

I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.

Well, sometimes maybe. Just not this time.

Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”

What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.

I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.

In other words, eczema has no butt. So you can’t kick it.

The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.

The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?

No, actually it sometimes isn’t.

We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.

Or that there are indeed butts, big and small. But not everything has one to kick.

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.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency now has come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their chart including all their providers’ notes.

Patients always have had the right to see their record. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their chart. They would have to supply a reason and often pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas one in three patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions, although one-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including physician notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges. First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Not as bad as it sounds. Or consider, “differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It also must include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law was viewable by her. Clearly, bad transparency, bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency now has come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their chart including all their providers’ notes.

Patients always have had the right to see their record. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their chart. They would have to supply a reason and often pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas one in three patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions, although one-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including physician notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges. First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Not as bad as it sounds. Or consider, “differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It also must include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law was viewable by her. Clearly, bad transparency, bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Transparency, until recently, was rarely associated with health care. Not anymore. For better and sometimes worse, there is a revolutionary movement toward transparency in all facets of health care: transparency of costs, outcomes, quality, service, and reputation. Full transparency now has come to medical records in the form of OpenNotes. This is a patient-centered initiative that allows patients full access to their chart including all their providers’ notes.

Patients always have had the right to see their record. Ordinarily though, they would be required to go to the medical records office, fill out paperwork, and request copies of their chart. They would have to supply a reason and often pay a fee. OpenNotes changes that. Open patient charts are free and easy to access, usually digitally. OpenNotes programs are still rare, and before we go any further, it’s important to examine what we’ve learned about them.

In 2010, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle invited 105 primary care physicians to open their notes to nearly 14,000 patients. The results were overwhelmingly (and to me, surprisingly) positive: More than 85% of patients accessed their notes at least once. Nearly 100% of patients wanted the program to continue. Patients reported a better understanding of their medical issues, better medication adherence, increased adoption of healthy habits, and less anxiety about their health. I would have expected more confusion and anxiety among the patients.

What about the physicians? According to the initiative, whereas one in three patients thought they should have unfettered access to their physicians’ notes, only 1 in 10 physicians did. That’s understandable. The physicians in the pilot shared many of the same concerns you and I have, namely that OpenNotes would lead to an increased workload to explain esoteric notes to patients and to allay anxieties.

Yet, this extra workload didn’t occur. Only 3% of physicians reported spending more time answering patients’ questions, although one-fifth did report that they changed the language they used when writing notes, primarily to avoid offending patients. Every physician in the initiative said he or she would continue using OpenNotes. Surprised? So was I.

Even the usually conservative SERMO physician audience responded in an unexpected manner. According to a poll conducted this June, SERMO asked 2,300 physicians if patients should have access to their medical records (including physician notes). Forty-nine percent said “only on a case-by-case basis,” 34% said “yes, always,” and 17% said “no, never.”

So, are OpenNotes a success? Let’s take a closer look at some of the challenges. First, we physicians use language that will confuse patients at best and lead them to incorrect conclusions at worst. “Acne necrotica?” Not as bad as it sounds. Or consider, “differential diagnosis includes neuroendocrine tumor.” It doesn’t mean you have it, but some patients will believe they do. Will we have to dumb down our charts then to appease them? Won’t this degrade note quality, one of the primary objectives we are trying to avoid? It’s unclear.

The purpose of a patient note is to inform other providers and to remind ourselves of the critical information needed to care for a patient. It must be pithy and honest. It often reflects our inchoate thoughts as much as our diagnoses. It also must include the sundry requirements we know and love that are needed only to bill for the visit. These are not characteristics that make for a good patient read.

Indeed, the benefits of transparency are not limitless. In some instances, more transparency is worse. Imagine if all your emails and texts were transparent to everyone. Or if everything you’ve ever said about your mother-in-law was viewable by her. Clearly, bad transparency, bad transparency. Not sharing everything doesn’t mean we are dishonest or duplicitous. It means we are civil. It doesn’t mean we don’t care; it means we do care. We care about our friends and family. We care about our patients and the best way to make them well.

Unless we make it clear to patients that the notes they are viewing are not written for them, I’m worried simply opening charts could damage the doctor-patient relationship as much as it fosters it. Interestingly, there are companies trying to build a technical solution for this conundrum. Others are advocating for standardization of pathology and lab reports that are patient friendly. I’ll research these topics and let you know what I find out in a future column.

Perhaps I shouldn’t have been surprised by the positive results from the OpenNotes initiative. After all, for the last several years, I have given patients their actual pathology report for every biopsy I’ve done (which numbers in the many thousands). I have had fewer than five follow-up questions from patients that I can remember. Pretty much all were legitimate, as I recall, including a wrong site error in a report.

Today, more than 5 million patients have access to their providers’ notes on OpenNotes. That number will grow. Our biggest risk is to not be involved. “Just say no” didn’t work for Nancy Reagan; it won’t do our cause any good either.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

In the previous two editions of this column, I have written about the new Medicare Access and CHIP Reauthorization Act (MACRA) and the changes it will bring to Medicare physician payment beginning in January 2019 with the Merit-Based Incentive Payment System (MIPS). In June’s column, three of the four MIPS performance categories were outlined. Specifically, those include the Quality, Resource Use, and Electronic Health Record Meaningful Use components and encompass the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), Physician Quality Reporting System (PQRS), and Electronic Health Record Meaningful Use (EHR-MU) programs with which Fellows are hopefully familiar. As promised, this month I will discuss the final performance category component, namely the Clinical Practice Improvement Activities (CPIA) as well as the Alternative Payment Models program (APMs). Lastly, I wish to bring to the attention of Fellows a new web-based resource developed by the ACS Division of Advocacy and Health Policy to assist them in avoiding current law Medicare penalties.

The CPIA are designed to assess and credit surgeons according to their effort toward improving their clinical practice OR their preparation toward participating in the APMs. The menu of specific, recognized activities will be established in collaboration with the Centers for Medicare & Medicaid Services and the providers to whom the activities will be applicable. Many of the specifics are yet to be determined and will be part of the rule-making process in coming years. However, the MACRA legislation specifies that the CPIA must be applicable to all specialties and be attainable for small practices and professionals in rural and underserved areas. To support the efforts of surgeons and other providers in small or rural practice, Congress set aside $20 million dollars for each year, 2016-2020, for technical assistance to support the efforts of practices with 15 or fewer professionals to improve MIPS performance or transition to APMs.

The new law takes concerted steps to incentivize and encourage the development of and participation in APMs. As with the CPIA outlined above, the details of APMs are not yet fully clear and will be established going forward. However, in general, these programs will base payment on quality measures, not volume or intensity, and will include an element of financial risk for providers. For those surgeons who receive a significant share of their revenue from an APM, an annual 5% bonus will be available for each of the years 2019-2024. To qualify for that bonus surgeons must receive 25% of their Medicare revenue from an APM in the years 2019 and 2020, with the requirement subsequently increasing to 50% in 2021 and ultimately to 75% beginning in 2023. Providers may qualify based on a combination of private APMs and Medicare APMs as well.

In recognition of the lack of APMs in many areas or applicability for many specialties, MACRA prioritizes development of models for small practices, models that are specialty specific, and model development in conjunction with private payers as well as Medicaid-based options, all with the ultimate goal of encouraging the development of new and innovative payment models. The legislative language in MACRA is broad enough that it may allow for creation of a model based on the ACS’ Clinical Affinity Group (CAG) concept whereby providers are grouped together based on the patients or conditions that they treat, not their specialty designation.

Surgeons who meet a threshold of payment received from a qualified APM will be exempted from participation in MIPS to include most EHR-MU requirements and also receive the 5% bonus as described above. Those who participate in an APM but fail to meet the threshold necessary to receive that bonus will receive credit for such in the CPIA portion of their MIPS composite score.

Finally, even though the permanent repeal of the SGR found in MACRA represents the successful culmination of long-standing, combined advocacy efforts of the American College of Surgeons (ACS) and other medical associations toward meaningful, future Medicare physician payment reform, Fellows should be well aware that the three current law Medicare quality programs, namely the PQRS, EHR-MU, and VBM and their corresponding requirements as well as their associated penalties remain in effect until January 2019.

Surgeons who do not successfully participate in the PQRS, EHR-MU, and VBM face significant penalties on future Medicare payments. Specifically, failure to meet the requirements imposed by these three programs in 2015 could result in total penalties of up to 9% in Medicare payments in 2017.

To assist Fellows in navigating the complexities of complying with current law quality program requirements and thus avoid Medicare penalties, the ACS Division of Advocacy and Health Policy has developed a new online interactive flowchart which can be found at [WEB ADDRESS]. Fellows may wish to refer to and bookmark this page as an ongoing reference in order to familiarize themselves with current law requirements, facilitate their individual compliance with same, and thus successfully avoid penalties. As always, Fellows with questions may contact the DAHP at 202-337-2701.

Until next month ….

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.

In the previous two editions of this column, I have written about the new Medicare Access and CHIP Reauthorization Act (MACRA) and the changes it will bring to Medicare physician payment beginning in January 2019 with the Merit-Based Incentive Payment System (MIPS). In June’s column, three of the four MIPS performance categories were outlined. Specifically, those include the Quality, Resource Use, and Electronic Health Record Meaningful Use components and encompass the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), Physician Quality Reporting System (PQRS), and Electronic Health Record Meaningful Use (EHR-MU) programs with which Fellows are hopefully familiar. As promised, this month I will discuss the final performance category component, namely the Clinical Practice Improvement Activities (CPIA) as well as the Alternative Payment Models program (APMs). Lastly, I wish to bring to the attention of Fellows a new web-based resource developed by the ACS Division of Advocacy and Health Policy to assist them in avoiding current law Medicare penalties.

The CPIA are designed to assess and credit surgeons according to their effort toward improving their clinical practice OR their preparation toward participating in the APMs. The menu of specific, recognized activities will be established in collaboration with the Centers for Medicare & Medicaid Services and the providers to whom the activities will be applicable. Many of the specifics are yet to be determined and will be part of the rule-making process in coming years. However, the MACRA legislation specifies that the CPIA must be applicable to all specialties and be attainable for small practices and professionals in rural and underserved areas. To support the efforts of surgeons and other providers in small or rural practice, Congress set aside $20 million dollars for each year, 2016-2020, for technical assistance to support the efforts of practices with 15 or fewer professionals to improve MIPS performance or transition to APMs.

The new law takes concerted steps to incentivize and encourage the development of and participation in APMs. As with the CPIA outlined above, the details of APMs are not yet fully clear and will be established going forward. However, in general, these programs will base payment on quality measures, not volume or intensity, and will include an element of financial risk for providers. For those surgeons who receive a significant share of their revenue from an APM, an annual 5% bonus will be available for each of the years 2019-2024. To qualify for that bonus surgeons must receive 25% of their Medicare revenue from an APM in the years 2019 and 2020, with the requirement subsequently increasing to 50% in 2021 and ultimately to 75% beginning in 2023. Providers may qualify based on a combination of private APMs and Medicare APMs as well.

In recognition of the lack of APMs in many areas or applicability for many specialties, MACRA prioritizes development of models for small practices, models that are specialty specific, and model development in conjunction with private payers as well as Medicaid-based options, all with the ultimate goal of encouraging the development of new and innovative payment models. The legislative language in MACRA is broad enough that it may allow for creation of a model based on the ACS’ Clinical Affinity Group (CAG) concept whereby providers are grouped together based on the patients or conditions that they treat, not their specialty designation.

Surgeons who meet a threshold of payment received from a qualified APM will be exempted from participation in MIPS to include most EHR-MU requirements and also receive the 5% bonus as described above. Those who participate in an APM but fail to meet the threshold necessary to receive that bonus will receive credit for such in the CPIA portion of their MIPS composite score.

Finally, even though the permanent repeal of the SGR found in MACRA represents the successful culmination of long-standing, combined advocacy efforts of the American College of Surgeons (ACS) and other medical associations toward meaningful, future Medicare physician payment reform, Fellows should be well aware that the three current law Medicare quality programs, namely the PQRS, EHR-MU, and VBM and their corresponding requirements as well as their associated penalties remain in effect until January 2019.

Surgeons who do not successfully participate in the PQRS, EHR-MU, and VBM face significant penalties on future Medicare payments. Specifically, failure to meet the requirements imposed by these three programs in 2015 could result in total penalties of up to 9% in Medicare payments in 2017.

To assist Fellows in navigating the complexities of complying with current law quality program requirements and thus avoid Medicare penalties, the ACS Division of Advocacy and Health Policy has developed a new online interactive flowchart which can be found at [WEB ADDRESS]. Fellows may wish to refer to and bookmark this page as an ongoing reference in order to familiarize themselves with current law requirements, facilitate their individual compliance with same, and thus successfully avoid penalties. As always, Fellows with questions may contact the DAHP at 202-337-2701.

Until next month ….

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.

In the previous two editions of this column, I have written about the new Medicare Access and CHIP Reauthorization Act (MACRA) and the changes it will bring to Medicare physician payment beginning in January 2019 with the Merit-Based Incentive Payment System (MIPS). In June’s column, three of the four MIPS performance categories were outlined. Specifically, those include the Quality, Resource Use, and Electronic Health Record Meaningful Use components and encompass the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), Physician Quality Reporting System (PQRS), and Electronic Health Record Meaningful Use (EHR-MU) programs with which Fellows are hopefully familiar. As promised, this month I will discuss the final performance category component, namely the Clinical Practice Improvement Activities (CPIA) as well as the Alternative Payment Models program (APMs). Lastly, I wish to bring to the attention of Fellows a new web-based resource developed by the ACS Division of Advocacy and Health Policy to assist them in avoiding current law Medicare penalties.

The CPIA are designed to assess and credit surgeons according to their effort toward improving their clinical practice OR their preparation toward participating in the APMs. The menu of specific, recognized activities will be established in collaboration with the Centers for Medicare & Medicaid Services and the providers to whom the activities will be applicable. Many of the specifics are yet to be determined and will be part of the rule-making process in coming years. However, the MACRA legislation specifies that the CPIA must be applicable to all specialties and be attainable for small practices and professionals in rural and underserved areas. To support the efforts of surgeons and other providers in small or rural practice, Congress set aside $20 million dollars for each year, 2016-2020, for technical assistance to support the efforts of practices with 15 or fewer professionals to improve MIPS performance or transition to APMs.

The new law takes concerted steps to incentivize and encourage the development of and participation in APMs. As with the CPIA outlined above, the details of APMs are not yet fully clear and will be established going forward. However, in general, these programs will base payment on quality measures, not volume or intensity, and will include an element of financial risk for providers. For those surgeons who receive a significant share of their revenue from an APM, an annual 5% bonus will be available for each of the years 2019-2024. To qualify for that bonus surgeons must receive 25% of their Medicare revenue from an APM in the years 2019 and 2020, with the requirement subsequently increasing to 50% in 2021 and ultimately to 75% beginning in 2023. Providers may qualify based on a combination of private APMs and Medicare APMs as well.

In recognition of the lack of APMs in many areas or applicability for many specialties, MACRA prioritizes development of models for small practices, models that are specialty specific, and model development in conjunction with private payers as well as Medicaid-based options, all with the ultimate goal of encouraging the development of new and innovative payment models. The legislative language in MACRA is broad enough that it may allow for creation of a model based on the ACS’ Clinical Affinity Group (CAG) concept whereby providers are grouped together based on the patients or conditions that they treat, not their specialty designation.

Surgeons who meet a threshold of payment received from a qualified APM will be exempted from participation in MIPS to include most EHR-MU requirements and also receive the 5% bonus as described above. Those who participate in an APM but fail to meet the threshold necessary to receive that bonus will receive credit for such in the CPIA portion of their MIPS composite score.

Finally, even though the permanent repeal of the SGR found in MACRA represents the successful culmination of long-standing, combined advocacy efforts of the American College of Surgeons (ACS) and other medical associations toward meaningful, future Medicare physician payment reform, Fellows should be well aware that the three current law Medicare quality programs, namely the PQRS, EHR-MU, and VBM and their corresponding requirements as well as their associated penalties remain in effect until January 2019.

Surgeons who do not successfully participate in the PQRS, EHR-MU, and VBM face significant penalties on future Medicare payments. Specifically, failure to meet the requirements imposed by these three programs in 2015 could result in total penalties of up to 9% in Medicare payments in 2017.

To assist Fellows in navigating the complexities of complying with current law quality program requirements and thus avoid Medicare penalties, the ACS Division of Advocacy and Health Policy has developed a new online interactive flowchart which can be found at [WEB ADDRESS]. Fellows may wish to refer to and bookmark this page as an ongoing reference in order to familiarize themselves with current law requirements, facilitate their individual compliance with same, and thus successfully avoid penalties. As always, Fellows with questions may contact the DAHP at 202-337-2701.

Until next month ….

Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, D.C.