Commentary

Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.

Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).

In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).

Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).

Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.

Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.

Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.

As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.

Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.

Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).

In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).

Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).

Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.

Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.

Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.

As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.

Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.

Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).

In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).

Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).

Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.

Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.

Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.

As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.

The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.

I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.

In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.

Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.

So, how well do they work?

Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.

The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.

Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.

The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.

Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.

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

The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.

I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.

In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.

Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.

So, how well do they work?

Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.

The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.

Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.

The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.

Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.

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

The other day, I received an electronic message that my patient presented to the emergency department following his attempt at lifting a relatively immovable object. The only thing apparently moved by this activity was his intervertebral disk – outward from its usual place and onto a nerve. He was quickly diagnosed with acute sciatica and treated with a healthy dose of steroids.

I enjoyed the subsequent soliloquy of the brilliance and outstanding clinical skill of our emergency department clinicians (which is true, by the way) when I saw him for follow-up. He was markedly improved.

In a moment of introspection, I questioned why we do not tend to use this strategy more in my practice, especially because it worked so well for my patient.

Perhaps it is because we are so used to dealing with medication side effects and the downstream consequences of insulin resistance in primary care that steroids make us squeamish. Perhaps it is also because we tend to see patients later in the course of their disease and think that it is too late for steroids to be beneficial. Maybe we are uncertain of their benefits.

So, how well do they work?

Dr. Harley Goldberg and colleagues recently published data from a randomized clinical trial exploring the efficacy of oral steroids for the treatment of acute sciatica (JAMA 2015;313:1915-23). A total of 269 adults with radicular pain for 3 months or less, an Oswestry Disability Index (ODI) of at least 30, and a herniated disk confirmed on MRI were randomized to prednisone or placebo. The prednisone dose was 60 mg for 5 days, then 40 mg for 5 days, and finally 20 mg for 5 days.

The prednisone group demonstrated significant reduction in the ODI at 3 weeks and 12 months, compared with placebo. No differences in pain or in rates of surgery were observed.

Adverse events were more common with prednisone, the most common being insomnia, increased appetite, and nervousness. No serious adverse events occurred related to treatment, and no differences were observed at 1 year.

The authors point out that the observation of a reduction in disability but no reduction in pain may be related to the fact that as patients improve functionally, they increase activity and experience more pain. Although analyses did not demonstrate a relationship between time until starting the steroids and identified effects of prednisone, clinical sense may press us to want to start them earlier in the course of disease.

Steroids might be a reasonable option in this setting, and combining them with other modalities (e.g., gabapentin) might further improve patients’ functional status and pain. As always, engaging patients in the shared decision making may help manage expectations.

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

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

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. Talakoub.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

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. Talakoub.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

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. Talakoub.

Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.

One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1_C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).

Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.

Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.

Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.

I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.

There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities. 

Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.

Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.

One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1_C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).

Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.

Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.

Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.

I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.

There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities. 

Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.

Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.

One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1_C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).

Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.

Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.

Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.

I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.

There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities. 

Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.

As mentioned at the end of last month’s column, in the wake of the permanent repeal of the SGR, it will be necessary for surgeons to become familiar with an entire new lexicon of acronyms. That being said, I would like to first borrow a line from Kevin Bacon at the end of the movie Animal House and assure you that “all is well.”

The first of the new acronyms is MIPS – Merit-based Incentive Payment System.

To start, there is good news for several reasons. First, the MIPS program does not go into effect until 2019. This gives all surgeons ample opportunity to become educated and to prepare for the new program. In addition, most surgeons are already familiar with most, if not all, of the individual components of MIPS. Finally, MIPS provides payment updates based on each surgeon’s individual performance. These updates are independent of an arbitrarily set aggregate spending target as was the case previously under the SGR.

Surgeons who treat few Medicare patients or who receive a significant portion of their revenue from an eligible Alternative Payment Model program (APM) will be excluded from the MIPS program. APMs will be discussed in a later edition of this column.

MIPS will provide annual updates, again starting in 2019, based on individual performance in four categories: Quality, Resource Use, Electronic Health Record Meaningful Use and Clinical Practice Improvement Activities.

Surgeons participating in MIPS will receive an individual composite score of 0-100 based on their performance in the aforementioned four categories. Each individual composite score will then be compared to a performance threshold. The threshold consists of the mean or median of the composite performance scores for all MIPS-eligible professionals during a performance period prior to the current period. The threshold resets each year such that an individual’s score in 1 year does not impact their composite score the following year. All those with an individual composite performance score above the threshold will receive a positive payment adjustment, while those with an individual composite performance score below the threshold will receive a negative payment adjustment.

Positive adjustments can be up to 4% in 2019 and grow to 9% in 2022. Should the number of providers achieving high composite scores be low, the positive adjustments can be increased by up to a factor of three. If the number of those over the threshold far exceeds the number of those below the threshold, the incentives are scaled back to ensure budget neutrality. An additional $500 million per year is available for the top 75% of providers above the performance threshold. This ensures that in a circumstance where all physicians met the MIPS threshold, there would be funds available for positive updates.

Similarly, negative adjustments will be capped at 4% in 2019, rising to 9% in 2022. Those whose composite performance score falls in the lowest quartile below the threshold (i.e., with a performance threshold set at 60, those with scores between 0 and 15), will be subject to the maximum possible payment adjustment. Those with composite performance scores closer to the threshold will be subject to proportionally smaller negative payment adjustments.

The quality component of the MIPS will consist of quality measures currently used in existing quality performance programs. Specifically, these are the PQRS (Physician Quality Reporting System), the VBM (Value-Based Modifier program), and EHR-MU (Electronic Health Record Meaningful Use), with which most surgeons are already familiar. The Secretary of the Department of Health & Human Services will also solicit other measures from professional organizations such as ACS. Composite measures from QCDR (Qualified Clinical Data Registries) may also be used. The College is working with CMS to determine how to ensure its data registries, NSQIP and the SSR (Surgeon Specific Registry), can be utilized to meet the QCDR requirements.

The resource use component of MIPS will also include measures used in the current VBM program. The methodology by which these measures are applied will be enhanced through public input to include directly engaging providers. Surgeons will be allowed to report their specific role in treating patients. This provision seeks to allay concerns that the current methodology and attribution rules fail to accurately link the cost of services to the correct, specific professional. Additionally, research and public input will be sought on how to improve risk-adjustment methodologies such that surgeons are not penalized for providing care to sicker patients whose care is more costly.

With regard to the EHR-MU component of MIPS, the current EHR-MU requirements will continue to apply. ACS continues to advocate for changes to the EHR-MU program to make it easier for surgeons to comply with the requirements. Electronic health records are required to be interoperable by 2018 and vendors are prohibited from deliberately blocking information sharing with another vendor’s product.

In next month’s column, we will discuss the final component category of MIPS, the CPIA (Clinical Practice Improvement Activities) and the APMs as mentioned above.

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.

As mentioned at the end of last month’s column, in the wake of the permanent repeal of the SGR, it will be necessary for surgeons to become familiar with an entire new lexicon of acronyms. That being said, I would like to first borrow a line from Kevin Bacon at the end of the movie Animal House and assure you that “all is well.”

The first of the new acronyms is MIPS – Merit-based Incentive Payment System.

To start, there is good news for several reasons. First, the MIPS program does not go into effect until 2019. This gives all surgeons ample opportunity to become educated and to prepare for the new program. In addition, most surgeons are already familiar with most, if not all, of the individual components of MIPS. Finally, MIPS provides payment updates based on each surgeon’s individual performance. These updates are independent of an arbitrarily set aggregate spending target as was the case previously under the SGR.

Surgeons who treat few Medicare patients or who receive a significant portion of their revenue from an eligible Alternative Payment Model program (APM) will be excluded from the MIPS program. APMs will be discussed in a later edition of this column.

MIPS will provide annual updates, again starting in 2019, based on individual performance in four categories: Quality, Resource Use, Electronic Health Record Meaningful Use and Clinical Practice Improvement Activities.

Surgeons participating in MIPS will receive an individual composite score of 0-100 based on their performance in the aforementioned four categories. Each individual composite score will then be compared to a performance threshold. The threshold consists of the mean or median of the composite performance scores for all MIPS-eligible professionals during a performance period prior to the current period. The threshold resets each year such that an individual’s score in 1 year does not impact their composite score the following year. All those with an individual composite performance score above the threshold will receive a positive payment adjustment, while those with an individual composite performance score below the threshold will receive a negative payment adjustment.

Positive adjustments can be up to 4% in 2019 and grow to 9% in 2022. Should the number of providers achieving high composite scores be low, the positive adjustments can be increased by up to a factor of three. If the number of those over the threshold far exceeds the number of those below the threshold, the incentives are scaled back to ensure budget neutrality. An additional $500 million per year is available for the top 75% of providers above the performance threshold. This ensures that in a circumstance where all physicians met the MIPS threshold, there would be funds available for positive updates.

Similarly, negative adjustments will be capped at 4% in 2019, rising to 9% in 2022. Those whose composite performance score falls in the lowest quartile below the threshold (i.e., with a performance threshold set at 60, those with scores between 0 and 15), will be subject to the maximum possible payment adjustment. Those with composite performance scores closer to the threshold will be subject to proportionally smaller negative payment adjustments.

The quality component of the MIPS will consist of quality measures currently used in existing quality performance programs. Specifically, these are the PQRS (Physician Quality Reporting System), the VBM (Value-Based Modifier program), and EHR-MU (Electronic Health Record Meaningful Use), with which most surgeons are already familiar. The Secretary of the Department of Health & Human Services will also solicit other measures from professional organizations such as ACS. Composite measures from QCDR (Qualified Clinical Data Registries) may also be used. The College is working with CMS to determine how to ensure its data registries, NSQIP and the SSR (Surgeon Specific Registry), can be utilized to meet the QCDR requirements.

The resource use component of MIPS will also include measures used in the current VBM program. The methodology by which these measures are applied will be enhanced through public input to include directly engaging providers. Surgeons will be allowed to report their specific role in treating patients. This provision seeks to allay concerns that the current methodology and attribution rules fail to accurately link the cost of services to the correct, specific professional. Additionally, research and public input will be sought on how to improve risk-adjustment methodologies such that surgeons are not penalized for providing care to sicker patients whose care is more costly.

With regard to the EHR-MU component of MIPS, the current EHR-MU requirements will continue to apply. ACS continues to advocate for changes to the EHR-MU program to make it easier for surgeons to comply with the requirements. Electronic health records are required to be interoperable by 2018 and vendors are prohibited from deliberately blocking information sharing with another vendor’s product.

In next month’s column, we will discuss the final component category of MIPS, the CPIA (Clinical Practice Improvement Activities) and the APMs as mentioned above.

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.

As mentioned at the end of last month’s column, in the wake of the permanent repeal of the SGR, it will be necessary for surgeons to become familiar with an entire new lexicon of acronyms. That being said, I would like to first borrow a line from Kevin Bacon at the end of the movie Animal House and assure you that “all is well.”

The first of the new acronyms is MIPS – Merit-based Incentive Payment System.

To start, there is good news for several reasons. First, the MIPS program does not go into effect until 2019. This gives all surgeons ample opportunity to become educated and to prepare for the new program. In addition, most surgeons are already familiar with most, if not all, of the individual components of MIPS. Finally, MIPS provides payment updates based on each surgeon’s individual performance. These updates are independent of an arbitrarily set aggregate spending target as was the case previously under the SGR.

Surgeons who treat few Medicare patients or who receive a significant portion of their revenue from an eligible Alternative Payment Model program (APM) will be excluded from the MIPS program. APMs will be discussed in a later edition of this column.

MIPS will provide annual updates, again starting in 2019, based on individual performance in four categories: Quality, Resource Use, Electronic Health Record Meaningful Use and Clinical Practice Improvement Activities.

Surgeons participating in MIPS will receive an individual composite score of 0-100 based on their performance in the aforementioned four categories. Each individual composite score will then be compared to a performance threshold. The threshold consists of the mean or median of the composite performance scores for all MIPS-eligible professionals during a performance period prior to the current period. The threshold resets each year such that an individual’s score in 1 year does not impact their composite score the following year. All those with an individual composite performance score above the threshold will receive a positive payment adjustment, while those with an individual composite performance score below the threshold will receive a negative payment adjustment.

Positive adjustments can be up to 4% in 2019 and grow to 9% in 2022. Should the number of providers achieving high composite scores be low, the positive adjustments can be increased by up to a factor of three. If the number of those over the threshold far exceeds the number of those below the threshold, the incentives are scaled back to ensure budget neutrality. An additional $500 million per year is available for the top 75% of providers above the performance threshold. This ensures that in a circumstance where all physicians met the MIPS threshold, there would be funds available for positive updates.

Similarly, negative adjustments will be capped at 4% in 2019, rising to 9% in 2022. Those whose composite performance score falls in the lowest quartile below the threshold (i.e., with a performance threshold set at 60, those with scores between 0 and 15), will be subject to the maximum possible payment adjustment. Those with composite performance scores closer to the threshold will be subject to proportionally smaller negative payment adjustments.

The quality component of the MIPS will consist of quality measures currently used in existing quality performance programs. Specifically, these are the PQRS (Physician Quality Reporting System), the VBM (Value-Based Modifier program), and EHR-MU (Electronic Health Record Meaningful Use), with which most surgeons are already familiar. The Secretary of the Department of Health & Human Services will also solicit other measures from professional organizations such as ACS. Composite measures from QCDR (Qualified Clinical Data Registries) may also be used. The College is working with CMS to determine how to ensure its data registries, NSQIP and the SSR (Surgeon Specific Registry), can be utilized to meet the QCDR requirements.

The resource use component of MIPS will also include measures used in the current VBM program. The methodology by which these measures are applied will be enhanced through public input to include directly engaging providers. Surgeons will be allowed to report their specific role in treating patients. This provision seeks to allay concerns that the current methodology and attribution rules fail to accurately link the cost of services to the correct, specific professional. Additionally, research and public input will be sought on how to improve risk-adjustment methodologies such that surgeons are not penalized for providing care to sicker patients whose care is more costly.

With regard to the EHR-MU component of MIPS, the current EHR-MU requirements will continue to apply. ACS continues to advocate for changes to the EHR-MU program to make it easier for surgeons to comply with the requirements. Electronic health records are required to be interoperable by 2018 and vendors are prohibited from deliberately blocking information sharing with another vendor’s product.

In next month’s column, we will discuss the final component category of MIPS, the CPIA (Clinical Practice Improvement Activities) and the APMs as mentioned above.

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.

The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.

This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”

This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.

The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.

It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.

What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.

The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.

Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.

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

The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.

This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”

This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.

The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.

It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.

What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.

The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.

Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.

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

The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.

This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”

This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.

The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.

It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.

What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.

The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.

Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.

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

They put Bill’s chart on my desk, with a cover sheet. “I authorize you to send all my medical records,” it read, over his signature. The destination was a dermatologist across town.

I reviewed Bill’s record. His last visit was 6 months ago, just a skin check to mop up some solar keratoses. One of many such visits over 20 years. A basal cell on the shoulder 10 years ago. Nothing eventful.

“What happened?” I wondered, as I signed off on sending his chart. Had I missed a skin cancer?

That thought brought to mind Maxine. She, too, had been my patient for many years. Her niece still comes in.

Maxine had a history of sun damage, along with a few low-grade skin cancers. One day I biopsied a hand lesion. It was a squamous cell. I called her with the results and referred her to a surgeon. Nothing new or special, or so it seemed.

A few weeks later I got Maxine’s letter. “Send all my medical records.”

So I had not missed her squamous cell, but she still wanted out. How come?

Over the course of a clinical career, patients drop out. They move away, pass away, change insurance, retire to Florida or Arizona. Sometimes they come back, years later. They lost their job in L.A., or moved back to nurse a sick parent. Perhaps they got their old insurance back, or their new doctor stopped accepting the kind they had. It’s been 5 years, 10 years. You didn’t even notice they were gone.

The same thing happens of course in other aspects of life. People move in and out of our orbit: school chums, work mates, parents of kids who play with our kids, neighbors. They grow up, move away, get lost somehow. Unless they reappear, we often don’t realize they aren’t there anymore.

Most of the time there was no special event, no angry falling out. Lives just diverged. We lost whatever we had in common. Nothing personal.

But former acquaintances don’t generally send you a note officially severing relations, a letter notifying you to, “Forget about me. You won’t be seeing me again.”

If we got such a letter, we might actually be relieved. Chances are, though, that if we weren’t expecting it (or secretly wishing for it), we would wonder what it was about. Was there a quarrel we didn’t even know about?

Chances are we wouldn’t try too hard to find out what the problem was, though. Whatever we did manage to learn would probably be unpleasant and unfixable.

The same is true when patients ask us to send all their records. Most people stay, unless something propels them to move on. Absent a shift in geography or health insurance, whatever did overcome their inertia it is probably not something we want to know.

“This will happen to you,” I tell my students. “Count on it. Patients will ask for their records. They may send you a note of complaint. ‘You didn’t find the skin cancer on mother’s leg,’ they may say. Or else, ‘Your treatments were useless. I went to another doctor who actually knew what was wrong and gave me what I needed.’ ” Nowadays, people put such sentiments into unfavorable online reviews.

“When you get letters or read reviews like those,” I advise, “count to 10 before you respond. Then count to 10 again. Then don’t respond. I’ve tried doing it the other way and regretted it every time.

“Mostly, there’s no potential litigation involved,” I continue. “If there is a threatened suit, you’ll need an attorney to respond anyway. Otherwise, learn what you can from the patient’s disappointment, file the letter, note the review, send all the records, and move on.”

We doctors tend to be an ingratiating sort. Because we try to help people, we want them to like us. Many will, often to excess. But good as we ever get, try as hard as we can, not everybody will like us. That’s life, in and out of medical practice.

Rejection is never pleasant. Experience thickens the skin, but even then a signed request to “Send all my records” can sting. Even after all these years, it still does.

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.

They put Bill’s chart on my desk, with a cover sheet. “I authorize you to send all my medical records,” it read, over his signature. The destination was a dermatologist across town.

I reviewed Bill’s record. His last visit was 6 months ago, just a skin check to mop up some solar keratoses. One of many such visits over 20 years. A basal cell on the shoulder 10 years ago. Nothing eventful.

“What happened?” I wondered, as I signed off on sending his chart. Had I missed a skin cancer?

That thought brought to mind Maxine. She, too, had been my patient for many years. Her niece still comes in.

Maxine had a history of sun damage, along with a few low-grade skin cancers. One day I biopsied a hand lesion. It was a squamous cell. I called her with the results and referred her to a surgeon. Nothing new or special, or so it seemed.

A few weeks later I got Maxine’s letter. “Send all my medical records.”

So I had not missed her squamous cell, but she still wanted out. How come?

Over the course of a clinical career, patients drop out. They move away, pass away, change insurance, retire to Florida or Arizona. Sometimes they come back, years later. They lost their job in L.A., or moved back to nurse a sick parent. Perhaps they got their old insurance back, or their new doctor stopped accepting the kind they had. It’s been 5 years, 10 years. You didn’t even notice they were gone.

The same thing happens of course in other aspects of life. People move in and out of our orbit: school chums, work mates, parents of kids who play with our kids, neighbors. They grow up, move away, get lost somehow. Unless they reappear, we often don’t realize they aren’t there anymore.

Most of the time there was no special event, no angry falling out. Lives just diverged. We lost whatever we had in common. Nothing personal.

But former acquaintances don’t generally send you a note officially severing relations, a letter notifying you to, “Forget about me. You won’t be seeing me again.”

If we got such a letter, we might actually be relieved. Chances are, though, that if we weren’t expecting it (or secretly wishing for it), we would wonder what it was about. Was there a quarrel we didn’t even know about?

Chances are we wouldn’t try too hard to find out what the problem was, though. Whatever we did manage to learn would probably be unpleasant and unfixable.

The same is true when patients ask us to send all their records. Most people stay, unless something propels them to move on. Absent a shift in geography or health insurance, whatever did overcome their inertia it is probably not something we want to know.

“This will happen to you,” I tell my students. “Count on it. Patients will ask for their records. They may send you a note of complaint. ‘You didn’t find the skin cancer on mother’s leg,’ they may say. Or else, ‘Your treatments were useless. I went to another doctor who actually knew what was wrong and gave me what I needed.’ ” Nowadays, people put such sentiments into unfavorable online reviews.

“When you get letters or read reviews like those,” I advise, “count to 10 before you respond. Then count to 10 again. Then don’t respond. I’ve tried doing it the other way and regretted it every time.

“Mostly, there’s no potential litigation involved,” I continue. “If there is a threatened suit, you’ll need an attorney to respond anyway. Otherwise, learn what you can from the patient’s disappointment, file the letter, note the review, send all the records, and move on.”

We doctors tend to be an ingratiating sort. Because we try to help people, we want them to like us. Many will, often to excess. But good as we ever get, try as hard as we can, not everybody will like us. That’s life, in and out of medical practice.

Rejection is never pleasant. Experience thickens the skin, but even then a signed request to “Send all my records” can sting. Even after all these years, it still does.

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.

They put Bill’s chart on my desk, with a cover sheet. “I authorize you to send all my medical records,” it read, over his signature. The destination was a dermatologist across town.

I reviewed Bill’s record. His last visit was 6 months ago, just a skin check to mop up some solar keratoses. One of many such visits over 20 years. A basal cell on the shoulder 10 years ago. Nothing eventful.

“What happened?” I wondered, as I signed off on sending his chart. Had I missed a skin cancer?

That thought brought to mind Maxine. She, too, had been my patient for many years. Her niece still comes in.

Maxine had a history of sun damage, along with a few low-grade skin cancers. One day I biopsied a hand lesion. It was a squamous cell. I called her with the results and referred her to a surgeon. Nothing new or special, or so it seemed.

A few weeks later I got Maxine’s letter. “Send all my medical records.”

So I had not missed her squamous cell, but she still wanted out. How come?

Over the course of a clinical career, patients drop out. They move away, pass away, change insurance, retire to Florida or Arizona. Sometimes they come back, years later. They lost their job in L.A., or moved back to nurse a sick parent. Perhaps they got their old insurance back, or their new doctor stopped accepting the kind they had. It’s been 5 years, 10 years. You didn’t even notice they were gone.

The same thing happens of course in other aspects of life. People move in and out of our orbit: school chums, work mates, parents of kids who play with our kids, neighbors. They grow up, move away, get lost somehow. Unless they reappear, we often don’t realize they aren’t there anymore.

Most of the time there was no special event, no angry falling out. Lives just diverged. We lost whatever we had in common. Nothing personal.

But former acquaintances don’t generally send you a note officially severing relations, a letter notifying you to, “Forget about me. You won’t be seeing me again.”

If we got such a letter, we might actually be relieved. Chances are, though, that if we weren’t expecting it (or secretly wishing for it), we would wonder what it was about. Was there a quarrel we didn’t even know about?

Chances are we wouldn’t try too hard to find out what the problem was, though. Whatever we did manage to learn would probably be unpleasant and unfixable.

The same is true when patients ask us to send all their records. Most people stay, unless something propels them to move on. Absent a shift in geography or health insurance, whatever did overcome their inertia it is probably not something we want to know.

“This will happen to you,” I tell my students. “Count on it. Patients will ask for their records. They may send you a note of complaint. ‘You didn’t find the skin cancer on mother’s leg,’ they may say. Or else, ‘Your treatments were useless. I went to another doctor who actually knew what was wrong and gave me what I needed.’ ” Nowadays, people put such sentiments into unfavorable online reviews.

“When you get letters or read reviews like those,” I advise, “count to 10 before you respond. Then count to 10 again. Then don’t respond. I’ve tried doing it the other way and regretted it every time.

“Mostly, there’s no potential litigation involved,” I continue. “If there is a threatened suit, you’ll need an attorney to respond anyway. Otherwise, learn what you can from the patient’s disappointment, file the letter, note the review, send all the records, and move on.”

We doctors tend to be an ingratiating sort. Because we try to help people, we want them to like us. Many will, often to excess. But good as we ever get, try as hard as we can, not everybody will like us. That’s life, in and out of medical practice.

Rejection is never pleasant. Experience thickens the skin, but even then a signed request to “Send all my records” can sting. Even after all these years, it still does.

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.

The reporter wanted to nail me, and shot me the zinger, “Doctor why do you get paid $106 to do a skin biopsy, and they only get $30 in Germany”?

I paused for minute (she was sure she had me), and then I said, “They only get $30? That stinks. You know I do get $49.”

The reporter said, “No, no, I see here in the Medicare database that doctors in the United States get paid $106.”

I explained to her that $57 of that was for equipment, staff, and supplies, and that doctors in Germany do everything in the hospital setting, where they don’t have to pay for any of that.

Oh.

This is an error that is repeated again and again, and you need to know the reason you get paid “so much.” The second year’s worth of the Medicare data were released last month, with a wrinkle: They removed the cost of medications. They floated the surgeons, oncologists, and ophthalmologists down and floated dermatology up to near the top, just under radiation oncology.

Let’s think about this for a minute. How many radiation oncologists have linear accelerators in their offices, and how many cardiologists have cath labs? How many ophthalmologists do cataract procedures in the office? The same is true for almost every other specialty. Most practitioners of procedural medicine do procedures in a hospital, where they pay no practice expenses. They may have a small office for consultations and suture removals, but for anything else they say, “Meet me at the hospital.” Often, the hospital supplies the office space for free or at a discount.

Now I don’t envy the primary care doctors, who also do everything in their offices, but guess what? Practice expense is only about 20% of the valuation of the evaluation and management codes. Think about this again. They don’t have power tables, OR lights, prep kits, sutures, hand tools, gauze, sponges, bandages, etc., to pay for, so it makes sense.

This means that most procedural physicians keep (before the huge tax bill we all are subject to) almost every Medicare dollar or insurance dollar they receive. Dermatologists’ reimbursements are 60% for practice expenses overall, with some even higher. Mohs surgery, for example, costs an average of 66% to provide. Dermatologists do almost nothing in the hospital, and instead provide more care for patients in the office setting. So, when the reporter tries to zing you about collecting $300,000 from Medicare, you explain that your dollars aren’t the same as everyone else’s dollars, and you really took $120,000 to the tax man (not that any of this is really their business anyway).

And, by the way, tell them you only get $24 for a second biopsy, which is just as much work as the first.

I think we should ask CMS to pull the practice expense out of its Medicare numbers in the next report. A dollar spent for surgical supplies is the same as a dollar spent for medications. It’s all money the doctor never sees.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

The reporter wanted to nail me, and shot me the zinger, “Doctor why do you get paid $106 to do a skin biopsy, and they only get $30 in Germany”?

I paused for minute (she was sure she had me), and then I said, “They only get $30? That stinks. You know I do get $49.”

The reporter said, “No, no, I see here in the Medicare database that doctors in the United States get paid $106.”

I explained to her that $57 of that was for equipment, staff, and supplies, and that doctors in Germany do everything in the hospital setting, where they don’t have to pay for any of that.

Oh.

This is an error that is repeated again and again, and you need to know the reason you get paid “so much.” The second year’s worth of the Medicare data were released last month, with a wrinkle: They removed the cost of medications. They floated the surgeons, oncologists, and ophthalmologists down and floated dermatology up to near the top, just under radiation oncology.

Let’s think about this for a minute. How many radiation oncologists have linear accelerators in their offices, and how many cardiologists have cath labs? How many ophthalmologists do cataract procedures in the office? The same is true for almost every other specialty. Most practitioners of procedural medicine do procedures in a hospital, where they pay no practice expenses. They may have a small office for consultations and suture removals, but for anything else they say, “Meet me at the hospital.” Often, the hospital supplies the office space for free or at a discount.

Now I don’t envy the primary care doctors, who also do everything in their offices, but guess what? Practice expense is only about 20% of the valuation of the evaluation and management codes. Think about this again. They don’t have power tables, OR lights, prep kits, sutures, hand tools, gauze, sponges, bandages, etc., to pay for, so it makes sense.

This means that most procedural physicians keep (before the huge tax bill we all are subject to) almost every Medicare dollar or insurance dollar they receive. Dermatologists’ reimbursements are 60% for practice expenses overall, with some even higher. Mohs surgery, for example, costs an average of 66% to provide. Dermatologists do almost nothing in the hospital, and instead provide more care for patients in the office setting. So, when the reporter tries to zing you about collecting $300,000 from Medicare, you explain that your dollars aren’t the same as everyone else’s dollars, and you really took $120,000 to the tax man (not that any of this is really their business anyway).

And, by the way, tell them you only get $24 for a second biopsy, which is just as much work as the first.

I think we should ask CMS to pull the practice expense out of its Medicare numbers in the next report. A dollar spent for surgical supplies is the same as a dollar spent for medications. It’s all money the doctor never sees.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

The reporter wanted to nail me, and shot me the zinger, “Doctor why do you get paid $106 to do a skin biopsy, and they only get $30 in Germany”?

I paused for minute (she was sure she had me), and then I said, “They only get $30? That stinks. You know I do get $49.”

The reporter said, “No, no, I see here in the Medicare database that doctors in the United States get paid $106.”

I explained to her that $57 of that was for equipment, staff, and supplies, and that doctors in Germany do everything in the hospital setting, where they don’t have to pay for any of that.

Oh.

This is an error that is repeated again and again, and you need to know the reason you get paid “so much.” The second year’s worth of the Medicare data were released last month, with a wrinkle: They removed the cost of medications. They floated the surgeons, oncologists, and ophthalmologists down and floated dermatology up to near the top, just under radiation oncology.

Let’s think about this for a minute. How many radiation oncologists have linear accelerators in their offices, and how many cardiologists have cath labs? How many ophthalmologists do cataract procedures in the office? The same is true for almost every other specialty. Most practitioners of procedural medicine do procedures in a hospital, where they pay no practice expenses. They may have a small office for consultations and suture removals, but for anything else they say, “Meet me at the hospital.” Often, the hospital supplies the office space for free or at a discount.

Now I don’t envy the primary care doctors, who also do everything in their offices, but guess what? Practice expense is only about 20% of the valuation of the evaluation and management codes. Think about this again. They don’t have power tables, OR lights, prep kits, sutures, hand tools, gauze, sponges, bandages, etc., to pay for, so it makes sense.

This means that most procedural physicians keep (before the huge tax bill we all are subject to) almost every Medicare dollar or insurance dollar they receive. Dermatologists’ reimbursements are 60% for practice expenses overall, with some even higher. Mohs surgery, for example, costs an average of 66% to provide. Dermatologists do almost nothing in the hospital, and instead provide more care for patients in the office setting. So, when the reporter tries to zing you about collecting $300,000 from Medicare, you explain that your dollars aren’t the same as everyone else’s dollars, and you really took $120,000 to the tax man (not that any of this is really their business anyway).

And, by the way, tell them you only get $24 for a second biopsy, which is just as much work as the first.

I think we should ask CMS to pull the practice expense out of its Medicare numbers in the next report. A dollar spent for surgical supplies is the same as a dollar spent for medications. It’s all money the doctor never sees.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.