Commentary

My life is not the same as it was 15 years ago; my children are grown, my parents are elderly, and what I do in my leisure time reflects both new friends and maturing old friends. Some of these changes I embrace; others I simply accept. Some changes I intensely dislike but still know I have to accept them. Family changes can be difficult for all of us to manage. But changes in our profession? Now that gets to our core. These changes are unwanted and we do not have the time or energy for them. We have patients waiting! We have worked hard to develop a practice style that fits our patients’ needs and that feels authentic to our personal experiences and skill set. I completed 7 years of postgraduate training and still spend a lot of time pursuing continuing medical education opportunities, but now my prescription pad has become a suggestion pad and my overhead has swollen. Sure, I am happy to have new bench-to-bedside approaches to understanding diseases and cutting-edge treatments, but role changes? Employer expectation changes? Changes in insurance benefits for my patients? Regulatory invasion? Alternative payment models? The tsunami of changes we heard about several years ago is now crashing up on the shore.

Take a minute and write down 3 changes in your practice over the last few years that you dislike the most and then turn over the paper. We will come back to them in a minute.

In the midst of all these changes or perhaps as a consequence, there has been an epidemic of physician burnout characterized by emotional fatigue; depersonalization as evidenced by a negative, callous, and cynical attitude toward patients and their concerns; and a decreased sense of personal accomplishment. Burnout symptoms are more common in physicians than in the general population and penetrate as high as 46% of physicians in general practice, but it is relatively low in dermatology, affecting approximately 24% of our colleagues.¹ Just working in a practice with high expectations surrounding the use of an electronic medical record creates burnout and the intent to leave the practice.² Consequences of burnout are major and can include³ decreased quality of care, increased clinical errors, frequent job changes, migration to other occupations,⁴ early retirement, and even suicide.⁵ Change can sometimes feel like too much to endure.

People manage change with a number of strategies. One group of strategies is labeled disengagement: wishful thinking, problem avoidance, self-criticism, and social avoidance.⁶ Some of us just do not implement any meaningful use measures; we wish they would just go away and, after all, the penalties are not pinching us yet. More alarmingly, rates of physician substance abuse are rising,^7,8 a response to stress that allows for at least temporary problem avoidance and creates social isolation. Disengagement strategies do not promote coping, our ability to reduce or control stress.

Another group of choices include engagement strategies: problem solving, social support, expression of emotion, and cognitive restructuring.⁶ These strategies develop resilience, which is the capacity to respond to stress in a healthy way so that goals are achieved at minimal psychological and physical costs. Resilience creates positive resource spirals, and resilient individuals bounce back with increased strength.⁹

Let’s do some cognitive restructuring: First, we accept that change happens. Even facts change. Psoriasis was once said to be a disease of the keratinocytes, but now we consider it a disease of the immune system gone awry. It was dogma 30 years ago that excision of melanoma required 5-cm margins of normal skin, but the standard of care today includes much narrower margins. Once we accept that change happens, we learn to expect it as the natural course of events, and then we can look for the parts of change that we can enjoy. Learning something new about psoriasis and melanoma can be stimulating. Learning something new about the science of population health, patient management rubrics, quality measure development, and practice business models can be energizing too. Spend time and effort working on embracing changes that both interest you and are relevant to your practice. Do you hate the idea of having to incorporate quality measures in your practice? The fact that regulatory policy requires quality measures is not going to change, but we can gain some control by reading quality measure literature, working within our practice settings to develop quality improvement projects that are relevant and effective, and contributing to the discussion of quality measures in dermatology either in print or through committee work. Accepting change as well as working with our colleagues to promote relevant and positive change are examples of engagement strategies that help develop resilience.

Studies have shown that job satisfaction is highest among physicians who practice with defined professional and personal boundaries and pursue continued professional development, particularly by attending continuing medical education programs.¹⁰ Learning something new can be an antidote for boredom and depression. Being with other dermatologists, a wonderful group of interesting and passionate people, also can provide social support and allows us to express frustration regarding stresses in the workplace. I almost always return from dermatology meetings energized and stimulated.

Another factor related to job satisfaction is a focus on the positive aspects of one’s work. Dermatology is a fascinating study of a group of diseases that we can actually see and touch and biopsy. Some diseases are benign, while others may be fatal. They can occur in patients young and old, sick and healthy. Effective treatments exist that can change the course of these diseases, and new therapies continue to evolve. The art of diagnosis and patient care appeals to me as much as the science. A Canadian study found that appreciating the value of a relationship with the patient correlated with job satisfaction among physicians.¹¹ As dermatologists, we have this opportunity every day with each patient that we see.

Dermatologists indeed are very privileged. Take out another piece of paper and write down 3 aspects of our profession that you are thankful for. You can include things you are grateful for in other parts of your life too because physicians with strong relationships and activities outside of work report fewer episodes of emotional exhaustion.¹²

Now flip over the paper with the recent changes you do not like. They do not seem so bad anymore, do they?

My life is not the same as it was 15 years ago; my children are grown, my parents are elderly, and what I do in my leisure time reflects both new friends and maturing old friends. Some of these changes I embrace; others I simply accept. Some changes I intensely dislike but still know I have to accept them. Family changes can be difficult for all of us to manage. But changes in our profession? Now that gets to our core. These changes are unwanted and we do not have the time or energy for them. We have patients waiting! We have worked hard to develop a practice style that fits our patients’ needs and that feels authentic to our personal experiences and skill set. I completed 7 years of postgraduate training and still spend a lot of time pursuing continuing medical education opportunities, but now my prescription pad has become a suggestion pad and my overhead has swollen. Sure, I am happy to have new bench-to-bedside approaches to understanding diseases and cutting-edge treatments, but role changes? Employer expectation changes? Changes in insurance benefits for my patients? Regulatory invasion? Alternative payment models? The tsunami of changes we heard about several years ago is now crashing up on the shore.

Take a minute and write down 3 changes in your practice over the last few years that you dislike the most and then turn over the paper. We will come back to them in a minute.

In the midst of all these changes or perhaps as a consequence, there has been an epidemic of physician burnout characterized by emotional fatigue; depersonalization as evidenced by a negative, callous, and cynical attitude toward patients and their concerns; and a decreased sense of personal accomplishment. Burnout symptoms are more common in physicians than in the general population and penetrate as high as 46% of physicians in general practice, but it is relatively low in dermatology, affecting approximately 24% of our colleagues.¹ Just working in a practice with high expectations surrounding the use of an electronic medical record creates burnout and the intent to leave the practice.² Consequences of burnout are major and can include³ decreased quality of care, increased clinical errors, frequent job changes, migration to other occupations,⁴ early retirement, and even suicide.⁵ Change can sometimes feel like too much to endure.

People manage change with a number of strategies. One group of strategies is labeled disengagement: wishful thinking, problem avoidance, self-criticism, and social avoidance.⁶ Some of us just do not implement any meaningful use measures; we wish they would just go away and, after all, the penalties are not pinching us yet. More alarmingly, rates of physician substance abuse are rising,^7,8 a response to stress that allows for at least temporary problem avoidance and creates social isolation. Disengagement strategies do not promote coping, our ability to reduce or control stress.

Another group of choices include engagement strategies: problem solving, social support, expression of emotion, and cognitive restructuring.⁶ These strategies develop resilience, which is the capacity to respond to stress in a healthy way so that goals are achieved at minimal psychological and physical costs. Resilience creates positive resource spirals, and resilient individuals bounce back with increased strength.⁹

Let’s do some cognitive restructuring: First, we accept that change happens. Even facts change. Psoriasis was once said to be a disease of the keratinocytes, but now we consider it a disease of the immune system gone awry. It was dogma 30 years ago that excision of melanoma required 5-cm margins of normal skin, but the standard of care today includes much narrower margins. Once we accept that change happens, we learn to expect it as the natural course of events, and then we can look for the parts of change that we can enjoy. Learning something new about psoriasis and melanoma can be stimulating. Learning something new about the science of population health, patient management rubrics, quality measure development, and practice business models can be energizing too. Spend time and effort working on embracing changes that both interest you and are relevant to your practice. Do you hate the idea of having to incorporate quality measures in your practice? The fact that regulatory policy requires quality measures is not going to change, but we can gain some control by reading quality measure literature, working within our practice settings to develop quality improvement projects that are relevant and effective, and contributing to the discussion of quality measures in dermatology either in print or through committee work. Accepting change as well as working with our colleagues to promote relevant and positive change are examples of engagement strategies that help develop resilience.

Studies have shown that job satisfaction is highest among physicians who practice with defined professional and personal boundaries and pursue continued professional development, particularly by attending continuing medical education programs.¹⁰ Learning something new can be an antidote for boredom and depression. Being with other dermatologists, a wonderful group of interesting and passionate people, also can provide social support and allows us to express frustration regarding stresses in the workplace. I almost always return from dermatology meetings energized and stimulated.

Another factor related to job satisfaction is a focus on the positive aspects of one’s work. Dermatology is a fascinating study of a group of diseases that we can actually see and touch and biopsy. Some diseases are benign, while others may be fatal. They can occur in patients young and old, sick and healthy. Effective treatments exist that can change the course of these diseases, and new therapies continue to evolve. The art of diagnosis and patient care appeals to me as much as the science. A Canadian study found that appreciating the value of a relationship with the patient correlated with job satisfaction among physicians.¹¹ As dermatologists, we have this opportunity every day with each patient that we see.

Dermatologists indeed are very privileged. Take out another piece of paper and write down 3 aspects of our profession that you are thankful for. You can include things you are grateful for in other parts of your life too because physicians with strong relationships and activities outside of work report fewer episodes of emotional exhaustion.¹²

Now flip over the paper with the recent changes you do not like. They do not seem so bad anymore, do they?

My life is not the same as it was 15 years ago; my children are grown, my parents are elderly, and what I do in my leisure time reflects both new friends and maturing old friends. Some of these changes I embrace; others I simply accept. Some changes I intensely dislike but still know I have to accept them. Family changes can be difficult for all of us to manage. But changes in our profession? Now that gets to our core. These changes are unwanted and we do not have the time or energy for them. We have patients waiting! We have worked hard to develop a practice style that fits our patients’ needs and that feels authentic to our personal experiences and skill set. I completed 7 years of postgraduate training and still spend a lot of time pursuing continuing medical education opportunities, but now my prescription pad has become a suggestion pad and my overhead has swollen. Sure, I am happy to have new bench-to-bedside approaches to understanding diseases and cutting-edge treatments, but role changes? Employer expectation changes? Changes in insurance benefits for my patients? Regulatory invasion? Alternative payment models? The tsunami of changes we heard about several years ago is now crashing up on the shore.

Take a minute and write down 3 changes in your practice over the last few years that you dislike the most and then turn over the paper. We will come back to them in a minute.

In the midst of all these changes or perhaps as a consequence, there has been an epidemic of physician burnout characterized by emotional fatigue; depersonalization as evidenced by a negative, callous, and cynical attitude toward patients and their concerns; and a decreased sense of personal accomplishment. Burnout symptoms are more common in physicians than in the general population and penetrate as high as 46% of physicians in general practice, but it is relatively low in dermatology, affecting approximately 24% of our colleagues.¹ Just working in a practice with high expectations surrounding the use of an electronic medical record creates burnout and the intent to leave the practice.² Consequences of burnout are major and can include³ decreased quality of care, increased clinical errors, frequent job changes, migration to other occupations,⁴ early retirement, and even suicide.⁵ Change can sometimes feel like too much to endure.

People manage change with a number of strategies. One group of strategies is labeled disengagement: wishful thinking, problem avoidance, self-criticism, and social avoidance.⁶ Some of us just do not implement any meaningful use measures; we wish they would just go away and, after all, the penalties are not pinching us yet. More alarmingly, rates of physician substance abuse are rising,^7,8 a response to stress that allows for at least temporary problem avoidance and creates social isolation. Disengagement strategies do not promote coping, our ability to reduce or control stress.

Another group of choices include engagement strategies: problem solving, social support, expression of emotion, and cognitive restructuring.⁶ These strategies develop resilience, which is the capacity to respond to stress in a healthy way so that goals are achieved at minimal psychological and physical costs. Resilience creates positive resource spirals, and resilient individuals bounce back with increased strength.⁹

Let’s do some cognitive restructuring: First, we accept that change happens. Even facts change. Psoriasis was once said to be a disease of the keratinocytes, but now we consider it a disease of the immune system gone awry. It was dogma 30 years ago that excision of melanoma required 5-cm margins of normal skin, but the standard of care today includes much narrower margins. Once we accept that change happens, we learn to expect it as the natural course of events, and then we can look for the parts of change that we can enjoy. Learning something new about psoriasis and melanoma can be stimulating. Learning something new about the science of population health, patient management rubrics, quality measure development, and practice business models can be energizing too. Spend time and effort working on embracing changes that both interest you and are relevant to your practice. Do you hate the idea of having to incorporate quality measures in your practice? The fact that regulatory policy requires quality measures is not going to change, but we can gain some control by reading quality measure literature, working within our practice settings to develop quality improvement projects that are relevant and effective, and contributing to the discussion of quality measures in dermatology either in print or through committee work. Accepting change as well as working with our colleagues to promote relevant and positive change are examples of engagement strategies that help develop resilience.

Studies have shown that job satisfaction is highest among physicians who practice with defined professional and personal boundaries and pursue continued professional development, particularly by attending continuing medical education programs.¹⁰ Learning something new can be an antidote for boredom and depression. Being with other dermatologists, a wonderful group of interesting and passionate people, also can provide social support and allows us to express frustration regarding stresses in the workplace. I almost always return from dermatology meetings energized and stimulated.

Another factor related to job satisfaction is a focus on the positive aspects of one’s work. Dermatology is a fascinating study of a group of diseases that we can actually see and touch and biopsy. Some diseases are benign, while others may be fatal. They can occur in patients young and old, sick and healthy. Effective treatments exist that can change the course of these diseases, and new therapies continue to evolve. The art of diagnosis and patient care appeals to me as much as the science. A Canadian study found that appreciating the value of a relationship with the patient correlated with job satisfaction among physicians.¹¹ As dermatologists, we have this opportunity every day with each patient that we see.

Dermatologists indeed are very privileged. Take out another piece of paper and write down 3 aspects of our profession that you are thankful for. You can include things you are grateful for in other parts of your life too because physicians with strong relationships and activities outside of work report fewer episodes of emotional exhaustion.¹²

Now flip over the paper with the recent changes you do not like. They do not seem so bad anymore, do they?

An Important Use of a National Joint Registry

I enjoyed the 2 articles on the issue of “Orthopedic Registries” by Dr. Sarmiento and Dr. Mont and colleagues in the April 2015 issue of The American Journal of Orthopedics (pages 159-162). Both authors have valid points, but I think they both miss what is to me the most important use of a national registry. It is for identifying an old prosthesis.

Many times in my 35-plus years of practice, I have seen patients that need revision hips or knees that were initially done 15 or 20 years ago. It would be extremely helpful if the physician could call the registry with the patient’s name, Social Security number, birth date, and approximate date of surgery to find out what prosthesis was used—specifically, the size and manufacturer. So often the implanting surgeon has retired and the hospital where the patient thinks he or she had the surgery is closed or cannot find old records.

James C. Cobey, MD, MPH, FACS

Washington, DC

Authors’ Responses

Dr. Cobey should be congratulated for expressing his sincere concern and suggestion regarding the national registry dealing with long-term follow-up of total joint implants.

However, I think that the registry must maintain a consistent evaluation criterion throughout. Needless to say, adherence to it is essential when addressing revision surgery. Dr. Cobey’s proposal would allow a possibly large number of patients to enter the registry without meeting the established criterion. They would enter without having provided truly relevant information, such as history of infection, trauma, fracture, recurrent dislocations, wear, lysis, etc, which are the most common conditions leading to revision surgery. The data from patients entering with only the minimal information proposed by Dr. Cobey—date of birth, size of the prosthesis, and name of the manufacturer—is meaningless. It could even be harmful by trivializing and weakening whatever sound goals the national registry hopes to reach.

On the other hand, if Dr. Cobey’s suggestion is favorably considered by the registry’s leaders and its value is felt to be potentially significant, the issue should be seriously studied and debated prior to its implementation.

Augusto Sarmiento, MD
Coral Gables, FL

We would like to thank Dr. Cobey for his comments and thoughts regarding the American Joint Replacement Registry (AJRR). We wholeheartedly agree that an important purpose of this effort is to provide hospital staff and surgeons with as much information as possible regarding our patients. Incorporating information on previous surgeries, and specifically, previous prostheses that have been implanted, is no exception.

The registry is a process that requires the gradual accumulation of data. The AJRR has collected level I data, which, from a 2011 article in AAOS Now, “is an institutional responsibility and includes several core data elements, such as patient data (name, sex, date of birth, social security number, ICD-9 code for diagnosis), surgeon data (name, number of surgeries performed), procedure data (ICD-I code for type of surgery, date of surgery, patient age at surgery, laterality, implant), and hospital data (name, address, number of surgeries performed there). Each patient, surgeon, and hospital has a unique identifier, which enables index procedures to be linked to subsequent events, permits patients to access their own information, allows data to be linked to other databases, and helps maintain confidentiality.”¹ Therefore, it would certainly be possible for a surgeon to collect the data that  Dr. Cobey has mentioned, which would be “extremely helpful.”

In addition, as the AJRR continues to evolve its component element database, identification of implants will become easier. Also, collaborative efforts are underway with the International Society of Arthroplasty Registries (ISAR) to expand and harmonize data collection, including the recognition of implants.² The US Food and Drug Administration has also proposed the incorporation of unique device identifiers into patient medical records, although this is a concept that remains in debate with the Centers for Medicare & Medicaid Services (CMS).³

We would like to thank Dr. Sarmiento and Dr. Cobey for their contributions to this discussion, and we welcome any ongoing suggestions and queries to improve the development of the AJRR.

Randa K. Elmallah, MD
Baltimore, MD

Bryan D. Springer, MD
Charlotte, NC

Michael A. Mont, MD
Baltimore, MD

An Important Use of a National Joint Registry

I enjoyed the 2 articles on the issue of “Orthopedic Registries” by Dr. Sarmiento and Dr. Mont and colleagues in the April 2015 issue of The American Journal of Orthopedics (pages 159-162). Both authors have valid points, but I think they both miss what is to me the most important use of a national registry. It is for identifying an old prosthesis.

Many times in my 35-plus years of practice, I have seen patients that need revision hips or knees that were initially done 15 or 20 years ago. It would be extremely helpful if the physician could call the registry with the patient’s name, Social Security number, birth date, and approximate date of surgery to find out what prosthesis was used—specifically, the size and manufacturer. So often the implanting surgeon has retired and the hospital where the patient thinks he or she had the surgery is closed or cannot find old records.

James C. Cobey, MD, MPH, FACS

Washington, DC

Authors’ Responses

Dr. Cobey should be congratulated for expressing his sincere concern and suggestion regarding the national registry dealing with long-term follow-up of total joint implants.

However, I think that the registry must maintain a consistent evaluation criterion throughout. Needless to say, adherence to it is essential when addressing revision surgery. Dr. Cobey’s proposal would allow a possibly large number of patients to enter the registry without meeting the established criterion. They would enter without having provided truly relevant information, such as history of infection, trauma, fracture, recurrent dislocations, wear, lysis, etc, which are the most common conditions leading to revision surgery. The data from patients entering with only the minimal information proposed by Dr. Cobey—date of birth, size of the prosthesis, and name of the manufacturer—is meaningless. It could even be harmful by trivializing and weakening whatever sound goals the national registry hopes to reach.

On the other hand, if Dr. Cobey’s suggestion is favorably considered by the registry’s leaders and its value is felt to be potentially significant, the issue should be seriously studied and debated prior to its implementation.

Augusto Sarmiento, MD
Coral Gables, FL

We would like to thank Dr. Cobey for his comments and thoughts regarding the American Joint Replacement Registry (AJRR). We wholeheartedly agree that an important purpose of this effort is to provide hospital staff and surgeons with as much information as possible regarding our patients. Incorporating information on previous surgeries, and specifically, previous prostheses that have been implanted, is no exception.

The registry is a process that requires the gradual accumulation of data. The AJRR has collected level I data, which, from a 2011 article in AAOS Now, “is an institutional responsibility and includes several core data elements, such as patient data (name, sex, date of birth, social security number, ICD-9 code for diagnosis), surgeon data (name, number of surgeries performed), procedure data (ICD-I code for type of surgery, date of surgery, patient age at surgery, laterality, implant), and hospital data (name, address, number of surgeries performed there). Each patient, surgeon, and hospital has a unique identifier, which enables index procedures to be linked to subsequent events, permits patients to access their own information, allows data to be linked to other databases, and helps maintain confidentiality.”¹ Therefore, it would certainly be possible for a surgeon to collect the data that  Dr. Cobey has mentioned, which would be “extremely helpful.”

In addition, as the AJRR continues to evolve its component element database, identification of implants will become easier. Also, collaborative efforts are underway with the International Society of Arthroplasty Registries (ISAR) to expand and harmonize data collection, including the recognition of implants.² The US Food and Drug Administration has also proposed the incorporation of unique device identifiers into patient medical records, although this is a concept that remains in debate with the Centers for Medicare & Medicaid Services (CMS).³

We would like to thank Dr. Sarmiento and Dr. Cobey for their contributions to this discussion, and we welcome any ongoing suggestions and queries to improve the development of the AJRR.

Randa K. Elmallah, MD
Baltimore, MD

Bryan D. Springer, MD
Charlotte, NC

Michael A. Mont, MD
Baltimore, MD

An Important Use of a National Joint Registry

I enjoyed the 2 articles on the issue of “Orthopedic Registries” by Dr. Sarmiento and Dr. Mont and colleagues in the April 2015 issue of The American Journal of Orthopedics (pages 159-162). Both authors have valid points, but I think they both miss what is to me the most important use of a national registry. It is for identifying an old prosthesis.

Many times in my 35-plus years of practice, I have seen patients that need revision hips or knees that were initially done 15 or 20 years ago. It would be extremely helpful if the physician could call the registry with the patient’s name, Social Security number, birth date, and approximate date of surgery to find out what prosthesis was used—specifically, the size and manufacturer. So often the implanting surgeon has retired and the hospital where the patient thinks he or she had the surgery is closed or cannot find old records.

James C. Cobey, MD, MPH, FACS

Washington, DC

Authors’ Responses

Dr. Cobey should be congratulated for expressing his sincere concern and suggestion regarding the national registry dealing with long-term follow-up of total joint implants.

However, I think that the registry must maintain a consistent evaluation criterion throughout. Needless to say, adherence to it is essential when addressing revision surgery. Dr. Cobey’s proposal would allow a possibly large number of patients to enter the registry without meeting the established criterion. They would enter without having provided truly relevant information, such as history of infection, trauma, fracture, recurrent dislocations, wear, lysis, etc, which are the most common conditions leading to revision surgery. The data from patients entering with only the minimal information proposed by Dr. Cobey—date of birth, size of the prosthesis, and name of the manufacturer—is meaningless. It could even be harmful by trivializing and weakening whatever sound goals the national registry hopes to reach.

On the other hand, if Dr. Cobey’s suggestion is favorably considered by the registry’s leaders and its value is felt to be potentially significant, the issue should be seriously studied and debated prior to its implementation.

Augusto Sarmiento, MD
Coral Gables, FL

We would like to thank Dr. Cobey for his comments and thoughts regarding the American Joint Replacement Registry (AJRR). We wholeheartedly agree that an important purpose of this effort is to provide hospital staff and surgeons with as much information as possible regarding our patients. Incorporating information on previous surgeries, and specifically, previous prostheses that have been implanted, is no exception.

The registry is a process that requires the gradual accumulation of data. The AJRR has collected level I data, which, from a 2011 article in AAOS Now, “is an institutional responsibility and includes several core data elements, such as patient data (name, sex, date of birth, social security number, ICD-9 code for diagnosis), surgeon data (name, number of surgeries performed), procedure data (ICD-I code for type of surgery, date of surgery, patient age at surgery, laterality, implant), and hospital data (name, address, number of surgeries performed there). Each patient, surgeon, and hospital has a unique identifier, which enables index procedures to be linked to subsequent events, permits patients to access their own information, allows data to be linked to other databases, and helps maintain confidentiality.”¹ Therefore, it would certainly be possible for a surgeon to collect the data that  Dr. Cobey has mentioned, which would be “extremely helpful.”

In addition, as the AJRR continues to evolve its component element database, identification of implants will become easier. Also, collaborative efforts are underway with the International Society of Arthroplasty Registries (ISAR) to expand and harmonize data collection, including the recognition of implants.² The US Food and Drug Administration has also proposed the incorporation of unique device identifiers into patient medical records, although this is a concept that remains in debate with the Centers for Medicare & Medicaid Services (CMS).³

We would like to thank Dr. Sarmiento and Dr. Cobey for their contributions to this discussion, and we welcome any ongoing suggestions and queries to improve the development of the AJRR.

Randa K. Elmallah, MD
Baltimore, MD

Bryan D. Springer, MD
Charlotte, NC

Michael A. Mont, MD
Baltimore, MD

A 57-year-old man presents with pain and swelling in his leg. He has had low-grade fevers. He has a history of type 2 diabetes. On exam, his right lower extremity is warm, erythematous, and swollen to the midcalf. There is no purulence, fluctuance, or weeping skin. Labs are: WBC, 12,000; Na, 134; K, 5.2; BUN, 20; creatinine, 1.4.

What therapy would you recommend?

A) Ciprofloxacin.

B) Cefazolin.

C) Vancomycin.

D) Trimethoprim-sulfamethoxazole.

Myth: Cellulitis treatment should include MRSA coverage.

Cellulitis is almost always caused by group A streptococcus. There are exceptional circumstances where other organisms must be considered; but for the most part, those situations are rare. With the growing concern for community-associated methicillin-resistant Staphylococcus aureus infection (MRSA), more and more patients are receiving empiric coverage for MRSA for all skin infections. Is this coverage for MRSA in patients with cellulitis a new myth in evolution?

In a study by Dr. Arthur Jeng and colleagues, all patients admitted to one hospital over a 3-year period with diffuse cellulitis were studied (Medicine 2010;89:217-26). A total of 179 patients were enrolled in the study; all patients had serologic studies for exposure to streptococci and what antibiotics they received, and outcomes were recorded.

Almost all patients with positive antibodies to streptococci responded to beta-lactam antibiotics (97%). But 91% of the patients who did not develop streptococcal antibodies also responded to beta-lactam antibiotics, for an overall response rate of 95% for treatment with beta-lactam antibiotics.

The most recent clinical practice guidelines published by the Infectious Diseases Society of America recommend treatment for infection with beta-hemolytic streptococci for outpatients with nonpurulent cellulitis (Clin. Infect. Dis. 2011;52:285-92). The addition of vancomycin is reserved for patients with purulence/evidence of abscess or exudate.

How common is it to prescribe antibiotics that cover MRSA in patients with cellulitis?

In a 2013 study, 61% of patients treated for cellulitis received antibiotics that included community-acquired MRSA coverage (Am. J. Med. 2013;126:1099-106).

A recent study looked at whether additional community-associated MRSA coverage with trimethoprim-sulfamethoxazole in addition to beta-lactam therapy for cellulitis showed any benefit over therapy with only a beta-lactam (Clin. Infect. Dis. 2013;56:1754-62). The study was a randomized, double-blind, placebo-controlled trial. The experimental group received trimethoprim-sulfamethoxazole and cephalexin, while the control group received cephalexin plus placebo.

There was no difference in outcome between the two groups, with the conclusion that addition of trimethoprim-sulfamethoxazole to cephalexin did not lead to a better outcome than cephalexin alone in patients with nonpurulent cellulitis.

A study by Dr. Thana Khawcharoenporn and Dr. Alan Tice looked at whether cephalexin, trimethoprim-sulfamethoxazole, or clindamycin was superior for the treatment of outpatient cellulitis (Am. J. Med. 2010;123:942-50). They concluded that trimethoprim-sulfamethoxazole and clindamycin were better than cephalexin. However, more than 50% of patients in this study had abscesses or ulcers – clinical criteria that increase the possibility of MRSA.

The most commonly used oral antibiotic for the coverage of community-associated MRSA is trimethoprim-sulfamethoxazole. This increasing use of TMP-sulfa has its risks, especially in elderly populations (Ann. Emerg. Med. 2014; 63:783-4). Trimethoprim-sulfamethoxazole can cause serious skin reactions and hyperkalemia (especially in the elderly and those with renal impairment), and the drug has a marked drug interaction with warfarin, leading to high risk of excessive anticoagulation.

These risks of TMP-sulfa use make it extremely important to have clear and worthwhile indications for its use.

The best evidence right now is that for simple cellulitis (no purulence, abscess, or exudate), treatment with a beta-lactam antibiotic is the best option. There is no need to add MRSA coverage to beta-lactam therapy.

If there is no response to treatment, then broadening coverage to include MRSA would be appropriate.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

A 57-year-old man presents with pain and swelling in his leg. He has had low-grade fevers. He has a history of type 2 diabetes. On exam, his right lower extremity is warm, erythematous, and swollen to the midcalf. There is no purulence, fluctuance, or weeping skin. Labs are: WBC, 12,000; Na, 134; K, 5.2; BUN, 20; creatinine, 1.4.

What therapy would you recommend?

A) Ciprofloxacin.

B) Cefazolin.

C) Vancomycin.

D) Trimethoprim-sulfamethoxazole.

Myth: Cellulitis treatment should include MRSA coverage.

Cellulitis is almost always caused by group A streptococcus. There are exceptional circumstances where other organisms must be considered; but for the most part, those situations are rare. With the growing concern for community-associated methicillin-resistant Staphylococcus aureus infection (MRSA), more and more patients are receiving empiric coverage for MRSA for all skin infections. Is this coverage for MRSA in patients with cellulitis a new myth in evolution?

In a study by Dr. Arthur Jeng and colleagues, all patients admitted to one hospital over a 3-year period with diffuse cellulitis were studied (Medicine 2010;89:217-26). A total of 179 patients were enrolled in the study; all patients had serologic studies for exposure to streptococci and what antibiotics they received, and outcomes were recorded.

Almost all patients with positive antibodies to streptococci responded to beta-lactam antibiotics (97%). But 91% of the patients who did not develop streptococcal antibodies also responded to beta-lactam antibiotics, for an overall response rate of 95% for treatment with beta-lactam antibiotics.

The most recent clinical practice guidelines published by the Infectious Diseases Society of America recommend treatment for infection with beta-hemolytic streptococci for outpatients with nonpurulent cellulitis (Clin. Infect. Dis. 2011;52:285-92). The addition of vancomycin is reserved for patients with purulence/evidence of abscess or exudate.

How common is it to prescribe antibiotics that cover MRSA in patients with cellulitis?

In a 2013 study, 61% of patients treated for cellulitis received antibiotics that included community-acquired MRSA coverage (Am. J. Med. 2013;126:1099-106).

A recent study looked at whether additional community-associated MRSA coverage with trimethoprim-sulfamethoxazole in addition to beta-lactam therapy for cellulitis showed any benefit over therapy with only a beta-lactam (Clin. Infect. Dis. 2013;56:1754-62). The study was a randomized, double-blind, placebo-controlled trial. The experimental group received trimethoprim-sulfamethoxazole and cephalexin, while the control group received cephalexin plus placebo.

There was no difference in outcome between the two groups, with the conclusion that addition of trimethoprim-sulfamethoxazole to cephalexin did not lead to a better outcome than cephalexin alone in patients with nonpurulent cellulitis.

A study by Dr. Thana Khawcharoenporn and Dr. Alan Tice looked at whether cephalexin, trimethoprim-sulfamethoxazole, or clindamycin was superior for the treatment of outpatient cellulitis (Am. J. Med. 2010;123:942-50). They concluded that trimethoprim-sulfamethoxazole and clindamycin were better than cephalexin. However, more than 50% of patients in this study had abscesses or ulcers – clinical criteria that increase the possibility of MRSA.

The most commonly used oral antibiotic for the coverage of community-associated MRSA is trimethoprim-sulfamethoxazole. This increasing use of TMP-sulfa has its risks, especially in elderly populations (Ann. Emerg. Med. 2014; 63:783-4). Trimethoprim-sulfamethoxazole can cause serious skin reactions and hyperkalemia (especially in the elderly and those with renal impairment), and the drug has a marked drug interaction with warfarin, leading to high risk of excessive anticoagulation.

These risks of TMP-sulfa use make it extremely important to have clear and worthwhile indications for its use.

The best evidence right now is that for simple cellulitis (no purulence, abscess, or exudate), treatment with a beta-lactam antibiotic is the best option. There is no need to add MRSA coverage to beta-lactam therapy.

If there is no response to treatment, then broadening coverage to include MRSA would be appropriate.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

A 57-year-old man presents with pain and swelling in his leg. He has had low-grade fevers. He has a history of type 2 diabetes. On exam, his right lower extremity is warm, erythematous, and swollen to the midcalf. There is no purulence, fluctuance, or weeping skin. Labs are: WBC, 12,000; Na, 134; K, 5.2; BUN, 20; creatinine, 1.4.

What therapy would you recommend?

A) Ciprofloxacin.

B) Cefazolin.

C) Vancomycin.

D) Trimethoprim-sulfamethoxazole.

Myth: Cellulitis treatment should include MRSA coverage.

Cellulitis is almost always caused by group A streptococcus. There are exceptional circumstances where other organisms must be considered; but for the most part, those situations are rare. With the growing concern for community-associated methicillin-resistant Staphylococcus aureus infection (MRSA), more and more patients are receiving empiric coverage for MRSA for all skin infections. Is this coverage for MRSA in patients with cellulitis a new myth in evolution?

In a study by Dr. Arthur Jeng and colleagues, all patients admitted to one hospital over a 3-year period with diffuse cellulitis were studied (Medicine 2010;89:217-26). A total of 179 patients were enrolled in the study; all patients had serologic studies for exposure to streptococci and what antibiotics they received, and outcomes were recorded.

Almost all patients with positive antibodies to streptococci responded to beta-lactam antibiotics (97%). But 91% of the patients who did not develop streptococcal antibodies also responded to beta-lactam antibiotics, for an overall response rate of 95% for treatment with beta-lactam antibiotics.

The most recent clinical practice guidelines published by the Infectious Diseases Society of America recommend treatment for infection with beta-hemolytic streptococci for outpatients with nonpurulent cellulitis (Clin. Infect. Dis. 2011;52:285-92). The addition of vancomycin is reserved for patients with purulence/evidence of abscess or exudate.

How common is it to prescribe antibiotics that cover MRSA in patients with cellulitis?

In a 2013 study, 61% of patients treated for cellulitis received antibiotics that included community-acquired MRSA coverage (Am. J. Med. 2013;126:1099-106).

A recent study looked at whether additional community-associated MRSA coverage with trimethoprim-sulfamethoxazole in addition to beta-lactam therapy for cellulitis showed any benefit over therapy with only a beta-lactam (Clin. Infect. Dis. 2013;56:1754-62). The study was a randomized, double-blind, placebo-controlled trial. The experimental group received trimethoprim-sulfamethoxazole and cephalexin, while the control group received cephalexin plus placebo.

There was no difference in outcome between the two groups, with the conclusion that addition of trimethoprim-sulfamethoxazole to cephalexin did not lead to a better outcome than cephalexin alone in patients with nonpurulent cellulitis.

A study by Dr. Thana Khawcharoenporn and Dr. Alan Tice looked at whether cephalexin, trimethoprim-sulfamethoxazole, or clindamycin was superior for the treatment of outpatient cellulitis (Am. J. Med. 2010;123:942-50). They concluded that trimethoprim-sulfamethoxazole and clindamycin were better than cephalexin. However, more than 50% of patients in this study had abscesses or ulcers – clinical criteria that increase the possibility of MRSA.

The most commonly used oral antibiotic for the coverage of community-associated MRSA is trimethoprim-sulfamethoxazole. This increasing use of TMP-sulfa has its risks, especially in elderly populations (Ann. Emerg. Med. 2014; 63:783-4). Trimethoprim-sulfamethoxazole can cause serious skin reactions and hyperkalemia (especially in the elderly and those with renal impairment), and the drug has a marked drug interaction with warfarin, leading to high risk of excessive anticoagulation.

These risks of TMP-sulfa use make it extremely important to have clear and worthwhile indications for its use.

The best evidence right now is that for simple cellulitis (no purulence, abscess, or exudate), treatment with a beta-lactam antibiotic is the best option. There is no need to add MRSA coverage to beta-lactam therapy.

If there is no response to treatment, then broadening coverage to include MRSA would be appropriate.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

It is apparent from the many letters I have received as medical editor of Vascular Specialist that vascular surgeons are disappointed that our patients, insurance companies, hospital administrators, and the government do not recognize the special skills we provide.

I believe there are two principal reasons that, although different, may be related. First may be that we are still not recognized as a separate specialty from General Surgery. This despite the fact that, for most of us, endovascular procedures have supplanted a significant number of open operations. Second may be the failure of the Society for Vascular Surgery’s name to define its relevance or attract new members. If I am correct then perhaps SVS should be renamed the American College of Vascular Surgery. A brief review of past events may help explain why this name change would be beneficial.

Some years ago a poll of vascular surgeons favored establishing vascular surgery as a distinct specialty. However, despite considerable effort Frank Veith, Jim Stanley, and others were unsuccessful in creating a recognized American Board of Vascular Surgery.

In part this was because the leadership at the time did not support separation from the American Board of Surgery. Further, the American Board of Medical Specialties (ABMS) would not recognize Vascular Surgery as a distinct specialty.

Today our small group of actively practicing vascular surgeons, perhaps no more than 2,500, have splintered our institutional organizations. Cynics may suggest that we have almost as many societies as we have members.

We have SVS, SCVS, VESS, AVF, and even the new American Academy of Peripheral Vascular Surgeons, as well as many regional societies. Further, even though SVS may be the de facto umbrella organization, it is hampered by its restrictive name. The Society for Vascular Surgery sounds like an elitist club and not the governing body that we need to represent us on the national and international stage.

Accordingly there are still many vascular surgeons who, incorrectly, consider themselves unwelcome. They also may not realize just how involved the SVS has become in every aspect of our vascular practices.

SVS, with almost 50 committees staffed by paid employees as well as numerous volunteers, is involved in nearly every aspect of vascular surgery as well as postgraduate education. It represents us on the RUC and CMS and our active (but poorly supported) PAC represents our interests in Washington.

SVS generates research dollars and supports numerous grants and fellowships and encourages medical students to become vascular surgeons. It runs the most prestigious and all-encompassing scientific and social meeting. Vascular surgeons from all over the world are honored to be affiliated members of our Society yet some local surgeons still remain nonmembers.

By changing the SVS name to the American College of Vascular Surgery (ACVS) we provide our organization with a monicker that has the same gravitas as professional Societies that are recognized by the ABMS. It also demonstrates that our members, rather than being a select clique, have collegiality.

Furthermore, it confirms that it is our governing body and is the voice of all American vascular surgeons. It reaffirms that it is a unique organization dedicated to treating patients with vascular conditions and composed of surgeons who “operate, dilate, and medicate.”

We will not need the ABMS to approve this change. We don’t even need to sever our association with the American Board of Surgery. After all we are still surgeons!

We can continue to get Board certification through that body since our Board examination is, for practical purposes, developed and run by SVS. Members who pass the exam will become Fellows of the ACVS and will have the privilege of adding FACVS to their professional signature rather than FACS. Our Distinguished Fellows will use DFACVS. We can even have a formal convocation.

Certainly, some structural changes may need to accompany this name change in order for the American College of Vascular Surgeons to be fully representative of all vascular surgeons. But for now, with this simple change, we will encourage more vascular surgeons to join our ranks and advance the recognition of vascular as a distinct specialty.

It is apparent from the many letters I have received as medical editor of Vascular Specialist that vascular surgeons are disappointed that our patients, insurance companies, hospital administrators, and the government do not recognize the special skills we provide.

I believe there are two principal reasons that, although different, may be related. First may be that we are still not recognized as a separate specialty from General Surgery. This despite the fact that, for most of us, endovascular procedures have supplanted a significant number of open operations. Second may be the failure of the Society for Vascular Surgery’s name to define its relevance or attract new members. If I am correct then perhaps SVS should be renamed the American College of Vascular Surgery. A brief review of past events may help explain why this name change would be beneficial.

Some years ago a poll of vascular surgeons favored establishing vascular surgery as a distinct specialty. However, despite considerable effort Frank Veith, Jim Stanley, and others were unsuccessful in creating a recognized American Board of Vascular Surgery.

In part this was because the leadership at the time did not support separation from the American Board of Surgery. Further, the American Board of Medical Specialties (ABMS) would not recognize Vascular Surgery as a distinct specialty.

Today our small group of actively practicing vascular surgeons, perhaps no more than 2,500, have splintered our institutional organizations. Cynics may suggest that we have almost as many societies as we have members.

We have SVS, SCVS, VESS, AVF, and even the new American Academy of Peripheral Vascular Surgeons, as well as many regional societies. Further, even though SVS may be the de facto umbrella organization, it is hampered by its restrictive name. The Society for Vascular Surgery sounds like an elitist club and not the governing body that we need to represent us on the national and international stage.

Accordingly there are still many vascular surgeons who, incorrectly, consider themselves unwelcome. They also may not realize just how involved the SVS has become in every aspect of our vascular practices.

SVS, with almost 50 committees staffed by paid employees as well as numerous volunteers, is involved in nearly every aspect of vascular surgery as well as postgraduate education. It represents us on the RUC and CMS and our active (but poorly supported) PAC represents our interests in Washington.

SVS generates research dollars and supports numerous grants and fellowships and encourages medical students to become vascular surgeons. It runs the most prestigious and all-encompassing scientific and social meeting. Vascular surgeons from all over the world are honored to be affiliated members of our Society yet some local surgeons still remain nonmembers.

By changing the SVS name to the American College of Vascular Surgery (ACVS) we provide our organization with a monicker that has the same gravitas as professional Societies that are recognized by the ABMS. It also demonstrates that our members, rather than being a select clique, have collegiality.

Furthermore, it confirms that it is our governing body and is the voice of all American vascular surgeons. It reaffirms that it is a unique organization dedicated to treating patients with vascular conditions and composed of surgeons who “operate, dilate, and medicate.”

We will not need the ABMS to approve this change. We don’t even need to sever our association with the American Board of Surgery. After all we are still surgeons!

We can continue to get Board certification through that body since our Board examination is, for practical purposes, developed and run by SVS. Members who pass the exam will become Fellows of the ACVS and will have the privilege of adding FACVS to their professional signature rather than FACS. Our Distinguished Fellows will use DFACVS. We can even have a formal convocation.

Certainly, some structural changes may need to accompany this name change in order for the American College of Vascular Surgeons to be fully representative of all vascular surgeons. But for now, with this simple change, we will encourage more vascular surgeons to join our ranks and advance the recognition of vascular as a distinct specialty.

It is apparent from the many letters I have received as medical editor of Vascular Specialist that vascular surgeons are disappointed that our patients, insurance companies, hospital administrators, and the government do not recognize the special skills we provide.

I believe there are two principal reasons that, although different, may be related. First may be that we are still not recognized as a separate specialty from General Surgery. This despite the fact that, for most of us, endovascular procedures have supplanted a significant number of open operations. Second may be the failure of the Society for Vascular Surgery’s name to define its relevance or attract new members. If I am correct then perhaps SVS should be renamed the American College of Vascular Surgery. A brief review of past events may help explain why this name change would be beneficial.

Some years ago a poll of vascular surgeons favored establishing vascular surgery as a distinct specialty. However, despite considerable effort Frank Veith, Jim Stanley, and others were unsuccessful in creating a recognized American Board of Vascular Surgery.

In part this was because the leadership at the time did not support separation from the American Board of Surgery. Further, the American Board of Medical Specialties (ABMS) would not recognize Vascular Surgery as a distinct specialty.

Today our small group of actively practicing vascular surgeons, perhaps no more than 2,500, have splintered our institutional organizations. Cynics may suggest that we have almost as many societies as we have members.

We have SVS, SCVS, VESS, AVF, and even the new American Academy of Peripheral Vascular Surgeons, as well as many regional societies. Further, even though SVS may be the de facto umbrella organization, it is hampered by its restrictive name. The Society for Vascular Surgery sounds like an elitist club and not the governing body that we need to represent us on the national and international stage.

Accordingly there are still many vascular surgeons who, incorrectly, consider themselves unwelcome. They also may not realize just how involved the SVS has become in every aspect of our vascular practices.

SVS, with almost 50 committees staffed by paid employees as well as numerous volunteers, is involved in nearly every aspect of vascular surgery as well as postgraduate education. It represents us on the RUC and CMS and our active (but poorly supported) PAC represents our interests in Washington.

SVS generates research dollars and supports numerous grants and fellowships and encourages medical students to become vascular surgeons. It runs the most prestigious and all-encompassing scientific and social meeting. Vascular surgeons from all over the world are honored to be affiliated members of our Society yet some local surgeons still remain nonmembers.

By changing the SVS name to the American College of Vascular Surgery (ACVS) we provide our organization with a monicker that has the same gravitas as professional Societies that are recognized by the ABMS. It also demonstrates that our members, rather than being a select clique, have collegiality.

Furthermore, it confirms that it is our governing body and is the voice of all American vascular surgeons. It reaffirms that it is a unique organization dedicated to treating patients with vascular conditions and composed of surgeons who “operate, dilate, and medicate.”

We will not need the ABMS to approve this change. We don’t even need to sever our association with the American Board of Surgery. After all we are still surgeons!

We can continue to get Board certification through that body since our Board examination is, for practical purposes, developed and run by SVS. Members who pass the exam will become Fellows of the ACVS and will have the privilege of adding FACVS to their professional signature rather than FACS. Our Distinguished Fellows will use DFACVS. We can even have a formal convocation.

Certainly, some structural changes may need to accompany this name change in order for the American College of Vascular Surgeons to be fully representative of all vascular surgeons. But for now, with this simple change, we will encourage more vascular surgeons to join our ranks and advance the recognition of vascular as a distinct specialty.

Mechanical valve is the best choice

BY THORALF M. SUNDT III, M.D.

It’s not very sexy to talk about mechanical valves, but the reasons for placing a mechanical valve in a 50-year-old patient with rheumatic disease are obvious: Mechanical valves provide outstanding hemodynamics, they are beautifully engineered devices, their durability is beyond question, and, importantly, there’s no survival advantage to a biological prosthesis although one incurs the penalty of reoperation, which in a 50-year-old is going to be inevitable.

While this patient will have to continue on anticoagulation therapy with a mechanical valve, many patients who receive a biological valve, especially those with rheumatic disease, need anticoagulation for atrial fibrillation anyway. One can argue that a maze procedure might convert them to sinus rhythm, but this is least reproducible in the subset of patients with rheumatic disease. What’s more, the American Heart Association/American College of Cardiology Guideline for the Management of Patients With Valvular Heart Disease states that a mechanical prosthesis is reasonable for aortic or mitral valve replacement in patients aged 60 and younger with no contraindication to anticoagulation.

The fact that you have to use Coumadin (warfarin, Bristol-Myers Squibb), is not a condemnation of the mechanical valve; it just means we need to get smarter and better about how we manage anticoagulation in people with these prostheses.

While neither option is desirable, surprisingly morbidity with mechanical and biological valves is not demonstrably different. Stroke, embolic events, and bleeding complications have been found to be similar in numerous studies including a recent one authored by Dr. Vinay Badhwar and colleagues. Among 469 patients aged 65 years or younger who received a bileaflet mechanical prostheses or tissue valves, researchers found nearly identical rates of bleeding and thromboembolic complications when the anticoagulation was closely monitored (Ann. Thorac. Surg. 2012;93:748-53) Indeed, they even identified a mortality benefit among those with mechanical valves.

It’s also worth noting that the risk of anticoagulation-related complications is higher when the patient’s INR (international normalized ratio) is poorly controlled; up to 60% of INR values are outside the therapeutic range when thromboembolic complications occur. One can anticipate home INR testing and home management as ways to help patients stay within therapeutic range and reduce these risks. If the issue is anticoagulation, let’s improve it.

In summary, if you implant a biological valve in a 50-year-old patient, I guarantee that patient is going to be back for a reoperation and the prosthesis is going to deteriorate. For the surgeon, a biological valve can be an annuity of sorts. The mechanical valve has a clear advantage in durability, especially in younger patients.

Neither one is perfect, but there is no difference in morbidity between the two. A tissue prosthesis just buys you a reoperation – maybe valve-in-valve transcatheter valve. Maybe.

Dr. Sundt is chief of the division of cardiac surgery, Massachusetts General Hospital, Harvard Medical School, Boston. He is an adviser to Thrasos Innovation, but has no relevant relationships to disclose.

Why biological valve is the better choice

BY ANELECHI C. ANYANWU, M.D.

The reality is that whether you implant a mechanical or biological valve for mitral regurgitation, neither is good. The survival is poor. The half-life or median survival of a patient after either valve is about 15-20 years. The death rates are about 3% per year. The morbidity is high whether you have mechanical or biological valve, and none of them are good mitral substitutes.

Yet the biological valve is often a reasonable choice for a 50-year-old patient, despite studies that have shown a higher reoperation rate and decreased survival rate after biological mitral valve repair when compared to mechanical valve implantation in patients aged 65 and younger. But those study results may be skewed.

Dr. Tsuyoshi Kaneko and colleagues at Brigham and Women’s Hospital, Boston, showed that survival at about 20 years was much better with the mechanical valve. (J. Thorac. Cardiovasc. Surg. 2014;147:117-26). However, the difference in survival is greatest immediately after surgery. By 1 year the survival difference between mechanical valve and a tissue valve was more than 10%.

Why is this? I would argue this is a function of patient selection. We know in the United States that a patient with no insurance or low socioeconomic status does poorly compared to one who does have insurance. With a mechanical valve, they can thrombose; but with a biological valve, if they don’t take care of their health, of course they can die early. The reality is surgeons tend to use biological valves in patients of lower socioeconomic status and those with questionable compliance. None of these factors were considered in the propensity matching used in this study.

Dr. Joanna Chikwe and colleagues at Mount Sinai recently compared outcomes in several thousand patients who underwent biological or mechanical mitral valve replacement in New York State (JAMA 2015:323:1435-42). They found no survival difference in the first 30 or 90 days after surgery, or even at 15 years among patients aged 50-69 years. Indeed, a critical review of any study that has shown a survival advantage of the mechanical valve would find that the advantage occurred within the first few months after surgery, making it likely that such differences are due to patient selection, or other systematic bias, rather than a prostheses effect.

Mayo Clinic investigators, including Dr. Thoralf M. Sundt III, reported that among a cohort that received a mechanical valve, with an average age of 65 years, 16% had had a stroke at 5 years, compared with 8% of the biological valve group (J. Am. Coll. Cardiol. 2008;51:1203-11). You can only imagine what would happen at 10 or 20 years. They followed the data out to 10 years for thromboembolic events; that rate was 30% in the mechanical valve group. They concluded, “the mechanical valve is the least desirable correction of mitral regurgitation.”

As for managing anticoagulation, the literature provides no evidence that self-testing is superior to clinic testing. A trial published in the New England Journal of Medicine involving more than 2,000 patients, 700 of whom had a mechanical valve, showed a higher rate of stroke in patients who were randomized to home-INR monitoring compared with INR in the clinic. (N. Engl. J. Med. 2010;363:1608-20). Self-testing did not delay the time to first stroke, bleeding, or death.

Anticoagulation can be problematic if the patient needs to undergo another operation or medical procedure later, especially on an emergent basis. If the patient with a mechanical valve stops anticoagulation for even a short period of time, the risk of valve thrombosis is great. A patient with a biological valve can stop anticoagulation for a week or more without any consequence.

Finally, I relate the story of a man who could not bear the clicking sound of his mechanical valve. He asked for a new valve, but the surgeon would not take his request seriously. The man was taking drugs and started treatment for posttraumatic stress disorder. After 3 years, he killed himself. How many times have we sat down and talked to patients about what the clicking sound can do to them? Why don’t we make more of this? The patient should be given more choice.

Dr. Anyanwu is with the department of cardiac surgery, Mount Sinai Medical Center, New York. He has no relationships to disclose.

Mechanical valve is the best choice

BY THORALF M. SUNDT III, M.D.

It’s not very sexy to talk about mechanical valves, but the reasons for placing a mechanical valve in a 50-year-old patient with rheumatic disease are obvious: Mechanical valves provide outstanding hemodynamics, they are beautifully engineered devices, their durability is beyond question, and, importantly, there’s no survival advantage to a biological prosthesis although one incurs the penalty of reoperation, which in a 50-year-old is going to be inevitable.

While this patient will have to continue on anticoagulation therapy with a mechanical valve, many patients who receive a biological valve, especially those with rheumatic disease, need anticoagulation for atrial fibrillation anyway. One can argue that a maze procedure might convert them to sinus rhythm, but this is least reproducible in the subset of patients with rheumatic disease. What’s more, the American Heart Association/American College of Cardiology Guideline for the Management of Patients With Valvular Heart Disease states that a mechanical prosthesis is reasonable for aortic or mitral valve replacement in patients aged 60 and younger with no contraindication to anticoagulation.

The fact that you have to use Coumadin (warfarin, Bristol-Myers Squibb), is not a condemnation of the mechanical valve; it just means we need to get smarter and better about how we manage anticoagulation in people with these prostheses.

While neither option is desirable, surprisingly morbidity with mechanical and biological valves is not demonstrably different. Stroke, embolic events, and bleeding complications have been found to be similar in numerous studies including a recent one authored by Dr. Vinay Badhwar and colleagues. Among 469 patients aged 65 years or younger who received a bileaflet mechanical prostheses or tissue valves, researchers found nearly identical rates of bleeding and thromboembolic complications when the anticoagulation was closely monitored (Ann. Thorac. Surg. 2012;93:748-53) Indeed, they even identified a mortality benefit among those with mechanical valves.

It’s also worth noting that the risk of anticoagulation-related complications is higher when the patient’s INR (international normalized ratio) is poorly controlled; up to 60% of INR values are outside the therapeutic range when thromboembolic complications occur. One can anticipate home INR testing and home management as ways to help patients stay within therapeutic range and reduce these risks. If the issue is anticoagulation, let’s improve it.

In summary, if you implant a biological valve in a 50-year-old patient, I guarantee that patient is going to be back for a reoperation and the prosthesis is going to deteriorate. For the surgeon, a biological valve can be an annuity of sorts. The mechanical valve has a clear advantage in durability, especially in younger patients.

Neither one is perfect, but there is no difference in morbidity between the two. A tissue prosthesis just buys you a reoperation – maybe valve-in-valve transcatheter valve. Maybe.

Dr. Sundt is chief of the division of cardiac surgery, Massachusetts General Hospital, Harvard Medical School, Boston. He is an adviser to Thrasos Innovation, but has no relevant relationships to disclose.

Why biological valve is the better choice

BY ANELECHI C. ANYANWU, M.D.

The reality is that whether you implant a mechanical or biological valve for mitral regurgitation, neither is good. The survival is poor. The half-life or median survival of a patient after either valve is about 15-20 years. The death rates are about 3% per year. The morbidity is high whether you have mechanical or biological valve, and none of them are good mitral substitutes.

Yet the biological valve is often a reasonable choice for a 50-year-old patient, despite studies that have shown a higher reoperation rate and decreased survival rate after biological mitral valve repair when compared to mechanical valve implantation in patients aged 65 and younger. But those study results may be skewed.

Dr. Tsuyoshi Kaneko and colleagues at Brigham and Women’s Hospital, Boston, showed that survival at about 20 years was much better with the mechanical valve. (J. Thorac. Cardiovasc. Surg. 2014;147:117-26). However, the difference in survival is greatest immediately after surgery. By 1 year the survival difference between mechanical valve and a tissue valve was more than 10%.

Why is this? I would argue this is a function of patient selection. We know in the United States that a patient with no insurance or low socioeconomic status does poorly compared to one who does have insurance. With a mechanical valve, they can thrombose; but with a biological valve, if they don’t take care of their health, of course they can die early. The reality is surgeons tend to use biological valves in patients of lower socioeconomic status and those with questionable compliance. None of these factors were considered in the propensity matching used in this study.

Dr. Joanna Chikwe and colleagues at Mount Sinai recently compared outcomes in several thousand patients who underwent biological or mechanical mitral valve replacement in New York State (JAMA 2015:323:1435-42). They found no survival difference in the first 30 or 90 days after surgery, or even at 15 years among patients aged 50-69 years. Indeed, a critical review of any study that has shown a survival advantage of the mechanical valve would find that the advantage occurred within the first few months after surgery, making it likely that such differences are due to patient selection, or other systematic bias, rather than a prostheses effect.

Mayo Clinic investigators, including Dr. Thoralf M. Sundt III, reported that among a cohort that received a mechanical valve, with an average age of 65 years, 16% had had a stroke at 5 years, compared with 8% of the biological valve group (J. Am. Coll. Cardiol. 2008;51:1203-11). You can only imagine what would happen at 10 or 20 years. They followed the data out to 10 years for thromboembolic events; that rate was 30% in the mechanical valve group. They concluded, “the mechanical valve is the least desirable correction of mitral regurgitation.”

As for managing anticoagulation, the literature provides no evidence that self-testing is superior to clinic testing. A trial published in the New England Journal of Medicine involving more than 2,000 patients, 700 of whom had a mechanical valve, showed a higher rate of stroke in patients who were randomized to home-INR monitoring compared with INR in the clinic. (N. Engl. J. Med. 2010;363:1608-20). Self-testing did not delay the time to first stroke, bleeding, or death.

Anticoagulation can be problematic if the patient needs to undergo another operation or medical procedure later, especially on an emergent basis. If the patient with a mechanical valve stops anticoagulation for even a short period of time, the risk of valve thrombosis is great. A patient with a biological valve can stop anticoagulation for a week or more without any consequence.

Finally, I relate the story of a man who could not bear the clicking sound of his mechanical valve. He asked for a new valve, but the surgeon would not take his request seriously. The man was taking drugs and started treatment for posttraumatic stress disorder. After 3 years, he killed himself. How many times have we sat down and talked to patients about what the clicking sound can do to them? Why don’t we make more of this? The patient should be given more choice.

Dr. Anyanwu is with the department of cardiac surgery, Mount Sinai Medical Center, New York. He has no relationships to disclose.

Mechanical valve is the best choice

BY THORALF M. SUNDT III, M.D.

It’s not very sexy to talk about mechanical valves, but the reasons for placing a mechanical valve in a 50-year-old patient with rheumatic disease are obvious: Mechanical valves provide outstanding hemodynamics, they are beautifully engineered devices, their durability is beyond question, and, importantly, there’s no survival advantage to a biological prosthesis although one incurs the penalty of reoperation, which in a 50-year-old is going to be inevitable.

While this patient will have to continue on anticoagulation therapy with a mechanical valve, many patients who receive a biological valve, especially those with rheumatic disease, need anticoagulation for atrial fibrillation anyway. One can argue that a maze procedure might convert them to sinus rhythm, but this is least reproducible in the subset of patients with rheumatic disease. What’s more, the American Heart Association/American College of Cardiology Guideline for the Management of Patients With Valvular Heart Disease states that a mechanical prosthesis is reasonable for aortic or mitral valve replacement in patients aged 60 and younger with no contraindication to anticoagulation.

The fact that you have to use Coumadin (warfarin, Bristol-Myers Squibb), is not a condemnation of the mechanical valve; it just means we need to get smarter and better about how we manage anticoagulation in people with these prostheses.

While neither option is desirable, surprisingly morbidity with mechanical and biological valves is not demonstrably different. Stroke, embolic events, and bleeding complications have been found to be similar in numerous studies including a recent one authored by Dr. Vinay Badhwar and colleagues. Among 469 patients aged 65 years or younger who received a bileaflet mechanical prostheses or tissue valves, researchers found nearly identical rates of bleeding and thromboembolic complications when the anticoagulation was closely monitored (Ann. Thorac. Surg. 2012;93:748-53) Indeed, they even identified a mortality benefit among those with mechanical valves.

It’s also worth noting that the risk of anticoagulation-related complications is higher when the patient’s INR (international normalized ratio) is poorly controlled; up to 60% of INR values are outside the therapeutic range when thromboembolic complications occur. One can anticipate home INR testing and home management as ways to help patients stay within therapeutic range and reduce these risks. If the issue is anticoagulation, let’s improve it.

In summary, if you implant a biological valve in a 50-year-old patient, I guarantee that patient is going to be back for a reoperation and the prosthesis is going to deteriorate. For the surgeon, a biological valve can be an annuity of sorts. The mechanical valve has a clear advantage in durability, especially in younger patients.

Neither one is perfect, but there is no difference in morbidity between the two. A tissue prosthesis just buys you a reoperation – maybe valve-in-valve transcatheter valve. Maybe.

Dr. Sundt is chief of the division of cardiac surgery, Massachusetts General Hospital, Harvard Medical School, Boston. He is an adviser to Thrasos Innovation, but has no relevant relationships to disclose.

Why biological valve is the better choice

BY ANELECHI C. ANYANWU, M.D.

The reality is that whether you implant a mechanical or biological valve for mitral regurgitation, neither is good. The survival is poor. The half-life or median survival of a patient after either valve is about 15-20 years. The death rates are about 3% per year. The morbidity is high whether you have mechanical or biological valve, and none of them are good mitral substitutes.

Yet the biological valve is often a reasonable choice for a 50-year-old patient, despite studies that have shown a higher reoperation rate and decreased survival rate after biological mitral valve repair when compared to mechanical valve implantation in patients aged 65 and younger. But those study results may be skewed.

Dr. Tsuyoshi Kaneko and colleagues at Brigham and Women’s Hospital, Boston, showed that survival at about 20 years was much better with the mechanical valve. (J. Thorac. Cardiovasc. Surg. 2014;147:117-26). However, the difference in survival is greatest immediately after surgery. By 1 year the survival difference between mechanical valve and a tissue valve was more than 10%.

Why is this? I would argue this is a function of patient selection. We know in the United States that a patient with no insurance or low socioeconomic status does poorly compared to one who does have insurance. With a mechanical valve, they can thrombose; but with a biological valve, if they don’t take care of their health, of course they can die early. The reality is surgeons tend to use biological valves in patients of lower socioeconomic status and those with questionable compliance. None of these factors were considered in the propensity matching used in this study.

Dr. Joanna Chikwe and colleagues at Mount Sinai recently compared outcomes in several thousand patients who underwent biological or mechanical mitral valve replacement in New York State (JAMA 2015:323:1435-42). They found no survival difference in the first 30 or 90 days after surgery, or even at 15 years among patients aged 50-69 years. Indeed, a critical review of any study that has shown a survival advantage of the mechanical valve would find that the advantage occurred within the first few months after surgery, making it likely that such differences are due to patient selection, or other systematic bias, rather than a prostheses effect.

Mayo Clinic investigators, including Dr. Thoralf M. Sundt III, reported that among a cohort that received a mechanical valve, with an average age of 65 years, 16% had had a stroke at 5 years, compared with 8% of the biological valve group (J. Am. Coll. Cardiol. 2008;51:1203-11). You can only imagine what would happen at 10 or 20 years. They followed the data out to 10 years for thromboembolic events; that rate was 30% in the mechanical valve group. They concluded, “the mechanical valve is the least desirable correction of mitral regurgitation.”

As for managing anticoagulation, the literature provides no evidence that self-testing is superior to clinic testing. A trial published in the New England Journal of Medicine involving more than 2,000 patients, 700 of whom had a mechanical valve, showed a higher rate of stroke in patients who were randomized to home-INR monitoring compared with INR in the clinic. (N. Engl. J. Med. 2010;363:1608-20). Self-testing did not delay the time to first stroke, bleeding, or death.

Anticoagulation can be problematic if the patient needs to undergo another operation or medical procedure later, especially on an emergent basis. If the patient with a mechanical valve stops anticoagulation for even a short period of time, the risk of valve thrombosis is great. A patient with a biological valve can stop anticoagulation for a week or more without any consequence.

Finally, I relate the story of a man who could not bear the clicking sound of his mechanical valve. He asked for a new valve, but the surgeon would not take his request seriously. The man was taking drugs and started treatment for posttraumatic stress disorder. After 3 years, he killed himself. How many times have we sat down and talked to patients about what the clicking sound can do to them? Why don’t we make more of this? The patient should be given more choice.

Dr. Anyanwu is with the department of cardiac surgery, Mount Sinai Medical Center, New York. He has no relationships to disclose.

I consider my role as an editorialist to be to inform, persuade, or—sometimes—just comment on current issues that affect PAs and NPs. There have been many opportunities in recent years to address “hot” topics, and this is certainly one of them: the rise of distance entry-level education for health professions students.

The catalyst for this discussion? Earlier this year, Yale University announced it was launching an online entry-level PA program.¹ Within minutes of that announcement, there was a conflagration of criticism from the profession, alumni, and the general public. Most of the backlash centered on concerns about adequate delivery of such intense content—including how to instill or enhance professional behaviors and attitudes, or teach hands-on procedures, objective structured clinical examinations (OSCEs), and physical exam techniques—from a distance.

See also: Letter to the Editor from Janet Evans Emery, RN, MSN, CFNP

Share YOUR thoughts with us!

In our professions, we tend to be fairly conservative when it comes to change—particularly in terms of innovations in our education programs. But as e-learning, simulations, and distance education modalities become ever more prevalent across the spectrum of higher learning, we require an improved understanding of how these methods will transform ­entry-level education for health care providers.

Until recently, there has been minimal data on the impact of these technologic advances and teaching methods in health professions education, although this is changing.² We do have a research gap when it comes to the effect of learning style on NP and PA students’ perceptions of online instruction (despite the rapidly increasing use of it). We also have not firmly established how this delivery method affects professional development (ie, how effectively it prepares clinicians to provide care to patients). None of this has prevented the proliferation of these concepts.

While many were stunned by the Yale venture, it should be ­noted that the idea is not new. Rather, such programs have steadily ­become part of health professions education (particularly nursing) in recent years.³ Yale itself was an early adopter of “bridge” programs; for example, someone with a Bachelor of Science in any field could enter the NP program, becoming an RN in one year and an NP in the second.

As far as “distance learning,” offering graduate degrees in a health profession to remote students dates back to at least the early 1990s, when the University of Pennsylvania offered a ­videoconference-based master’s in nurse-midwifery. Since then, of course, technology has advanced to a level that allows individuals to view videos and “conference” online via personal electronic devices of one kind or another—a vast improvement on the expensive and inflexible room-scale video presentations of 20 years ago.

As these technologic limitations have fallen by the wayside and alterations to our educational structure have become more feasible, more colleges and universities are exploring their options. The PA programs at the University of North Dakota and the University of Wisconsin–Madison have experimented with blended online learning environments. My own university has an interest in moving to ever-higher levels of distant interaction.

Major criticism of distance education includes the perception that it is a “watered-down” version of the “real thing.” There is also concern that educational institutions might be motivated purely by money, if the sole impetus for distance learning is to significantly increase enrollment. And some critics, while not opposed to online courses per se, do not want an NP or PA seeing patients if his/her degree was earned online—not even in part!

Perhaps the larger issue we’re struggling with is that a new paradigm of teaching is emerging: We are moving away from the traditional Socratic method to more interactive modalities, such as flipped classrooms (settings in which students collaborate via online discussion). Synchronous classes can be delivered ­seminar-style, with each student able to hear the others and instructors able to share content and even give control of a class to a student for questions or presentations. Asynchronous courses offer opportunities for students to study on their own time and at their own pace. Many suggest that more comprehensive learning, including the development of critical thinking skills, occurs in programs of this design than in traditional education programs.⁴

I think there is little argument that the educational content (didactics) of a program can be successfully delivered through a nonresidential venue. The concern, rightly so, in health professional education is how to adequately deliver the practical and cocurricular experiences at a distance. Some of us may have a difficult time understanding how this new method of teaching can create the kind of clinicians that are needed, particularly in the relatively short period in which PAs and NPs are prepared for their roles.

Proponents insist that these programs can be successful, as long as they are accredited by the appropriate agency and demonstrate high educational standards (comparable to traditional programs). Programs also need to provide clinical experiences in which the students observe and actually work with patients in order to develop skills in the art of history taking and physical examination, establishment of a differential diagnosis, creation of a plan of action, and appropriate ­decision-making with regard to available tests and treatment options. Advocates of distance learning also agree that students must be observed by peer clinicians who can confirm that they are ethical and competent to practice, have good bedside manners, and demonstrate respect for the profession and for life.

And who knows? Distance learning may create opportunities to improve access to care in remote, rural, and underserved areas, as these could become fertile training grounds for NPs and PAs (a return to our roots, in a sense). In this age of successful telemedicine, why shouldn’t “tele-education” be the next success story? Although the jury is still out on this concept, the proverbial cat has already been let out of the bag! Only time will tell what results we will see. But I think with the significant enhancement of technology, and participation of committed educators who are willing to step into the arena to ensure that competency-based education persists, we will be pleasantly surprised by the success of this venture.

I would be interested in your views. Please email me at PAEditor@frontlinemedcom.com.

REFERENCES
1. Monir M. Yale to offer full-time master’s program online. USA Today. www.usatoday.com/story/news/nation/2015/03/12/yale-full-time-online-masters-program/70163994. Accessed May 2, 2015.
2. Kushniruk AW. Advances in health education applying e-learning, simulations and distance technologies [editorial]. Knowledge Manage E-Learning Int J. 2011;3(1):1-4.
3. Robley LR, Farnsworth BJ, Flynn JB, Horne CD. This new house: building knowledge through online learning. J Prof Nurs. 2004;20(5):333-343.
4. Yang YTC, Chou HA. Beyond critical thinking skills: investigating the relationship between critical thinking skills and dispositions through different online instructional strategies. Br J Educ Technol. 2008;39(4):666-684.

I consider my role as an editorialist to be to inform, persuade, or—sometimes—just comment on current issues that affect PAs and NPs. There have been many opportunities in recent years to address “hot” topics, and this is certainly one of them: the rise of distance entry-level education for health professions students.

The catalyst for this discussion? Earlier this year, Yale University announced it was launching an online entry-level PA program.¹ Within minutes of that announcement, there was a conflagration of criticism from the profession, alumni, and the general public. Most of the backlash centered on concerns about adequate delivery of such intense content—including how to instill or enhance professional behaviors and attitudes, or teach hands-on procedures, objective structured clinical examinations (OSCEs), and physical exam techniques—from a distance.

See also: Letter to the Editor from Janet Evans Emery, RN, MSN, CFNP

Share YOUR thoughts with us!

In our professions, we tend to be fairly conservative when it comes to change—particularly in terms of innovations in our education programs. But as e-learning, simulations, and distance education modalities become ever more prevalent across the spectrum of higher learning, we require an improved understanding of how these methods will transform ­entry-level education for health care providers.

Until recently, there has been minimal data on the impact of these technologic advances and teaching methods in health professions education, although this is changing.² We do have a research gap when it comes to the effect of learning style on NP and PA students’ perceptions of online instruction (despite the rapidly increasing use of it). We also have not firmly established how this delivery method affects professional development (ie, how effectively it prepares clinicians to provide care to patients). None of this has prevented the proliferation of these concepts.

While many were stunned by the Yale venture, it should be ­noted that the idea is not new. Rather, such programs have steadily ­become part of health professions education (particularly nursing) in recent years.³ Yale itself was an early adopter of “bridge” programs; for example, someone with a Bachelor of Science in any field could enter the NP program, becoming an RN in one year and an NP in the second.

As far as “distance learning,” offering graduate degrees in a health profession to remote students dates back to at least the early 1990s, when the University of Pennsylvania offered a ­videoconference-based master’s in nurse-midwifery. Since then, of course, technology has advanced to a level that allows individuals to view videos and “conference” online via personal electronic devices of one kind or another—a vast improvement on the expensive and inflexible room-scale video presentations of 20 years ago.

As these technologic limitations have fallen by the wayside and alterations to our educational structure have become more feasible, more colleges and universities are exploring their options. The PA programs at the University of North Dakota and the University of Wisconsin–Madison have experimented with blended online learning environments. My own university has an interest in moving to ever-higher levels of distant interaction.

Major criticism of distance education includes the perception that it is a “watered-down” version of the “real thing.” There is also concern that educational institutions might be motivated purely by money, if the sole impetus for distance learning is to significantly increase enrollment. And some critics, while not opposed to online courses per se, do not want an NP or PA seeing patients if his/her degree was earned online—not even in part!

Perhaps the larger issue we’re struggling with is that a new paradigm of teaching is emerging: We are moving away from the traditional Socratic method to more interactive modalities, such as flipped classrooms (settings in which students collaborate via online discussion). Synchronous classes can be delivered ­seminar-style, with each student able to hear the others and instructors able to share content and even give control of a class to a student for questions or presentations. Asynchronous courses offer opportunities for students to study on their own time and at their own pace. Many suggest that more comprehensive learning, including the development of critical thinking skills, occurs in programs of this design than in traditional education programs.⁴

I think there is little argument that the educational content (didactics) of a program can be successfully delivered through a nonresidential venue. The concern, rightly so, in health professional education is how to adequately deliver the practical and cocurricular experiences at a distance. Some of us may have a difficult time understanding how this new method of teaching can create the kind of clinicians that are needed, particularly in the relatively short period in which PAs and NPs are prepared for their roles.

Proponents insist that these programs can be successful, as long as they are accredited by the appropriate agency and demonstrate high educational standards (comparable to traditional programs). Programs also need to provide clinical experiences in which the students observe and actually work with patients in order to develop skills in the art of history taking and physical examination, establishment of a differential diagnosis, creation of a plan of action, and appropriate ­decision-making with regard to available tests and treatment options. Advocates of distance learning also agree that students must be observed by peer clinicians who can confirm that they are ethical and competent to practice, have good bedside manners, and demonstrate respect for the profession and for life.

And who knows? Distance learning may create opportunities to improve access to care in remote, rural, and underserved areas, as these could become fertile training grounds for NPs and PAs (a return to our roots, in a sense). In this age of successful telemedicine, why shouldn’t “tele-education” be the next success story? Although the jury is still out on this concept, the proverbial cat has already been let out of the bag! Only time will tell what results we will see. But I think with the significant enhancement of technology, and participation of committed educators who are willing to step into the arena to ensure that competency-based education persists, we will be pleasantly surprised by the success of this venture.

I would be interested in your views. Please email me at PAEditor@frontlinemedcom.com.

REFERENCES
1. Monir M. Yale to offer full-time master’s program online. USA Today. www.usatoday.com/story/news/nation/2015/03/12/yale-full-time-online-masters-program/70163994. Accessed May 2, 2015.
2. Kushniruk AW. Advances in health education applying e-learning, simulations and distance technologies [editorial]. Knowledge Manage E-Learning Int J. 2011;3(1):1-4.
3. Robley LR, Farnsworth BJ, Flynn JB, Horne CD. This new house: building knowledge through online learning. J Prof Nurs. 2004;20(5):333-343.
4. Yang YTC, Chou HA. Beyond critical thinking skills: investigating the relationship between critical thinking skills and dispositions through different online instructional strategies. Br J Educ Technol. 2008;39(4):666-684.

I consider my role as an editorialist to be to inform, persuade, or—sometimes—just comment on current issues that affect PAs and NPs. There have been many opportunities in recent years to address “hot” topics, and this is certainly one of them: the rise of distance entry-level education for health professions students.

The catalyst for this discussion? Earlier this year, Yale University announced it was launching an online entry-level PA program.¹ Within minutes of that announcement, there was a conflagration of criticism from the profession, alumni, and the general public. Most of the backlash centered on concerns about adequate delivery of such intense content—including how to instill or enhance professional behaviors and attitudes, or teach hands-on procedures, objective structured clinical examinations (OSCEs), and physical exam techniques—from a distance.

See also: Letter to the Editor from Janet Evans Emery, RN, MSN, CFNP

Share YOUR thoughts with us!

In our professions, we tend to be fairly conservative when it comes to change—particularly in terms of innovations in our education programs. But as e-learning, simulations, and distance education modalities become ever more prevalent across the spectrum of higher learning, we require an improved understanding of how these methods will transform ­entry-level education for health care providers.

Until recently, there has been minimal data on the impact of these technologic advances and teaching methods in health professions education, although this is changing.² We do have a research gap when it comes to the effect of learning style on NP and PA students’ perceptions of online instruction (despite the rapidly increasing use of it). We also have not firmly established how this delivery method affects professional development (ie, how effectively it prepares clinicians to provide care to patients). None of this has prevented the proliferation of these concepts.

While many were stunned by the Yale venture, it should be ­noted that the idea is not new. Rather, such programs have steadily ­become part of health professions education (particularly nursing) in recent years.³ Yale itself was an early adopter of “bridge” programs; for example, someone with a Bachelor of Science in any field could enter the NP program, becoming an RN in one year and an NP in the second.

As far as “distance learning,” offering graduate degrees in a health profession to remote students dates back to at least the early 1990s, when the University of Pennsylvania offered a ­videoconference-based master’s in nurse-midwifery. Since then, of course, technology has advanced to a level that allows individuals to view videos and “conference” online via personal electronic devices of one kind or another—a vast improvement on the expensive and inflexible room-scale video presentations of 20 years ago.

As these technologic limitations have fallen by the wayside and alterations to our educational structure have become more feasible, more colleges and universities are exploring their options. The PA programs at the University of North Dakota and the University of Wisconsin–Madison have experimented with blended online learning environments. My own university has an interest in moving to ever-higher levels of distant interaction.

Major criticism of distance education includes the perception that it is a “watered-down” version of the “real thing.” There is also concern that educational institutions might be motivated purely by money, if the sole impetus for distance learning is to significantly increase enrollment. And some critics, while not opposed to online courses per se, do not want an NP or PA seeing patients if his/her degree was earned online—not even in part!

Perhaps the larger issue we’re struggling with is that a new paradigm of teaching is emerging: We are moving away from the traditional Socratic method to more interactive modalities, such as flipped classrooms (settings in which students collaborate via online discussion). Synchronous classes can be delivered ­seminar-style, with each student able to hear the others and instructors able to share content and even give control of a class to a student for questions or presentations. Asynchronous courses offer opportunities for students to study on their own time and at their own pace. Many suggest that more comprehensive learning, including the development of critical thinking skills, occurs in programs of this design than in traditional education programs.⁴

I think there is little argument that the educational content (didactics) of a program can be successfully delivered through a nonresidential venue. The concern, rightly so, in health professional education is how to adequately deliver the practical and cocurricular experiences at a distance. Some of us may have a difficult time understanding how this new method of teaching can create the kind of clinicians that are needed, particularly in the relatively short period in which PAs and NPs are prepared for their roles.

Proponents insist that these programs can be successful, as long as they are accredited by the appropriate agency and demonstrate high educational standards (comparable to traditional programs). Programs also need to provide clinical experiences in which the students observe and actually work with patients in order to develop skills in the art of history taking and physical examination, establishment of a differential diagnosis, creation of a plan of action, and appropriate ­decision-making with regard to available tests and treatment options. Advocates of distance learning also agree that students must be observed by peer clinicians who can confirm that they are ethical and competent to practice, have good bedside manners, and demonstrate respect for the profession and for life.

And who knows? Distance learning may create opportunities to improve access to care in remote, rural, and underserved areas, as these could become fertile training grounds for NPs and PAs (a return to our roots, in a sense). In this age of successful telemedicine, why shouldn’t “tele-education” be the next success story? Although the jury is still out on this concept, the proverbial cat has already been let out of the bag! Only time will tell what results we will see. But I think with the significant enhancement of technology, and participation of committed educators who are willing to step into the arena to ensure that competency-based education persists, we will be pleasantly surprised by the success of this venture.

I would be interested in your views. Please email me at PAEditor@frontlinemedcom.com.

REFERENCES
1. Monir M. Yale to offer full-time master’s program online. USA Today. www.usatoday.com/story/news/nation/2015/03/12/yale-full-time-online-masters-program/70163994. Accessed May 2, 2015.
2. Kushniruk AW. Advances in health education applying e-learning, simulations and distance technologies [editorial]. Knowledge Manage E-Learning Int J. 2011;3(1):1-4.
3. Robley LR, Farnsworth BJ, Flynn JB, Horne CD. This new house: building knowledge through online learning. J Prof Nurs. 2004;20(5):333-343.
4. Yang YTC, Chou HA. Beyond critical thinking skills: investigating the relationship between critical thinking skills and dispositions through different online instructional strategies. Br J Educ Technol. 2008;39(4):666-684.