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COMMENT & CONTROVERSY
PHYSICIAN LEADERSHIP: RACIAL DISPARITIES AND RACISM. WHERE DO WE GO FROM HERE?
BIFTU MENGESHA, MD, MAS; KAVITA SHAH ARORA, MD, MBE, MS; AND BARBARA LEVY, MD
(COMMENTARY; AUGUST 2020)
Political diatribe paints a huge swath
I read the above referenced article with equal measure of angst and offense, amazement and incredulity, irritation and, some would say, typical white male denial. The authors have succumbed to the zeitgeist currently enveloping our country and painted us all with one huge swath of the same proverbial brush—inappropriately.
No doubt certain reforms are needed in our society and perhaps within areas of medicine. I am for anything that improves all peoples’ lives and health. The country is rightfully clamoring for equality. That means equality for all, however. But by way of one small example of systemic overreaction, many articles now are replete with comments about “Black people and Brown people and white people.” Adjectives have been turned into proper nouns, but applied only to some groups, not all. That foments continued inequity, not equality.
The authors implore us to strive for “engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.” In my view, the best way I can do that is not by words but actions, and that is to do what I am trained to do, which is take care of patients the best I can regardless of their color or creed. I have always done that, and everyone I work with does as well. For the authors to imply I (we) don’t is at a minimum offensive and pejorative, and flat wrong.
I agree to a certain extent that our health care contributes to poor, or at least less desirable, outcomes. But so do the actions or inactions of our patients. I do not agree that it is a racial issue. It affects all people. I see it every day. I am probably in the minority of physicians who think we should go to a single-payor system (note I did not say free). But to state that the system creates poor outcomes only for “Blacks, Indigenous, and Latinx,” I disagree. Tennessee has TennCare (Medicaid) and almost anyone can get it, and if they are pregnant they certainly can. Access is not an issue. All people have to do is avail themselves of it. It does not matter the race!
The authors call for the implementation “of system-wide intersectional and antiracist practices” to address “racism, sexism, gender discrimination, economic and social injustice.” They are preaching to the wrong crowd. If I (we) pursued all these lofty goals, I (we) would not have time to care for the very patients they are now lamenting don’t have enough care or proper care.
I facilitate conversations on a regular basis with my black patients as well as my white patients. I recently asked a patient if she distrusted me because I am a white male. It is enlightening to hear patient comments, which are mostly along the lines of “the world has gone crazy.” That is a polite interpretation of their comments. Maybe they say what they think I want to hear, but I don’t think so.
“Repair what we have broken…” by “uplifting their voices and redistributing our power to them.” I don’t see how I (we) have broken anything. If taking care of all comers as best as one can has broken something, then I am guilty. Regarding that I need to examine how “we have eroded the trust of the very communities we care for” and that we are guilty of “medical experimentation on and exploitation of Black and Brown bodies,” what are we to examine? How have I (we) eroded the trust? Present-day physicians had nothing to do with things like the Tuskegee Institute experiment, and I hardly see how blaming us today for that abominable episode in our HISTORY is a valid point. Implying that we add to that distrust by not giving the same pain relief to certain people because of race is just preposterous. Further, asking to let others lead, for example, on the medical executive committee or in positions such as chief of service or chief of staff usually are not something one “gets” to be, but something one usually is “talked into.” There is not a racial barrier to those roles, at least at my institution, and once again the brush has inappropriately painted us all.
I understand the general gestalt of this article and agree with its basic premises. But while well meaning, this political diatribe belongs in the halls of Congress, not in the halls of our hospitals or the pages of a medical journal. I am tired of being told, directly or indirectly, that I am a racist by TV news, newspapers, social media, professional sports teams, and now by my medical journals. I would ask the authors to be careful who they throw under the bus.
Scott Peters, MD
Oak Ridge, Tennessee
Continue to: Drs. Mengesha, Arora, and Levy respond...
Drs. Mengesha, Arora, and Levy respond
We appreciate the opportunity to respond to Dr. Peters. Our article brings long overdue awareness to systemic and structural problems that result in disproportionately inequitable outcomes for people of color. We are not debating the morality of individuals or talking about racism as an inherently “bad” trait that some people have, but rather recognizing the impact of social structures on health and well-being in which we all—Black, Brown, and White—live. We all have inherent biases, recognized or unrecognized, that impact our actions, decisions, and behaviors. We are humans with upbringing, backgrounds, and learned frameworks influenced by our sociocultural context that conditions our responses to a given situation. This is also woven into our hospitals, exam rooms, and even our medical journals. It constantly influences the health, well-being, and livelihood of patients—nothing that we do in medicine is in isolation of this greater context. Our health care system is steeped in this sociocultural context and impacts all patients in intersecting ways, whether that be by race, class, gender, or other social identities. And while we did not create the system in which we operate, we now have abundant evidence that shows it continually delivers inequitable outcomes particularly for people of color.
We are very clear that physicians and health care professionals strive to provide the very best care for each and every patient. We do not discount the hard work and good intentions of our colleagues. And while some individual patient behaviors may somewhat modify outcomes, we also strongly disagree with the premise that patients are to blame for poor or less desirable outcomes they face. Instead, our position is focused on the impact that the systems we work in are creating barriers to equitable care at levels of influence above a single individual, and that it is our collective professional responsibility to acknowledge and take action to lessen those barriers.
System-wide changes would not be at the expense of patient care, and physicians cannot and in fact should not shoulder these changes alone. Our current paradigm of training does not give us the capacity to do so, and a single individual cannot make such a large system change alone. The change we are advocating for requires collaboration within multidisciplinary and interprofessional teams, long-term planning, and incremental but intentional change. This is not dissimilar to the recognition over 20 years ago by the Institute of Medicine (now the National Academy of Medicine) that “to err is human.” Our eyes were opened to the structural issues resulting in medical errors, and very slowly our profession has acknowledged the necessity to recognize, report, and analyze the root causes of those errors. We do so because it is critically important to ensure that the same error never happens again. It is part of the commitment to honor our oath to “do no harm.” Similarly, racial inequities in health outcomes should also be “never events” as there is no biological basis or individual blame for these inequities, but rather systemic and structural processes (which is de facto racism) that contribute to disproportionately worse outcomes.
Disparities in COVID-19 vaccination rates for people of color is a current example that illustrates the deep distrust in our health care system that historical events, like Tuskegee, have created. In Tennessee, for example, 7% of COVID-19 vaccines have been administered to Black people despite the fact that they make up 15% of cases, 18% of deaths, and 16% of the total population.1 There are other ongoing systemic issues, including inequities in distribution, prioritization, and access, that are contributing to the lower vaccination rates among people of color; however, as physicians and advocates for our patients, it is crucial for us to acknowledge the fear of, and resistance to, government-sponsored health programs which has resulted from events like Tuskegee.
We are advocating for building our systems to help support all of the social and societal determinants of health our patients are faced with, including racism, while they are receiving care from us. Patients are faced with undue morbidity and mortality because of our health care system’s ineffectiveness in incorporating this as a part of systemic care delivery to all. We must work together alongside other health care professionals, public health and policy agencies, and community advocates to stop this deadly cycle. There will be no improvement and no end in sight unless we work together toward this common goal.
Reference
- Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations: race/ethnicity. Kaiser Family Foundation website. February 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-covid-19-vaccinations-cases-deaths-race-ethnicity/. Accessed February 11, 2021.
PHYSICIAN LEADERSHIP: RACIAL DISPARITIES AND RACISM. WHERE DO WE GO FROM HERE?
BIFTU MENGESHA, MD, MAS; KAVITA SHAH ARORA, MD, MBE, MS; AND BARBARA LEVY, MD
(COMMENTARY; AUGUST 2020)
Political diatribe paints a huge swath
I read the above referenced article with equal measure of angst and offense, amazement and incredulity, irritation and, some would say, typical white male denial. The authors have succumbed to the zeitgeist currently enveloping our country and painted us all with one huge swath of the same proverbial brush—inappropriately.
No doubt certain reforms are needed in our society and perhaps within areas of medicine. I am for anything that improves all peoples’ lives and health. The country is rightfully clamoring for equality. That means equality for all, however. But by way of one small example of systemic overreaction, many articles now are replete with comments about “Black people and Brown people and white people.” Adjectives have been turned into proper nouns, but applied only to some groups, not all. That foments continued inequity, not equality.
The authors implore us to strive for “engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.” In my view, the best way I can do that is not by words but actions, and that is to do what I am trained to do, which is take care of patients the best I can regardless of their color or creed. I have always done that, and everyone I work with does as well. For the authors to imply I (we) don’t is at a minimum offensive and pejorative, and flat wrong.
I agree to a certain extent that our health care contributes to poor, or at least less desirable, outcomes. But so do the actions or inactions of our patients. I do not agree that it is a racial issue. It affects all people. I see it every day. I am probably in the minority of physicians who think we should go to a single-payor system (note I did not say free). But to state that the system creates poor outcomes only for “Blacks, Indigenous, and Latinx,” I disagree. Tennessee has TennCare (Medicaid) and almost anyone can get it, and if they are pregnant they certainly can. Access is not an issue. All people have to do is avail themselves of it. It does not matter the race!
The authors call for the implementation “of system-wide intersectional and antiracist practices” to address “racism, sexism, gender discrimination, economic and social injustice.” They are preaching to the wrong crowd. If I (we) pursued all these lofty goals, I (we) would not have time to care for the very patients they are now lamenting don’t have enough care or proper care.
I facilitate conversations on a regular basis with my black patients as well as my white patients. I recently asked a patient if she distrusted me because I am a white male. It is enlightening to hear patient comments, which are mostly along the lines of “the world has gone crazy.” That is a polite interpretation of their comments. Maybe they say what they think I want to hear, but I don’t think so.
“Repair what we have broken…” by “uplifting their voices and redistributing our power to them.” I don’t see how I (we) have broken anything. If taking care of all comers as best as one can has broken something, then I am guilty. Regarding that I need to examine how “we have eroded the trust of the very communities we care for” and that we are guilty of “medical experimentation on and exploitation of Black and Brown bodies,” what are we to examine? How have I (we) eroded the trust? Present-day physicians had nothing to do with things like the Tuskegee Institute experiment, and I hardly see how blaming us today for that abominable episode in our HISTORY is a valid point. Implying that we add to that distrust by not giving the same pain relief to certain people because of race is just preposterous. Further, asking to let others lead, for example, on the medical executive committee or in positions such as chief of service or chief of staff usually are not something one “gets” to be, but something one usually is “talked into.” There is not a racial barrier to those roles, at least at my institution, and once again the brush has inappropriately painted us all.
I understand the general gestalt of this article and agree with its basic premises. But while well meaning, this political diatribe belongs in the halls of Congress, not in the halls of our hospitals or the pages of a medical journal. I am tired of being told, directly or indirectly, that I am a racist by TV news, newspapers, social media, professional sports teams, and now by my medical journals. I would ask the authors to be careful who they throw under the bus.
Scott Peters, MD
Oak Ridge, Tennessee
Continue to: Drs. Mengesha, Arora, and Levy respond...
Drs. Mengesha, Arora, and Levy respond
We appreciate the opportunity to respond to Dr. Peters. Our article brings long overdue awareness to systemic and structural problems that result in disproportionately inequitable outcomes for people of color. We are not debating the morality of individuals or talking about racism as an inherently “bad” trait that some people have, but rather recognizing the impact of social structures on health and well-being in which we all—Black, Brown, and White—live. We all have inherent biases, recognized or unrecognized, that impact our actions, decisions, and behaviors. We are humans with upbringing, backgrounds, and learned frameworks influenced by our sociocultural context that conditions our responses to a given situation. This is also woven into our hospitals, exam rooms, and even our medical journals. It constantly influences the health, well-being, and livelihood of patients—nothing that we do in medicine is in isolation of this greater context. Our health care system is steeped in this sociocultural context and impacts all patients in intersecting ways, whether that be by race, class, gender, or other social identities. And while we did not create the system in which we operate, we now have abundant evidence that shows it continually delivers inequitable outcomes particularly for people of color.
We are very clear that physicians and health care professionals strive to provide the very best care for each and every patient. We do not discount the hard work and good intentions of our colleagues. And while some individual patient behaviors may somewhat modify outcomes, we also strongly disagree with the premise that patients are to blame for poor or less desirable outcomes they face. Instead, our position is focused on the impact that the systems we work in are creating barriers to equitable care at levels of influence above a single individual, and that it is our collective professional responsibility to acknowledge and take action to lessen those barriers.
System-wide changes would not be at the expense of patient care, and physicians cannot and in fact should not shoulder these changes alone. Our current paradigm of training does not give us the capacity to do so, and a single individual cannot make such a large system change alone. The change we are advocating for requires collaboration within multidisciplinary and interprofessional teams, long-term planning, and incremental but intentional change. This is not dissimilar to the recognition over 20 years ago by the Institute of Medicine (now the National Academy of Medicine) that “to err is human.” Our eyes were opened to the structural issues resulting in medical errors, and very slowly our profession has acknowledged the necessity to recognize, report, and analyze the root causes of those errors. We do so because it is critically important to ensure that the same error never happens again. It is part of the commitment to honor our oath to “do no harm.” Similarly, racial inequities in health outcomes should also be “never events” as there is no biological basis or individual blame for these inequities, but rather systemic and structural processes (which is de facto racism) that contribute to disproportionately worse outcomes.
Disparities in COVID-19 vaccination rates for people of color is a current example that illustrates the deep distrust in our health care system that historical events, like Tuskegee, have created. In Tennessee, for example, 7% of COVID-19 vaccines have been administered to Black people despite the fact that they make up 15% of cases, 18% of deaths, and 16% of the total population.1 There are other ongoing systemic issues, including inequities in distribution, prioritization, and access, that are contributing to the lower vaccination rates among people of color; however, as physicians and advocates for our patients, it is crucial for us to acknowledge the fear of, and resistance to, government-sponsored health programs which has resulted from events like Tuskegee.
We are advocating for building our systems to help support all of the social and societal determinants of health our patients are faced with, including racism, while they are receiving care from us. Patients are faced with undue morbidity and mortality because of our health care system’s ineffectiveness in incorporating this as a part of systemic care delivery to all. We must work together alongside other health care professionals, public health and policy agencies, and community advocates to stop this deadly cycle. There will be no improvement and no end in sight unless we work together toward this common goal.
Reference
- Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations: race/ethnicity. Kaiser Family Foundation website. February 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-covid-19-vaccinations-cases-deaths-race-ethnicity/. Accessed February 11, 2021.
PHYSICIAN LEADERSHIP: RACIAL DISPARITIES AND RACISM. WHERE DO WE GO FROM HERE?
BIFTU MENGESHA, MD, MAS; KAVITA SHAH ARORA, MD, MBE, MS; AND BARBARA LEVY, MD
(COMMENTARY; AUGUST 2020)
Political diatribe paints a huge swath
I read the above referenced article with equal measure of angst and offense, amazement and incredulity, irritation and, some would say, typical white male denial. The authors have succumbed to the zeitgeist currently enveloping our country and painted us all with one huge swath of the same proverbial brush—inappropriately.
No doubt certain reforms are needed in our society and perhaps within areas of medicine. I am for anything that improves all peoples’ lives and health. The country is rightfully clamoring for equality. That means equality for all, however. But by way of one small example of systemic overreaction, many articles now are replete with comments about “Black people and Brown people and white people.” Adjectives have been turned into proper nouns, but applied only to some groups, not all. That foments continued inequity, not equality.
The authors implore us to strive for “engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.” In my view, the best way I can do that is not by words but actions, and that is to do what I am trained to do, which is take care of patients the best I can regardless of their color or creed. I have always done that, and everyone I work with does as well. For the authors to imply I (we) don’t is at a minimum offensive and pejorative, and flat wrong.
I agree to a certain extent that our health care contributes to poor, or at least less desirable, outcomes. But so do the actions or inactions of our patients. I do not agree that it is a racial issue. It affects all people. I see it every day. I am probably in the minority of physicians who think we should go to a single-payor system (note I did not say free). But to state that the system creates poor outcomes only for “Blacks, Indigenous, and Latinx,” I disagree. Tennessee has TennCare (Medicaid) and almost anyone can get it, and if they are pregnant they certainly can. Access is not an issue. All people have to do is avail themselves of it. It does not matter the race!
The authors call for the implementation “of system-wide intersectional and antiracist practices” to address “racism, sexism, gender discrimination, economic and social injustice.” They are preaching to the wrong crowd. If I (we) pursued all these lofty goals, I (we) would not have time to care for the very patients they are now lamenting don’t have enough care or proper care.
I facilitate conversations on a regular basis with my black patients as well as my white patients. I recently asked a patient if she distrusted me because I am a white male. It is enlightening to hear patient comments, which are mostly along the lines of “the world has gone crazy.” That is a polite interpretation of their comments. Maybe they say what they think I want to hear, but I don’t think so.
“Repair what we have broken…” by “uplifting their voices and redistributing our power to them.” I don’t see how I (we) have broken anything. If taking care of all comers as best as one can has broken something, then I am guilty. Regarding that I need to examine how “we have eroded the trust of the very communities we care for” and that we are guilty of “medical experimentation on and exploitation of Black and Brown bodies,” what are we to examine? How have I (we) eroded the trust? Present-day physicians had nothing to do with things like the Tuskegee Institute experiment, and I hardly see how blaming us today for that abominable episode in our HISTORY is a valid point. Implying that we add to that distrust by not giving the same pain relief to certain people because of race is just preposterous. Further, asking to let others lead, for example, on the medical executive committee or in positions such as chief of service or chief of staff usually are not something one “gets” to be, but something one usually is “talked into.” There is not a racial barrier to those roles, at least at my institution, and once again the brush has inappropriately painted us all.
I understand the general gestalt of this article and agree with its basic premises. But while well meaning, this political diatribe belongs in the halls of Congress, not in the halls of our hospitals or the pages of a medical journal. I am tired of being told, directly or indirectly, that I am a racist by TV news, newspapers, social media, professional sports teams, and now by my medical journals. I would ask the authors to be careful who they throw under the bus.
Scott Peters, MD
Oak Ridge, Tennessee
Continue to: Drs. Mengesha, Arora, and Levy respond...
Drs. Mengesha, Arora, and Levy respond
We appreciate the opportunity to respond to Dr. Peters. Our article brings long overdue awareness to systemic and structural problems that result in disproportionately inequitable outcomes for people of color. We are not debating the morality of individuals or talking about racism as an inherently “bad” trait that some people have, but rather recognizing the impact of social structures on health and well-being in which we all—Black, Brown, and White—live. We all have inherent biases, recognized or unrecognized, that impact our actions, decisions, and behaviors. We are humans with upbringing, backgrounds, and learned frameworks influenced by our sociocultural context that conditions our responses to a given situation. This is also woven into our hospitals, exam rooms, and even our medical journals. It constantly influences the health, well-being, and livelihood of patients—nothing that we do in medicine is in isolation of this greater context. Our health care system is steeped in this sociocultural context and impacts all patients in intersecting ways, whether that be by race, class, gender, or other social identities. And while we did not create the system in which we operate, we now have abundant evidence that shows it continually delivers inequitable outcomes particularly for people of color.
We are very clear that physicians and health care professionals strive to provide the very best care for each and every patient. We do not discount the hard work and good intentions of our colleagues. And while some individual patient behaviors may somewhat modify outcomes, we also strongly disagree with the premise that patients are to blame for poor or less desirable outcomes they face. Instead, our position is focused on the impact that the systems we work in are creating barriers to equitable care at levels of influence above a single individual, and that it is our collective professional responsibility to acknowledge and take action to lessen those barriers.
System-wide changes would not be at the expense of patient care, and physicians cannot and in fact should not shoulder these changes alone. Our current paradigm of training does not give us the capacity to do so, and a single individual cannot make such a large system change alone. The change we are advocating for requires collaboration within multidisciplinary and interprofessional teams, long-term planning, and incremental but intentional change. This is not dissimilar to the recognition over 20 years ago by the Institute of Medicine (now the National Academy of Medicine) that “to err is human.” Our eyes were opened to the structural issues resulting in medical errors, and very slowly our profession has acknowledged the necessity to recognize, report, and analyze the root causes of those errors. We do so because it is critically important to ensure that the same error never happens again. It is part of the commitment to honor our oath to “do no harm.” Similarly, racial inequities in health outcomes should also be “never events” as there is no biological basis or individual blame for these inequities, but rather systemic and structural processes (which is de facto racism) that contribute to disproportionately worse outcomes.
Disparities in COVID-19 vaccination rates for people of color is a current example that illustrates the deep distrust in our health care system that historical events, like Tuskegee, have created. In Tennessee, for example, 7% of COVID-19 vaccines have been administered to Black people despite the fact that they make up 15% of cases, 18% of deaths, and 16% of the total population.1 There are other ongoing systemic issues, including inequities in distribution, prioritization, and access, that are contributing to the lower vaccination rates among people of color; however, as physicians and advocates for our patients, it is crucial for us to acknowledge the fear of, and resistance to, government-sponsored health programs which has resulted from events like Tuskegee.
We are advocating for building our systems to help support all of the social and societal determinants of health our patients are faced with, including racism, while they are receiving care from us. Patients are faced with undue morbidity and mortality because of our health care system’s ineffectiveness in incorporating this as a part of systemic care delivery to all. We must work together alongside other health care professionals, public health and policy agencies, and community advocates to stop this deadly cycle. There will be no improvement and no end in sight unless we work together toward this common goal.
Reference
- Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations: race/ethnicity. Kaiser Family Foundation website. February 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-covid-19-vaccinations-cases-deaths-race-ethnicity/. Accessed February 11, 2021.
COMMENT & CONTROVERSY
9vHPV VACCINE: PREVENTION OF OROPHARYNGEAL CANCER
ROBERT L. BARBIERI, MD (EDITORIAL; NOVEMBER 2020)
HPV vaccine for older ObGyns?
I am 67 years old and recently retired. I breathed in the smoke from laser conizations, LEEPs (loop electrosurgical excision procedures), and cautery of condyloma for 35 years. Am I a good candidate for the HPV vaccine?
Gus Barkett, DO
Muskegon, Michigan
Dr. Barbieri responds
I thank Dr. Barkett for his important question. As you know, the US Food and Drug Administration has approved 9vHPV vaccination for people 27 to 45 years of age. I do not believe there are sufficient data to provide an evidence-based answer for physicians with occupational exposure to HPV who are more than 45 years of age. My recommendation would be to have a consult with an otolaryngologist expert in HPV-induced oral-pharyngeal cancer.
EXAMINING THE EVIDENCE: HOW EFFECTIVE IS SCREENING MAMMOGRAPHY FOR PREVENTING BREAST CANCER MORTALITY?
ANDREW M. KAUNITZ, MD (AUGUST 2020)
Discordant results on screening mammography
In regard to the discussion on screening mammography for preventing breast cancer mortality, I would like to call attention to a more recent study than the ones referenced in the article. The study by Duffy and colleagues was from Sweden and included almost 550,000 women.1 Results of the study showed a statistically significant reduction of 41% in 10-year mortality and a 25% reduction in the incidence of advanced-stage disease at the time of diagnosis in women who underwent routine screening mammograms. In Sweden, routine screening is defined as a mammogram every 18 months for women aged 40 to 54 years and every 24 months after that, up to age 69.
I do not know if we will ever come to a consensus on the utility of mammograms or how often they should be done, but I wanted to illustrate this counterpoint.
Lisa Gennari, MD
Cincinnati, Ohio
Reference
1. Duffy SW, Tabar L, Yen AM, et al. Mammography screening reduces rates of advanced and fatal breast cancers: results in 549,091 women. Cancer. 2020;126:2971-2979.
Dr. Kaunitz responds
I thank Dr. Gennari for her interest in the Examining the Evidence discussion that summarized the findings of an article from Australia published in late summer of last year.1 That article indicated that as screening mammograms became common in the state of Victoria over several decades, the incidence of advanced breast cancer doubled, mirroring findings from the United States, Holland, and Norway. During the same time period, breast cancer mortality declined substantially. The authors concluded that all of the decline in breast cancer mortality that they observed since 1994 could be attributed not to screening mammography but rather to the introduction and uptake of adjuvant therapy (tamoxifen and chemotherapy).
In contrast, in the article Dr. Gennari cites, also published last summer, the authors found that the widespread uptake of screening mammograms among women residing in 9 counties in Sweden was associated with a decline in the incidence of advanced breast cancer. I am not able to explain these discrepant findings. However, as the authors pointed out, they employed a new strategy: measuring the incidence of breast cancer that proved fatal one decade after diagnosis.
Differing findings and interpretations of data that address benefits and risks of screening mammography lead to differing recommendations from professional societies and confusion among clinicians and our patients. Although it can be challenging in the constraints of time allotted for well-woman visits, I try to engage in shared decision making with my patients regarding when to start/stop mammography as well as frequency of screening.
Reference
- Burton R, Stevenson C. Assessment of breast cancer mortality trends associated with mammographic screening and adjuvant therapy from 1986 to 2013 in the state of Victoria, Australia. JAMA Netw Open. 2020:3:e208249.
Continue to: NEW HORMONAL MEDICAL TREATMENT...
NEW HORMONAL MEDICAL TREATMENT IS AN IMPORTANT ADVANCE FOR AUB CAUSED BY UTERINE FIBROIDS
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2020)
New AUB medical treatment
I appreciate Dr. Barbieri’s concise and pertinent review of myomatous disease etiology and treatments. I have a question regarding therapy with Oriahnn (elagolix, estradiol, and norethindrone acetate capsules). Most myomatous-related bleeding occurs in premenopausal women. The elagolix suppresses luteinizing hormone and follicle stimulating hormone, and the norethindrone is added to protect the endometrium from the estradiol. Do the elagolix and norethindrone also provide contraception?
Geoffrey J. Zann, MD, MBA
Boca Raton, Florida
Dr. Barbieri responds
Dr. Zann raises an important clinical question that arises often in practice. The US Food and Drug Administration (FDA) has not approved Oriahnn as a contraceptive. The FDA prescribing information recommends: Advise women to use non-hormonal contraception during treatment and for one week after discontinuing Oriahnn. Oriahnn may delay the ability to recognize the occurrence of a pregnancy because it alters menstrual bleeding. Perform pregnancy testing if pregnancy is suspected and discontinue Oriahnn if pregnancy is confirmed.
In Oriahnn, the elagolix dose is 300 mg twice daily. If a patient reliably takes 600 mg of elagolix daily, it is highly unlikely that she will ovulate. However, in practice, many patients miss doses of their medication, reducing the contraceptive effectiveness. For example, the combined estrogen-progestin contraceptive is highly effective at suppressing ovulation, but the Centers for Disease Control and Prevention (CDC) estimates that 9% of women taking an estrogen-progestin contraceptive will become pregnant each year.1,2
Oriahnn also contains norethindrone acetate at a dose of 0.5 mg daily. The FDA has approved norethindrone at a dose of 0.35 mg daily as a contraceptive. The CDC estimates that 9% of women prescribed a progestin-only pill will become pregnant each year with typical use.1,2
I counsel my patients that if they reliably take their prescribed Oriahnn medication as directed, they are unlikely to become pregnant, and a backup method of contraception will further help to reduce their risk of becoming pregnant.
References
- Centers for Disease Control and Prevention. US selected practice recommendations for contraceptive use, 2013. MMWR Morbid Mortal Weekly Rep. 2013;62(RR-5):1-59.
- Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397-404.
9vHPV VACCINE: PREVENTION OF OROPHARYNGEAL CANCER
ROBERT L. BARBIERI, MD (EDITORIAL; NOVEMBER 2020)
HPV vaccine for older ObGyns?
I am 67 years old and recently retired. I breathed in the smoke from laser conizations, LEEPs (loop electrosurgical excision procedures), and cautery of condyloma for 35 years. Am I a good candidate for the HPV vaccine?
Gus Barkett, DO
Muskegon, Michigan
Dr. Barbieri responds
I thank Dr. Barkett for his important question. As you know, the US Food and Drug Administration has approved 9vHPV vaccination for people 27 to 45 years of age. I do not believe there are sufficient data to provide an evidence-based answer for physicians with occupational exposure to HPV who are more than 45 years of age. My recommendation would be to have a consult with an otolaryngologist expert in HPV-induced oral-pharyngeal cancer.
EXAMINING THE EVIDENCE: HOW EFFECTIVE IS SCREENING MAMMOGRAPHY FOR PREVENTING BREAST CANCER MORTALITY?
ANDREW M. KAUNITZ, MD (AUGUST 2020)
Discordant results on screening mammography
In regard to the discussion on screening mammography for preventing breast cancer mortality, I would like to call attention to a more recent study than the ones referenced in the article. The study by Duffy and colleagues was from Sweden and included almost 550,000 women.1 Results of the study showed a statistically significant reduction of 41% in 10-year mortality and a 25% reduction in the incidence of advanced-stage disease at the time of diagnosis in women who underwent routine screening mammograms. In Sweden, routine screening is defined as a mammogram every 18 months for women aged 40 to 54 years and every 24 months after that, up to age 69.
I do not know if we will ever come to a consensus on the utility of mammograms or how often they should be done, but I wanted to illustrate this counterpoint.
Lisa Gennari, MD
Cincinnati, Ohio
Reference
1. Duffy SW, Tabar L, Yen AM, et al. Mammography screening reduces rates of advanced and fatal breast cancers: results in 549,091 women. Cancer. 2020;126:2971-2979.
Dr. Kaunitz responds
I thank Dr. Gennari for her interest in the Examining the Evidence discussion that summarized the findings of an article from Australia published in late summer of last year.1 That article indicated that as screening mammograms became common in the state of Victoria over several decades, the incidence of advanced breast cancer doubled, mirroring findings from the United States, Holland, and Norway. During the same time period, breast cancer mortality declined substantially. The authors concluded that all of the decline in breast cancer mortality that they observed since 1994 could be attributed not to screening mammography but rather to the introduction and uptake of adjuvant therapy (tamoxifen and chemotherapy).
In contrast, in the article Dr. Gennari cites, also published last summer, the authors found that the widespread uptake of screening mammograms among women residing in 9 counties in Sweden was associated with a decline in the incidence of advanced breast cancer. I am not able to explain these discrepant findings. However, as the authors pointed out, they employed a new strategy: measuring the incidence of breast cancer that proved fatal one decade after diagnosis.
Differing findings and interpretations of data that address benefits and risks of screening mammography lead to differing recommendations from professional societies and confusion among clinicians and our patients. Although it can be challenging in the constraints of time allotted for well-woman visits, I try to engage in shared decision making with my patients regarding when to start/stop mammography as well as frequency of screening.
Reference
- Burton R, Stevenson C. Assessment of breast cancer mortality trends associated with mammographic screening and adjuvant therapy from 1986 to 2013 in the state of Victoria, Australia. JAMA Netw Open. 2020:3:e208249.
Continue to: NEW HORMONAL MEDICAL TREATMENT...
NEW HORMONAL MEDICAL TREATMENT IS AN IMPORTANT ADVANCE FOR AUB CAUSED BY UTERINE FIBROIDS
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2020)
New AUB medical treatment
I appreciate Dr. Barbieri’s concise and pertinent review of myomatous disease etiology and treatments. I have a question regarding therapy with Oriahnn (elagolix, estradiol, and norethindrone acetate capsules). Most myomatous-related bleeding occurs in premenopausal women. The elagolix suppresses luteinizing hormone and follicle stimulating hormone, and the norethindrone is added to protect the endometrium from the estradiol. Do the elagolix and norethindrone also provide contraception?
Geoffrey J. Zann, MD, MBA
Boca Raton, Florida
Dr. Barbieri responds
Dr. Zann raises an important clinical question that arises often in practice. The US Food and Drug Administration (FDA) has not approved Oriahnn as a contraceptive. The FDA prescribing information recommends: Advise women to use non-hormonal contraception during treatment and for one week after discontinuing Oriahnn. Oriahnn may delay the ability to recognize the occurrence of a pregnancy because it alters menstrual bleeding. Perform pregnancy testing if pregnancy is suspected and discontinue Oriahnn if pregnancy is confirmed.
In Oriahnn, the elagolix dose is 300 mg twice daily. If a patient reliably takes 600 mg of elagolix daily, it is highly unlikely that she will ovulate. However, in practice, many patients miss doses of their medication, reducing the contraceptive effectiveness. For example, the combined estrogen-progestin contraceptive is highly effective at suppressing ovulation, but the Centers for Disease Control and Prevention (CDC) estimates that 9% of women taking an estrogen-progestin contraceptive will become pregnant each year.1,2
Oriahnn also contains norethindrone acetate at a dose of 0.5 mg daily. The FDA has approved norethindrone at a dose of 0.35 mg daily as a contraceptive. The CDC estimates that 9% of women prescribed a progestin-only pill will become pregnant each year with typical use.1,2
I counsel my patients that if they reliably take their prescribed Oriahnn medication as directed, they are unlikely to become pregnant, and a backup method of contraception will further help to reduce their risk of becoming pregnant.
References
- Centers for Disease Control and Prevention. US selected practice recommendations for contraceptive use, 2013. MMWR Morbid Mortal Weekly Rep. 2013;62(RR-5):1-59.
- Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397-404.
9vHPV VACCINE: PREVENTION OF OROPHARYNGEAL CANCER
ROBERT L. BARBIERI, MD (EDITORIAL; NOVEMBER 2020)
HPV vaccine for older ObGyns?
I am 67 years old and recently retired. I breathed in the smoke from laser conizations, LEEPs (loop electrosurgical excision procedures), and cautery of condyloma for 35 years. Am I a good candidate for the HPV vaccine?
Gus Barkett, DO
Muskegon, Michigan
Dr. Barbieri responds
I thank Dr. Barkett for his important question. As you know, the US Food and Drug Administration has approved 9vHPV vaccination for people 27 to 45 years of age. I do not believe there are sufficient data to provide an evidence-based answer for physicians with occupational exposure to HPV who are more than 45 years of age. My recommendation would be to have a consult with an otolaryngologist expert in HPV-induced oral-pharyngeal cancer.
EXAMINING THE EVIDENCE: HOW EFFECTIVE IS SCREENING MAMMOGRAPHY FOR PREVENTING BREAST CANCER MORTALITY?
ANDREW M. KAUNITZ, MD (AUGUST 2020)
Discordant results on screening mammography
In regard to the discussion on screening mammography for preventing breast cancer mortality, I would like to call attention to a more recent study than the ones referenced in the article. The study by Duffy and colleagues was from Sweden and included almost 550,000 women.1 Results of the study showed a statistically significant reduction of 41% in 10-year mortality and a 25% reduction in the incidence of advanced-stage disease at the time of diagnosis in women who underwent routine screening mammograms. In Sweden, routine screening is defined as a mammogram every 18 months for women aged 40 to 54 years and every 24 months after that, up to age 69.
I do not know if we will ever come to a consensus on the utility of mammograms or how often they should be done, but I wanted to illustrate this counterpoint.
Lisa Gennari, MD
Cincinnati, Ohio
Reference
1. Duffy SW, Tabar L, Yen AM, et al. Mammography screening reduces rates of advanced and fatal breast cancers: results in 549,091 women. Cancer. 2020;126:2971-2979.
Dr. Kaunitz responds
I thank Dr. Gennari for her interest in the Examining the Evidence discussion that summarized the findings of an article from Australia published in late summer of last year.1 That article indicated that as screening mammograms became common in the state of Victoria over several decades, the incidence of advanced breast cancer doubled, mirroring findings from the United States, Holland, and Norway. During the same time period, breast cancer mortality declined substantially. The authors concluded that all of the decline in breast cancer mortality that they observed since 1994 could be attributed not to screening mammography but rather to the introduction and uptake of adjuvant therapy (tamoxifen and chemotherapy).
In contrast, in the article Dr. Gennari cites, also published last summer, the authors found that the widespread uptake of screening mammograms among women residing in 9 counties in Sweden was associated with a decline in the incidence of advanced breast cancer. I am not able to explain these discrepant findings. However, as the authors pointed out, they employed a new strategy: measuring the incidence of breast cancer that proved fatal one decade after diagnosis.
Differing findings and interpretations of data that address benefits and risks of screening mammography lead to differing recommendations from professional societies and confusion among clinicians and our patients. Although it can be challenging in the constraints of time allotted for well-woman visits, I try to engage in shared decision making with my patients regarding when to start/stop mammography as well as frequency of screening.
Reference
- Burton R, Stevenson C. Assessment of breast cancer mortality trends associated with mammographic screening and adjuvant therapy from 1986 to 2013 in the state of Victoria, Australia. JAMA Netw Open. 2020:3:e208249.
Continue to: NEW HORMONAL MEDICAL TREATMENT...
NEW HORMONAL MEDICAL TREATMENT IS AN IMPORTANT ADVANCE FOR AUB CAUSED BY UTERINE FIBROIDS
ROBERT L. BARBIERI, MD (EDITORIAL; AUGUST 2020)
New AUB medical treatment
I appreciate Dr. Barbieri’s concise and pertinent review of myomatous disease etiology and treatments. I have a question regarding therapy with Oriahnn (elagolix, estradiol, and norethindrone acetate capsules). Most myomatous-related bleeding occurs in premenopausal women. The elagolix suppresses luteinizing hormone and follicle stimulating hormone, and the norethindrone is added to protect the endometrium from the estradiol. Do the elagolix and norethindrone also provide contraception?
Geoffrey J. Zann, MD, MBA
Boca Raton, Florida
Dr. Barbieri responds
Dr. Zann raises an important clinical question that arises often in practice. The US Food and Drug Administration (FDA) has not approved Oriahnn as a contraceptive. The FDA prescribing information recommends: Advise women to use non-hormonal contraception during treatment and for one week after discontinuing Oriahnn. Oriahnn may delay the ability to recognize the occurrence of a pregnancy because it alters menstrual bleeding. Perform pregnancy testing if pregnancy is suspected and discontinue Oriahnn if pregnancy is confirmed.
In Oriahnn, the elagolix dose is 300 mg twice daily. If a patient reliably takes 600 mg of elagolix daily, it is highly unlikely that she will ovulate. However, in practice, many patients miss doses of their medication, reducing the contraceptive effectiveness. For example, the combined estrogen-progestin contraceptive is highly effective at suppressing ovulation, but the Centers for Disease Control and Prevention (CDC) estimates that 9% of women taking an estrogen-progestin contraceptive will become pregnant each year.1,2
Oriahnn also contains norethindrone acetate at a dose of 0.5 mg daily. The FDA has approved norethindrone at a dose of 0.35 mg daily as a contraceptive. The CDC estimates that 9% of women prescribed a progestin-only pill will become pregnant each year with typical use.1,2
I counsel my patients that if they reliably take their prescribed Oriahnn medication as directed, they are unlikely to become pregnant, and a backup method of contraception will further help to reduce their risk of becoming pregnant.
References
- Centers for Disease Control and Prevention. US selected practice recommendations for contraceptive use, 2013. MMWR Morbid Mortal Weekly Rep. 2013;62(RR-5):1-59.
- Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397-404.
Comment & Controversy
OBG Manag. 2020 November; 32(11).
The Fetal Pillow: A new option for delivering the deeply impacted fetal head
Robert L. Barbieri, MD
(Editorial; July 2020)
Alternative option to the Fetal Pillow
obgm03207c1.jpg
I enjoyed Dr. Barbieri’s editorial on the Fetal Pillow. I worry, however, that applying high air pressure to the upper vagina could result in an air embolism.
I have experienced good results using a vacuum cup. Like the pillow, it distributes the force more evenly than a hand. Also, the handle makes elevation of the vertex much less awkward and allows elevation to a higher station. Whatever approach is employed, using an open internal monitor catheter allows for a gentler procedure than when brute force alone is used to “break the seal” to allow ingress of air into the uterine cavity (at just 1 atmosphere of pressure).
John H. Sand, MD
Ellensburg, Washington
Cost of device must be considered
The information on the Fetal Pillow in Dr. Barbieri’s timely editorial, while limited in scope, does make the device look like a promising option.
One of my institution’s biggest issues relates to cost. We have had some interest in incorporating the Fetal Pillow into our practice, and we have been quoted a rate of about $600.00 per device. I had our Fetal Pillow representative look into reimbursement and have been informed that, at least in our region, there has been no reimbursement for the cost.
When I look at the cost of a hospital stay for a normal spontaneous vaginal delivery (NSVD), the cost of the Fetal Pillow would actually add 15% to 20% to that stay. Now, one must consider also the cost of extension of the uterine incision versus the cost of the Fetal Pillow. When we did a superficial look at when the Fetal Pillow might be used versus how many uterine extensions we experienced, the cost of the Fetal Pillow over a year far exceeded the cost of the uterine extensions. Without reimbursement, this appeared unsustainable. It has been interesting as some sites had no awareness of cost and the fact that essentially “the system” was absorbing those costs.
This issue is worthy of thought but likely one that most obstetricians will not consider.
Casey Morris, MD
Downers Grove, Illinois
Tip for dislodging the fetal head
I read Dr. Barbieri’s editorial regarding the Fetal Pillow and would like to share my experience. Over the last 30 years, I have used a simple trick. After entering the pelvic cavity, we push on the lower uterine segment toward the fundus prior to uterine incision. This helps dislodge the fetal head. Occasionally, you can feel the “pop” when the suction is broken, which sets the head free. We then proceed with the uterine incision and delivery of the head. We have had great success over the years, and the poor nurse does not have to go under the drapes.
Walter Kobasa Jr, MD
Wilmington, Delaware
Dr. Barbieri responds
I appreciate the recommendations and insights of Drs. Sand, Morris, and Kobasa. As I mentioned in the editorial on the Fetal Pillow, there are many clinical pearls about management of a second stage, deep-transverse cephalic arrest at the time of cesarean delivery, including to extend or T the uterine incision, push with a hand from below, reverse breech extraction, use a Coyne spoon, administer nitroglycerine or terbutaline, break the vaginal suction before attempting delivery, and incise a Bandl ring. Dr. Sand adds vaginal placement of a vacuum cup to our armamentarium, and Dr. Kobasa recommends dislodging the fetal head with a push on the lower uterine segment before making the hysterotomy incision. I thank Dr. Morris for correcting my failure to report the cost of the Fetal Pillow, reporting a quoted price of $600 for each Fetal Pillow. I agree with Dr. Morris that physicians have an important responsibility to be good stewards of health care resources and weigh the benefits and costs of our decisions.
Continue to: In your practice, are you planning to have a chaperone present for all intimate examinations?
In your practice, are you planning to have a chaperone present for all intimate examinations?
Robert L. Barbieri, MD
(Editorial; June 2020)
Enough is enough
I have always thought that many doctors who write opinions and pontificate about what should be done in practice live in la-la land. This editorial, for me, confirms it.
I personally am becoming tired of all this: dividing the specialty into obstetricians and gynecologists; pelvic exams are not necessary during annual visits; HPV testing by patients at home; doing away with Pap smears; Pap smears are not necessary for patients after a certain age; scribes in your footsteps to document all findings in the EMR; heaven forbid you do not ask the patient if she has a fire extinguisher in her house or some other stupid information; interpreters for people who speak Mongolian because their partner should not be used to interpret for them; and so on.
Now you want us to have a chaperone for every pelvic exam! Not any chaperone, but a specialized one! You worry about the sanctity and privacy of the patient but now have 2 additional people in the room for the patient’s exam. First, most patients prefer to have the least number of people looking at their bodies during an exam, especially a pelvic exam. Second, where do we get the money to support all of this? Does this type of policy make any sense? Are lawyers now controlling what medical care is all about? Is that what is now considered quality medical care?
By the way, I am not a burned out physician. I use common sense and consider what is best for my patients in everything that I do. If a patient requests a chaperone, my medical assistant will come to the room and provide that service. You do not need to be specialized to provide this service! Ivory tower people have lost all common sense. You consider yourselves the authorities in whatever medical field you specialize in, but let me tell you something: You really are not.
I know I will be criticized and demonized publicly by many; however, I have the courage to say what, in my opinion, I feel is right and what is wrong. Many physicians are afraid to do so, and, like sheep, will comply with your misguided opinions. I truly do not mean any disrespect to your knowledge and good intentions. I just think that enough is enough!
Gabriel G. Hakim, MD
Waterbury, Connecticut
Dr. Barbieri responds
In response to my editorial on the American College of Obstetricians and Gynecologists (ACOG) recommendation that chaperones be present for intimate examinations (ACOG Committee Opinion No. 796), Dr. Hakim outlines many concerns with the rapidly evolving practice of medicine.1 I am confident that the ACOG Committee on Ethics wisely considered the benefits, costs, and unintended consequences of the recommendation. The United States Veterans Administration, the Royal College of Obstetricians and Gynaecologists, and the American College Health Association endorse a similar recommendation. I do not think the distinguished members of the committees who issued the recommendation “live in la-la land.”
Reference
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual misconduct: ACOG Committee Opinion No. 796. Obstet Gynecol. 2020;135:e43-e50.
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual misconduct: ACOG Committee Opinion No. 796. Obstet Gynecol. 2020;135:e43-e50.
OBG Manag. 2020 November; 32(11).
The Fetal Pillow: A new option for delivering the deeply impacted fetal head
Robert L. Barbieri, MD
(Editorial; July 2020)
Alternative option to the Fetal Pillow
obgm03207c1.jpg
I enjoyed Dr. Barbieri’s editorial on the Fetal Pillow. I worry, however, that applying high air pressure to the upper vagina could result in an air embolism.
I have experienced good results using a vacuum cup. Like the pillow, it distributes the force more evenly than a hand. Also, the handle makes elevation of the vertex much less awkward and allows elevation to a higher station. Whatever approach is employed, using an open internal monitor catheter allows for a gentler procedure than when brute force alone is used to “break the seal” to allow ingress of air into the uterine cavity (at just 1 atmosphere of pressure).
John H. Sand, MD
Ellensburg, Washington
Cost of device must be considered
The information on the Fetal Pillow in Dr. Barbieri’s timely editorial, while limited in scope, does make the device look like a promising option.
One of my institution’s biggest issues relates to cost. We have had some interest in incorporating the Fetal Pillow into our practice, and we have been quoted a rate of about $600.00 per device. I had our Fetal Pillow representative look into reimbursement and have been informed that, at least in our region, there has been no reimbursement for the cost.
When I look at the cost of a hospital stay for a normal spontaneous vaginal delivery (NSVD), the cost of the Fetal Pillow would actually add 15% to 20% to that stay. Now, one must consider also the cost of extension of the uterine incision versus the cost of the Fetal Pillow. When we did a superficial look at when the Fetal Pillow might be used versus how many uterine extensions we experienced, the cost of the Fetal Pillow over a year far exceeded the cost of the uterine extensions. Without reimbursement, this appeared unsustainable. It has been interesting as some sites had no awareness of cost and the fact that essentially “the system” was absorbing those costs.
This issue is worthy of thought but likely one that most obstetricians will not consider.
Casey Morris, MD
Downers Grove, Illinois
Tip for dislodging the fetal head
I read Dr. Barbieri’s editorial regarding the Fetal Pillow and would like to share my experience. Over the last 30 years, I have used a simple trick. After entering the pelvic cavity, we push on the lower uterine segment toward the fundus prior to uterine incision. This helps dislodge the fetal head. Occasionally, you can feel the “pop” when the suction is broken, which sets the head free. We then proceed with the uterine incision and delivery of the head. We have had great success over the years, and the poor nurse does not have to go under the drapes.
Walter Kobasa Jr, MD
Wilmington, Delaware
Dr. Barbieri responds
I appreciate the recommendations and insights of Drs. Sand, Morris, and Kobasa. As I mentioned in the editorial on the Fetal Pillow, there are many clinical pearls about management of a second stage, deep-transverse cephalic arrest at the time of cesarean delivery, including to extend or T the uterine incision, push with a hand from below, reverse breech extraction, use a Coyne spoon, administer nitroglycerine or terbutaline, break the vaginal suction before attempting delivery, and incise a Bandl ring. Dr. Sand adds vaginal placement of a vacuum cup to our armamentarium, and Dr. Kobasa recommends dislodging the fetal head with a push on the lower uterine segment before making the hysterotomy incision. I thank Dr. Morris for correcting my failure to report the cost of the Fetal Pillow, reporting a quoted price of $600 for each Fetal Pillow. I agree with Dr. Morris that physicians have an important responsibility to be good stewards of health care resources and weigh the benefits and costs of our decisions.
Continue to: In your practice, are you planning to have a chaperone present for all intimate examinations?
In your practice, are you planning to have a chaperone present for all intimate examinations?
Robert L. Barbieri, MD
(Editorial; June 2020)
Enough is enough
I have always thought that many doctors who write opinions and pontificate about what should be done in practice live in la-la land. This editorial, for me, confirms it.
I personally am becoming tired of all this: dividing the specialty into obstetricians and gynecologists; pelvic exams are not necessary during annual visits; HPV testing by patients at home; doing away with Pap smears; Pap smears are not necessary for patients after a certain age; scribes in your footsteps to document all findings in the EMR; heaven forbid you do not ask the patient if she has a fire extinguisher in her house or some other stupid information; interpreters for people who speak Mongolian because their partner should not be used to interpret for them; and so on.
Now you want us to have a chaperone for every pelvic exam! Not any chaperone, but a specialized one! You worry about the sanctity and privacy of the patient but now have 2 additional people in the room for the patient’s exam. First, most patients prefer to have the least number of people looking at their bodies during an exam, especially a pelvic exam. Second, where do we get the money to support all of this? Does this type of policy make any sense? Are lawyers now controlling what medical care is all about? Is that what is now considered quality medical care?
By the way, I am not a burned out physician. I use common sense and consider what is best for my patients in everything that I do. If a patient requests a chaperone, my medical assistant will come to the room and provide that service. You do not need to be specialized to provide this service! Ivory tower people have lost all common sense. You consider yourselves the authorities in whatever medical field you specialize in, but let me tell you something: You really are not.
I know I will be criticized and demonized publicly by many; however, I have the courage to say what, in my opinion, I feel is right and what is wrong. Many physicians are afraid to do so, and, like sheep, will comply with your misguided opinions. I truly do not mean any disrespect to your knowledge and good intentions. I just think that enough is enough!
Gabriel G. Hakim, MD
Waterbury, Connecticut
Dr. Barbieri responds
In response to my editorial on the American College of Obstetricians and Gynecologists (ACOG) recommendation that chaperones be present for intimate examinations (ACOG Committee Opinion No. 796), Dr. Hakim outlines many concerns with the rapidly evolving practice of medicine.1 I am confident that the ACOG Committee on Ethics wisely considered the benefits, costs, and unintended consequences of the recommendation. The United States Veterans Administration, the Royal College of Obstetricians and Gynaecologists, and the American College Health Association endorse a similar recommendation. I do not think the distinguished members of the committees who issued the recommendation “live in la-la land.”
Reference
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual misconduct: ACOG Committee Opinion No. 796. Obstet Gynecol. 2020;135:e43-e50.
OBG Manag. 2020 November; 32(11).
The Fetal Pillow: A new option for delivering the deeply impacted fetal head
Robert L. Barbieri, MD
(Editorial; July 2020)
Alternative option to the Fetal Pillow
obgm03207c1.jpg
I enjoyed Dr. Barbieri’s editorial on the Fetal Pillow. I worry, however, that applying high air pressure to the upper vagina could result in an air embolism.
I have experienced good results using a vacuum cup. Like the pillow, it distributes the force more evenly than a hand. Also, the handle makes elevation of the vertex much less awkward and allows elevation to a higher station. Whatever approach is employed, using an open internal monitor catheter allows for a gentler procedure than when brute force alone is used to “break the seal” to allow ingress of air into the uterine cavity (at just 1 atmosphere of pressure).
John H. Sand, MD
Ellensburg, Washington
Cost of device must be considered
The information on the Fetal Pillow in Dr. Barbieri’s timely editorial, while limited in scope, does make the device look like a promising option.
One of my institution’s biggest issues relates to cost. We have had some interest in incorporating the Fetal Pillow into our practice, and we have been quoted a rate of about $600.00 per device. I had our Fetal Pillow representative look into reimbursement and have been informed that, at least in our region, there has been no reimbursement for the cost.
When I look at the cost of a hospital stay for a normal spontaneous vaginal delivery (NSVD), the cost of the Fetal Pillow would actually add 15% to 20% to that stay. Now, one must consider also the cost of extension of the uterine incision versus the cost of the Fetal Pillow. When we did a superficial look at when the Fetal Pillow might be used versus how many uterine extensions we experienced, the cost of the Fetal Pillow over a year far exceeded the cost of the uterine extensions. Without reimbursement, this appeared unsustainable. It has been interesting as some sites had no awareness of cost and the fact that essentially “the system” was absorbing those costs.
This issue is worthy of thought but likely one that most obstetricians will not consider.
Casey Morris, MD
Downers Grove, Illinois
Tip for dislodging the fetal head
I read Dr. Barbieri’s editorial regarding the Fetal Pillow and would like to share my experience. Over the last 30 years, I have used a simple trick. After entering the pelvic cavity, we push on the lower uterine segment toward the fundus prior to uterine incision. This helps dislodge the fetal head. Occasionally, you can feel the “pop” when the suction is broken, which sets the head free. We then proceed with the uterine incision and delivery of the head. We have had great success over the years, and the poor nurse does not have to go under the drapes.
Walter Kobasa Jr, MD
Wilmington, Delaware
Dr. Barbieri responds
I appreciate the recommendations and insights of Drs. Sand, Morris, and Kobasa. As I mentioned in the editorial on the Fetal Pillow, there are many clinical pearls about management of a second stage, deep-transverse cephalic arrest at the time of cesarean delivery, including to extend or T the uterine incision, push with a hand from below, reverse breech extraction, use a Coyne spoon, administer nitroglycerine or terbutaline, break the vaginal suction before attempting delivery, and incise a Bandl ring. Dr. Sand adds vaginal placement of a vacuum cup to our armamentarium, and Dr. Kobasa recommends dislodging the fetal head with a push on the lower uterine segment before making the hysterotomy incision. I thank Dr. Morris for correcting my failure to report the cost of the Fetal Pillow, reporting a quoted price of $600 for each Fetal Pillow. I agree with Dr. Morris that physicians have an important responsibility to be good stewards of health care resources and weigh the benefits and costs of our decisions.
Continue to: In your practice, are you planning to have a chaperone present for all intimate examinations?
In your practice, are you planning to have a chaperone present for all intimate examinations?
Robert L. Barbieri, MD
(Editorial; June 2020)
Enough is enough
I have always thought that many doctors who write opinions and pontificate about what should be done in practice live in la-la land. This editorial, for me, confirms it.
I personally am becoming tired of all this: dividing the specialty into obstetricians and gynecologists; pelvic exams are not necessary during annual visits; HPV testing by patients at home; doing away with Pap smears; Pap smears are not necessary for patients after a certain age; scribes in your footsteps to document all findings in the EMR; heaven forbid you do not ask the patient if she has a fire extinguisher in her house or some other stupid information; interpreters for people who speak Mongolian because their partner should not be used to interpret for them; and so on.
Now you want us to have a chaperone for every pelvic exam! Not any chaperone, but a specialized one! You worry about the sanctity and privacy of the patient but now have 2 additional people in the room for the patient’s exam. First, most patients prefer to have the least number of people looking at their bodies during an exam, especially a pelvic exam. Second, where do we get the money to support all of this? Does this type of policy make any sense? Are lawyers now controlling what medical care is all about? Is that what is now considered quality medical care?
By the way, I am not a burned out physician. I use common sense and consider what is best for my patients in everything that I do. If a patient requests a chaperone, my medical assistant will come to the room and provide that service. You do not need to be specialized to provide this service! Ivory tower people have lost all common sense. You consider yourselves the authorities in whatever medical field you specialize in, but let me tell you something: You really are not.
I know I will be criticized and demonized publicly by many; however, I have the courage to say what, in my opinion, I feel is right and what is wrong. Many physicians are afraid to do so, and, like sheep, will comply with your misguided opinions. I truly do not mean any disrespect to your knowledge and good intentions. I just think that enough is enough!
Gabriel G. Hakim, MD
Waterbury, Connecticut
Dr. Barbieri responds
In response to my editorial on the American College of Obstetricians and Gynecologists (ACOG) recommendation that chaperones be present for intimate examinations (ACOG Committee Opinion No. 796), Dr. Hakim outlines many concerns with the rapidly evolving practice of medicine.1 I am confident that the ACOG Committee on Ethics wisely considered the benefits, costs, and unintended consequences of the recommendation. The United States Veterans Administration, the Royal College of Obstetricians and Gynaecologists, and the American College Health Association endorse a similar recommendation. I do not think the distinguished members of the committees who issued the recommendation “live in la-la land.”
Reference
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual misconduct: ACOG Committee Opinion No. 796. Obstet Gynecol. 2020;135:e43-e50.
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual misconduct: ACOG Committee Opinion No. 796. Obstet Gynecol. 2020;135:e43-e50.
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual misconduct: ACOG Committee Opinion No. 796. Obstet Gynecol. 2020;135:e43-e50.
Comment & Controversy
How do you feel about expectantly managing a well-dated pregnancy past 41 weeks’ gestation?
obgm0320814_cc.f1.jpg
ROBERT L. BARBIERI, MD
(EDITORIAL; FEBRUARY 2019)
Is it reasonable to choose the age of 40 for proposing an anticipation of labor induction?
In physiologic ongoing pregnancies (whether they are spontaneous or autologous in vitro fertilization [IVF] or heterologous IVF), the evidence for anticipating labor induction based upon the only factor of age (after 40 years) is missing. Nonetheless, the number of women becoming pregnant at an older age is expected to increase, and from my perspective, to induce all physiologic pregnancies at term by 41 weeks and 5 days’ gestation does not appear to be best practice. I favor the idea of all women aged 40 and older to start labor induction earlier (for instance, to offer labor induction, with proper informed consent, by 41+ 0 and not 41+ 5 through 42+ 0 weeks of pregnancy).
Luca Bernardini, MD
La Spezia, Italy
Dr. Barbieri responds
At Brigham and Women’s Hospital in Boston, Massachusetts, our approach is to offer women ≥40 years of age induction of labor (IOL) at 39 weeks’ gestation, unless there is an obstetric contraindication to IOL. We believe that IOL at 39 weeks’ gestation is associated with a reduced risk of both cesarean delivery and a new diagnosis of hypertension.1
Reference
- Grobman WA, Rice MM, Reddy, UM, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379:513-523.
What is the optimal hormonal treatment for women with polycystic ovary syndrome?
ROBERT L. BARBIERI, MD
(EDITORIAL; JANUARY 2020)
OCs and spironolactone study
I often recommend oral contraceptives (OCs) containing drospirenone for patients with polycyctic ovary syndrome (PCOS)-associated mild acne and hirsutism—since OCs are already approved by the US Food and Drug Administration for acne, with similar effects as spironolactone. My patients seem to do well on an OC, and require only one medication. Of course, I would add spironolactone to the treatment regimen and switch OCs if she was not responding well.
Michael T. Cane, MD
Arlington, Texas
Dr. Barbieri responds
The Endocrine Society agrees with Dr. Cane’s approach, recommending the initiation of monotherapy with an estrogen-progestin followed by the addition of spironolactone if 6 months of monotherapy produces insufficient improvement in dermatologic symptoms of PCOS, including hirsutism and acne. Most contraceptives contain 3 mg or 4 mg of drospirenone, which is thought to have antiandrogenic effects similar to spironolactone 25 mg. I believe that spironolactone 100 mg provides more complete and rapid resolution of the dermatologic symptoms caused by PCOS. Hence, I initiate both an estrogen-progestin contraceptive with spironolactone.
How do you feel about expectantly managing a well-dated pregnancy past 41 weeks’ gestation?
obgm0320814_cc.f1.jpg
ROBERT L. BARBIERI, MD
(EDITORIAL; FEBRUARY 2019)
Is it reasonable to choose the age of 40 for proposing an anticipation of labor induction?
In physiologic ongoing pregnancies (whether they are spontaneous or autologous in vitro fertilization [IVF] or heterologous IVF), the evidence for anticipating labor induction based upon the only factor of age (after 40 years) is missing. Nonetheless, the number of women becoming pregnant at an older age is expected to increase, and from my perspective, to induce all physiologic pregnancies at term by 41 weeks and 5 days’ gestation does not appear to be best practice. I favor the idea of all women aged 40 and older to start labor induction earlier (for instance, to offer labor induction, with proper informed consent, by 41+ 0 and not 41+ 5 through 42+ 0 weeks of pregnancy).
Luca Bernardini, MD
La Spezia, Italy
Dr. Barbieri responds
At Brigham and Women’s Hospital in Boston, Massachusetts, our approach is to offer women ≥40 years of age induction of labor (IOL) at 39 weeks’ gestation, unless there is an obstetric contraindication to IOL. We believe that IOL at 39 weeks’ gestation is associated with a reduced risk of both cesarean delivery and a new diagnosis of hypertension.1
Reference
- Grobman WA, Rice MM, Reddy, UM, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379:513-523.
What is the optimal hormonal treatment for women with polycystic ovary syndrome?
ROBERT L. BARBIERI, MD
(EDITORIAL; JANUARY 2020)
OCs and spironolactone study
I often recommend oral contraceptives (OCs) containing drospirenone for patients with polycyctic ovary syndrome (PCOS)-associated mild acne and hirsutism—since OCs are already approved by the US Food and Drug Administration for acne, with similar effects as spironolactone. My patients seem to do well on an OC, and require only one medication. Of course, I would add spironolactone to the treatment regimen and switch OCs if she was not responding well.
Michael T. Cane, MD
Arlington, Texas
Dr. Barbieri responds
The Endocrine Society agrees with Dr. Cane’s approach, recommending the initiation of monotherapy with an estrogen-progestin followed by the addition of spironolactone if 6 months of monotherapy produces insufficient improvement in dermatologic symptoms of PCOS, including hirsutism and acne. Most contraceptives contain 3 mg or 4 mg of drospirenone, which is thought to have antiandrogenic effects similar to spironolactone 25 mg. I believe that spironolactone 100 mg provides more complete and rapid resolution of the dermatologic symptoms caused by PCOS. Hence, I initiate both an estrogen-progestin contraceptive with spironolactone.
How do you feel about expectantly managing a well-dated pregnancy past 41 weeks’ gestation?
obgm0320814_cc.f1.jpg
ROBERT L. BARBIERI, MD
(EDITORIAL; FEBRUARY 2019)
Is it reasonable to choose the age of 40 for proposing an anticipation of labor induction?
In physiologic ongoing pregnancies (whether they are spontaneous or autologous in vitro fertilization [IVF] or heterologous IVF), the evidence for anticipating labor induction based upon the only factor of age (after 40 years) is missing. Nonetheless, the number of women becoming pregnant at an older age is expected to increase, and from my perspective, to induce all physiologic pregnancies at term by 41 weeks and 5 days’ gestation does not appear to be best practice. I favor the idea of all women aged 40 and older to start labor induction earlier (for instance, to offer labor induction, with proper informed consent, by 41+ 0 and not 41+ 5 through 42+ 0 weeks of pregnancy).
Luca Bernardini, MD
La Spezia, Italy
Dr. Barbieri responds
At Brigham and Women’s Hospital in Boston, Massachusetts, our approach is to offer women ≥40 years of age induction of labor (IOL) at 39 weeks’ gestation, unless there is an obstetric contraindication to IOL. We believe that IOL at 39 weeks’ gestation is associated with a reduced risk of both cesarean delivery and a new diagnosis of hypertension.1
Reference
- Grobman WA, Rice MM, Reddy, UM, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379:513-523.
What is the optimal hormonal treatment for women with polycystic ovary syndrome?
ROBERT L. BARBIERI, MD
(EDITORIAL; JANUARY 2020)
OCs and spironolactone study
I often recommend oral contraceptives (OCs) containing drospirenone for patients with polycyctic ovary syndrome (PCOS)-associated mild acne and hirsutism—since OCs are already approved by the US Food and Drug Administration for acne, with similar effects as spironolactone. My patients seem to do well on an OC, and require only one medication. Of course, I would add spironolactone to the treatment regimen and switch OCs if she was not responding well.
Michael T. Cane, MD
Arlington, Texas
Dr. Barbieri responds
The Endocrine Society agrees with Dr. Cane’s approach, recommending the initiation of monotherapy with an estrogen-progestin followed by the addition of spironolactone if 6 months of monotherapy produces insufficient improvement in dermatologic symptoms of PCOS, including hirsutism and acne. Most contraceptives contain 3 mg or 4 mg of drospirenone, which is thought to have antiandrogenic effects similar to spironolactone 25 mg. I believe that spironolactone 100 mg provides more complete and rapid resolution of the dermatologic symptoms caused by PCOS. Hence, I initiate both an estrogen-progestin contraceptive with spironolactone.
Comanagement of Hip Fracture Patients
We read with interest the article by Maxwell and Mirza.1 We appreciate using the large National Surgical Quality Improvement Project (NSQIP) database to assess comanagement outcomes, although we have concerns about the study design. Propensity score–matching (PSM) studies are limited; PSMs generate an average effect that neither establishes whether a treatment is optimal for a given patient nor control for unmeasured confounders.2 Some baseline characteristics suggest that the comanaged and noncomanaged populations are quite different and, therefore, likely had unmeasured confounders that contributed to not detecting true effects. Also, as suggested by the authors, the NSQIP definitions of comanagement and standardized hip fracture program are broad. Recent studies in hip fracture comanagement attribute best outcomes to an organized program, shared decision making, expert comanagers, and each service having full responsibility including writing their own orders.3-5 As no large database captures this distinction, it is not yet possible to perform a large, multicenter analysis. This type of comanagement cannot be studied in a randomized controlled trial. We recommend caution in overinterpreting the conclusions because there is substantial evidence in favor of optimized comanagement.
1. Maxwell BG, Mirza A. Medical comanagement of hip fracture patients is not associated with superior perioperative outcomes: a propensity score-matched retrospective cohort analysis of the National Surgical Quality Improvement Project J Hosp Med. 2020;15:468-474. https://doi.org/10.12788/jhm.3343
2. Benedetto U, Head SJ, Angelini GD, Blackstone EH. Statistical primer: propensity score matching and its alternatives. Eur J Cardiothorac Surg. 2018;53(6):1112-1117. https://doi.org/10.1093/ejcts/ezy167
3. Friedman SM, Mendelson DA, Kates SL, McCann RM. Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008;56(7):1349-1356. https://doi.org/10.1111/j.1532-5415.2008.01770.x
4. Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil. 2010;1(1):6-14. https://doi.org/10.1177/2151458510378105
5. Mendelson DA, Friedman SM. Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014;30(2):183-189. https://doi.org/10.1016/j.cger.2014.01.016
We read with interest the article by Maxwell and Mirza.1 We appreciate using the large National Surgical Quality Improvement Project (NSQIP) database to assess comanagement outcomes, although we have concerns about the study design. Propensity score–matching (PSM) studies are limited; PSMs generate an average effect that neither establishes whether a treatment is optimal for a given patient nor control for unmeasured confounders.2 Some baseline characteristics suggest that the comanaged and noncomanaged populations are quite different and, therefore, likely had unmeasured confounders that contributed to not detecting true effects. Also, as suggested by the authors, the NSQIP definitions of comanagement and standardized hip fracture program are broad. Recent studies in hip fracture comanagement attribute best outcomes to an organized program, shared decision making, expert comanagers, and each service having full responsibility including writing their own orders.3-5 As no large database captures this distinction, it is not yet possible to perform a large, multicenter analysis. This type of comanagement cannot be studied in a randomized controlled trial. We recommend caution in overinterpreting the conclusions because there is substantial evidence in favor of optimized comanagement.
We read with interest the article by Maxwell and Mirza.1 We appreciate using the large National Surgical Quality Improvement Project (NSQIP) database to assess comanagement outcomes, although we have concerns about the study design. Propensity score–matching (PSM) studies are limited; PSMs generate an average effect that neither establishes whether a treatment is optimal for a given patient nor control for unmeasured confounders.2 Some baseline characteristics suggest that the comanaged and noncomanaged populations are quite different and, therefore, likely had unmeasured confounders that contributed to not detecting true effects. Also, as suggested by the authors, the NSQIP definitions of comanagement and standardized hip fracture program are broad. Recent studies in hip fracture comanagement attribute best outcomes to an organized program, shared decision making, expert comanagers, and each service having full responsibility including writing their own orders.3-5 As no large database captures this distinction, it is not yet possible to perform a large, multicenter analysis. This type of comanagement cannot be studied in a randomized controlled trial. We recommend caution in overinterpreting the conclusions because there is substantial evidence in favor of optimized comanagement.
1. Maxwell BG, Mirza A. Medical comanagement of hip fracture patients is not associated with superior perioperative outcomes: a propensity score-matched retrospective cohort analysis of the National Surgical Quality Improvement Project J Hosp Med. 2020;15:468-474. https://doi.org/10.12788/jhm.3343
2. Benedetto U, Head SJ, Angelini GD, Blackstone EH. Statistical primer: propensity score matching and its alternatives. Eur J Cardiothorac Surg. 2018;53(6):1112-1117. https://doi.org/10.1093/ejcts/ezy167
3. Friedman SM, Mendelson DA, Kates SL, McCann RM. Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008;56(7):1349-1356. https://doi.org/10.1111/j.1532-5415.2008.01770.x
4. Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil. 2010;1(1):6-14. https://doi.org/10.1177/2151458510378105
5. Mendelson DA, Friedman SM. Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014;30(2):183-189. https://doi.org/10.1016/j.cger.2014.01.016
1. Maxwell BG, Mirza A. Medical comanagement of hip fracture patients is not associated with superior perioperative outcomes: a propensity score-matched retrospective cohort analysis of the National Surgical Quality Improvement Project J Hosp Med. 2020;15:468-474. https://doi.org/10.12788/jhm.3343
2. Benedetto U, Head SJ, Angelini GD, Blackstone EH. Statistical primer: propensity score matching and its alternatives. Eur J Cardiothorac Surg. 2018;53(6):1112-1117. https://doi.org/10.1093/ejcts/ezy167
3. Friedman SM, Mendelson DA, Kates SL, McCann RM. Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008;56(7):1349-1356. https://doi.org/10.1111/j.1532-5415.2008.01770.x
4. Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil. 2010;1(1):6-14. https://doi.org/10.1177/2151458510378105
5. Mendelson DA, Friedman SM. Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014;30(2):183-189. https://doi.org/10.1016/j.cger.2014.01.016
© 2020 Society of Hospital Medicine
In Reply to “Be Careful What We Call It”
I appreciate the input from Dr. Rauch regarding the terminology of “fellowship” in regards to APP postgraduate training programs.1 When researching these programs, the overwhelming majority we surveyed described themselves as fellowships. Because of this, we chose to use the same nomenclature. The survey we used was meant to explore and quantify certain discreet components of program creation and execution, and further study would be needed to shed light on how they name themselves.
While it is not known if the term “fellowship” in this context would be confusing to patients, it does seem that the ideal terminology has not yet been clarified. In 2014, the American Association of Nurse Practitioners released a position statement that, for NP postgraduate training programs, the term “fellowship” should be used above other terms.2 We were unable to find a similar position statement regarding postgraduate physician assistant training, but did note that the Association of Post-Graduate PA Programs website uses the terms “residency” and “fellowship” seemingly interchangeably.3 As most of the programs that we surveyed train mixed groups of nurse practitioners and physician assistants, developing unified language will be an important step in the future.
1. Rauch D. Be Careful What We Call it. J Hosp Med. 2019;15(1):64. https://doi.org/10.12788/jhm.3297.
2. AANP and the NP Roundtable Joint Statements (2014). Nurse Practitioner Perspective on Education a nd Post-Graduate Training. [online] Available at: https://storage.aanp.org/www/documents/advocacy/nproundtablestatementmay6th.pdf Accessed August 27, 2019.
3. Home - APPAP. APPAP. https://appap.org. Published 2019. Accessed August 27, 2019.
I appreciate the input from Dr. Rauch regarding the terminology of “fellowship” in regards to APP postgraduate training programs.1 When researching these programs, the overwhelming majority we surveyed described themselves as fellowships. Because of this, we chose to use the same nomenclature. The survey we used was meant to explore and quantify certain discreet components of program creation and execution, and further study would be needed to shed light on how they name themselves.
While it is not known if the term “fellowship” in this context would be confusing to patients, it does seem that the ideal terminology has not yet been clarified. In 2014, the American Association of Nurse Practitioners released a position statement that, for NP postgraduate training programs, the term “fellowship” should be used above other terms.2 We were unable to find a similar position statement regarding postgraduate physician assistant training, but did note that the Association of Post-Graduate PA Programs website uses the terms “residency” and “fellowship” seemingly interchangeably.3 As most of the programs that we surveyed train mixed groups of nurse practitioners and physician assistants, developing unified language will be an important step in the future.
I appreciate the input from Dr. Rauch regarding the terminology of “fellowship” in regards to APP postgraduate training programs.1 When researching these programs, the overwhelming majority we surveyed described themselves as fellowships. Because of this, we chose to use the same nomenclature. The survey we used was meant to explore and quantify certain discreet components of program creation and execution, and further study would be needed to shed light on how they name themselves.
While it is not known if the term “fellowship” in this context would be confusing to patients, it does seem that the ideal terminology has not yet been clarified. In 2014, the American Association of Nurse Practitioners released a position statement that, for NP postgraduate training programs, the term “fellowship” should be used above other terms.2 We were unable to find a similar position statement regarding postgraduate physician assistant training, but did note that the Association of Post-Graduate PA Programs website uses the terms “residency” and “fellowship” seemingly interchangeably.3 As most of the programs that we surveyed train mixed groups of nurse practitioners and physician assistants, developing unified language will be an important step in the future.
1. Rauch D. Be Careful What We Call it. J Hosp Med. 2019;15(1):64. https://doi.org/10.12788/jhm.3297.
2. AANP and the NP Roundtable Joint Statements (2014). Nurse Practitioner Perspective on Education a nd Post-Graduate Training. [online] Available at: https://storage.aanp.org/www/documents/advocacy/nproundtablestatementmay6th.pdf Accessed August 27, 2019.
3. Home - APPAP. APPAP. https://appap.org. Published 2019. Accessed August 27, 2019.
1. Rauch D. Be Careful What We Call it. J Hosp Med. 2019;15(1):64. https://doi.org/10.12788/jhm.3297.
2. AANP and the NP Roundtable Joint Statements (2014). Nurse Practitioner Perspective on Education a nd Post-Graduate Training. [online] Available at: https://storage.aanp.org/www/documents/advocacy/nproundtablestatementmay6th.pdf Accessed August 27, 2019.
3. Home - APPAP. APPAP. https://appap.org. Published 2019. Accessed August 27, 2019.
© 2020 Society of Hospital Medicine
In Reference to: “The Current State of Advanced Practice Provider Fellowships in Hospital Medicine: A Survey of Program Directors.” Be Careful What We Call It
I read with interest the recent article by Klimpl et al. “The Current State of Advanced Practice provider Fellowships in Hospital Medicine: A Survey of Program Directors.”1 I appreciate the description of the variation in training as well as the discussion points about the driving forces behind
1. Klimpl D, Franco T, Tackett S, Cardin TE, Wolfe B, Wright S, Kisuule F. The current state of advanced practice provider fellowships in hospital medicine: a survey of program directors. J Hosp Med. 2019;14(7):401-406. https://doi.org/10.12788/jhm.3191.
I read with interest the recent article by Klimpl et al. “The Current State of Advanced Practice provider Fellowships in Hospital Medicine: A Survey of Program Directors.”1 I appreciate the description of the variation in training as well as the discussion points about the driving forces behind
I read with interest the recent article by Klimpl et al. “The Current State of Advanced Practice provider Fellowships in Hospital Medicine: A Survey of Program Directors.”1 I appreciate the description of the variation in training as well as the discussion points about the driving forces behind
1. Klimpl D, Franco T, Tackett S, Cardin TE, Wolfe B, Wright S, Kisuule F. The current state of advanced practice provider fellowships in hospital medicine: a survey of program directors. J Hosp Med. 2019;14(7):401-406. https://doi.org/10.12788/jhm.3191.
1. Klimpl D, Franco T, Tackett S, Cardin TE, Wolfe B, Wright S, Kisuule F. The current state of advanced practice provider fellowships in hospital medicine: a survey of program directors. J Hosp Med. 2019;14(7):401-406. https://doi.org/10.12788/jhm.3191.
© 2020 Society of Hospital Medicine
Colorectal cancer screening: Folic acid supplementation alters the equation
To the Editor: In their paper on colorectal cancer screening, Mankaney and colleagues noted the increasing rates of colorectal cancer in young adults in the United States.1 Recent epidemiologic data demonstrate an increasing incidence of the disease in people ages 40 through 49 since the mid-1990s.2 Even though screening starting at age 45 is not uniformly accepted,1 there is evidence supporting earlier screening.
During the mid-1990s, the US government mandated that all enriched flour and uncooked cereal grains were to be fortified with folic acid in order to prevent births complicated by neural tube defects.3 Subsequently, there was a 2-fold increase in plasma folate concentrations and, disturbingly, a temporally associated significant increase in the incidence of colorectal cancer.3
Notably, a US trial4 testing the efficacy of folic acid 1 mg taken daily for 6 years to prevent colorectal adenomas in those with a history of colorectal adenomas failed to show a reduction in adenoma risk. Instead, participants randomized to folic acid exhibited a significantly increased risk of an advanced adenoma. Another trial,5 conducted in the Netherlands, where there is no mandatory folic acid fortification, investigated folic acid 400 µg and vitamin B12 500 µg daily over 2 to 3 years for the prevention of osteoporotic fractures. The group randomized to the vitamins had a nearly 2-fold increase in the risk of colorectal cancer.
Folic acid can be a double-edged sword.3,5 Although folic acid intake may protect against carcinogenesis through increased genetic stability, if precancerous or neoplastic cells are present, excess folic acid may promote cancer by increasing DNA synthesis and cell proliferation. Cancer cells have folic acid receptors.
Since screening colonoscopy is typically done in individuals over 50, advanced adenomas from folic acid exposure in people younger than 50 likely go undiagnosed. Therefore, colorectal cancer screening should start at a younger age in countries where folic acid fortification is mandatory.
- Mankaney G, Sutton RA, Burke CA. Colorectal cancer screening: choosing the right test. Cleve Clin J Med 2019; 86(6):385–392. doi:10.3949/ccjm.86a.17125
- Meester RGS, Mannalithara A, Lansdorp-Vogelaar I, Ladabaum U. Trends in incidence and stage at diagnosis of colorectal cancer in adults aged 40 through 49 years, 1975–2015. JAMA 2019; 321(19):1933–1934. doi:10.1001/jama.2019.3076
- Mason JB, Dickstein A, Jacques PF, et al. A temporal association between folic acid fortification and an increase in colorectal cancer rates may be illuminating important biological principles: a hypothesis. Cancer Epidemiol Biomarkers Prev 2007;16(7):1325–1329. doi:10.1158/1055-9965.EPI-07-0329
- Cole BF, Baron JA, Sandler RS, et al; POlyp Prevention Study Group. Folic acid for the prevention of colorectal adenomas: a randomized clinical trial. JAMA 2007; 297(21):2351–2359. doi:10.1001/jama.297.21.2351
- Oliai Araghi S, Kiefte-de Jong JC, van Dijk SC, et al. Folic acid and vitamin B12 supplementation and the risk of cancer: long-term follow-up of the B vitamins for the prevention of osteoporotic fractures (B-PROOF) Trial. Cancer Epidemiol Biomarkers Prev 2019; 28(2):275–282. doi:10.1158/1055-9965.EPI-17-1198
To the Editor: In their paper on colorectal cancer screening, Mankaney and colleagues noted the increasing rates of colorectal cancer in young adults in the United States.1 Recent epidemiologic data demonstrate an increasing incidence of the disease in people ages 40 through 49 since the mid-1990s.2 Even though screening starting at age 45 is not uniformly accepted,1 there is evidence supporting earlier screening.
During the mid-1990s, the US government mandated that all enriched flour and uncooked cereal grains were to be fortified with folic acid in order to prevent births complicated by neural tube defects.3 Subsequently, there was a 2-fold increase in plasma folate concentrations and, disturbingly, a temporally associated significant increase in the incidence of colorectal cancer.3
Notably, a US trial4 testing the efficacy of folic acid 1 mg taken daily for 6 years to prevent colorectal adenomas in those with a history of colorectal adenomas failed to show a reduction in adenoma risk. Instead, participants randomized to folic acid exhibited a significantly increased risk of an advanced adenoma. Another trial,5 conducted in the Netherlands, where there is no mandatory folic acid fortification, investigated folic acid 400 µg and vitamin B12 500 µg daily over 2 to 3 years for the prevention of osteoporotic fractures. The group randomized to the vitamins had a nearly 2-fold increase in the risk of colorectal cancer.
Folic acid can be a double-edged sword.3,5 Although folic acid intake may protect against carcinogenesis through increased genetic stability, if precancerous or neoplastic cells are present, excess folic acid may promote cancer by increasing DNA synthesis and cell proliferation. Cancer cells have folic acid receptors.
Since screening colonoscopy is typically done in individuals over 50, advanced adenomas from folic acid exposure in people younger than 50 likely go undiagnosed. Therefore, colorectal cancer screening should start at a younger age in countries where folic acid fortification is mandatory.
To the Editor: In their paper on colorectal cancer screening, Mankaney and colleagues noted the increasing rates of colorectal cancer in young adults in the United States.1 Recent epidemiologic data demonstrate an increasing incidence of the disease in people ages 40 through 49 since the mid-1990s.2 Even though screening starting at age 45 is not uniformly accepted,1 there is evidence supporting earlier screening.
During the mid-1990s, the US government mandated that all enriched flour and uncooked cereal grains were to be fortified with folic acid in order to prevent births complicated by neural tube defects.3 Subsequently, there was a 2-fold increase in plasma folate concentrations and, disturbingly, a temporally associated significant increase in the incidence of colorectal cancer.3
Notably, a US trial4 testing the efficacy of folic acid 1 mg taken daily for 6 years to prevent colorectal adenomas in those with a history of colorectal adenomas failed to show a reduction in adenoma risk. Instead, participants randomized to folic acid exhibited a significantly increased risk of an advanced adenoma. Another trial,5 conducted in the Netherlands, where there is no mandatory folic acid fortification, investigated folic acid 400 µg and vitamin B12 500 µg daily over 2 to 3 years for the prevention of osteoporotic fractures. The group randomized to the vitamins had a nearly 2-fold increase in the risk of colorectal cancer.
Folic acid can be a double-edged sword.3,5 Although folic acid intake may protect against carcinogenesis through increased genetic stability, if precancerous or neoplastic cells are present, excess folic acid may promote cancer by increasing DNA synthesis and cell proliferation. Cancer cells have folic acid receptors.
Since screening colonoscopy is typically done in individuals over 50, advanced adenomas from folic acid exposure in people younger than 50 likely go undiagnosed. Therefore, colorectal cancer screening should start at a younger age in countries where folic acid fortification is mandatory.
- Mankaney G, Sutton RA, Burke CA. Colorectal cancer screening: choosing the right test. Cleve Clin J Med 2019; 86(6):385–392. doi:10.3949/ccjm.86a.17125
- Meester RGS, Mannalithara A, Lansdorp-Vogelaar I, Ladabaum U. Trends in incidence and stage at diagnosis of colorectal cancer in adults aged 40 through 49 years, 1975–2015. JAMA 2019; 321(19):1933–1934. doi:10.1001/jama.2019.3076
- Mason JB, Dickstein A, Jacques PF, et al. A temporal association between folic acid fortification and an increase in colorectal cancer rates may be illuminating important biological principles: a hypothesis. Cancer Epidemiol Biomarkers Prev 2007;16(7):1325–1329. doi:10.1158/1055-9965.EPI-07-0329
- Cole BF, Baron JA, Sandler RS, et al; POlyp Prevention Study Group. Folic acid for the prevention of colorectal adenomas: a randomized clinical trial. JAMA 2007; 297(21):2351–2359. doi:10.1001/jama.297.21.2351
- Oliai Araghi S, Kiefte-de Jong JC, van Dijk SC, et al. Folic acid and vitamin B12 supplementation and the risk of cancer: long-term follow-up of the B vitamins for the prevention of osteoporotic fractures (B-PROOF) Trial. Cancer Epidemiol Biomarkers Prev 2019; 28(2):275–282. doi:10.1158/1055-9965.EPI-17-1198
- Mankaney G, Sutton RA, Burke CA. Colorectal cancer screening: choosing the right test. Cleve Clin J Med 2019; 86(6):385–392. doi:10.3949/ccjm.86a.17125
- Meester RGS, Mannalithara A, Lansdorp-Vogelaar I, Ladabaum U. Trends in incidence and stage at diagnosis of colorectal cancer in adults aged 40 through 49 years, 1975–2015. JAMA 2019; 321(19):1933–1934. doi:10.1001/jama.2019.3076
- Mason JB, Dickstein A, Jacques PF, et al. A temporal association between folic acid fortification and an increase in colorectal cancer rates may be illuminating important biological principles: a hypothesis. Cancer Epidemiol Biomarkers Prev 2007;16(7):1325–1329. doi:10.1158/1055-9965.EPI-07-0329
- Cole BF, Baron JA, Sandler RS, et al; POlyp Prevention Study Group. Folic acid for the prevention of colorectal adenomas: a randomized clinical trial. JAMA 2007; 297(21):2351–2359. doi:10.1001/jama.297.21.2351
- Oliai Araghi S, Kiefte-de Jong JC, van Dijk SC, et al. Folic acid and vitamin B12 supplementation and the risk of cancer: long-term follow-up of the B vitamins for the prevention of osteoporotic fractures (B-PROOF) Trial. Cancer Epidemiol Biomarkers Prev 2019; 28(2):275–282. doi:10.1158/1055-9965.EPI-17-1198
