Interview with Matthew K. Wynia, MD, MPH, author of The Role of Professionalism and Self-regulation in Detecting Impaired or Incompetent Physicians. Summary Points: At the conclusion of this activity, participants will be able to: 1. Describe the frequency with which physicians report encountering other physician who may be impaired or incompetent. 2. Explain the 3 basic options available to policy-makers for regulating and ensuring the quality of medical practitioners. 3. Name at least 3 newer mechanisms by which the profession of medicine is enhancing its ability to self-regulate and detect physicians who are not providing high quality care.

Interview with Ralph Gonzales, MD, MSPH, author of Does This Coughing Adolescent or Adult Patient Have Pertussis? Summary Points: 1. When evaluating adolescents and adults with persistent cough illness, the presence of classic symptoms of pertussis (paroxysmal cough, whooping cough, post-tussive emesis) modestly increase the likelihood of pertussis, and their absence modestly decreases the likelihood of pertussis; but they are not strong enough to rule-in or rule-out disease. 2. Most patients in whom pertussis is suspected will not derive symptomatic benefit from antibiotic treatment because their illness duration is usually greater than 10 days. 3. Vigilant testing and treatment should be provided to adolescents and adults who have been exposed to a known case of pertussis, or have contact with individuals at high risk for serious complications of pertussis, ie, child care providers and teachers, health care workers, and patients who live or work with infants less than 6 months of age; unvaccinated children; or immunosuppressed individuals.

Interview with Michael A. Steinman, MD, author of Managing Medications in Clinically Complex Elders. Summary Points: 1. First, a systematic approach to approaching prescribing is essential. 2. Second, an essential first step is to know what the patient is actually taking right now, and to clarify what goals you are trying to achieve by prescribing drugs. 3. Third, it is critical to individualize care based on what benefits and harms a patient is actually experiencing from their drugs.

Interview with Julia Neily, RN, MS, MPH, author of Association Between Implementation of a Medical Team Training Program and Surgical Mortality. Summary Points: 1. Improved communication is associated with decreased surgical mortality. 2. Since there was a dose response relationship, this indicates that continuing follow up was related to better results. 3. Briefings and debriefings is more than a checklist, it is about the conversation.

Interview with Julia Howell Hayes, MD, author of Active Surveillance Compared With Initial Treatment for Men With Low-Risk Prostate Cancer: A Decision Analysis. Summary Points: 1. Active surveillance is a reasonable approach to consider for carefully selected 65-year-old men with low-risk clinically localized prostate cancer, providing improved quality of life even if associated with an increased risk of prostate cancer–specific death. 2. The results depend on patient preferences. 3. It is crucial that individual patients make this decision in conjunction with their physicians.

Interview with Steven J. Jacobsen, MD, PhD, author of Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease. Summary Points: 1. The findings suggest that the zoster vaccine is as effective in a community setting with its mixed population and routine clinical practices as was found in the controlled clinical trials. 2. To date, the uptake of the zoster vaccine has been modest due to a number of reasons, including weaknesses in the adult vaccine infrastructure, knowledge and beliefs of clinicians and patients, periodic supply shortfalls, as well as financial reasons. 3. Because zoster and its attendant neurologic complication of postherpetic neuralgia are common and serious among the elderly, it seems prudent to recommend zoster vaccine. The potential impact of vaccination on the burden of the disease in this population is significant.

Interview with Gabriela Schmajuk, MD, author of Receipt of Disease-Modifying Antirheumatic Drugs Among Patients With Rheumatoid Arthritis in Medicare Managed Care Plans. Summary Points: 1. One third of Medicare managed care patients diagnosed with rheumatoid arthritis are not receiving disease-modifying antirheumatic drugs. 2. There is variation in disease-modifying antirheumatic drug receipt based on "accidental factors": sociodemographics, geographic location, and health plan. 3. Because disease-modifying antirheumatic drug use is the main way to affect outcomes in rheumatoid arthritis, these patient groups and the physicians treating them are a reasonable target for quality improvement interventions.

Interview with Monica Morrow, MD, author of Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis. Summary Points: 1. Axillary dissection is a major cause of morbidity after breast cancer surgery. 2. In women who have 3 or fewer sentinel nodes and are undergoing breast conserving surgery, removal of only the sentinel nodes produces local axillary control in 99% of cases. 3. Axillary dissection does not contribute to survival. 4. In women with T1 and T2 clinically node negative BRCA who are undergoing lumpectomy and whole breast radiation, removal of sentinel nodes only is an appropriate management strategy.

Interview with Lydia A. Bazzano, MD, PhD, and Angela M. Thompson, authors of Antihypertensive Treatment and Secondary Prevention of Cardiovascular Disease Events Among Persons Without Hypertension: A Meta-analysis. Summary Points: 1. Cardiovascular disease (CVD) risk increases beginning at systolic blood pressure levels of 115 mm Hg and the use of antihypertensive medications among patients with a history of CVD or diabetes and without hypertension have been debated. 2. Among patients with clinical history of CVD but with blood pressure lower than 140/90 mm Hg, antihypertensive treatment was associated with decreased risk of stroke, congestive heart failure, composite CVD events, and all-cause mortality. 3. Additional randomized trial data are necessary to assess these outcomes in patients without CVD events.

Interview with Eric Widera, MD, author of Finances in the Older Patient With Cognitive Impairment: 'He Didn't Want Me to Take Over'. Summary Points: 1. Individuals with Alzheimer disease will have increasing difficulty with finances over time, and the very first signs of this difficulty will occur prior to the diagnosis of dementia, when they have only mild cognitive impairment. 2. Health care professionals, including physicians, should educate older adult patients and families about the need for advance financial planning and encourage the use of Durable Power of Attorney for Financial Matters. 3. Using objective information from performance-based financial tests can help decide whether, when, and in which financial areas families or caregivers need to assume proxy financial responsibility.

Interview with Gordon D. Schiff, MD, author of Medical Error: A 60-Year-Old Man With Delayed Care for a Renal Mass. Summary Points: The goals of this Author in the Room teleconference are to: 1. Appreciate the frequency, faces, and challenges of test result follow-up management errors. 2. Understand selected reliability science concepts and the ways they apply to the problem of test result management. 3. Learn about some specific change ideas that can help to ensure more fail-safe test follow-up.

Interview with Ross Zafonte, DO, author of Diagnosis and Management of Sports-Related Concussion: A 15-Year-Old Athlete With a Concussion. Summary Points: 1. Concussion does not require a loss of consciousness and is typically a transient and reversible neurologic dysfunction. 2. Those with sports-related concussion should not return to play the same day. 3. Initial treatment often begins with rest and subsequent gradual activation.

Interview with Laura Mosqueda, MD, author of Elder Abuse and Self-neglect: "I Don't Care Anything About Going to the Doctor, to Be Honest..."

Interview with Michael Paasche-Orlow, MD, MA, MPH, author of Caring for Patients With Limited Health Literacy: A 76-Year-Old Man With Multiple Medical Problems. Summary Points: 1. Massively increase patient education. 2. Systematically reduce unneeded complexity and variability. 3. Universal precautions (not screening), flip the default, and confirm comprehension (T2G).

Interview with Steven C. Zweig, MD, MSPH, author of The Physician's Role in Patients' Nursing Home Care. Summary Points: 1. Prevalent, fragile population, cared for until the end of life. 2. Care must be interdisciplinary (Facility, staff, physicians; Residents, family members). 3. Understand and anticipate natural history of aging and decline in long-term care, including planning, assessment, continuing care, acute care, and end-of-life care.

Interview with Daniel Leffler, MD, MS, author of Celiac Disease Diagnosis and Management: A 46-Year-Old Woman With Anemia. Summary points: 1. Celiac disease can present at any age with a wide variety of signs and symptoms and delay in diagnosis is common. 2. Testing for celiac disease with IgA tissue transglutaminase is accurate and cost-effective. 3. The only treatment for celiac disease is the gluten-free diet, but this is very burdensome and requires ongoing education and support.

Interview with Harold Sox, MD, author of New American Cancer Society Process for Creating Trustworthy Cancer Screening Guidelines. Summary Points: 1. Trustworthy guidelines require transparency about purpose, process, evidence, and rationale. 2. Trustworthy guidelines require a systematic review of the pertinent evidence. 3. Expertise in evaluating evidence and freedom from financial conflicts of interest are the main requirements for membership on a guidelines panel. If these are present, then clinical skills are important.

Interview with David S. Ludwig, MD, PhD, author of Weight Loss Strategies for Adolescents: A 14-Year-Old Struggling to Lose Weight. Summary Points: 1. Childhood obesity arises from a complex interplay of biology, behavior, and the environment.  Consequently, successful treatment requires targeting multiple determinants of body weight. 2. Family-based treatment offers the most immediate and effective approach for childhood obesity, with benefits for all family members. 3. Ultimately, the solution to the obesity epidemic will require a comprehensive public health strategy to make the social environment healthier for children and adults.

Interview with James T. Pacala, MD, MS, author of Hearing Deficits in the Older Patient: "I Didn't Notice Anything". Summary Points: 1. Age-related hearing loss is extremely common and underrecognized by most health care providers. 2. There are many effective methods of detection of hearing loss that are easy and efficient. 3. Although the main stay of treatment is amplification, there remain many challenges to effective hearing aid use.

Interview with Mary A. Whooley, MD, author of Diagnosis and Treatment of Depression in Adults With Comorbid Medical Conditions: A 52-Year-Old Man With Depression. Summary Points:

• Depression screening has no benefit unless it is combined with team-based management
• Self-management strategies (behavioral activation and exercise) improve depression
• "TEAMcare" can improve both depression and chronic medical conditions

Interview with Peter B. Bach, MD, MAPP, author of Benefits and Harms of CT Screening for Lung Cancer: A Systematic Review; and George T. O’Connor, MD, MS, author of Lung Cancer Screening, Radiation, Risks, Benefits, and Uncertainty. Summary Points:

• Three randomized trials examined computed tomography (CT) screening for lung cancer’s effect on lung cancer mortality—one showed a benefit, the other 2 did not but were smaller studies.
• CT screening does not appear to reduce mortality from causes other than lung cancer.
• There are still a lot of uncertainties regarding the risks and how to mitigate them.

Interview with Philip Greenland, MD, author of Comparison of Novel Risk Markers for Improvement in Cardiovascular Risk Assessment in Intermediate-Risk Individuals. Summary Points:

• In comparison with other competing biomarkers and risk factors, coronary artery calcium (CAC) is currently the most potent risk marker of subclinical coronary heart disease (CHD).
• CAC was shown in several observational studies to improve the prediction of risk beyond traditional risk factors.
• In this JAMA paper, CAC outperformed various competing risk assessment markers among asymptomatic people at intermediate risk for CHD. Whether CAC should be used in routine clinical practice, however, is still a matter of personal opinion or further research.

Interview with Robert W. Haley, MD, author of Controlling Urban Epidemics of West Nile Virus Infection. Summary Points:

• Epidemics of West Nile neuroinvasive disease have become a serious medical and public health challenge that will be with us for the foreseeable future.
• Ultra low-volume aerial spraying of urban areas, guided by surveillance of mosquito trap positivity and human cases, is necessary and cost-effective to prevent chronic neurologic disability and death.
• Complete, accurate, and timely diagnosis of West Nile viral disease in an epidemic is vitally important to spare patients needless prolonged antimicrobial therapy and build support for public health control measures.

Interview with Nancy A. Rigotti, MD, author of Strategies to Help a Smoker Who Is Struggling to Quit. Summary Points:

• Treat tobacco use like the chronic disease that it is. Don't give up if your first few efforts do not succeed.
• Medications and brief counseling are each effective, but combining the two is most effective.
• Link your smokers to free national resources like the tobacco quit lines (1-800-QUIT-NOW). New noncombustible tobacco products are coming.

Interview with Laura N. Gitlin, PhD, author of Nonpharmacologic Management of Behavioral Symptoms in Dementia. Summary Points:

• Attending to behavioral symptoms is part of comprehensive dementia care and requires ongoing long-term management.
• Use 6 steps to systematically prevent, assess, manage, eliminate or reduce behavioral symptoms.
• Use combination of nonpharmacologic approaches.
• Keep trying—nonpharmacologic approaches are relatively adverse free.
• Create a health professional team to offset time needed for provision of nonpharmacologic approaches.

Interview with Robert H. Shmerling, MD, author of Management of Gout: A 57-Year-Old Man With a History of Podagra, Hyperuricemia, and Mild Renal Insufficiency. Summary Points:

• Risk factor modification: alcohol intake, excess weight, diet, medications (although overall impact on gout uncertain).
• Acute gout can be treated with NSAIDs, colchicine, corticosteroids, or a combination of these.
• Urate-lowering treatment to prevent attacks and tophi is appropriate for certain patients with gout. (In my opinion, allopurinol is the best initial choice to suppress uric acid.)
• Urate-lowering treatment should suppress uric acid to 6.0 mg/dL or less; allopurinol should start no higher than 100 mg/d but titrate up based on uric acid levels; it is common to require more than 300 mg/d.
• Concomitant prophylaxis (eg, low-dose colchicine, 0.6 mg/d) is appropriate for 6-9 months or longer.

Take home message:
We now have new therapies and guidelines for the treatment of gout. Appropriate use of therapeutics for gout—both new and old—will provide optimal outcomes for the increasing number of patients with this common disease.

Interview with Daniel J. Buysse, MD, author of Insomnia. Summary Points:

• Insomnia is a frequent comorbid condition that increases costs and worsens outcomes.
• Insomnia is a chronic condition for which there are effective and widely available acute treatments (medications) and effective but hard-to-find long-term treatments (behavioral).
• Need to consider other health professionals such as nurses, physician assistants, and behavioral health managers (smoking, obesity, diet, exercise, sleep/insomnia).

Interview with Phillip M. Boiselle, MD, author of Computed Tomography Screening for Lung Cancer. Summary Points:

• CT screening reduced lung cancer-specific mortality by 20% in a large randomized trial of a high-risk population.
• CT is associated with a high false-positive rate, with associated risks and costs associated with follow-up CT and the potential for more invasive diagnostic procedures.
• Physicians should consider discussing CT screening with their high-risk patients who meet criteria in published guidelines.

This Viewpoint discusses considerations that might lead physicians to change their practice based on RCTs reporting non–statistically significant differences in primary outcomes, including trial methodology, totality of evidence, cost, invasiveness, and labor-intensiveness of the interventions being compared.

In this narrative medicine essay, a primary care physician describes a drawing by a 7-year-old patient who is sitting on an examination table with her mother cradling her baby sister with the physician’s back to them entering data in the computer as an example of a system that is sacrificing human contact for electronics.

In this narrative medicine essay, an attending physician shares his observations of how the changing nature of electronic medical record (EMR) hospital progress notes—often entered out of sequence and becoming ever longer and more unreadable—can hamper interacting with patients and providing patient care.

In this narrative medicine essay, an African American physician reflects on her experience one day with a white member of her ward team made up of two interns, three medical students, and a senior resident that sparked cultural and racial discussions throughout their month together that usually do not occur in such a diverse group.

In this narrative medicine essay, a physician reflects on an experience during his medical residency involving the family dynamics of a couple in an effort to treat the pain of the husband.

In this essay, the author relays his personal experience with ethnicity-based discrimination and discusses the “microaggressions” that medical trainees from underrepresented groups based on race/ethnicity, gender, or sexual orientation experience.

In this narrative medicine essay, a surgeon and palliative care physician describes the isolating silence that she felt her after the slaying of her father in Egypt when she was 18 years old and how that lingering silence has come to guide her when sitting with patients, when there are no words.

In this narrative medicine essay, a clinical educator uses her experiences enduring the aftermath of treatment for acute myeloid leukemia to reflect on the difference between physician-teachers and patients’ experience of illness and to locate meaning in what she can offer her colleagues and trainees despite persistent disability.