Interview with Stephen M. Shortell, PhD, MBA, MPH, author of Improving Patient Safety by Taking Systems Seriously. Summary Points: 1. To make real progress in patient safety will require redesigning the underlying system of care such that healthcare professionals and institutions providing a continuum of services from prevention to hospice can address multiple conditions and episodes over time. A "culture of systems" must be established. 2. Competing priorities, professional autonomy, solo and small physician practices, disciplinary silos, miss-aligned financial incentives, and inadequate feedback about performance all undermine efforts to create safe healthcare systems. 3. A number of strategic, cultural, technical, and structural barriers need to be addressed to assure safer care. This includes the need for patient safety organizations to gather information across the continuum of care and provide both rapid feedback to practitioners and analyze trends over time.

Interview with Laura P. Svetky, MD, MHS, author of Comparison of Strategies for Sustaining Weight Loss: The Weight Loss Maintenance Randomized Controlled Trial. Summary Points: 1. Weight loss is feasible and long term weight loss is possible. 2. Ongoing personal contact and technology based interventions were effective but the overall benefits were small. 3. The role of clinicians is to reinforce the message that weight loss can prevent and treat multiple chronic conditions. Even small amounts of weight loss can lead to significant health benefits. 4. Our focus should be on long term healthy life style changes rather than dieting, which is by its very nature short term.

Interview with Barbara V. Howard, PhD, author of Effect of Lower Targets for Blood Pressure and LDL Cholesterol on Atherosclerosis in Diabetes: The SANDS Randomized Trial. Summary Points: 1. Both standard and aggressive targets for blood pressure and LDL cholesterol in individuals with diabetes can be achieved and are safe. 2. Aggressive targets were associated with regression in IMT and greater decrease in LV mass, but long term data are needed to determine if they will result in improvement in clinical events. 3. Aggressive targets for blood pressure and LDL cholesterol may be considered on an individual basis.

Interview with Wendie A. Berg, MD, PhD, author of Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer. Summary Points: 1. Adding a single screening ultrasound examination to screening mammography in women at increased risk of breast cancer with at least heterogeneously dense breasts increases the cancer detection rate from 50% to 78%. 2. The risk of a biopsy for a benign lesion in our series was 1 in 40 for women undergoing mammography versus 1 in 10 for women undergoing mammography combined with ultrasound screening. 3. Using the standardized technique and interpretive criteria developed for this study, other radiologists and facilities with similar equipment and experience should expect similar results.

Interview with Sherita Hill Golden, MD, MHS, author of Examining a Bidirectional Association Between Depressive Symptoms and Diabetes. Summary Points: 1. People with symptoms of depression are more likely to engage in diabetes-producing health behaviors, including eating more, exercising less, and smoking more. As a consequence, they were more obese. 2. People with elevated symptoms of depression had a 42 percent increased risk of developing Type 2 diabetes over 3 years. This was partially explained by unhealthy behaviors. 3. People with treated Type 2 diabetes had a 52 percent increased risk of developing depressive symptoms over 3 years. This suggests that individuals with diabetes should be monitored for development of depression.

Interview with Beverly Beth Green, MD, MPH, author of Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control: The e-BP Randomized Controlled Trial. Summary Points: 1. If blood pressure (BP) control could be improved, many deaths from cardiovascular and renal disease could be prevented. 2. The Chronic Care Model was used to design an intervention that empowered patients to be more involved in their own care using home BP monitoring, a patient shared electronic medical record, and Web-based pharmacist assistance. 3. The group of patients that received BP monitors and training to use an existing patient website (with encouragement to send their BP numbers to their physician) had a modest decrease in systolic blood pressure, but BP control did not significantly improve. The group that received BP monitors, web training, and web-based pharmacy assistance had greater decreases in BP and were almost two times as likely to have controlled BP.

Interview with H. George Nurnberg, MD, author of Sildenafil Treatment of Women With Antidepressant-Associated Sexual Dysfunction: A Randomized Controlled Trial. Summary Points: 1. Emergent sexual dysfunction (SD) is a principal reason for a three-fold increased risk of non-adherence that leads to increased relapse, recurrence, and poor disease management outcomes. 2. Selective phosphodiesterase-type 5 inhibitors (PDE5Is), limited to studies in men, have demonstrated evidence based data to support broad based and clinically meaningful treatment efficacy. 3. In an intention-to-treat analysis, women treated with sildenafil showed significant improvement in adverse sexual effects compared with those taking placebo. 4. Evidence shows that selective phosphodiesterase type 5 inhibitors are effective in both sexes for patients who have been effectively treated for depression but need to continue on their medication to avoid relapse or recurrence.

Interview with Ingrid E. Nygaard, MD, MS, author of Symptomatic Pelvic Floor Disorders in Women. Summary Points: 1. The three primary pelvic floor disorders include urinary and fecal incontinence, and pelvic organ prolapse. 2. In a national population-based sample, nearly one-quarter of U.S. women reported at least one symptomatic pelvic floor disorder: overall, 15.7 percent experienced moderate to severe urinary incontinence, 9.0 percent experienced fecal incontinence at least monthly and 2.9 percent experienced symptomatic pelvic organ prolapse (a bulge in the vagina they could see or feel). 3. Older women, overweight and obese women and multiparous women were more likely to report a pelvic floor disorder.

Interview with Rita Redberg, MD, MSc, author of Stress Testing to Document Ischemia Prior to Elective PCI. Summary Points: 1. A majority (55.5% ) of Medicare patients with stable coronary artery disease who underwent an elective percutaneous coronary intervention (PCI) did not have a recommended stress test performed to document ischemia. 2. The rate of stress testing before elective PCI shows significant geographic variation, from a low of 22% in Fresno, CA to a high of 71% in Rochester, MN. 3. Patient characteristics (female sex, age of 85 years or older, and having co-existing illnesses) and physician characteristics (physicians who performed a higher volume of PCI procedures) were associated with lower rates of stress testing.

Interview with Brett D. Thombs, PhD, and Roy Ziegelstein, MD, authors of Depression Screening for Patients with Cardiovascular Disease. Summary Points: 1. Depression is a common and serious condition in patients with heart disease; therefore health care workers should inquire about symptoms of depression in their heart disease patients. 2. Our recent systematic review shows that there is not sufficient evidence at this time to call for routine screening for depression in patients with heart disease. 3. Additional research is needed to determine the optimal model(s) of care that will allow depression to be appropriately diagnosed and treated in patients with heart disease, particularly at times when these patients are being cared for primarily by heart disease experts rather than by experts in depression diagnosis and treatment.

Interview with David J.A. Jenkins, MD, PhD, author of Effect of a Low Glycemic Index or a High Cereal Fiber Diet on Type 2 Diabetes: A Randomized Trial. Summary Points: 1. Drugs such as the a–glucosidase inhibitor acarbose, which reduces the rate of digestion and absorption of carbohydrate and so flattens the post prandial glycemic response, have been shown to improve diabetes control, reduce the risk of developing hypertension, and lower the risk for cardiovascular disease. 2. Can a selection of more slowly digested carbohydrate foods achieve qualitatively similar benefits to drugs? Current data suggest that selection of diets containing low–glycemic intake foods have modest benefits in reducing glycated hemoglobin A1c even in patients with type 2 diabetes treated with 1 to 3 antihyperglycemic medications. 3. Foods with a low glycemic index include many traditional study foods such as dried peas, beans, lentils, intact-grain breads, pasta, oats, barley, parboiled rice, and temperate-climate fruits and berries. Low–glycemic index starchy foods are digested less readily in vitro. 4. Other effects include a tendency for higher high-density lipoprotein cholesterol levels, lower C-reactive protein values, and greater weight loss in the per-protocol completers, ie, those who completed the study with no change in medications.

Interview with Mary M. McDermott, MD, author of Treadmill Exercise and Resistance Training in Patients With Peripheral Arterial Disease With and Without Intermittent Claudication. Summary Points: 1. Supervised treadmill exercise improves walking performance for patients with peripheral arterial disease (PAD), whether or not the patient has classic symptoms of intermittent claudication. 2. Supervised lower extremity strength training improves quality of life, stair climbing ability, and treadmill walking performance for PAD patients with and without intermittent claudication. 3. Supervised treadmill walking exercise improves brachial arterial flow mediated dilation in patients with PAD, suggesting a global cardiovascular health benefit.

Interview with Steven A. Schroeder, MD, author of A 51-Year-Old Woman With Bipolar Disorder Who Wants to Quit Smoking. Summary Points: 1. Smoking is extremely common among persons with mental illness and exerts a huge toll in terms of morbidity and mortality. 2. We are now in the midst of a culture change. Formerly smoking was an integral part of the mental health culture and smoking cessation was not deemed pertinent. Now it is evolving into an important component of mental health and wellness. 3. Most smokers who have mental illness would like to quit. And many are able to do so, using the standard smoking cessation techniques used for the general population. There is still much more to know, but we know enough to encourage persons with mental illness to stop smoking and to provide them the tools to do so.

Interview with Michael K. Kearney, MD, author of Self-care of Physicians Caring for Patients at the End of Life. Summary Points: 1. Burnout and compassion fatigue are fundamentally different phenomena. Understanding the difference is helpful for effective intervention. 2. Investments in self-awareness and self-care are sound business strategies that can be expected to reduce staff turnover and increase patient satisfaction. 3. Mindfulness meditation and reflective writing have both been shown to increase self-awareness and self-care. They are among a number of strategies that can be built into clinical practice to prevent burnout and compassion fatigue.

Interview with Lisa A. Cooper, MD, author of A 41-Year-Old African American Man With Poorly Controlled Hypertension. Summary Points: 1. Cardiovascular disease accounts for 35% of the excess mortality in African Americans, in large part because of hypertension. 2. Racial disparities in physicians' clinical decision-making and in quality of care for cardiovascular disease have been documented extensively; studies also show racial differences in patient-physician communication, particularly when the patient and physician come from different racial backgrounds, and unconscious racial biases among physicians. 3. A categorical approach that lumps patients of particular cultural backgrounds into groups and outlines their characteristics values, customs and beliefs may lead to over-simplication and stereotyping. Instead, an understanding of broad cultural concepts and skills that emphasize a patient-centered approach are preferred. This approach takes into account the individual patients' explanatory model, illness agenda and behaviors, and social context, and attitudes and skills with regard to negotiating treatment. It also includes participatory behaviors such as asking open-ended questions, using reflective listening, and avoiding arguments in which one tries to change the patient's views. 4. Systematic reviews of interventions to improve patient adherence to treatments for hypertension show that simplifying dosing regimens is most effective; using motivational strategies such as home monitoring, small-group training, counseling by a nurse or other professional, and reminder calls for patients are somewhat effective; and patient education alone is not effective. Quality improvement strategies for hypertension management show team change interventions that include assignment of some responsibilities to a health professional other than the patient's physician (such as a nurse or pharmacist) are associated with the largest reductions in blood pressure. Improvement in patient-physician communication is linked to improved outcomes for mental health; more studies are needed that examine how patient-physician communication may improve hypertension control and other physiologic measures.

Interview with Peter H. Hwang, MD, author of A 51-Year-Old Woman With Acute Onset of Facial Pressure, Rhinorrhea, and Tooth Pain. Summary Points: 1. There are now published consensus guidelines for the diagnosis and treatment of acute rhinosinusitis. 2. Acute viral rhinosinusitis and acute bacterial rhinosinusitis can be difficult to distinguish in the first 10 days of symptoms. 3. Radiologic imaging is often "positive" in both viral and bacterial etiologies of acute sinusitis and therefore cannot be used to distinguish the two. 4. Oral antibiotics when prescribed appropriately confer a higher rate of partial or complete resolution of acute sinusitis symptoms compared to placebo. However, it should be noted that the spontaneous rate of resolution of acute bacterial rhinosinusitis may be as high as 40-60%. 5. Adjunctive therapies such as topical and oral decongestants may offer symptomatic relief but have not been proven to shorten the duration of illness.

Interview with Charles M. Morin, PhD, author of Cognitive-Behavior Therapy, Singly and Combined with Medication, for Persistent Insomnia. Summary Points: 1. Cognitive Behavioral Therapy (CBT) is an effective treatment for chronic insomnia and can help reduce medication treatment for this condition. 2. Clinicians can be successfully trained in CBT. 3. CBT works well alone for insomnia and while medication treatment may help early in the course of this condition, it has not advantages for long term use.

Interview with John P. Forman, MD, MSc, author of Diet and Lifestyle Risk Factors Associated With Incident Hypertension in Women. Summary Points: 1. At an individual level, combining healthy lifestyle factors may substantially reduce the risk of developing hypertension; according to the findings of the study, women who followed 6 healthy factors had nearly an 80% reduction in risk. 2. At a population level, a large fraction of all new cases of hypertension could hypothetically be prevented if all individuals in the population followed combinations of healthy lifestyle factors; according to the findings of the study, this fraction may is 78%. 3. Given that hypertension is a leading cause of preventable death in the population, and given that the majority of hypertension may be preventable through lifestyle modification, efforts should be intensified to improve lifestyle as a means of improving public health.

Interview with Thomas H. Gallagher, MD, author of A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery. Summary Points: 1. Errors and adverse events are common, and disclosure of these events to patients is recommended but often does not take place. 2. Physician fear of litigation inhibits disclosure, but so does physicians' lack of confidence in their communication skills and concern that disclosure might be harmful to the patient. 3. Important future developments in the field include linking disclosure with offers of compensation, and using performance improvement tools to enhance the disclosure process.

Interview with John Iskander, MD, author of Postlicensure Safety Surveillance for Quadrivalent Human Papillomavirus Recombinant Vaccine. Summary Points: 1. Since quadrivalent HPV vaccine was licensed in June 2006, more than 23 million doses have been administered nationally. 2. There were a total of 12,424 reports to the Vaccine Adverse Event Reporting System (VAERS) of adverse events following HPV vaccination through December 2008. The vast majority (94%) of adverse events reported to VAERS after receiving this vaccine have not been considered serious. The findings of this first published post-licensure safety review were generally not different from what is seen in safety reviews of other vaccines recommended for 9 to 26 year olds. 3. The most common events reported were syncope, local reactions at the site of immunization (pain and redness), dizziness, nausea, and headache.

Interview with Michael S. Krasner, MD, author of Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. Summary Points: 1. Burnout is prevalent among physicians, and has untoward effects not only on the physicians themselves but also on the quality of the care they provide to their patients. 2. Mindful Communication training among a group of primary care physicians resulted in not only improvements in burnout and measures of well-being, but also improvements in markers of relationship-centered care to their patients. 3. Mindful Communication should be considered among a menu of continuing medical education opportunities available for physicians to enhance well-being, meaning, and interpersonal relationships in the practice of medicine.

Interview with Laura Esserman, MD, MBA, author of Rethinking Screening for Breast Cancer and Prostate Cancer. Summary Points: 1. The effectiveness of screening depends on the underlying biology of cancer. Routine mammographic screening works best for slow to moderate growth tumors, most common in women 50-74 and explains why the Preventive Services guidelines actually make sense. 2. There are ways that we can improve screening today. Trained mammographers find the most cancers and have the fewest false positives. Offering follow-up as an option for low risk mammographic lesions will decrease false positives. Screening the populations who benefit most will also avoid false positives and overdiagnosis in those who benefit less from screening. The prostate cancer risk calculator is a good tool to use to determine whether to do a biopsy. 3. We can and must do better. Mammography and PSA testing can detect very low risk cancers, and these cancers can be less aggressively treated. Tools are available to distinguish these low risk cancers. The most aggressive cancers often present between normal screens, so women with new masses, regardless of a recent normal mammogram should be evaluated. Men and women at high risk to develop breast and prostate cancer should consider prevention interventions. Future screening should be developed to reduce mortality from the highest risk cancers.

Interview with Hussein Hollands, MD, MSc, author of Acute-Onset Floaters and Flashes: Is This Patient at Risk for Retinal Detachment? Summary Points: 1. The most likely cause of acute onset monocular floaters or flashes is posterior vitreous detachment. If left untreated, vitreous detachment complicated by retinal tear can progress to vision-threatening retinal detachment. 2. A minimum approach to evaluating a patient with suspected posterior vitreous detachment should include a history of change in vision or curtain of darkness, measurement of visual acuity, and assessment of confrontational visual fields. 3. High-risk features for retinal tear in the setting of acute posterior vitreous detachment are subjective or objective visual acuity loss, monocular visual field loss (or curtain of darkness), and vitreous pigment or hemorrhage on slit-lamp examination. Patients with any of these clinical findings should be referred for same day ophthalmology assessment.

Interview with David Reuben, MD, author of Medical Care for the Final Years of Life. Summary Points: 1. When caring for older patients, the conventional evidence-based approach is modified by 3 important caveats: prognosis, insufficient evidence, and patient goals and preferences. 2. Conceptually, the care of older persons can be divided into 3 time frames: short term, which focuses on remediating the current problems; mid-range, focusing on preventive and foreseeable problems; and long-range, which focus on eventual decline and living arrangements. 3. Individual clinicians need to structure their practices to efficiently and comprehensively accommodate the diverse needs of elderly patients.

Interview with Frank Davidoff, MD, author of Heterogeneity Is Not Always Noise. Summary Points: 1. A clinical trial is a powerful tool for showing whether an intervention works, but the heterogeneity of trial participants means it may be a mistake to assume that the overall (or group) benefit of an intervention found in such a trial is the same for every participant. 2. The absolute benefit of an intervention is greater for trial participants-and for patients generally-whose baseline risk for a bad outcome is high than it is for those whose baseline risk is low. 3. A quality improvement program in any one organization is like an individual patient in the sense that it is highly complex, it is unstable (ie, changes over time), and its local circumstances are unique. It is thus hard-although not impossible-to judge whether a quality improvement program in any particular setting actually works and to know whether it would work elsewhere.

Interview with Mary E. Tinetti, MD, author of The Patient Who Falls. Summary Points: 1. Falls are common health events that cause discomfort and disability for older adults and stress for caregivers. Previous falls; strength, gait and balance impairments; and medications are the strongest risk factors for falling. 2. The most effective strategy for reducing the rate of falling in community-living older adults may be intervening on multiple risk factors including strengthening and balance exercises through physical therapy, medication reduction, environmental modifications to reduce fall hazards, cataract surgery. Vitamin D has strong evidence of benefit for preventing fractures among older men at risk and probably of preventing falls in all at risk older adults. 3. While challenges and barriers exist, fall prevention strategies can be incorporated into clinical practice.

Interview with Roger Chou, MD, author of Will This Patient Develop Persistent Disabling Low Back Pain? Summary Points: 1. A small proportion of patients with acute LBP go on to develop chronic LBP, these patients account for a very high proportion of costs, services, and suffering. 2. The most helpful items to predict persistent disabling low back pain are presence of maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities. 3. Early identification of patients with these risk factors could help guide early use of psychological therapies and exercise therapy to reduce the likelihood that they will go on to develop chronic disabling low back pain.

Interview with David B. Carr, MD, author of The Older Adult Driver With Cognitive Impairment. Summary Points: 1. Know how to assess a cognitively impaired older driver in the office setting. 2. Know how and where to refer at-risk cognitively impaired older drivers. 3. Know how to counsel cognitively impaired older drivers in regards to driving retirement.

Interview with Kenneth J. Mukamal, MD, MPH, MA, author of A 42-Year-Old Man Considering Whether to Drink Alcohol for His Health. Summary Points:1. Careful alcohol histories are needed for all patients, particularly to identify binge drinking, which is frequent among moderate and especially younger drinkers. 2. Even moderate alcohol consumption has important and plausible health effects based on short-term trials and observational studies, including lower risk of heart disease presumably via higher HDL-cholesterol and higher risk of breast cancer (presumably via higher levels of estrone and DHEA sulfates). 3. Given these points, even controlled alcohol consumption is unlikely to benefit younger drinkers, but is a reasonable point of discussion for middle-aged and older adults, especially as a launching point for education about problem drinking and the potential risks and benefits of including alcohol as part of a healthy diet in older age.

Interview with Patricia S. Goode, MSN, MD, author of Incontinence in Older Women. Summary Points: 1. UI is very common in older women and should be in Review of System for ALL older women. 2. Initial behavioral therapy (pelvic floor muscle exercises, urge and stress strategies, caffeine avoidance) is easy to do and should be FIRST line treatment for older women with urge and stress urinary incontinence. 3. Modifiable Contributing Factors for urinary incontinence should be addressed before prescribing antimuscarinic medications and include: urinary tract infection, constipation, diabetes control, mobility impairment, sleep apnea, caffeine, timing of diuretics, over-sedation.

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