SGO Issues Dec. 28, 2017
Nov. 30, 2017: The courage to leave | Stephen L. Rose, MD
July 13, 2017: The art of saying ‘NO’ | Kimberly Resnick, MD
Feb. 23, 2017: The myth of ‘effortless perfection’ | Brittany Davidson, MD
June 29, 2017: SGO releases review on post-treatment surveillance
July 27, 2017: SLN mapping and staging for endometrial cancer in Gyn Onc
Top 5 SGO Issues articles of 2017
It was 4:00 p.m. My cases had finished early on a Monday and I was trying to catch up on the roughly 100 emails that had come in that day. I was still tired from a busy weekend of call, and it made focusing on anything difficult. As I read the same sentence six times over, I felt the sun on my back through my window. It was a beautiful spring day in Madison. There was no rain or wind and I knew there were still many hours of daylight. On a whim, I texted my friend Brian, who works in marketing at a local appliance company.
“Any chance you can play this afternoon?”
“I can leave right now!” he replied within seconds.
“Meet you at 5. I will call for a tee time” I answered.
I quietly shut down my computer, grabbed my bag and slinked down the hall to the back elevators, all the while hoping not to see another partner. I even considered for a moment, devising some reasonable excuse for why I was leaving early, but saw no one and averted that dilemma. I am certain had I seen a partner, they would not have cared where I was going. I am lucky to work with an amazing group of people who genuinely care about each other’s’ well-being, but leaving early still turns me in to an 8-year-old trying to steal a cookie from the pantry. Why do I feel the need to lie about taking care of myself? Because I have also been on the other side. I would love to tell you I have never cast a judgmental eye toward a colleague leaving early. The truth is, I have.
It is into this crucible that we have cast wellness.
We are a culture that values hard work. We lionize physicians who can seemingly do it all and are always available. But in this era of what the Accreditation Council for Graduate Medical Education (ACGME) calls “work compression,” where Relative Value Unit (RVU) targets have not changed despite new and different tasks such as Electronic Medical Record (EMR) use, patient satisfaction demands, multiple online safety and compliance trainings, we need to shelter wellness from becoming just another check on our to-do list.
How do we do this? We must change the culture that makes us feel guilty for leaving a few hours early. We must foster opportunities to take care of ourselves how we need to, when we need to. This culture will not change until we appreciate that everyone needs something different to be well. For me, golf is a mindfulness practice. At its core, mindfulness is about the quality of attention that you bring to an activity, not the activity itself. Golf engages my mind and body, allows me a few hours of work-free thought and re-energizes me. For others this might be aviation, cycling, gardening, or simply lying in a hammock, but all of these restorative activities must be met with encouragement, not judgment. Interestingly, while the age-old argument is that you have to work harder to accomplish more, science would tell us that sustained work without rest is actually less effective.
In the book Peak Performance: Elevate Your Game, Avoid Burnout and Thrive with the New Science of Success, authors Brad Stulberg and Steve Magness review the conditions required for sustained success. Chief among their findings is that productivity actually decreases without both short and long breaks away from work. Just as a muscle requires both stress and rest to grow, we require both to perform optimally in our professional lives. Rest is not a one size fits all model and we must allow our colleagues and ourselves reasonable flexibility to meet our needs. This culture change requires work from each of us, but especially from those of us leading divisions who need to model wellness by being more forgiving, more encouraging, and less judgmental. It requires all of us to have the courage to leave from the front elevators.
Stulberg B and Magness S. (2017). Peak Performance: Elevate Your Game, Avoid Burnout and Thrive with the New Science of Success. New York, NY.
Stephen L. Rose, MD, is the Director of the UW Gynecologic Oncology program at the University of Wisconsin School of Medicine and Public Health.
Ping. Ping. Ping. The invitations come pouring into my calendar—a meeting, a committee, a conference call. My spouse groans as I accept another commitment. I am the Division Director, Associate Residency Director, swim team mom and first grade room parent. I find my mind flooded with thoughts of swim meet snacks as I prepare the residents’ complicated master schedule.
Travis Bradberry in a Forbes magazine post recently shared an interesting anecdote about President Lyndon Johnson. In 1965, President Johnson was trying to get his chief economist on the phone when he was stymied by his economist’s housekeeper. The housekeeper told the president that her employer was napping and left a message that he was not to be disturbed. When the president asked the housekeeper to wake up her boss, the woman replied that she did not work for the president. The call did not go through.
As we advance in our careers and our lives we find that the requests for our attention and our time become overwhelming. If we are unable to say “no,” research shows that we are more likely to experience burnout and depression. There is a subtle art to saying “no” that we must master if we wish to be successful physicians, academicians, parents and spouses. Mr. Bradberry goes on to discuss that when we say “no” we are actually making a conscious decision to say “yes” to something else. If we decline the committee meeting that happens every other Thursday evening, will we make it to the gym? Can we make dinner for the family? Realize that with every “no” we are prioritizing our life goals and making a statement about what is important in our lives.
I have found a number of helpful and creative “life hacks” in order to help all of us become more successful at saying “no”:
- Get a good night’s sleep: Before you respond to an invitation, sleep on it. We are often times more able to view the invitation in the context of our current commitments and time limitations after a 24-hour period.
- Offer an alternate: When asked to review a manuscript or give a presentation, why not offer the name of a more junior colleague? Consider where you are on your career trajectory and ask yourself if somebody else could more readily benefit from this experience?
- Set your annual limits: Decide at the beginning of the year what you can say “yes” to over a 12-month period. Decide well in advance that you will review 10 manuscripts, serve on one additional committee and volunteer at school four times a year. Once you have reached this personal limit all further requests may be answered with “no.” No justification is needed. Utilize your chair or division director to help you set these boundaries if needed. This individual can serve as backup if necessary.
It is not until we master the art of saying “no” that we are truly able to say “yes” and devote our time, energy and intellect towards the causes and commitments that we truly find worthwhile.
Kimberly Resnick, MD, is the Division Director of Gynecologic Oncology at the MetroHealth Medical Center at Case Western Reserve University in Cleveland, OH.
I had a healthy fear of GYN/ONC fellowship when I started. My OB/GYN residency wasn’t one I would particularly designate as “onc-heavy” and, while I loved taking care of the oncology patients, I worried whether I would be happy or capable of doing so on a full-time basis. I worried about whether my surgical skills would be up to snuff, whether my attendings would regret ranking me, whether I was emotionally capable to provide these women with the care they needed during one of the most vulnerable times in their lives. What can I say; I worried.
I looked at my mentors and saw them performing a complex dance, navigating the physical and psychological demands of being a gynecologic oncologist, being a present parent and somehow managing to have a successful research career with numerous publications, accolades and grant funding. I, on the other hand, had never operated on the robot, had yet to have a paper published and was trying to figure out how to have a successful two-physician marriage. Everyone around me looked so graceful, “effortlessly perfect,” while I struggled with what felt like two left feet.
During a fellows’ lecture one week, we watched a short YouTube video from the Cleveland Clinic’s Empathy Series, entitled “The Human Connection to Patient Care.” If you have never seen it, please—I urge you—watch it today. This four-minute video resonated with me that day and still does to this day. Meant to encourage care providers to “put themselves in their patients’ shoes,” I felt like I could (and do) apply this to all aspects of my life. When I see a patient, I remind myself that our 20-minute appointment together, while just a fraction of my day, may be the biggest, most important 20 minutes of her week, month or life, even if she doesn’t let on. I need to stay in the present, focus on what is in front of me and, most importantly, be kind—both to those I interact with throughout the day and myself.
Often times we “put on a good face”—for our patients, our family, our colleagues. Though many times the separation of work and life is important to maintain a healthy work-life balance, it’s not as black and white as we’d like. Difficult events are just that—difficult. Life bleeds over into work and vice versa. We like absolutes and concretes in medicine, but we all know, it’s rarely that simple. Try as we might, we’ve all had that unexpected patient outcome or an argument with a loved one. We are all human, we all have struggles, we all make mistakes; many times we opt not to outwardly share these trials and tribulations for fear of judgment or perceived inadequacy. For not being “effortlessly perfect.”
I miscarried towards the end of my fellowship last year and, again, felt the pangs of being imperfect. Most of my colleagues knew I was pregnant since I had struggled with significant nausea and vomiting (not so fun in the OR) from the start. It was one of those times where I thought to myself, “Work stays at work and life stays at home.” But again, it wasn’t that simple. In fact, the immense outpouring of love and support at work that I received during that difficult time helped me to climb out of my “imperfect” funk. The ability to talk about and share this particular struggle with others, many of whom had been through similar situations, was comforting beyond words. It’s taken me 33 years to start to realize that it’s okay to not be “effortlessly perfect” in whatever endeavors I may find myself. The ability to treat everyone, those with internal and external struggles, with kindness, is perhaps the most important. Practicing self-kindness and acceptance is not something I master on a daily basis, but certainly a task worth striving for. Many times I feel that my patients are better at this—acceptance of situations they cannot control, self-kindness as their body changes and strength to persevere through life’s storms. Being “effortlessly perfect” is impossible when you are battling cancer and isn’t even important. Kindness. Kindness to yourself, and others, is really what matters in the end.
Brittany Davidson, MD, is an Assistant Professor of Obstetrics and Gynecology at Duke University School of Medicine in Durham, NC.
The July 2017 edition of Gynecologic Oncology features an evidenced-based review, “An update on post-treatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncology (SGO) recommendations,” by Ritu Salani, MD, MBA; Namita Khanna, MD; Marina Frimer, MD; Robert E. Bristow, MD; and Lee-may Chen, MD.
Noting that there is a “paucity of research regarding the most effective strategies for surveillance after patients have achieved a complete response,” the main findings were that testing beyond symptoms and examination are of limited benefit.
“There is very little evidence that routine cytology or imaging improves the ability to detect gynecologic cancer recurrence that will impact cure or response rates to salvage therapy,” the authors wrote.
“These results are not particularly surprising, but it is important that most data is based on limited or retrospective results,” said lead author Dr. Salani. “Until prospective trials are conducted, surveillance evaluations will continue to have variability.”
The article’s authors pointed out two items from SGO’s Choosing Wisely list of tests and procedures that physicians and patients should question:
- Avoid routine imaging for cancer surveillance in women with gynecologic cancer, specifically ovarian, endometrial, cervical, vulvar and vaginal cancer.
- Don’t perform colposcopy in patients treated for cervical cancer with Pap tests of low-grade squamous intraepithelial lesion (LGSIL) or less.
“Unfortunately, the overuse of imaging in the setting of surveillance continues to occur at high rates despite lack of data demonstrating any benefit,” said Dr. Salani. “I suspect this is a result of resistance or slow adoption of change to current practice, lack of awareness of guidelines/data, and patient requests/demands. Providing patients and other health care providers with the updated SGO guidelines may help set expectations and eliminate unnecessary testing.”
Based on their review, Dr. Salani explained that it was not possible to tell if the use of colposcopy has decreased for cytology less than high grade. “However, there are studies showing that the use of cytology after cancer treatment did decrease,” she said. “Regardless, we agree with the Choosing Wisely campaign and advocate for limited use of cytology and reserving colposcopy for cases with high grade findings when cytology is performed.”
Dr. Salani added that while she is not aware of any clinical trials evaluating surveillance at this time, it would be an ideal opportunity to incorporate surveillance as a part of other clinical trials.
According to lead author Robert Holloway, MD, “Sentinel lymph node mapping and staging in endometrial cancer: A Society of Gynecologic Oncology literature review with consensus recommendations” in the August 2017 edition of Gynecologic Oncology is the product of an exhaustive review of contemporary literature from experts who have clinical and/or published experience in sentinel lymph node (SLN) mapping techniques and pathology.
The article examines various techniques of SLN mapping in endometrial cancer, pathology and clinical outcomes from SLN assessment, clinical controversies, and future directions for research in SLN assessment. Through a process of review and debate that progressed over six months, the authors proposed consensus recommendations for the introduction of SLN mapping into clinical practice for patients with endometrial cancer.
Dr. Holloway explained that the 2015 SGO Clinical Practice statement on SLN mapping was the first response from the SGO to rapidly emerging clinical questions about the introduction of SLN mapping into surgical practice following the 2014 National Comprehensive Cancer Network (NCCN) guidelines that described the Memorial Sloan Kettering SLN surgical algorithm.
“Since the release of the 2015 Clinical Practice Committee statement on SLN mapping, many observational studies have been presented and published,” he said. “The current consensus recommendations publication is a comprehensive review of the expanding literature on SLN mapping in endometrial cancer and focuses on all aspects of SLN mapping including history, mapping techniques, pathology, clinical outcomes, controversies, and future directions with suggestions for additional clinical investigations.”
Dr. Holloway noted that the American Society of Clinical Oncology (ASCO) guidelines describe benchmarks for determining proficiency in SLN mapping in breast cancer that are generalizable to SLN mapping in other malignancies.
“We have adopted these benchmarks as recommendations such that each surgeon should evaluate their own individual proficiency including identification of SLNs in 80 to 90 percent of cases with a false negative rate less than 5 percent, before standard lymphadenectomy procedures are abandoned,” said Dr. Holloway. “The SGO consensus recommendations emphasize that use of the NCCN surgical algorithm reduces false negative staging. The NCCN surgical algorithm is specific for endometrial cancer, but the concepts likely apply to other cancers as well.”
According to Dr. Holloway, the most current NCCN endometrial staging guidelines—NCCN Clinical Practice Guidelines in Oncology: Uterine Neoplasms, Version 1.2017, 2016—contain specific information about SLN mapping techniques, and are a good source for additional information.