Medical Year in Review: Excerpts From Journal Watch (www.jwatch.org)

Journal Watch (General Medicine) is published by the same publisher as The New England Journal of Medicine. This newsletter-like booklet is published every two weeks and gives a "Cliffs Notes-like" summary (with expert commentary) on contemporary issues in general medicine. We have selected topics we feel may be of interest to many of you. This reading will truly expand your scope of clinical knowledge.

Subscribe today! Click above to print off subscription form (.pdf) to fill out and send in.

 

From Journal Watch (December 1, 2011)

Mobile Phone Subscribers Don’t Experience Higher Risks for Cancer
In the only cohort study to date, mobile phone subscribers did not experience greater risk for any cancer or CNS tumors than nonsubscribers (J Natl Cancer Inst 2006; 98-1707). The same investigators now report long-term follow-up results.

Comment
In this large nationwide cohort study, mobile phone subscribers did not experience higher risks for cancer or CNS tumors than nonsubscribers. These results should be reassuring for the billions of phone users worldwide.

Complications After Prostate Biopsies Are Rising

Comment
The authors conclude that “there is a nontrivial risk of serious complications after prostate biopsy. The authors also express concern that quinolone resistance might account for the temporal trend of increasing infection rates. Interestingly, a recent Canadian study also documented that the incidence of post-biopsy hospitalization for infection increased strikingly between 1996 and 2005.

Odds of False-Positive Mammograms During 10 Years of Screening
The U.S. Prevention Services Task Force recommends biennial screening mammograms starting at age 50 unless a woman is at high risk for breast cancer.

Despite this recommendation, many patients request, and many providers and societies continue to recommend, earlier and more frequent screening.

During 10 years, the adjusted cumulative probabilities of a false-positive mammography result were 61% for annual screening, and 42% for biennial screening.

Comment
During 10 years, a majority of women who undergo annual screening mammograms will receive at least one false-positive mammography result. Because rates for both annual and biennial screening are high, that false-positive concerns would be a decisive factor for most women’s choice of annual versus biennial screening seems unlikely.

Intensive Intervention Improves Medication Adherence…
But the benefits were fleeting.

Precise adherence to a medication regimen is necessary for therapeutic success, but patients take their medications far more erratically than we like to think.

At the end of the trial, the directly observed therapy (DOT) group had significantly better overall medication adherence than the control group. However, after DOT was stopped, these differences quickly abated. At 3-month follow-up, reading from an electronic pill monitoring system indicated that adherence rates were similar in both groups with about 50% of the doses missed.

Mysterious Leg Lesions? Ask about Pedicures
Nail salons footbaths are implicated in furunculosis caused by atypical mycobacteria.

The researchers visited some of the implicated nail salons, where they noted debris or visual biofilms in the footbaths more commonly than they did when they visited control salons without associated cases. However, footbath water samples yielded organisms in 15 of 24 salons, with no differences between case and control salons.

Comment
Women commonly shave their legs before pedicures; resulting nicks can provide a portal of entry for whatever organisms splash up from the footbath. Clinicians should keep this scenario in mind when patients with leg furunculosis fail to respond to standard antistaphylococcal treatment.

Chondroitin Sulfate Holds Promise for Hand Osteoarthritis
In randomized trials, chondroitin sulfate has not been much more effective than placebo for patients with hip or knee osteoarthritis. Now, Swiss researchers have examined whether chondroitin relieves pain in hand osteoarthritis.

Improvement in hand function score was significantly greater with chondroitin than with placebo. Grip strength and use of rescue acetaminophen did not differ between the placebo and chondroitin groups.

Comment
Chondroitin and its companion drug glucosamine have had a checkered history – with some successes and some failures – in randomized trials that involved patients with lower extremity osteoarthritis. Clinicians can recommend the drug based on this trial, but corroborating studies would be ideal. The preparation used in this study consisted of chondroitins 4 and 6 sulfate of fish origin.

From Journal Watch (November 15, 2011)

Carotid Artery Stenting in the Real World
Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA), although their comparability remains controversial.

An examination of Medicare data showed that thirty-day mortality rate after CAS was nearly 2%, compared with about 1% in randomized trials. High-volume providers (³ 24 procedures annually) were significantly more likely to operate on asymptomatic patients than were low-volume providers. Thirty-day mortality in patients treated by very low-volume providers (<6 procedures annually) was almost double that in patients treated by high-volume providers, even after adjustments for potential confounders. Patients treated earlier in an operator’s career also had higher mortality than those treated later in an operator’s career.

Comment
An accompanying editorial justifiably calls for referral of patients with carotid stenosis to neurologists for a balanced discussion of risks and benefits of various treatment options before carotid revascularization is undertaken.

MRI Studies Can Be Performed Safely in Patients with Implantable Cardiac Devices

Comment
In this study, MRI procedures were performed safely using a defined protocol in patients who had implantable cardiac devices. Editorialists suggest that the presence of an implantable cardiac device “should no longer be considered an absolute contraindication to MRI.” However, these results should not be extrapolated to MRI scanners with field strengths lower or higher than 1.5 T. Notably, the FDA recently approved a pacemaker designed to function safely in the MRI environment under certain conditions (e.g., at defined MRI magnet strength).

Must We Stop Clopidogrel Before Vascular Surgery?
Many surgeons believe that clopidogrel raises risk for perioperative bleeding complications.

In data analysis in a U.S. multicenter registry of 10,000 vascular surgery cases representing 66 surgeons, 48 hours before surgery, 69% of patients were taking aspirin alone, 2% were taking clopidogrel alone, 10% were taking both, and 19% were taking neither drug. The incidence of reoperation for bleeding was similar among all four groups – about 1%.

Comment
The results suggest that patients with valid indications for clopidogrel can continue the drug preoperatively when they undergo vascular surgery.

Dietary Supplement use and Mortality in Older Women
Dietary supplements, particularly iron, calcium, and several vitamins , are used by at least half of older adults, despite little evidence of benefit and some suggestion of harm. In this study, researchers assessed use of 15 supplements in 38,722 women.

In adjusted analyses, use of multivitamins, folic acid, iron, or magnesium was associated with a 6% to 15% increase in risk for death, and copper supplements were associated with a 45% increased risk. Calcium use was associated with a 9% lower risk.

Comment
At the very least, dietary supplements seem to provide no benefit in older women.

Say No to Adenoidectomy for Recurrent URIs in Children
For children referred to surgeons because of frequent upper respiratory tract infections, adenoidectomy conferred no clinical benefit over watchful waiting.

Severity of URIs also did not differ, although children in the adenoidectomy group had significantly more days with fever ( 20.0 vs. 16.5 days per person-year).

Comment
Adenoidectomy is beneficial in children with recurrent otitis media. This study demonstrates that adenoidectomy is NOT beneficial in children with recurrent URIs. The natural history of recurrent URIs is gradual improvement over time. Therefore, the surgical approach should be abandoned for most patients.

Swimming Against the Current: Hormonal Forces Drive Excess Body Weight
Hormones that regulate hunger and energy storage make it hard for overweight people to lose weight.

Many of us were taught, and still believe, that being overweight or obese results from lack of discipline about diet and exercise. However, during the past 20 years, a group of hormones produced by adipose tissue and the gut have been shown to affect appetite and energy metabolism.

Caloric restriction and weight loss were associated with dramatic increases in hormones (such as ghrelin), which increase appetite and energy storage, and with dramatic decreases in multiple hormones that encourage satiety and promote energy expenditure (such as leptin). Even those participants who remained very overweight after the weight-loss program, experienced strong hormonal urges to eat more and to burn less energy.

Comment
Ubiquitous fast food and lack of exercise profoundly influence obesity. Although limited by its relatively small size and high attrition rate, this study suggests that a biological component also might be present. People who are overweight are constantly in a hormonal environment that makes them hungry and causes them to burn less energy during exercise. Trying to lose weight through diet and exercise feels like swimming against the current.

From Journal Watch (November 1, 2011)
Physicians Perceive That Patients Receive Excessive Care

Health services and economics research suggest that much healthcare in the U.S. is unnecessary. To assess physicians’ perceptions of this issue, investigators surveyed 600 practicing primary care physicians (evenly split between family medicine and internal medicine; median practice experience, 24 years).

Nearly half (42%) believed their own patients were receiving too much medical care in general; 6% thought their patients received too little care. About one quarter reported that they and other primary care physicians were too aggressive in their care (e.g., ordering more tests and referrals than necessary). Respondents blamed excessive care on three factors: inadequate time (40% of respondents), clinical performance measures (52%), and fear of malpractice suits (76%). 

Comment
Until physicians, as a profession, “own” this issue, it is unlikely to be effectively addressed.

Treating Lower Urinary Tract Symptoms with Saw Palmetto
Older men often use an extract of fruit from the saw palmetto tree as an alternative treatment for lower urinary tract symptoms (LUTS) caused by benign prostate hyperplasia.

Comment
In the most recent studies, the usual dosage of saw palmetto (325mg daily) provided no benefit, and in this trial, no benefit accrued when the usual dosage was tripled. No basis exists for recommending saw palmetto for patients with LUTS.

Some Subjective Memory Complaints Predict Cognitive Dysfunction
In this study, researchers asked 17,000 women (mean age, 74) about seven subjective memory complaints; (1) a general change in ability to remember things; (2) trouble remembering short lists; (3) trouble remembering things from one second to the next; (4) trouble remembering recent events; (5) difficulty understanding instructions; (6) trouble following a group conversation or a TV program’s plot; and (7) trouble finding one’s way around familiar streets.

An affirmative answer to question 3 (trouble remembering things from one second to the next) was not associated with cognitive impairment. However, an affirmative answer to any of the other six questions predicted cognitive impairment.

Comment
The authors were not surprised by the finding that “trouble remembering things from one second to the next” did not predict cognitive impairment: they note that this complaint is associated with normal aging.

Xanthelasmata Signals Excess Risks for Ischemic Vascular Disease and Death
No such association was found for arcus senilis corneae.

Both xanthelasmata (yellow plaques on the upper and lower eyelids) and arcus senilis corneae (gray-yellow opacity near the periphery of the cornea; also known as arcus senilis) are rich in lipids.

After adjustment for multiple potential confounders, people with xanthelasmata had significantly higher risks for myocardial infarction (odds ratio, 1.5), ischemic heart disease (OR, 1.4), severe atherosclerosis (OR 1.7), and death (OR, 1.1) than people without xanthelasmata. In contrast, people with arcus corneae did not have higher risk for death than people without arcus corneae. 

Comment
These results suggest that patients with xanthelasmata require aggressive management of modifiable cardiovascular risk factors.

From Journal Watch (October 1, 2011)
Does Gabapentin Prevent Postherpetic Neuralgia?

Researchers believe so, but their uncontrolled trial doesn’t prove it.

Gabapentin is approved for treating postherpetic neuralgia (PHN) after shingles, based on clinical trials in which it was started only when pain had persisted for at least 3 months.

The authors compare this result with findings from eight previous natural history studies, in which PHN incidence at 6 months ranged from about 15% to 40%.

Comment
The researchers conclude that early gabapentin therapy prevents PHN. However, their conclusion is purely speculative, given the absence of contemporaneous controls. Interestingly, in the largest shingles study ever conducted, the incidence of PHN among unvaccinated patients who developed shingles was only 12%.

Intensive Glucose-Lowering Treatment Does Not Lower 5-Year Mortality
Recent trials cast doubt on the assumption that intensive glucose-lowering treatment in patients with type 2 diabetes lowers short- or long-term mortality and adverse cardiovascular (CV) events.

After a mean follow-up of 5 years, intensive glucose-lowering did not lower risks for all-cause mortality and CV death; in fact, these adverse outcomes were slightly – although nonsignificantly – more common with intensive treatment.

Comment
Compared with standard treatment, intensive glucose-lowering treatment in patients with type 2 diabetes did not lower risks for all-cause or CV death or, for that matter, most other adverse outcomes associated with diabetes. Patients and clinicians should aim for reasonable glucose control that minimizes hypoglycemia and should focus on controlling other CV risk factors.

Asymptomatic Carotid Stenosis
Carotid endarterectomy (CEA) was compared with medical therapy in asymptomatic carotid stenosis (ACS) patients in two large randomized trials.

In both trials, the 5-year risk for stroke (including perioperative stroke or death) was significantly lower with CEA than with medical therapy, but the difference was only about 5 percentage points (5% - 6% vs. 11% - 12%), and no benefit was seen in women. Given the 2% to 3% rate of perioperative stroke or death, it took several years for the benefit of CEA to clearly surpass that of medical therapy.

Because medical therapy has improved since these trials were conducted, researchers have examined whether stroke rates in patients with ACS have declined during the past decade, In fact, rates have fallen to around 1% annually in medically treated patients.

In one study of 435 patients with ACS (>70% stenosis by ultrasound), only 10 patients (2%) had strokes during average follow-up of 2 years.

The most striking aspect of these studies is their confirmation of a very low overall incidence of stroke – about 1% annually. Thus, many asymptomatic patients who now undergo CEA (or carotid stenting, which is not safer than CEA) are likely risking harm without commensurate benefit.

Editorialists argue for “intensified medical management rather than revascularization procedures in patients with ACS,” until strategies to identify high-risk patients have been thoroughly investigated. Their position is compelling.

From Journal Watch (September 15, 2011)

Is Insomnia a Disease?
Or, is it a normal part of life that’s been medicalized by available treatment?

We generally indentify a disease before we look around for its treatment. Observers argue that, these days, the sequence sometimes is reversed: The marketing of a pharmaceutical agent gives birth to a disease, often by “medicalizing” what is actually a natural part of human existence. Has this process created an epidemic of insomnia in the U.S.?

Researchers examined recent trends in the diagnosis and treatment of sleeplessness, using data from an annual population-based survey of U.S. outpatient visits. Between 1993 and 2007, patient complaints of sleeplessness more than doubled, and ICD-9 diagnoses of insomnia rose more than sevenfold. Both these increases, however, were dwarfed by the skyrocketing number of prescriptions written for sedative hypnotics. Benzodiazepine prescriptions increased modestly (by about 50%) from 1993 to 2007, whereas prescriptions for non-benzodiazepine sedative hypnotics (zolpidem [Ambien and others] and similar drugs) soared 30-fold.

The results in 2007: an estimated 5.7 million complaints of sleeplessness, 6.1 million diagnoses of insomnia, and 16 million prescriptions written. The authors suggest that these divergent curves imply that “life problems are being treated with medical solutions,” without much attention being given to anything but the prescription pad.

Comment
These authors make a cogent case for the cart leading the horse (or the pill leading the pen, as the case may be) in the creation of a pseudo-epidemic of insomnia. To be fair, it could also be argued that in the pre-zolpidem era, the dearth of convenient therapy meant patients never bothered to complain. The same chicken-or-egg scenario undoubtedly also applies to “social phobia” and a host of other conditions born at about the same time as their indicated treatments.

Rivaroxaban for Stroke Prevention in Atrial Fibrillation Patients
Rivaroxaban, an oral factor Xa inhibitor, might be a new alternative to warfarin for anticoagulation in patients with atrial fibrillation (AF).

In the on-treatment noninferiority study, the annual primary event rates were 1.7% in rivaroxaban recipients and 2.2% in warfarin recipients.  The overall rates of bleeding were similar in the two groups, but intracranial and fatal bleeding were significantly more common in the warfarin recipients than in rivaroxaban recipients.

Comment
This study supports adding rivaroxaban to the growing list of anticoagulation agents to prevent stroke and systemic embolism in patients with atrial fibrillation. Note that rivaroxaban is FDA-approved for DVT prophylaxis after knee and hip surgery, but is not yet approved for atrial fibrillation.

M & T:
Rivaroxaban and other alternatives to warfarin are a most welcome advance, though they are more expensive.

Lifetime Risk for Malpractice Suit Might Exceed 75%
For all our professional obsession about malpractice suits, we lack good data on recent patterns of risk and payment.

Neurosurgeons and cardiovascular surgeons faced the highest annual risk for claims (almost 20%), and pediatricians and psychiatrists had the lowest (less than 5%).

Overall, only 22% of suits resulted in payments to claimants, with patterns that did not correlate well with overall risk for suit. For example, gynecologists who do not practice obstetrics (a “medium-risk” specialty) faced the highest risk for payment if sued, whereas obstetrician-gynecologists were more likely to be sued, but less likely to pay claims. Overall mean settlement amount was about US$275,000.

The researchers estimated that, by age 45, 36% of physicians in low-risk specialties and 88% of those in high-risk specialties had faced their first claims. By age 65, these numbers became 75% and 99%, respectively. The practice of internal medicine – a medium-risk specialty – entailed an almost 90% risk of suit by age 65.

Comment
Although these results represent only one insurer’s experience and are not necessarily widely generalizable, they still point to a surprisingly high lifetime risk for suit, even among what have always been perceived as low-risk specialties. The researchers suggest their figures help explain the pervasive fear of malpractice suit and the practice of defensive medicine.

From Journal Watch (September 1, 2011)

Clinic-Based BP Measurement Is Inaccurate for Diagnosing Hypertension
Compared with ambulatory blood pressure measurements, those obtained in the clinic or at home are far less accurate.

Most clinicians rely on clinic – or home-based measurement of blood pressure (BP) for diagnosing hypertension. However, whether such measurements are accurate is unclear. In this systematic review and meta-analysis of 20 studies that involved 5700 patients, U.K. investigators determined how accurately clinic- and home-based BP measurements diagnosed hypertension; daytime ambulatory BP measurements were the reference standard.

The studies varied in the number of BP measurements obtained for ambulatory (24-111), clinic (2-18), and home (18-56) monitoring. Compared with a mean daytime ambulatory BP of >153/85mmHg for diagnosing hypertension (the reference standard), a mean clinic BP of >140/90 had a sensitivity of 75% and a specificity of 75%, and a mean home BP of >135/85 had a sensitivity of 86% and a specificity of 62%.

Comment
The results have important implications: Many people with diagnosed hypertension are not really hypertensive, especially if the diagnoses were based on clinic BP measurements (i.e., white-coat hypertension). The study investigators suggest using clinic- or home-based BP measurements to screen for hypertension, followed by ambulatory BP measurement to diagnosis hypertension so that unnecessary antihypertensive treatment can be avoided. Notably, Medicare reimburses for 24-hour ambulatory BP measurements only in patients with white-coat hypertension (ICD-( code 796.2).

Are Hospitalists Really Cost-Effective?
A retrospective cohort study suggests that hospitalist care leads to higher total expenditures and more medical utilization following hospital discharge.

Inpatient care by hospitalists is associated with shorter lengths of stay (LOS) and lower hospital costs. However, some experts have voiced concerns that the hospitalist framework can fragment patients’ overall care and lead to higher downstream costs. Discontinuity between hospitalists and primary care providers (PCPs) might cause miscommunication, more emergency department (ED) visits, and more hospital readmissions.

In a study, researchers reviewed more than 58,000 Medicare admissions (all with identified PCPs) at 454 U.S. hospitals. Mean hospital LOS was 0.64 days shorter and mean costs were US$282 lower for hospitalist-attended patients than for PCP-attended patients, in analyses adjusted for baseline differences between groups. However, mean Medicare costs in the 30 days after discharge were $332 higher for hospitalist-attended patients. Patients cared for by hospitalists experienced significantly more ED visits and hospital readmissions.

Comment
Despite inherent limitations of retrospective studies, this analyses emphasizes that hospitalists must coordinate patient management by engaging PCPs during patient follow-up.

M & T:
Speaking of good communication, and just as a  reminder – always communicate with the diabetic patient’s PCP and/or endocrinologist following your  diabetic patient eye examination.

From Journal Watch (August 15, 2011)

Use of NSAIDs and COX-2 Inhibitors Raises Risk for AF
Risk for atrial fibrillation was especially elevated among new users of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors.

Results of this study were similar for individual NSAIDs and Cox-2 inhibitors.

Comment
These findings have important public health implications because these drugs are used widely and because AF prevalence increases with age.

These drugs can exacerbate hypertension and heart failure and, therefore, might precipitate AF or flutter.

Risk for Sudden Cardiac Death in Women
Most risk was attributed to four lifestyle factors; smoking, weight, exercise, and diet.

The women [in this study], whose lifestyle factors were updated every 2 to 4 years were considered to have one or more low-risk factors if they were not current smokers, had body-mass indexes of <25kg/m²_, exercised ³ 30 minutes daily, or scored in the top 40% of the cohort for adherence to a Mediterranean diet.

Comment
The magnitude of lower risk for sudden cardiac death (SCD) in women with one or more low-risk lifestyle factors is striking. Only 8% of the study population possessed all four low-risk factors, but their risk for SCD was lower by 92%. The population-attributable risk of 81% for all four factors emphasizes the relative importance of lifestyle over heredity as the primary risk factor for SCD in women.

The Placebo Response in Asthma
Researchers explored this issue in a study of 46 patients with stable asthma who exhibited large spirometric responses to inhaled albuterol.

On separate days, each patient received inhaled albuterol, inhaled placebo, an acupuncture sham treatment, and no intervention.

Albuterol increased mean forced expiratory volume in 1 second (FEV,) by 20%; in contrast, placebo inhaler, sham acupuncture, and no intervention were each associated with 7% mean increases in FEV. Subjective ratings were quite different: mean symptom scores improved by about 50% with albuterol inhaler, placebo inhaler, and sham acupuncture, but only by 20% during no-intervention days.

Comment
In patients with stable asthma, albuterol was superior to placebo in improving FEV, and placebo was similar to no intervention. In contrast, both albuterol and placebo improved subjective symptoms equally, and both were significantly better than no intervention.

Dissociation between objective and subjective placebo effects surely exists for many other diseases.

From Journal Watch (August 1, 2011)

Does the HbA_1c Criterion For Prediabetes Predict Incident Diabetes?
The American Diabetes Association recently added a new criterion for diagnosis of prediabetes – glycosylated hemoglobin (HbA_1c) level of 5.7% to 6.4%

At their baseline examinations, 2092 patients were identified as prediabetic; 60% by impaired fasting glucose (FG; 100-125mg/dL) alone, 20% by HbA_1c alone, and 20% by both tests. During a mean 4.7-year follow-up, 338 patients progressed to diabetes, of whom 292 (86%) had been identified as prediabetic at baseline; 32% by IFG alone, 9% by HbA_1c alone, and 46% by both tests. Patients who were prediabetic by both criteria at baseline were 32 times more likely to progress to diabetes than those who were normoglycemic.

Comment
Impaired fasting glucose and HbA_1c measure different aspects of dysglycemia and, together, provide more sensitive and specific prediction of excess risk for diabetes than does either test alone.

An Endorsement for Nitrofurantoin in UTI
Uncomplicated urinary tract infection (UTI) has become surprisingly complicated to treat in recent years because of growing prevalence of microbial resistance to trimethoprim-sulfamethoxazole (TMP-SMX) and quinolones. May experts now propose resurrection of the venerable antibiotic nitrofurantoin as a first-line treatment for uncomplicated cystitis.

Comment
This is the second major shout-out for nitrofurantoin this year. Earlier, the Infectious Disease Society of America endorsed it as a first-line treatment for cystitis, not because of cost, but for efficacy and ecology: Minimal resistance to this drug has developed among Enterobacteriaceae and, because ingested drug largely stays in the urine, little resistance is likely to evolve. Clinicians should keep this old standby in mind.

CT for Suspected Acute Appendicitis
Use of computed tomography (CT) for diagnosing suspected acute appendicitis rose from approximately 20% in 2000 to >90% in 2006. However, few researchers have examined the diagnostic performance of multidetector CT (MDCT) for this purpose. The sensitivity of MDCT for acute appendicitis was 98.5%, specificity was 98.0%, and negative and positive predictive values were 99.5% and 93.9%.

Effect of Urban Life on Our Brains
In stressful situations, city dwellers exhibited different brain activations than did rural residents.

Increasingly, the world’s population is concentrated urban areas. Many researchers have found that those who live in cities have higher rates of anxiety and mood disorders than do those who live in rural areas; in addition, rates of schizophrenia are nearly double among people raised in cities.

Comment
This study suggests that two parts of the brain that are central to the stress response are activated differently by stress, based on whether people currently live in or were raised in urban versus rural areas. How and why this happens remains to be determined.

Measuring Blood Pressure: Once Is Not Enough
The optimal number of readings was four to five.

Comment
In this study, BP readings varied substantially when measured at home, in a clinic, or as part of a research protocol. Although we don’t clearly know which approach to measuring BP correlates best with cardiovascular outcomes, the data convincingly demonstrate that a single BP measurement is inadequate.

M & T:
In like manner, more than one tonometric measurement is desirable in assessing a patient for glaucoma.

We hope you found this window into select areas of important contemporary issues in general medicine beneficial. We aim to do what we can to truly expand our fund of knowledge in all aspects of healthcare. It doesn't matter what we each call ourselves; the reality is that we are all optometric physicians, and we can never learn too much as we care for our patients.