Interview with Dena M. Bravata, MD, MS, author of Using Pedometers to Increase Physical Activity and Improve Users' Health. Summary Points: 1. Pedometer users increase their physical activity. They walked 2000 steps per day more than people who do not use a pedometer. 2000 steps is equivalent to about 1 mile per day or about 100 calories per day. 2. Having a daily step goal is important for increasing physical activity with a pedometer. Pedometer users with any goal plus or minus either 10,000 steps per day or an individualized step goal plus or minus increase their physical activity whereas those pedometer users without a goal do not. 3. Pedometer users lose weight and lower their blood pressure. 4. Pedometer interventions that take place in the workplace are less likely to result in improvements in physical activity than interventions that took place in non-workplace settings. This is because the people who chose to participate in workplace interventions already had relatively high baseline physical activity which suggests that workplace interventions should target sedentary employees.

Interview with Ian G. Williamson, MD, author of Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis. Summary Points: 1. Antibiotics are not so effective in the routine treatment of cases of acute sinusitis even when of probable bacterial origin, and should therefore be used more judiciously and with greater caution. 2. Expectations should not necessarily be for antibiotics but balanced risk assessments and symptom advice are still important. 3. Findings of lack of efficacy for antibiotics should drive a research agenda which aims to identify subgroups that might benefit from their use and/or other types of treatment.

Interview with Mark J. Pletcher, MD, MPH, author of Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments. Summary Points: 1. Doctors appear to prescribe opioids less often to blacks and Hispanics/Latinos than they do to whites in the emergency department. 2. These differences do not appear to be explained by differences in type or severity of pain. To address these disparities, we would recommend: 1. Educating patients to make sure non-white patients expect good pain control and know how/when to ask for it. 2. Educating physicians and nurses about the existing disparities and the need to eliminate them, specifically addressing fears of prescription opioid abuse and other reasons physicians may withhold opioids. 3. Creating systems that minimize barriers to prescribing and monitor resolution of pain. 4. Monitoring quality of care by measuring resolution of pain and collecting and analyzing data by race/ethnicity.

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 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 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 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 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 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 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 proposes a framework for international cooperation among governments and organizations to replace competition and hoarding with equitable global distribution of COVID-19 therapeutics and vaccines as they are developed.

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