American College of Physicians: Internal Medicine — Doctors for Adults ®

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Internal Medicine 2013 News



Scientific Meeting News for April 13, 2013




Highlights

Contraception overview offers varied solutions to a perennial problem

There's been a lack of progress in preventing unintended pregnancies in the United States, said Raquel D. Arias, MD. Of the 6.7 million pregnancies in the U.S. each year, about one half are unintended, and 10.7% of women who report not using contraceptives account for roughly half of all unintended pregnancies. More...

What it takes to lead

You don't need to get an MBA to be a leader, according to Brian J. Harte, MD, FACP. Time and money are better spent developing skills and experience on the job, with a modest amount of complementary curriculum. More...

Consider a holiday from bisphosphonates

Consider a bisphosphonate drug holiday for low-risk patients after five years, with a reevaluation of bone mineral density after two years, said Susan L. Greenspan, MD, FACP. More...

Don't be anxious about identifying psychiatric problems

It doesn't usually take intensive questioning to identify a patient with a common psychiatric problem like anxiety disorder, according to Heidi Combs, MD. Just ask the patient how much time he spends worrying in a day. More...


Breaking news

ACP unveils tools to improve acute coronary syndrome care

ACP yesterday unveiled two evidence-based interventions and two videos to improve the health outcomes of patients in the first year after an initial acute coronary syndrome (ACS) event, such as heart attack and unstable angina, the most common ACS indications. More...


For attendees

ACP Annual Business Meeting to be held today

All members are encouraged to attend ACP's Annual Business Meeting to be held today at Internal Medicine 2013. Current College Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced. More...

Learn the 'nuts and bolts' of joining an accountable care organization

Today's panel "ACOs and New Payment Models," to be held from 11:15 a.m. to 12:45 p.m. in Room 130, will provide attendees with a practical discussion of issues to consider when deciding to join or establish an accountable care organization (ACO). More...

New data on old and new drugs featured in update

Are you up for some fun with drugs this afternoon? Don't worry, it's all totally legal, as the Update in New Medications session will provide entertainment and education about both old and new medications, according to moderator Gerald W. Smetana, MD, FACP. More...


Highlights


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Contraception overview offers varied solutions to a perennial problem

There's been a lack of progress in preventing unintended pregnancies in the United States, Raquel D. Arias, MD, pointed out at Friday morning's "Contraception Update."

Dr. Arias, who is associate professor of clinical obstetrics and gynecology at the Keck School of Medicine at University of Southern California, said that of the 6.7 million pregnancies in the U.S. each year, about one half are unintended, a statistic that hasn't really changed in the past decade. This rate puts the U.S. on a par with developing countries, she noted. Moreover, she said, the 10.7% of women who report not using contraceptives account for roughly half of all unintended pregnancies.

"You may wonder 'Why were they not using anything?' and the answer is that when asked, they said they didn't think they were at risk to get pregnant," she said. This may be especially true of women at the beginning and end of their reproductive life, who often think that pregnancy isn't physically possible, she said.

Among the former group, unintended pregnancy rates are only going to become a greater problem, she said, because rising childhood obesity rates are leading to a younger age at menarche. "The one thing you need to become mature at the hypothalamus-pituitary-adrenal axis is to weigh 98 pounds," she said.

"The average age at menarche [in the U.S.] in general is about 12. The average age in Detroit is 8," Dr. Arias continued. "To the degree that childhood obesity contributes to many medical problems, it also contributes to … unintended pregnancy."

There are many effective contraceptive options available, but when considering which to recommend, it's very important to focus on the failure rate with typical rather than perfect use, Dr. Arias stressed. "I want you to never use perfect-use rates again," she said. "I do not want you to use them in your practice. I want you to use typical-use rates."

As an example, Dr. Arias said many people, even physicians, still think the most effective form of reversible contraception is abstinence, but although its perfect-use failure rate is 0%, its typical-use failure rate is 80%. "Even if abstinence applied to the FDA as a contraceptive, it would fail," she said.

The most effective methods, defined as those with a failure rate of less than 1%, are female sterilization, IUDs, depot medroxyprogesterone acetate (DMPA, sold in the U.S. as Depo-Provera), and implants. Oral contraceptives, the patch, the ring, and progestin-only pills are considered effective, with a failure rate of approximately 1%. Less effective methods, defined as a failure rate above 1%, include condoms, spermicides, diaphragms, withdrawal and natural family planning.

One type of IUD, the levonorgestrel intrauterine system (LNG-IUS), sold in the U.S. under the brand name Mirena, is approved for five years' use and works as a barrier method. The cervical mucus is thickened, inhibiting sperm motility and function, as well as ovulation in some cycles, Dr. Arias said. There's also good evidence for noncontraceptive uses of the LNG-IUS, including treating heavy bleeding, reducing dysmenorrhea and pain, and providing endometrial protection during hormone therapy in perimenopausal and postmenopausal women. Use with tamoxifen is popular in other countries but is contraindicated in package inserts, she noted. The copper IUD, meanwhile, is approved for 10 years' use and can also be used as an emergency contraceptive, Dr. Arias said.

"There is essentially no medical problem for which a copper IUD is contraindicated," she said. "If that's the only thing you remember from this lecture, I'll be happy." She also noted that the copper IUD is as effective as a tubal ligation but very easily reversible. "A medical student could do it—with supervision, of course," she said.

Among the other most effective options, etonogestrel implants last for three years and are immediately reversible, Dr. Arias said. She also noted that they are safe in patients in whom estrogen is contraindicated. One downside of implants is that bleeding patterns during use can be unpredictable, ranging from amenorrhea to spotting to frequent bleeding.

DMPA's side effects include unpredictable bleeding approaching amenorrhea with time and a slow return to fertility, which gets longer with advancing age. Dr. Arias noted that there is some concern about weight gain in patients using DMPA, but added, "Warn your patients starting [DMPA] to watch what they eat, and they will be fine."

She also noted that although DMPA has a black-box warning for more than two years of use due to decreases in bone mineral density, subsequent studies have shown that bone mineral density rebounds after use. DMPA is a good choice in women with sickle-cell anemia, those with seizure disorders, and, especially, women who are breast feeding. "If you want to use something for a breast-feeding woman, this is what you use," she stressed.

Oral contraceptives remain very popular in the U.S., Dr. Arias said, with more than 18 million current users. In fact, approximately 80% of all women use oral contraceptives at some point during their reproductive years, she noted. Although discontinuation rates are high, about 50% during the first year of use, the average duration of use is almost five years in those who continue past that point. Oral contraceptives can be safely prescribed for women into their early fifties without other contraindications (for example, smoking), Dr. Arias said.

Dr. Arias also discussed emergency contraception, for which there are three options in the U.S.: progestin-only pills, progesterone-receptor antagonists, and the copper IUD. Progestin-only pills reduce the pregnancy rate by 85%, while progesterone-receptor antagonists delay ovulation for up to five days. The latter may be more effective in women with a BMI over 30 kg/m2.

The copper IUD can be inserted within seven days after unprotected intercourse and has the added benefit of offering 10 more years of highly effective contraception, Dr. Arias said. It's also the most effective form of emergency contraception, she noted, with a pregnancy rate of 0.2%.

Contraception is generally safe, Dr. Arias said, but certain contraceptives can exacerbate medical problems in some women. If there's a question about your patient's specific circumstances, she recommended checking the medical eligibility criteria from the Centers for Disease Control and Prevention or the World Health Organization. Use this guidance to evaluate each individual case and decide what's best for your patient, she said. "Make the choice that's safer for her, safer for you, and safer for society."


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What it takes to lead

You don't need to get an MBA to be a leader, according to Brian J. Harte, MD, FACP, president of South Pointe Hospital in Warrensville Heights, Ohio, part of the Cleveland Clinic Health System.

"Your time and money is better spent developing skills and experience on site, with a modest amount of complementary curriculum," said Dr. Harte, during the Friday session "Leading and Managing Change."

Not so fast, said co-speaker Edmondo J. Robinson, MD, FACP, associate chief medical officer of Christiana Care Health System in Wilmington, Del.

"You want to fast-track your leadership, not spend 25 years as a clinician until someone notices you've done good work and gives you a job. You want to use [the MBA] as a signal of business competency and acumen. Physicians like credentials," said Dr. Robinson.

The problem, countered Dr. Harte, is that much of the MBA curriculum is overkill, teaching skills that could be delegated to team members. "You don't have to be the operator of every part of the business; your role as leader is to keep everyone focused on patients and quality," he said.

Physicians who anticipate they may someday move from medical practice to another field, however, may be wise to get an advanced business degree, Dr. Harte acknowledged.

The debate wasn't merely academic, so to speak. Dr. Robinson himself got an MBA more than a decade ago, and said his education was invaluable in teaching him how to manage people, as well as how to affect change at a system-wide level.

Eventually the speakers found common ground in their friendly debate. "Neither of us believes all [the skills needed for leadership] can be acquired solely by living in the trenches day in and day out," Dr. Harte said, noting that professional organizations like ACP offer many opportunities for education.

Some of those leadership skills include having self-awareness; being visionary and communicating one's vision; and being able to energize staff, mentor individuals and teams, and listen and give feedback. The abilities to build consensus, make decisions, and stimulate creativity and adaptability are also important, Dr. Robinson said.

There is also emotional intelligence, which is part of self-awareness and deserves elaboration, Dr. Robinson added. "This means being able to recognize your personal strengths and weaknesses, having sensitivity toward others, recognizing emotional cues, being an open communicator, and being able to handle conflict and tense situations effectively," he said.

Many internists start with some of the raw material required for leadership: problem-solving abilities, training in using a broad scope, a passion for lifelong learning, strong interpersonal and communication skills, and a sense of ethical and social responsibility, Dr. Robinson said.

However, leadership involves other aspects which may not come as easily for physicians, he added. Physicians tend to be action-oriented and prefer immediate gratification, while leaders are strategic planners who accept delayed gratification. Physicians are focused on autonomy, professional identity and credentials, while leaders focus on teams, organizational culture and results. Many physicians also see finances as a hindrance to doing their jobs, while leaders embrace fiscal realities, Dr. Robinson said.

Acquiring the right skills for leadership has become increasingly important in a health care landscape that's gotten increasingly complex, Dr. Harte said.

"Physicians play a critical role in moving health care forward," said Dr. Harte. "Whether learned formally or informally, business skills are a necessary complement to clinical skills."


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Consider a holiday from bisphosphonates

Consider a bisphosphonate drug holiday for low-risk patients after five years, with a reevaluation of bone mineral density after two years, said Susan L. Greenspan, MD, FACP, to an audience of hundreds of Internal Medicine 2013 attendees on Friday morning.

Bisphosphonates are the mainstay of therapy for osteoporosis, said Dr. Greenspan, a professor of medicine at the University of Pittsburgh, but they carry side effects such as atypical fractures or osteonecrosis of the jaw that may justify a drug holiday.

For low-risk patients, if bone mineral density is stable or increasing, consider a drug holiday after five years, and restart the drugs if bone mineral density declines or a fracture occurs. In high-risk patients (those with fractures, those taking glucocorticoids, or those with very low bone mineral density), consider a drug holiday at 10 years and restart even if bone mineral density is stable. Patients can take teriparatide or raloxifene during the drug holiday.

But, Dr. Greenspan added, drug holidays can be "a data-free zone. We don't have a lot of hard data on what we're doing with these holidays."

She did cite a few studies that offer some insight on the effects of bisphosphonates. Analysis of a very large database of 90 million U.S. inpatient hospital records from 1997 and 2007 found that the hip fracture rates decreased about 32% during that time. In comparison, bisphosphonate use increased from 3.5% to 16.6%. When researchers looked at atypical fractures, they suggested that for every 100 hip fractures prevented, there was one atypical fracture observed.

A large study in Canada found that among nearly 2,000 women age 68 and older taking bisphosphonates between 2002 and 2008, atypical fractures occurred in only 71 patients after one year and 117 patients after two years. Researchers calculated that patients taking bisphosphonates more than five years had a 2.7 times higher risk of an atypical fracture but a 25% decrease in their risk of a typical fracture, Dr. Greenspan said.

Many other studies have suggested similar results, she added.

Osteonecrosis of the jaw is not necessarily a justifiable reason to take a drug holiday, Dr. Greenspan continued. "This is something that our dentists are worried about more than our patients and physicians." It is extremely rare, in the range from 1 case in every 1,000 patients to 1 in 100,000.

Most of the cases are occurring in patients who have had cancer, were on a high-dose IV bisphosphonate or had an invasive procedure for their jaw such as an implant. It is not generally occurring after patients get their teeth cleaned, have a filling fixed, or get their dentures repaired, Dr. Greenspan said.

"Originally dentists and oral surgeons were treating it very aggressively," she said. "Now, most of the time it heals on its own just with conservative management and by leaving it alone." Antibiotics help if the exposed area becomes infected.

"What do we do when the patient comes to you and says, 'My dentist will not work on my teeth, will not put that implant in, will not pull that tooth, unless I stop the bisphosphonate?' What do you do? You stop it," Dr. Greenspan said.

Bisphosphonates stay in bone for years—they recycle themselves, in a way—and the benefit of the drugs continues even if the patient stops the drug for the three or six months that the dentist requests. Dr. Greenspan said the American Dental Association now states in its guidelines that continuing or halting a bisphosphonate should be based on skeletal health, not dental health.

Often, patients ask how often side effects might occur before deciding to take a drug holiday from bisphosphonates. "And it turns out that their risk of a fracture is much, much more common than either of these other two events," Dr. Greenspan said.

Depending on individual risk factors, a patient might have the same rate of a fatal motor vehicle accident as she does of an atypical fracture, Dr. Greenspan noted. And while her chance of being murdered in the next 10 years is 0.06%, chances for osteonecrosis of the jaw are 0.007%. "This is really not something for her to worry about," Dr. Greenspan said.


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Don't be anxious about identifying psychiatric problems

It doesn't usually take intensive questioning to identify a patient with a common psychiatric problem like anxiety disorder, according to Heidi Combs, MD, assistant professor of psychiatry at Harborview Medical Center in Seattle.

Just ask the patient how much time he spends worrying in a day, she advised attendees of "Psychiatry: Beyond Depression" on Thursday afternoon. "People with generalized anxiety disorder will say, 'Uh, all the hours I'm conscious?'" Dr. Combs said.

During the session, she provided tips on screening and treatment of several mental disorders likely to be seen by internists, including somatoform, bipolar, post-traumatic stress (PTSD) and anxiety disorders. "You see these patients all the time. Anxiety disorders in primary care are very, very common," Dr. Combs said.

A series of questions so brief that even a busy internist should be able to fit them into a short visit can identify many of these patients, including "Have you ever experienced a panic attack?" to identify panic problems or "Have you ever had anything happen that still haunts you?" for PTSD.

Bipolar disorder is a bit trickier to diagnose, Dr. Combs said, noting that there are several lengthy questionnaires available, all of which have some evidence to support their effectiveness. "They aren't perfect, so you're going to have to use your clinical acumen," she said. When questioning a patient with suspected bipolar disorder, she usually starts with questions about depressive symptoms (which most people are more comfortable talking about), then asks if the patient has ever experienced "the opposite."

With any of these quick screens, "if you get a positive hit, it will take longer to go down the path" of complete diagnosis and treatment, Dr. Combs acknowledged, but it's also reasonable to take note of the positive answer and return to the issue when you have time, she said.

After diagnosis, "now you've got to do something about it," said Dr. Combs. If a patient has anxiety disorder, she should be screened for possible comorbid psychiatric conditions, such as obsessive compulsive disorder and depression. "It is the exception that they have an anxiety disorder and nothing else," said Dr. Combs.

The primary treatments for anxiety are cognitive behavioral therapy (CBT) and pharmacotherapy. Among the medication options, antidepressants are the first line of treatment and should be started at low doses, since they tend to increase anxiety at first. Benzodiazepines can be used to get patients through this initial period, but consider the risks of dependence and tolerance. And "Don't use alprazolam!" warned Dr. Combs. The drug peaks early and leaves the blood quickly, causing patients to take another pill soon after.

Her drug treatment pearl for PTSD was a positive recommendation. Dr. Combs asked how many in the audience prescribe prazosin for nightmares, and some hands went up. "That's awesome," she said. "It's a nice ace in the hole to have for patients with PTSD."

As with anxiety, CBT can also be good for PTSD patients, but don't force them to recount their traumatic experiences. "People have this idea that they have to get this off their chest. For some patients, it's absolutely true. For other patients, it's counter-therapeutic," said Dr. Combs.

Somatoform patients, on the other hand, will tell you all about their problems. "I think of it as physical manifestations of people's psychic distress," said Dr. Combs. "[If] a patient has a pan-positive [review of systems], you need to stop looking at medical problems and start looking at psychiatric problems."

These patients are frustrating to treat, Dr. Combs acknowledged. "They come to see you a lot, and they're not happy that you can't fix them, and you aren't happy that you can't fix them," she said. Treating somatoform disorder requires empathy and good communication. "First, acknowledge their suffering. It is no less painful, no less distressing for them than for someone who has an organic cause" of their symptoms, said Dr. Combs.

Then, warn the patient that while you will thoroughly investigate their symptoms, you might not find a physical cause of their problem. "Bring up this idea early, early, early," she said. "Once you feel you have turned over the rocks, stop testing."

See these patients regularly, not just when they're in crisis or presenting a new symptom. Otherwise, "It reinforces that they have to be ill to get care," said Dr. Combs. Screen them for comorbid psychiatric conditions and offer CBT solutions, including relaxation techniques and pleasurable physical activities.

Antidepressants are the most commonly used medication for somatoform disorder, although there's been relatively little research on this condition. "It's like they have a magnifying glass on their entire body. Some antidepressants can help to make them experience these things less intensely," Dr. Combs said.

Be prepared that the patients will have lots of drug side effects, and make sure that they don't expect a pill to fix all their problems. "You want them not to have an unrealistic expectation of what the medication is going to do," she said. Compare it to diabetes or hypertension, conditions that are managed rather than cured, Dr. Combs suggested.

And remember to dig deep into your "empathy well," Dr. Combs said. "They are not trying to make you miserable, and they are not trying to make themselves miserable. This is the best coping strategy that they have."



Breaking news


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ACP unveils tools to improve acute coronary syndrome care

ACP yesterday unveiled two evidence-based interventions and two videos to improve the health outcomes of patients in the first year after an initial acute coronary syndrome (ACS) event, such as heart attack and unstable angina, the most common ACS indications.

ACP's Initiative on Acute Coronary Syndrome aims to bridge the communication gap between clinicians and patients in the home or hospital. Because care in the 12 months after an initial ACS event is so important, the initiative focuses on improving health outcomes in the first year utilizing four key interventions suited to the varied needs of patients and clinicians: a patient guide, a clinician support tool, and two videos.

"These easy-to-understand, straightforward materials in multiple formats will facilitate communication between clinicians and patients, helping to prevent instances of and improve treatment of heart attack and unstable angina," said David L. Bronson, MD, FACP, president of ACP.

A patient-friendly educational guide, "Keeping Your Heart Healthy: What You and Your Family Should Do," is designed to enhance patient-clinician communication by helping patients and caregivers talk to the physician and other members of the health care team and encouraging them to ask questions. The guide includes information to help patients maintain a healthy heart, with sections on lifestyle modifications, medications and supplements, and recovery issues, such as when to go back to work and when normal activities can be resumed. Color-coded sections further emphasize necessary actions such as when to call 911 (red) or the doctor (yellow).

A decision-support tool, "Practice Guide for the Post Acute Coronary Syndrome Hospitalization Office Visit," enables busy clinicians to make the most of the first post-discharge office visit. Assessment suggestions, such as medication adherence and lifestyle modifications, include corresponding interventions, such as teach-back or reviewing approved physical activities like walking or driving.

In addition to these print materials, two patient videos geared toward empowering patients to actively engage in their care have been produced: "Discharge from the Hospital" and "Medications after a Heart Attack." The videos will be available online.

"By working with experts in clinical practice, health care quality, and patient advocacy to develop interventions that close gaps in understanding and communication, ACP has developed interventions to improve patient comprehension and management of ACS," said Doron Schneider, MD, FACP, chief safety and quality officer at Abington Health System in Abington, Pa. and a member of the initiative's National Steering Committee. "Improved patient understanding coupled with evidence-based practice is essential to better health outcomes."

Members of the National Steering Committee that developed the interventions include experts from ACP, the American Academy of Physician Assistants, the American Association of Critical-Care Nurses, the American College of Cardiology, the American Pharmacists Association, The Joint Commission, the Society for Cardiovascular Angiography and Interventions, and America's Health Insurance Plans.

The materials for acute coronary syndrome can be ordered online or by calling ACP Customer Service at 800-523-1546, extension 2600. They are available for all physicians to order for themselves and for their patients free of charge.

ACP's Initiative on Acute Coronary Syndrome is funded by a grant from Janssen Pharmaceuticals, Inc.



For attendees


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ACP Annual Business Meeting to be held today

All members are encouraged to attend ACP's Annual Business Meeting to be held today at Internal Medicine 2013. Current College Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced.

The meeting will be held in Room 120 from 12:45 p.m. to 1:45 p.m., with David L. Bronson, MD, FACP, ACP President, presiding. Dennis R. Schaberg, MD, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2013-14 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.


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Learn the 'nuts and bolts' of joining an accountable care organization

Today's panel "ACOs and New Payment Models," to be held from 11:15 a.m. to 12:45 p.m. in Room 130, will provide attendees with a practical discussion of issues to consider when deciding to join or establish an accountable care organization (ACO).

Panel participants have direct experience with ACO development, both within the traditional Medicare Shared Savings model and the advanced payment model, which provides participants with up-front capital to assist in program development.

This panel will include Randall Curnow, MD, MBA, FACP, executive vice president and chief medical officer of the Summit Medical Group in Knoxville, Tenn., and Stephen W. Nuckolls, chief executive officer of Coastal Carolina Quality Care, Inc., located in New Burn, N.C.


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New data on old and new drugs featured in update

Are you up for some fun with drugs this afternoon?

Don't worry, it's all totally legal. At 2:15 p.m. today in Room 134, the Update in New Medications session will provide entertainment and education about both old and new medications, according to moderator Gerald W. Smetana, MD, FACP.

"Many new drugs are approved each year by the FDA and many more are in the pipeline. It's difficult for busy practicing internists to keep up with all that information, to sort through it all, and to get balanced information about which ones would be appropriate for them to use. I've done that for them," said Dr. Smetana, who is an associate professor of medicine at Harvard Medical School in Boston.

The session will be particularly focused on outpatient primary care, rather than inpatient or specialty settings, he noted. "I'm going to be discussing three novel drugs for primary care which work by a new or different mechanism than any existing medications," he said.

Sound mysterious? You'll have to attend the update to find out what the new drugs are, said Dr. Smetana, who did hint that the diagnoses under discussion will include irritable bowel syndrome, lipid disorders and obesity.

"We're going to look at novel drugs for each of these indications. The goal would be to help [clinician attendees] understand which of these novel drugs are safe and effective and should have a place in their own practices," he said.

During the second half of the session, co-moderator Jane S. Sillman, MD, will advise internists on the proper place in practice for some older drugs. Dr. Sillman is an assistant professor at Harvard.

"Dr. Sillman is going to look at three categories of drug therapy which are used commonly in primary care for which there's either a new concern or new potential indications," said Dr. Smetana. "We're going to talk about some new side effects and associations that have been raised with statins. We'll talk about the risks and benefits of the use of aspirin and how that might change our approach in primary prevention. We'll revisit issues related to postmenopausal hormone treatment."

Drs. Smetana and Sillman have presented on this topic before, at past Internal Medicine gatherings and other medical meetings, and they report that the session usually satisfies attendees' needs for both Saturday afternoon entertainment and Monday morning utility.

"We hope to have fun. It usually keeps people lively and engaged throughout the course of the session," said Dr. Smetana. "We're going to be practical. We're going to be presenting information in a way that will be useful and actually change their practice when they go home to their offices the next week."





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