Viewpoints in JAMA



The Attending Physician on the Wards - Finding a New Homeostasis


Robert M. Wachter, M.D., of the University of California, San Francisco, and Abraham Verghese, M.D., M.A.C.P., of Stanford University, Stanford, Calif., examine the changes that have taken place in recent years regarding attending physicians, including the reasons for the marked shift in demographics (such as from older to younger attendings), consider its effects on education and clinical care, and suggest interventions that may help improve the experience of trainees as well as attendings.

“Although some challenges will be more easily addressed by junior attendings and others by senior ones, the goals are the same. All attendings will need encouragement and wisdom to take a step back, keeping a measured distance that allows house staff to achieve and demonstrate competency while still ensuring patient safety. It is time that programs, trainees, and attendings take vigorous action to balance all these competing imperatives and establish a ‘new normal.’"

(JAMA. 2012;308[10]:977-978.


Engaging Physicians and Leveraging Professionalism - A Key to Success for Quality Measurement and Improvement


Patrick H. Conway, M.D., M.Sc., of the Centers for Medicare & Medicaid Services, Baltimore, and Cincinnati Children's Hospital Medical Center, and Christine K. Cassel, M.D., M.Sc., of the American Board of Internal Medicine, Philadelphia, discuss the topic of quality measurement and improvement, including the implementation of Maintenance of Certification, which includes assessment of physician performance. Also, the authors examine initiatives by the Centers for Medicare & Medicaid Services on this topic.

(JAMA. 2012;308[10]:979-980.


Surgical vs. Lifestyle Treatment for Type 2 Diabetes


David S. Ludwig, M.D., Ph.D., of Boston Children's Hospital, and colleagues write that “recent clinical trials have reported that substantially more weight loss and greater likelihood of diabetes remission occur following bariatric surgery compared with medical therapy, leading to calls for earlier consideration of surgery in the treatment of this obesity-related metabolic disease. Although these studies demonstrate the lack of efficacy of conventional practices, they do not prove the inherent superiority of surgery to lifestyle change.”

In this Viewpoint, the authors consider the limitations of published research and highlight the need for clinical trials with improved design.

“Before bariatric surgery becomes a mainstay for obesity-related complications, additional research is needed to compare the efficacy and safety of these procedures with that of truly intensive lifestyle intervention, not just standard practice. Design issues warranting consideration include the need for standardization of treatment, statistical methods (e.g., superiority vs. noninferiority trial), and generalizability. Because drug and device manufacturers would not profit from, and therefore have little incentive to sponsor, lifestyle intervention, the federal government should consider funding this research as a high priority.”

(JAMA. 2012;308[10]:981-982.


Changing Eating Habits for the Medical Profession


Lenard I. Lesser, M.D., M.S.H.S., of the Palo Alto Medical Foundation Research Institute, Palo Alto, Calif., and colleagues write that health professionals spend a great deal of time at meetings. “Grand rounds, noon seminars, research meetings, and medical conferences are part of the life of a health professional. At many of these activities, food is available. Although some members of the health professional community have called for changes to the food environment in the community in which they live, they have paid less attention to the quality of food served at hospitals, physician offices, and at conferences.”

The authors examine steps that the medical profession can take to improve eating habits.

“The medical profession was influential in reducing smoking in the United States; it has the capacity to encourage food-system change within its own institutions. This would likely reduce caloric consumption of health professionals, promote the health of physicians, and could also cause a ripple effect in local food economies.”

(JAMA. 2012;308[10]:983-984.