Abstract

• Objective: To describe Acceptance and Commitment Therapy (ACT) and its application in the treatment of chronic pain.
• Methods: Review of the theoretical and clinical literature and presentation of a case example.
• Results: General cognitive behavioral approaches for chronic pain have a consistent and large evidence base supporting their benefits. Even so, these treatments continue to develop with the aim to improve. One example of a relatively new development within the cognitive behavioral approaches is ACT, a treatment that focuses on increasing psychological flexibility. Here we describe ACT and the therapeutic model on which it is based, present its distinguishing features, and summarize the evidence for it as a treatment for chronic pain. We also discuss such issues as dissemination, implementation, and training.
• Conclusion: There are now 7 randomized controlled trials, a number of innovative uncontrolled trials, and at least 1 systematic review that support the clinical efficacy and effectiveness of ACT for chronic pain. Further research and development of this approach is underway.

The introduction of the gate control theory of pain [1] in 1965, among other events, signaled a shift in our understanding of pain, particularly chronic pain. This shift, which continues today, is a shift from a predominantly biomedical model of chronic pain to a biospsychosocial model. This model, as the name suggests, includes psycho-social influences in a key role in relation to the experience of pain and the impact of this experience. During this same period of time, psychosocial models and treatment methods have also shifted and evolved. This evolution has included the operant approach [2], the cognitive behavioral approach [3], and the latest developments, contextual cognitive behavioral approaches [4,5], among which Acceptance and Commitment Therapy (ACT) and mindfulness-based therapies are key examples.

Until about 10 years ago, the mainstream of psycho-logical treatments for chronic pain and other physical health problems was dominated almost exclusively by concepts and methods of what we will refer to as “traditional” cognitive behavioral therapy (CBT). Specific constructs within what is called the “common sense model” [6], such as illness perceptions, beliefs about control over one’s illness, amongst other constructs such as self-efficacy, catastrophising, fear avoidance, and pain-related anxiety, captured a substantial focus of research and treatment development during most of the past 3 decades [7]. The treatment methods that have emerged and persisted from this work have included relaxation, attention-based and cognitive coping strategies, cognitive restructuring, the use of imagery, and certain activity management strategies [8]. However, despite consistent supportive evidence for CBT interventions for chronic pain [9], there remain gaps and areas of relative weakness, both in the conceptual models underlying this work and in the base of evidence. Research clearly shows that not all patients benefit from traditional CBT interventions, and recent reviews of CBT for chronic pain generally show effect sizes that are usually small or mediumat best [9–11].

The Problem with Pain

Pain hurts and is often viewed as harmful, and this leads to fear or anxiety, avoidance, or attempts to control the pain. Seeking to control pain is entirely natural and even seems necessary to reduce the undesirable effects of pain in one’s life.

Dependent on the situation, pain avoidance, sometimes also referred to as “fear avoidance,” in studies of chronic pain can present itself in many forms. Avoidance behavior can include refusal to engage in any activity believed to cause an increase in pain. It may also include “guarding” or bracing around an area of pain, information seeking, treatment seeking, taking medications, overdosing on medications, using aids like heat or ice, withdrawing from social activity, as well as being unwilling to talk about emotional experiences, amongst others [5]. Today, avoidance is recognized as a key foundation element in pain-related suffering and disability [12], and addressing it effectively has become a prime focus in many or most current treatments.

Acceptance and Psychological Flexibility

In recent years, the concept of “acceptance” has gained prominence as a potentially important process for addressing a broad array of psychological problems, including those associated with chronic pain. From this new interest, a fundamentally different treatment emphasis has emerged. This includes a shift away from a predominant focus on changing thoughts and feelings, a focus sometimes adopted within some traditional CBT methods, towards a focus on reducing the influence of thoughts and feelings on our actions instead. This can be a rather confusing distinction. This is because the influence of our thoughts and feelings is often automatic and even invisible to us as it occurs. As such, the influences of our thoughts and feelings appear directly tied to the content of thoughts and feelings, but the matter is not that simple. Clearly there are occasions when our actions contradict our thoughts and feelings, such as when we have perfectly confident beliefs and fail, or significant anxiety and perform successfully. Such instances illustrate what we might call a “2-dimensional” quality of experience; it is the content of experience and the context of experience that determine the influence exerted. Suffice it to say acceptance-based methods are designed to address the difference between experiences that are difficult to control, such as thoughts and feelings, and things that are easier to control: the actions we take in relation to our thoughts and feelings. They do this by taking a focus on creating changes in context and ultimately in behavior. Acceptance includes especially a focus on allowing or opening up to feelings rather than struggling with them or retreating from them. Here, the capacity for openness is a contextual process.

Acceptance methods are not used in isolation. They are usually used in combination with other traditional behavior change strategies, with methods to facilitate values clarification, committed action, and other methods from ACT. Notions of acceptance have even been incorporated into many behavioral and cognitive therapies before, including dialectical behavior therapy [13] and mindfulness-based treatment [14,15], and so this process is not the exclusive domain of ACT. In implementing acceptance-based methods, patients are taught skills, such as to (a) notice feelings specifically in detail, (b) notice that thoughts about pain are products of thinking and not the same as direct experience, (c) notice urges to struggle with thoughts and feelings, (d) to practice refraining from struggling and adopt an observing, allowing, and “making room”–type posture, and (e) take action in line with their goals [4,5].

The wider processes around acceptance in combination are referred to as psychological flexibility [16]. Psychological flexibility relates to one’s ability to directly contact the present moment; to be aware of the thoughts, feelings and potentially unwanted internal experiences it brings; and to follow through with a behavior change or persist with a chosen behavior in the direction of chosen values. Psychological flexibility is the model for psychological health from an ACT perspective [17].

Psychological Flexibility and the 6 Core ACT Processes

Acceptance

Acceptance involves the patients’ willingness to have pain while remaining able to actively choose to continue participating in their life as they want it to be. ACT encour-ages patients to act in ways that are consistent with direct experiences rather than what the mind interprets these events to mean.

Cognitive Defusion

Cognitive defusion is the process of modifying one’s reaction to thoughts by constructing contexts where the influences of these thoughts on behavior are lessened [18]. Unlike traditional cognitive behavior approaches, in ACT it is not the content and actual validity of these thoughts that is challenged but the functions, or influences, of thoughts [19].

Present Moment Awareness

Contact with the present moment reflects the process wherein the person is aware of the situation in “the now” as opposed to focusing on events that happened in the past or might happen in the future [18]. To be “present” requires the individual to flexibly focus attention on experiences as they are happening in the environment, in real time, and to be fully open to what is taking place [20]. It is important the individual is able to notice when he or she is not acting in relation to the present moment and has the ability to shift attention to the present if this shift benefits them.

Self as Context

The sense of self-as-context or self-as-observer is considered the ability to adopt a perspective or point of view that is separate from and not defined by thoughts and feelings or even the physical body. This contrasts a sense of self as made up of personality characteristics, self-evaluations, or a narrative about who we are [5,16]. In ACT, perspective taking can be trained to help people connect with the experience of a distinction between self and psychological experiences. From this, one can choose to follow one’s inner verbal constructions of what defines us, our “stories” of who we are, in certain situations when it works to do so, and not in situations where it leads to unhealthy responses and behavioral restriction.

Values

Values are defined as guiding principles in one’s life. Values are often contrasted with goals, where the difference is that goals can be achieved while values are part of an ongoing process of action and cannot be completed once and for all. In a sense, goals represent set plans of action to be achieved while values are general life directions. If life is like a journey, then goals would be the chosen destination and values would simply be represented by a general direction of travel. Values are helpful when patients struggle with unwanted internal experiences like pain, as they not only serve as a guide for the client to persist in behavior change but also function as a motivating element. Values clarification exercise in therapy encourages the patient to define their values in specific domains of “career, family, intimate relationships, friendships, health, education and spirituality” [4,21] regardless of the primary problem. Personally chosen and clarified values can function as guides when people have difficulty initiating and maintaining behavior change in the presence of unwanted internal experiences.

Committed Action

Committed action is an ongoing process of redirecting behavior in order to create patterns of flexible and effective action in line with a defined value [22]. Patients are encouraged to follow through with their chosen actions that are in line with their values, and to persist or alter their course flexibly. Without the capacity for committed action, behavior change is less likely to persist and integrate into patterns of behavior more generally.

Case Study

Initial Presentation and History

Ms X, a 45-year-old woman, presents with the chief complaint of low back pain, which she has experienced for 3 years. She works part-time due to her pain problem. When she is not at work, she busies herself with seeking both conventional and alternative treatments for her pain condition. In the past, during periods where she experienced pain relief, she attempted to engage in her hobby of photography. However, this often led to a pain flare the next day and required 2 to 3 days of medical leave with increased medication from her PCP before she is able to return to work. As a result, Ms X chose to give up her hobby and focus on treating her pain instead. Ms X in in a constant struggle with her pain condition and believes that she can only return to photography, and live a more normal life, after her pain is cured.

• What are considerations for applying ACT in this scenario?

From an ACT conceptualization this case shows patterns of avoidance that are apparently not helping the person to reach her goals but are causing her distress and restrictions in functioning. An ACT therapist would approach this scenario by first reflecting how normal it is to struggle with pain and stop activities when in pain. From there they might (a) identify what the patient wants from treatment, (b) look at what has been done so far to attain this, (c) examine how well those things have been working, (d) consider the costs of the approach being taken, and (e) if the approach is not working and the cost is high, see if the patient is willing to stop this approach [23].

Therapist’s Initial Approach

Therapist: By what you have told me, your pain has become a big problem for you and it has been going on a long time—3 years. I can see some of the impacts it has had in your life, such as on your work, your photography, and time spent seeking treatment.

Ms X: Yes, it seems like pain has taken over …

Therapist: Exactly, it seems that is a good way to say it. So, understanding that pain has taken over, can I ask you another question?

Ms X: If your question will help me get over this problem, of course.

Therapist: Ok. What is it you want from coming here to participate in this treatment?

Ms X: Well, I want to get rid of this pain, obviously. It’s ruining my life.

Therapist: Ah, that makes sense. You want to eliminate your pain because it has, as you say, ruined your life, and then I guess your life will be better again.

Ms X: Correct.

Therapist: So, can I check in with the things you have been doing so far to reach this goal to eliminate pain?

 Ms X: You name it, I’ve tried it: acupuncture, medication, herbs, rest, exercise, magnets, yoga, and more.

 Therapist: Ok, you have tried many treatments focused on trying to get rid of the pain. I think that’s a very natural thing to do. In your experience have these methods been successful?

 Ms X: Well, some of them seem to work at the time but it all becomes very confusing, because here I am looking for another treatment. It can feel good to get away from the pain for a little while, but soon I will experience a pain flare bringing me back to square one.

 Therapist: I see what you are saying. Let me ask my earlier question in a different way. What would your life look like, and what would you be doing, if your pain were not the problem it is today?

 Ms X: I would be taking pictures again, be more consistent at work, and spend less time seeking treatments.

Therapist: So, is it your experience that the methods you have been using have helped you to live life this way?

Ms X: … I never thought about it that way ...

• What exercises or techniques are used in ACT?

In practice, ACT is somewhat unique in that it often relies on the use of metaphors and experiential exercises in treatment delivery. Metaphors and stories are used in treatment and communicated in terms that fit with the experience and background of the person seeking treatment. Although therapists can select from among many widely used and often appropriate metaphors and stories, an experienced therapist is likely to create patient specific metaphors “live,” within the context of a particular session. This is consistent with the philosophical underpinning of ACT in its aims for individual tailoring of methods. Unlike other current psychotherapeutic approaches that place a higher value on sticking to a specified protocol, the theory and philosophy behind ACT allow for flexibility and are open to creativity, individual style, and situational sensitivity of the therapist. This is expected to allow the patient to also adopt a similar sensitivity to changing environmental contingencies [19]. In ACT, the techniques typically do not follow a cookbook style of treatment delivery.

Case Continued

Therapist: What if trying to control your thoughts and feelings were not the answer?

Ms X: I have no idea what you mean.

Therapist: Well, you certainly have focused a lot of your effort on trying not to have the thoughts and feelings that seem to block you.

Ms X: What else is there to do, really?

Therapist: If you are willing to experiment with something, try this. Don’t think of a pineapple. (pause for 30 to 60 seconds). Ok, what happens.

Ms X: It didn’t work—I kept thinking about a pineapple.

Therapist: Weird, huh? Notice what is happening here. I wonder if some of your struggles with your experiences are just like this. It’s like by trying to get rid of something, there it is! I wonder if there were another way to do this, do you think you might be willing to test it out?

Ms X: Yes, I can try.

Further ACT Methods

ACT includes numerous experience-based methods and also direct rehearsal of targeted skills. In the previous scen-ario, the therapist might then proceed to instruction and practice of one or another type of acceptance-based skill, something like an “exposure” session or a mindfulness type of exercise that includes having the participant sit with the experience without doing anything else but observe it. The other type of method used includes metaphors that reveal how circumstances and behavior often work in life [4,16].

An Acceptance-Based Metaphor

Therapist: Imagine that you are new to the neighborhood and you invited all your neighbors over to a housewarming party. Everyone in the neighborhood is invited. On that day, the party’s going great, and here comes Joe, who smells and looks like he has not bathed in days. You are embarrassed by the way he looks and smells and try to close the door on him. However, he shows you a flyer that you put up stating that everyone in the neighborhood is invited. So you let him in and quickly shove him to the kitchen so that he will not embarrass you and disrupt your party. However, to stop him from leaving the kitchen, you end up having to stand guard at the doorway. Meanwhile the party is going on and your guests are enjoying themselves, but do you notice what else is happening here?

Ms X: I’ve stopped myself from enjoying my party in order to keep Joe away.

Therapist: What if your pain was like Joe?

Ms X: Huh? … Ah, I think I see what you are saying…

Therapist: It’s like if you allow Joe to simply be another guest, you can do whatever you like at your party. On the other hand, if you say “no” to Joe you also say “no” to the party.

Ms X: Are you saying that it is for me to choose?

• What is the role of therapist in modeling behavior change in ACT?

An important distinction can be made between talking about behavior change and doing behavior change. Within the psychological flexibility model the emphasis is placed on the latter. Here, especially through the use of experiential exercises, clients are put into contact with the experiences that have coordinated unhealthy behavior patterns in the past so that more effective behavior patterns can be acquired. Treatment delivery is guided by the underlying behavioral philosophy and theory. Patients learn to reduce the dominant influence of the literal meaning of language as the only tool for behavior change. Direct experience is moved to the front of awareness and literal meaning, mental and verbal analysis, and so forth, are moved to the back [20]. In treatment, the therapist models for the patient the behavior change processes that are being targeted and also may use examples from his or her life as well as that of the patient’s to develop psychological flexibility [22]. An example might include a therapist’s response to a person who shows an experience of emotional distress and struggling to manage this distress. Here the therapist, in line with ACT, instead of acting in some way to attempt to lessen the distress, would consciously show openness to the experiences and to their own reactions to helplessness around these experiences.

The therapist might say:

 “I would feel tired and probably in pain too if I did what you just did. Could we do a little closed-eyes exercise? Shall we put the distressing thought you are having on the table, and focus on it, and we can “observe” what your mind does, and what happens in your body and your emotions when that thought shows up? Are you willing?”

 “I’m feeling confused about this issue myself - how about both of us sitting quietly for a moment or two and observe what our minds do in response to this, just slowing things down, and watching?”

 “I feel anxious when I believe that my thoughts about pain are true - like I have to do something to make it go away but I don’t know how. What shows up for you when you believe such thoughts about pain?”

• How and when should ACT be used?

Based on current evidence how and when ACT ought to be used, as opposed to other treatment options, will be largely up to the individual professional and their level of competence. ACT is a form of CBT and many of the same guides pertain. In line with the pragmatic approach of ACT, an approach that makes ACT broadly applicable, there is no one particular manualised or scripted treatment protocol that must be adhered to in treatment for one specific condition or another. As mentioned earlier, the ACT approach does not usually follow a cookbook style of delivery, nor is it rigidly guided by strict protocols. There are protocols shared by researchers to support further development but there is no process by which these are deemed “official” or “recognized” or approved by anyone in particular.

A wide range of metaphors and exercises based on a set of behavioral principles that target a particular function has been proposed in ACT and this is part of its uniqueness as a therapeutic model.

Those developing ACT also have not required a standardised certification process to delivering ACT. Instead, they have chosen to create an open community of contributing researchers and clinicians who are “members” by virtue of their commitment to the same approach to clinical development and the same clinical model. Practicing ACT requires that the clinician is aware of their own competencies and delivers treatment accordingly.

• How effective is ACT?

Numerous studies have supported a general role of psychological flexibility in improving the well-being and physical functioning of patients with chronic pain, including patients in specialty care [24,28] and primary care [26]. Many studies support the particular role of acceptance of pain in adjustment to chronic pain [27–30]. Pain acceptance is a better predictor of outcomes than pain severity itself [31,32].

There are now several relatively large-scale studies conducted in actual clinical practice settings that demonstrate the effectiveness of ACT for chronic pain [25,27,33,34]. A more recent study, also conducted in an actual clinical practice setting, provided support for the specific treatment processes proposed within this approach [35]. This study showed that changes in traditionally conceived methods of pain management were unrelated to treatment improvements of pain intensity, physical disability, anxiety and depression for those who participated in treatment, while changes in psychological flexibility were consistently and significantly related to these improvements, with the exception of the results for depression.

Randomised Controlled Trials (RCTs)

To date, there are a total of 7 RCTs related to ACT and chronic pain [36–42], each providing supportive evidence. For example, in one of the early studies, Dahl and colleagues [36] showed that in comparison to treatment as usual, a group of workers who were at risk of long-term absenteeism from work due to pain or stress had a significant reduction in sick leave and healthcare usage after attending four hours of ACT sessions.

Wicksell and colleagues [37,38] conducted 2 separate RCTs with participants who suffered whiplash-associated disorder (WAD) and fibromyalgia, respectively. Post-treatment results of both RCTs showed an improvement in physical functioning, depression and psychological flexibility in the treatment group with gains maintained at follow-up. In addition, participants in the treatment group with WAD showed an improvement in life satisfaction and fear of movement while those in the treatment group with fibromyalgia showed significant improvements in fibromyalgia impact, self-efficacy and anxiety. There was however no change in pain intensity in those who received the ACT-based treatments.

An ACT-based treatment including a self-help manual showed a significant increase in acceptance, satisfaction in life with a higher level of function and decreased pain intensity compared with a wait-list condition and with applied relaxation (AR) [40]. In comparison to the AR condition, participants in the ACT condition also reported a significantly higher level of engagement in meaningful activities and a willingness to experience pain. Follow-up data support the maintenance of these improvements at first follow-up but differences were not significant at the second follow-up. Both depression and anxiety scores improved in both treatment groups.

Wetherell and colleagues [39] compared the effectiveness of ACT and traditional CBT and found that they both produced positive results. Results from the study also showed higher satisfaction in participants who attended ACT treatment than those that attended CBT treatment, suggesting that ACT “is an effective and acceptable” intervention for patients with chronic pain. Overall acceptance of pain was shown to differentiate patients who could function well with chronic pain from those that continued to suffer with it after treatment.

More recently the first internet-based RCT for ACT with chronic pain was conducted [41]. The authors found a reduction in measures of pain-related distress, depressive symptoms, and anxiety, with these gains maintained at 6 months follow-up in the ACT treatment group compared with controls. The most recent RCT was a pilot trial of a group-based treatment of people with chronic pain recruited from general practices in the UK [42]. Participants were randomised to either an ACT-based treatment or treatment as usual. Participants in the ACT-based group underwent 4 sessions each lasting 4 hours with the first 3 sessions completed in 1 week and the last session completed a week later. At 3 months follow-up, participants in the ACT group had lower disability, depression, and higher pain acceptance.

In general, results from the ACT-based RCTs on chronic pain support the efficacy of the treatment and reflect a high degree of versatility, based on the wide variety of modes of delivery tested. However, RCTs for chronic pain are still relatively few with some studies limited to small sample sizes, thus making it difficult to reach definitive conclusions on the general efficacy of ACT in chronic pain treatment. What the studies do seem to show is that ACT is a good alternative treatment option to more traditionally conceived current CBT-based treatments for chronic pain. Larger sample sizes and higher quality studies are needed to strengthen and establish the effectiveness of ACT and to understand the potential impact of wider implementation in clinical practice.

Meta-Analyses

A total of 4 meta-analyses [43–46] have been conducted on acceptance- or ACT-based treatment studies. Although the earlier meta-analyses [43,44] did not separately report the effectiveness of ACT for chronic pain, they reported a moderate effect size for ACT in general, with no evidence that ACT is more effective than established treatments.

Ruiz [46] conducted a review focusing on outcome or mediation/moderation type studies that compared ACT and CBT treatments. His review was not specific to chronic pain, although one study [39] involving a sample of chronic pain patients was included. Moderate effect sizes were found that favored ACT, with ACT showing a greater impact on change processes (g = 0.38) compared to no impact found in CBT (g = 0.05).

Essentially, only one meta-analysis [45] specifically reviewed the efficacy in chronic pain studies. Pain inten-sity and depression were selected as primary outcome measures, with anxiety, physical well-being, and quality of life selected as secondary outcomes. Out of 22 studies that were included in the review, only 2 studies [36,37] were ACT-based RCTs, with the rest of the studies mindfulness-based interventions. The overall effect size of 0.37 was found for pain and 0.32 for depression. In general, results showed significant effect sizes for both primary and secondary outcome measures in favor of the “acceptance-based treatments.” The authors concluded that at present, mindfulness-based stress reduction programs and ACT-based programs may not be superior to CBT but could be good alternatives for people with chronic pain.

The appropriateness of using pain intensity as a primary outcome measure for ACT-based studies is questionable [45]. The focus of ACT is to increase function rather than to reduce pain symptoms; hence possibly including interference of pain in daily life might be a more appropriate outcome measure.

Other Studies

A particularly important question to answer about ACT concerns its cost-effectivness, and we still know relatively little about this. We do know that when people participate in ACT-based treatments they are able to reduce medication use and health care visits and return to work after extended periods away from work [27,28]. It remains to conduct full health economic analyses of this type of approach for chronic pain.

ACT is known to produce significant benefits widely, in other applications apart from chronic pain, such as in workplace stress [47], psychosis [48], obsessive-compulsive disorder [49], and depression [50], among other mental health conditions [51].

• What are implications for policy makers?

Results from studies of ACT in chronic pain and in other areas are disseminating rapidly. This dissemination is aided in part by a professional organization devoted to ACT and psychological flexibility (Association for Contextual Behavioral Science; www.contextualscience.org), which has a new journal, the Journal of Contextual Behavioral Science, started in 2012.

With the development of ACT a focus on implementation, training, and treatment integrity began early. There was an implementation study of ACT was published by Strosahl and colleagues in 1998. Their study showed that training clinicians in ACT produced better outcomes and better treatment completion rates in an outpatient setting in comparison to clinicians not receiving this training.

Processes of training have also appeared during relatively early phases of research into ACT. Lappalainen and colleagues [52] compared the impact of treatment provided by trainee therapists trained in both a traditional CBT model and ACT. Here each trainee therapist treated one patient with traditional CBT and one with ACT. Although the therapists reported higher confidence in delivering traditional CBT, patients treated within an ACT model showed better symptoms improvement. Also, improved acceptance during treatment significantly predicted improvements across both groups of patients. Essentially, therapists with only a limited amount of training in both models demonstrated better clinical results with ACT.

A group-based ACT intervention has also been shown to be effective in reducing stress and improving the professional performance of clinical psychology trainees [53]. Here the trainees found the intervention personally and professionally useful and a majority showed a significant increase in psychological flexibility. This supports the applicability of ACT not only as a model to guide therapy but also as a model to guide training and professional performance [54]. Other results in a pain management setting show that transitioning to ACT as a treatment model can have similar benefits and may increase job satisfaction and staff well-
being [55].

• What are criticisms of ACT?

Many strong supporters of cognitive therapy and more traditional versions of CBT in the field claim that ACT is not new nor better than other current versions of CBT [56]. The proponents of ACT openly acknowledge that many methods used within ACT are adopted or modified from other established therapies [4]. Criticisms are not specific to the application of ACT with chronic pain but are based on others’ perceptions of ACT as a treatment approach and treatment techniques used in ACT in general.

Ost [43] criticised ACT and the third-wave therapies on 2 main grounds. First, he concluded that ACT and the rest of the third-wave therapies were not meeting the criteria of empirically supported treatments. He further concluded that there is no strong evidence to show that ACT is more effective than cognitive therapy. The methods of the Ost review have been challenged [57], yet to a certain degree the points raised are correct. Most of the limitations noted reflect a difference in the maturity of the evidence base for ACT versus traditional CBT-based approaches. Indeed, in comparison to CBT, which is the most empirically established form of psychotherapy and an active area of research for more than 40 years, ACT can be considered to be in its infancy stage of empirically supported treatments, where treatment evidence and availability of high-quality RCTs in general are few at present. Specific research on ACT for chronic pain though supportive is still preliminary to a certain degree. Even so, ACT for pain is regarded as an empirically supported treatment by the body within the American Psychological Association authorized to make this determination [58].

Conclusion

ACT is essentially a form of CBT, considered broadly. ACT brings with it a different philosophy and approach to science compared with some other forms of CBT—this can lead to some distinctive strategies and methods in treatment for chronic pain. Like traditionally designed CBT, however, ACT similarly aims for behavior change as the end point.

ACT is grounded in specific philosophical assumptions and includes the model of psychological flexibility at its core. Preliminary findings in broad clinical and nonclinical populations support the efficacy, effectiveness, and processes in the psychological flexibility model as mediators of change, in ACT [46,59]. Research has shown that most of the 6 ACT processes, all of those so far investigated, correlate with improved daily functioning and emotional well-being in patients with chronic pain. The evidence base for ACT is still developing. Larger trials, more carefully designed trials, and a continued focus on processes of change will be needed to strengthen this base.

Corresponding author: Su-Yin Yang, Health Psychology Section, Psychology Department, Institute of Psychiatry, King’s College London, 5th Fl, Bermondsey Wing, Guy’s Campus, London SE1 9RT, su-yin.yang@kcl.ac.uk.

Financial disclosures: None.

Author contributions: conception and design, SY, LMM; analysis and interpretation of data, SY; drafting of article, SY, LMM; critical revision of the article, LMM; administrative or technical support, LMM; collection and assembly of data, SY.

Abstract

• Objective: To describe Acceptance and Commitment Therapy (ACT) and its application in the treatment of chronic pain.
• Methods: Review of the theoretical and clinical literature and presentation of a case example.
• Results: General cognitive behavioral approaches for chronic pain have a consistent and large evidence base supporting their benefits. Even so, these treatments continue to develop with the aim to improve. One example of a relatively new development within the cognitive behavioral approaches is ACT, a treatment that focuses on increasing psychological flexibility. Here we describe ACT and the therapeutic model on which it is based, present its distinguishing features, and summarize the evidence for it as a treatment for chronic pain. We also discuss such issues as dissemination, implementation, and training.
• Conclusion: There are now 7 randomized controlled trials, a number of innovative uncontrolled trials, and at least 1 systematic review that support the clinical efficacy and effectiveness of ACT for chronic pain. Further research and development of this approach is underway.

The introduction of the gate control theory of pain [1] in 1965, among other events, signaled a shift in our understanding of pain, particularly chronic pain. This shift, which continues today, is a shift from a predominantly biomedical model of chronic pain to a biospsychosocial model. This model, as the name suggests, includes psycho-social influences in a key role in relation to the experience of pain and the impact of this experience. During this same period of time, psychosocial models and treatment methods have also shifted and evolved. This evolution has included the operant approach [2], the cognitive behavioral approach [3], and the latest developments, contextual cognitive behavioral approaches [4,5], among which Acceptance and Commitment Therapy (ACT) and mindfulness-based therapies are key examples.

Until about 10 years ago, the mainstream of psycho-logical treatments for chronic pain and other physical health problems was dominated almost exclusively by concepts and methods of what we will refer to as “traditional” cognitive behavioral therapy (CBT). Specific constructs within what is called the “common sense model” [6], such as illness perceptions, beliefs about control over one’s illness, amongst other constructs such as self-efficacy, catastrophising, fear avoidance, and pain-related anxiety, captured a substantial focus of research and treatment development during most of the past 3 decades [7]. The treatment methods that have emerged and persisted from this work have included relaxation, attention-based and cognitive coping strategies, cognitive restructuring, the use of imagery, and certain activity management strategies [8]. However, despite consistent supportive evidence for CBT interventions for chronic pain [9], there remain gaps and areas of relative weakness, both in the conceptual models underlying this work and in the base of evidence. Research clearly shows that not all patients benefit from traditional CBT interventions, and recent reviews of CBT for chronic pain generally show effect sizes that are usually small or mediumat best [9–11].

The Problem with Pain

Pain hurts and is often viewed as harmful, and this leads to fear or anxiety, avoidance, or attempts to control the pain. Seeking to control pain is entirely natural and even seems necessary to reduce the undesirable effects of pain in one’s life.

Dependent on the situation, pain avoidance, sometimes also referred to as “fear avoidance,” in studies of chronic pain can present itself in many forms. Avoidance behavior can include refusal to engage in any activity believed to cause an increase in pain. It may also include “guarding” or bracing around an area of pain, information seeking, treatment seeking, taking medications, overdosing on medications, using aids like heat or ice, withdrawing from social activity, as well as being unwilling to talk about emotional experiences, amongst others [5]. Today, avoidance is recognized as a key foundation element in pain-related suffering and disability [12], and addressing it effectively has become a prime focus in many or most current treatments.

Acceptance and Psychological Flexibility

In recent years, the concept of “acceptance” has gained prominence as a potentially important process for addressing a broad array of psychological problems, including those associated with chronic pain. From this new interest, a fundamentally different treatment emphasis has emerged. This includes a shift away from a predominant focus on changing thoughts and feelings, a focus sometimes adopted within some traditional CBT methods, towards a focus on reducing the influence of thoughts and feelings on our actions instead. This can be a rather confusing distinction. This is because the influence of our thoughts and feelings is often automatic and even invisible to us as it occurs. As such, the influences of our thoughts and feelings appear directly tied to the content of thoughts and feelings, but the matter is not that simple. Clearly there are occasions when our actions contradict our thoughts and feelings, such as when we have perfectly confident beliefs and fail, or significant anxiety and perform successfully. Such instances illustrate what we might call a “2-dimensional” quality of experience; it is the content of experience and the context of experience that determine the influence exerted. Suffice it to say acceptance-based methods are designed to address the difference between experiences that are difficult to control, such as thoughts and feelings, and things that are easier to control: the actions we take in relation to our thoughts and feelings. They do this by taking a focus on creating changes in context and ultimately in behavior. Acceptance includes especially a focus on allowing or opening up to feelings rather than struggling with them or retreating from them. Here, the capacity for openness is a contextual process.

Acceptance methods are not used in isolation. They are usually used in combination with other traditional behavior change strategies, with methods to facilitate values clarification, committed action, and other methods from ACT. Notions of acceptance have even been incorporated into many behavioral and cognitive therapies before, including dialectical behavior therapy [13] and mindfulness-based treatment [14,15], and so this process is not the exclusive domain of ACT. In implementing acceptance-based methods, patients are taught skills, such as to (a) notice feelings specifically in detail, (b) notice that thoughts about pain are products of thinking and not the same as direct experience, (c) notice urges to struggle with thoughts and feelings, (d) to practice refraining from struggling and adopt an observing, allowing, and “making room”–type posture, and (e) take action in line with their goals [4,5].

The wider processes around acceptance in combination are referred to as psychological flexibility [16]. Psychological flexibility relates to one’s ability to directly contact the present moment; to be aware of the thoughts, feelings and potentially unwanted internal experiences it brings; and to follow through with a behavior change or persist with a chosen behavior in the direction of chosen values. Psychological flexibility is the model for psychological health from an ACT perspective [17].

Psychological Flexibility and the 6 Core ACT Processes

Acceptance

Acceptance involves the patients’ willingness to have pain while remaining able to actively choose to continue participating in their life as they want it to be. ACT encour-ages patients to act in ways that are consistent with direct experiences rather than what the mind interprets these events to mean.

Cognitive Defusion

Cognitive defusion is the process of modifying one’s reaction to thoughts by constructing contexts where the influences of these thoughts on behavior are lessened [18]. Unlike traditional cognitive behavior approaches, in ACT it is not the content and actual validity of these thoughts that is challenged but the functions, or influences, of thoughts [19].

Present Moment Awareness

Contact with the present moment reflects the process wherein the person is aware of the situation in “the now” as opposed to focusing on events that happened in the past or might happen in the future [18]. To be “present” requires the individual to flexibly focus attention on experiences as they are happening in the environment, in real time, and to be fully open to what is taking place [20]. It is important the individual is able to notice when he or she is not acting in relation to the present moment and has the ability to shift attention to the present if this shift benefits them.

Self as Context

The sense of self-as-context or self-as-observer is considered the ability to adopt a perspective or point of view that is separate from and not defined by thoughts and feelings or even the physical body. This contrasts a sense of self as made up of personality characteristics, self-evaluations, or a narrative about who we are [5,16]. In ACT, perspective taking can be trained to help people connect with the experience of a distinction between self and psychological experiences. From this, one can choose to follow one’s inner verbal constructions of what defines us, our “stories” of who we are, in certain situations when it works to do so, and not in situations where it leads to unhealthy responses and behavioral restriction.

Values

Values are defined as guiding principles in one’s life. Values are often contrasted with goals, where the difference is that goals can be achieved while values are part of an ongoing process of action and cannot be completed once and for all. In a sense, goals represent set plans of action to be achieved while values are general life directions. If life is like a journey, then goals would be the chosen destination and values would simply be represented by a general direction of travel. Values are helpful when patients struggle with unwanted internal experiences like pain, as they not only serve as a guide for the client to persist in behavior change but also function as a motivating element. Values clarification exercise in therapy encourages the patient to define their values in specific domains of “career, family, intimate relationships, friendships, health, education and spirituality” [4,21] regardless of the primary problem. Personally chosen and clarified values can function as guides when people have difficulty initiating and maintaining behavior change in the presence of unwanted internal experiences.

Committed Action

Committed action is an ongoing process of redirecting behavior in order to create patterns of flexible and effective action in line with a defined value [22]. Patients are encouraged to follow through with their chosen actions that are in line with their values, and to persist or alter their course flexibly. Without the capacity for committed action, behavior change is less likely to persist and integrate into patterns of behavior more generally.

Case Study

Initial Presentation and History

Ms X, a 45-year-old woman, presents with the chief complaint of low back pain, which she has experienced for 3 years. She works part-time due to her pain problem. When she is not at work, she busies herself with seeking both conventional and alternative treatments for her pain condition. In the past, during periods where she experienced pain relief, she attempted to engage in her hobby of photography. However, this often led to a pain flare the next day and required 2 to 3 days of medical leave with increased medication from her PCP before she is able to return to work. As a result, Ms X chose to give up her hobby and focus on treating her pain instead. Ms X in in a constant struggle with her pain condition and believes that she can only return to photography, and live a more normal life, after her pain is cured.

• What are considerations for applying ACT in this scenario?

From an ACT conceptualization this case shows patterns of avoidance that are apparently not helping the person to reach her goals but are causing her distress and restrictions in functioning. An ACT therapist would approach this scenario by first reflecting how normal it is to struggle with pain and stop activities when in pain. From there they might (a) identify what the patient wants from treatment, (b) look at what has been done so far to attain this, (c) examine how well those things have been working, (d) consider the costs of the approach being taken, and (e) if the approach is not working and the cost is high, see if the patient is willing to stop this approach [23].

Therapist’s Initial Approach

Therapist: By what you have told me, your pain has become a big problem for you and it has been going on a long time—3 years. I can see some of the impacts it has had in your life, such as on your work, your photography, and time spent seeking treatment.

Ms X: Yes, it seems like pain has taken over …

Therapist: Exactly, it seems that is a good way to say it. So, understanding that pain has taken over, can I ask you another question?

Ms X: If your question will help me get over this problem, of course.

Therapist: Ok. What is it you want from coming here to participate in this treatment?

Ms X: Well, I want to get rid of this pain, obviously. It’s ruining my life.

Therapist: Ah, that makes sense. You want to eliminate your pain because it has, as you say, ruined your life, and then I guess your life will be better again.

Ms X: Correct.

Therapist: So, can I check in with the things you have been doing so far to reach this goal to eliminate pain?

 Ms X: You name it, I’ve tried it: acupuncture, medication, herbs, rest, exercise, magnets, yoga, and more.

 Therapist: Ok, you have tried many treatments focused on trying to get rid of the pain. I think that’s a very natural thing to do. In your experience have these methods been successful?

 Ms X: Well, some of them seem to work at the time but it all becomes very confusing, because here I am looking for another treatment. It can feel good to get away from the pain for a little while, but soon I will experience a pain flare bringing me back to square one.

 Therapist: I see what you are saying. Let me ask my earlier question in a different way. What would your life look like, and what would you be doing, if your pain were not the problem it is today?

 Ms X: I would be taking pictures again, be more consistent at work, and spend less time seeking treatments.

Therapist: So, is it your experience that the methods you have been using have helped you to live life this way?

Ms X: … I never thought about it that way ...

• What exercises or techniques are used in ACT?

In practice, ACT is somewhat unique in that it often relies on the use of metaphors and experiential exercises in treatment delivery. Metaphors and stories are used in treatment and communicated in terms that fit with the experience and background of the person seeking treatment. Although therapists can select from among many widely used and often appropriate metaphors and stories, an experienced therapist is likely to create patient specific metaphors “live,” within the context of a particular session. This is consistent with the philosophical underpinning of ACT in its aims for individual tailoring of methods. Unlike other current psychotherapeutic approaches that place a higher value on sticking to a specified protocol, the theory and philosophy behind ACT allow for flexibility and are open to creativity, individual style, and situational sensitivity of the therapist. This is expected to allow the patient to also adopt a similar sensitivity to changing environmental contingencies [19]. In ACT, the techniques typically do not follow a cookbook style of treatment delivery.

Case Continued

Therapist: What if trying to control your thoughts and feelings were not the answer?

Ms X: I have no idea what you mean.

Therapist: Well, you certainly have focused a lot of your effort on trying not to have the thoughts and feelings that seem to block you.

Ms X: What else is there to do, really?

Therapist: If you are willing to experiment with something, try this. Don’t think of a pineapple. (pause for 30 to 60 seconds). Ok, what happens.

Ms X: It didn’t work—I kept thinking about a pineapple.

Therapist: Weird, huh? Notice what is happening here. I wonder if some of your struggles with your experiences are just like this. It’s like by trying to get rid of something, there it is! I wonder if there were another way to do this, do you think you might be willing to test it out?

Ms X: Yes, I can try.

Further ACT Methods

ACT includes numerous experience-based methods and also direct rehearsal of targeted skills. In the previous scen-ario, the therapist might then proceed to instruction and practice of one or another type of acceptance-based skill, something like an “exposure” session or a mindfulness type of exercise that includes having the participant sit with the experience without doing anything else but observe it. The other type of method used includes metaphors that reveal how circumstances and behavior often work in life [4,16].

An Acceptance-Based Metaphor

Therapist: Imagine that you are new to the neighborhood and you invited all your neighbors over to a housewarming party. Everyone in the neighborhood is invited. On that day, the party’s going great, and here comes Joe, who smells and looks like he has not bathed in days. You are embarrassed by the way he looks and smells and try to close the door on him. However, he shows you a flyer that you put up stating that everyone in the neighborhood is invited. So you let him in and quickly shove him to the kitchen so that he will not embarrass you and disrupt your party. However, to stop him from leaving the kitchen, you end up having to stand guard at the doorway. Meanwhile the party is going on and your guests are enjoying themselves, but do you notice what else is happening here?

Ms X: I’ve stopped myself from enjoying my party in order to keep Joe away.

Therapist: What if your pain was like Joe?

Ms X: Huh? … Ah, I think I see what you are saying…

Therapist: It’s like if you allow Joe to simply be another guest, you can do whatever you like at your party. On the other hand, if you say “no” to Joe you also say “no” to the party.

Ms X: Are you saying that it is for me to choose?

• What is the role of therapist in modeling behavior change in ACT?

An important distinction can be made between talking about behavior change and doing behavior change. Within the psychological flexibility model the emphasis is placed on the latter. Here, especially through the use of experiential exercises, clients are put into contact with the experiences that have coordinated unhealthy behavior patterns in the past so that more effective behavior patterns can be acquired. Treatment delivery is guided by the underlying behavioral philosophy and theory. Patients learn to reduce the dominant influence of the literal meaning of language as the only tool for behavior change. Direct experience is moved to the front of awareness and literal meaning, mental and verbal analysis, and so forth, are moved to the back [20]. In treatment, the therapist models for the patient the behavior change processes that are being targeted and also may use examples from his or her life as well as that of the patient’s to develop psychological flexibility [22]. An example might include a therapist’s response to a person who shows an experience of emotional distress and struggling to manage this distress. Here the therapist, in line with ACT, instead of acting in some way to attempt to lessen the distress, would consciously show openness to the experiences and to their own reactions to helplessness around these experiences.

The therapist might say:

 “I would feel tired and probably in pain too if I did what you just did. Could we do a little closed-eyes exercise? Shall we put the distressing thought you are having on the table, and focus on it, and we can “observe” what your mind does, and what happens in your body and your emotions when that thought shows up? Are you willing?”

 “I’m feeling confused about this issue myself - how about both of us sitting quietly for a moment or two and observe what our minds do in response to this, just slowing things down, and watching?”

 “I feel anxious when I believe that my thoughts about pain are true - like I have to do something to make it go away but I don’t know how. What shows up for you when you believe such thoughts about pain?”

• How and when should ACT be used?

Based on current evidence how and when ACT ought to be used, as opposed to other treatment options, will be largely up to the individual professional and their level of competence. ACT is a form of CBT and many of the same guides pertain. In line with the pragmatic approach of ACT, an approach that makes ACT broadly applicable, there is no one particular manualised or scripted treatment protocol that must be adhered to in treatment for one specific condition or another. As mentioned earlier, the ACT approach does not usually follow a cookbook style of delivery, nor is it rigidly guided by strict protocols. There are protocols shared by researchers to support further development but there is no process by which these are deemed “official” or “recognized” or approved by anyone in particular.

A wide range of metaphors and exercises based on a set of behavioral principles that target a particular function has been proposed in ACT and this is part of its uniqueness as a therapeutic model.

Those developing ACT also have not required a standardised certification process to delivering ACT. Instead, they have chosen to create an open community of contributing researchers and clinicians who are “members” by virtue of their commitment to the same approach to clinical development and the same clinical model. Practicing ACT requires that the clinician is aware of their own competencies and delivers treatment accordingly.

• How effective is ACT?

Numerous studies have supported a general role of psychological flexibility in improving the well-being and physical functioning of patients with chronic pain, including patients in specialty care [24,28] and primary care [26]. Many studies support the particular role of acceptance of pain in adjustment to chronic pain [27–30]. Pain acceptance is a better predictor of outcomes than pain severity itself [31,32].

There are now several relatively large-scale studies conducted in actual clinical practice settings that demonstrate the effectiveness of ACT for chronic pain [25,27,33,34]. A more recent study, also conducted in an actual clinical practice setting, provided support for the specific treatment processes proposed within this approach [35]. This study showed that changes in traditionally conceived methods of pain management were unrelated to treatment improvements of pain intensity, physical disability, anxiety and depression for those who participated in treatment, while changes in psychological flexibility were consistently and significantly related to these improvements, with the exception of the results for depression.

Randomised Controlled Trials (RCTs)

To date, there are a total of 7 RCTs related to ACT and chronic pain [36–42], each providing supportive evidence. For example, in one of the early studies, Dahl and colleagues [36] showed that in comparison to treatment as usual, a group of workers who were at risk of long-term absenteeism from work due to pain or stress had a significant reduction in sick leave and healthcare usage after attending four hours of ACT sessions.

Wicksell and colleagues [37,38] conducted 2 separate RCTs with participants who suffered whiplash-associated disorder (WAD) and fibromyalgia, respectively. Post-treatment results of both RCTs showed an improvement in physical functioning, depression and psychological flexibility in the treatment group with gains maintained at follow-up. In addition, participants in the treatment group with WAD showed an improvement in life satisfaction and fear of movement while those in the treatment group with fibromyalgia showed significant improvements in fibromyalgia impact, self-efficacy and anxiety. There was however no change in pain intensity in those who received the ACT-based treatments.

An ACT-based treatment including a self-help manual showed a significant increase in acceptance, satisfaction in life with a higher level of function and decreased pain intensity compared with a wait-list condition and with applied relaxation (AR) [40]. In comparison to the AR condition, participants in the ACT condition also reported a significantly higher level of engagement in meaningful activities and a willingness to experience pain. Follow-up data support the maintenance of these improvements at first follow-up but differences were not significant at the second follow-up. Both depression and anxiety scores improved in both treatment groups.

Wetherell and colleagues [39] compared the effectiveness of ACT and traditional CBT and found that they both produced positive results. Results from the study also showed higher satisfaction in participants who attended ACT treatment than those that attended CBT treatment, suggesting that ACT “is an effective and acceptable” intervention for patients with chronic pain. Overall acceptance of pain was shown to differentiate patients who could function well with chronic pain from those that continued to suffer with it after treatment.

More recently the first internet-based RCT for ACT with chronic pain was conducted [41]. The authors found a reduction in measures of pain-related distress, depressive symptoms, and anxiety, with these gains maintained at 6 months follow-up in the ACT treatment group compared with controls. The most recent RCT was a pilot trial of a group-based treatment of people with chronic pain recruited from general practices in the UK [42]. Participants were randomised to either an ACT-based treatment or treatment as usual. Participants in the ACT-based group underwent 4 sessions each lasting 4 hours with the first 3 sessions completed in 1 week and the last session completed a week later. At 3 months follow-up, participants in the ACT group had lower disability, depression, and higher pain acceptance.

In general, results from the ACT-based RCTs on chronic pain support the efficacy of the treatment and reflect a high degree of versatility, based on the wide variety of modes of delivery tested. However, RCTs for chronic pain are still relatively few with some studies limited to small sample sizes, thus making it difficult to reach definitive conclusions on the general efficacy of ACT in chronic pain treatment. What the studies do seem to show is that ACT is a good alternative treatment option to more traditionally conceived current CBT-based treatments for chronic pain. Larger sample sizes and higher quality studies are needed to strengthen and establish the effectiveness of ACT and to understand the potential impact of wider implementation in clinical practice.

Meta-Analyses

A total of 4 meta-analyses [43–46] have been conducted on acceptance- or ACT-based treatment studies. Although the earlier meta-analyses [43,44] did not separately report the effectiveness of ACT for chronic pain, they reported a moderate effect size for ACT in general, with no evidence that ACT is more effective than established treatments.

Ruiz [46] conducted a review focusing on outcome or mediation/moderation type studies that compared ACT and CBT treatments. His review was not specific to chronic pain, although one study [39] involving a sample of chronic pain patients was included. Moderate effect sizes were found that favored ACT, with ACT showing a greater impact on change processes (g = 0.38) compared to no impact found in CBT (g = 0.05).

Essentially, only one meta-analysis [45] specifically reviewed the efficacy in chronic pain studies. Pain inten-sity and depression were selected as primary outcome measures, with anxiety, physical well-being, and quality of life selected as secondary outcomes. Out of 22 studies that were included in the review, only 2 studies [36,37] were ACT-based RCTs, with the rest of the studies mindfulness-based interventions. The overall effect size of 0.37 was found for pain and 0.32 for depression. In general, results showed significant effect sizes for both primary and secondary outcome measures in favor of the “acceptance-based treatments.” The authors concluded that at present, mindfulness-based stress reduction programs and ACT-based programs may not be superior to CBT but could be good alternatives for people with chronic pain.

The appropriateness of using pain intensity as a primary outcome measure for ACT-based studies is questionable [45]. The focus of ACT is to increase function rather than to reduce pain symptoms; hence possibly including interference of pain in daily life might be a more appropriate outcome measure.

Other Studies

A particularly important question to answer about ACT concerns its cost-effectivness, and we still know relatively little about this. We do know that when people participate in ACT-based treatments they are able to reduce medication use and health care visits and return to work after extended periods away from work [27,28]. It remains to conduct full health economic analyses of this type of approach for chronic pain.

ACT is known to produce significant benefits widely, in other applications apart from chronic pain, such as in workplace stress [47], psychosis [48], obsessive-compulsive disorder [49], and depression [50], among other mental health conditions [51].

• What are implications for policy makers?

Results from studies of ACT in chronic pain and in other areas are disseminating rapidly. This dissemination is aided in part by a professional organization devoted to ACT and psychological flexibility (Association for Contextual Behavioral Science; www.contextualscience.org), which has a new journal, the Journal of Contextual Behavioral Science, started in 2012.

With the development of ACT a focus on implementation, training, and treatment integrity began early. There was an implementation study of ACT was published by Strosahl and colleagues in 1998. Their study showed that training clinicians in ACT produced better outcomes and better treatment completion rates in an outpatient setting in comparison to clinicians not receiving this training.

Processes of training have also appeared during relatively early phases of research into ACT. Lappalainen and colleagues [52] compared the impact of treatment provided by trainee therapists trained in both a traditional CBT model and ACT. Here each trainee therapist treated one patient with traditional CBT and one with ACT. Although the therapists reported higher confidence in delivering traditional CBT, patients treated within an ACT model showed better symptoms improvement. Also, improved acceptance during treatment significantly predicted improvements across both groups of patients. Essentially, therapists with only a limited amount of training in both models demonstrated better clinical results with ACT.

A group-based ACT intervention has also been shown to be effective in reducing stress and improving the professional performance of clinical psychology trainees [53]. Here the trainees found the intervention personally and professionally useful and a majority showed a significant increase in psychological flexibility. This supports the applicability of ACT not only as a model to guide therapy but also as a model to guide training and professional performance [54]. Other results in a pain management setting show that transitioning to ACT as a treatment model can have similar benefits and may increase job satisfaction and staff well-
being [55].

• What are criticisms of ACT?

Many strong supporters of cognitive therapy and more traditional versions of CBT in the field claim that ACT is not new nor better than other current versions of CBT [56]. The proponents of ACT openly acknowledge that many methods used within ACT are adopted or modified from other established therapies [4]. Criticisms are not specific to the application of ACT with chronic pain but are based on others’ perceptions of ACT as a treatment approach and treatment techniques used in ACT in general.

Ost [43] criticised ACT and the third-wave therapies on 2 main grounds. First, he concluded that ACT and the rest of the third-wave therapies were not meeting the criteria of empirically supported treatments. He further concluded that there is no strong evidence to show that ACT is more effective than cognitive therapy. The methods of the Ost review have been challenged [57], yet to a certain degree the points raised are correct. Most of the limitations noted reflect a difference in the maturity of the evidence base for ACT versus traditional CBT-based approaches. Indeed, in comparison to CBT, which is the most empirically established form of psychotherapy and an active area of research for more than 40 years, ACT can be considered to be in its infancy stage of empirically supported treatments, where treatment evidence and availability of high-quality RCTs in general are few at present. Specific research on ACT for chronic pain though supportive is still preliminary to a certain degree. Even so, ACT for pain is regarded as an empirically supported treatment by the body within the American Psychological Association authorized to make this determination [58].

Conclusion

ACT is essentially a form of CBT, considered broadly. ACT brings with it a different philosophy and approach to science compared with some other forms of CBT—this can lead to some distinctive strategies and methods in treatment for chronic pain. Like traditionally designed CBT, however, ACT similarly aims for behavior change as the end point.

ACT is grounded in specific philosophical assumptions and includes the model of psychological flexibility at its core. Preliminary findings in broad clinical and nonclinical populations support the efficacy, effectiveness, and processes in the psychological flexibility model as mediators of change, in ACT [46,59]. Research has shown that most of the 6 ACT processes, all of those so far investigated, correlate with improved daily functioning and emotional well-being in patients with chronic pain. The evidence base for ACT is still developing. Larger trials, more carefully designed trials, and a continued focus on processes of change will be needed to strengthen this base.

Corresponding author: Su-Yin Yang, Health Psychology Section, Psychology Department, Institute of Psychiatry, King’s College London, 5th Fl, Bermondsey Wing, Guy’s Campus, London SE1 9RT, su-yin.yang@kcl.ac.uk.

Financial disclosures: None.

Author contributions: conception and design, SY, LMM; analysis and interpretation of data, SY; drafting of article, SY, LMM; critical revision of the article, LMM; administrative or technical support, LMM; collection and assembly of data, SY.

Abstract

• Objective: To describe Acceptance and Commitment Therapy (ACT) and its application in the treatment of chronic pain.
• Methods: Review of the theoretical and clinical literature and presentation of a case example.
• Results: General cognitive behavioral approaches for chronic pain have a consistent and large evidence base supporting their benefits. Even so, these treatments continue to develop with the aim to improve. One example of a relatively new development within the cognitive behavioral approaches is ACT, a treatment that focuses on increasing psychological flexibility. Here we describe ACT and the therapeutic model on which it is based, present its distinguishing features, and summarize the evidence for it as a treatment for chronic pain. We also discuss such issues as dissemination, implementation, and training.
• Conclusion: There are now 7 randomized controlled trials, a number of innovative uncontrolled trials, and at least 1 systematic review that support the clinical efficacy and effectiveness of ACT for chronic pain. Further research and development of this approach is underway.

The introduction of the gate control theory of pain [1] in 1965, among other events, signaled a shift in our understanding of pain, particularly chronic pain. This shift, which continues today, is a shift from a predominantly biomedical model of chronic pain to a biospsychosocial model. This model, as the name suggests, includes psycho-social influences in a key role in relation to the experience of pain and the impact of this experience. During this same period of time, psychosocial models and treatment methods have also shifted and evolved. This evolution has included the operant approach [2], the cognitive behavioral approach [3], and the latest developments, contextual cognitive behavioral approaches [4,5], among which Acceptance and Commitment Therapy (ACT) and mindfulness-based therapies are key examples.

Until about 10 years ago, the mainstream of psycho-logical treatments for chronic pain and other physical health problems was dominated almost exclusively by concepts and methods of what we will refer to as “traditional” cognitive behavioral therapy (CBT). Specific constructs within what is called the “common sense model” [6], such as illness perceptions, beliefs about control over one’s illness, amongst other constructs such as self-efficacy, catastrophising, fear avoidance, and pain-related anxiety, captured a substantial focus of research and treatment development during most of the past 3 decades [7]. The treatment methods that have emerged and persisted from this work have included relaxation, attention-based and cognitive coping strategies, cognitive restructuring, the use of imagery, and certain activity management strategies [8]. However, despite consistent supportive evidence for CBT interventions for chronic pain [9], there remain gaps and areas of relative weakness, both in the conceptual models underlying this work and in the base of evidence. Research clearly shows that not all patients benefit from traditional CBT interventions, and recent reviews of CBT for chronic pain generally show effect sizes that are usually small or mediumat best [9–11].

The Problem with Pain

Pain hurts and is often viewed as harmful, and this leads to fear or anxiety, avoidance, or attempts to control the pain. Seeking to control pain is entirely natural and even seems necessary to reduce the undesirable effects of pain in one’s life.

Dependent on the situation, pain avoidance, sometimes also referred to as “fear avoidance,” in studies of chronic pain can present itself in many forms. Avoidance behavior can include refusal to engage in any activity believed to cause an increase in pain. It may also include “guarding” or bracing around an area of pain, information seeking, treatment seeking, taking medications, overdosing on medications, using aids like heat or ice, withdrawing from social activity, as well as being unwilling to talk about emotional experiences, amongst others [5]. Today, avoidance is recognized as a key foundation element in pain-related suffering and disability [12], and addressing it effectively has become a prime focus in many or most current treatments.

Acceptance and Psychological Flexibility

In recent years, the concept of “acceptance” has gained prominence as a potentially important process for addressing a broad array of psychological problems, including those associated with chronic pain. From this new interest, a fundamentally different treatment emphasis has emerged. This includes a shift away from a predominant focus on changing thoughts and feelings, a focus sometimes adopted within some traditional CBT methods, towards a focus on reducing the influence of thoughts and feelings on our actions instead. This can be a rather confusing distinction. This is because the influence of our thoughts and feelings is often automatic and even invisible to us as it occurs. As such, the influences of our thoughts and feelings appear directly tied to the content of thoughts and feelings, but the matter is not that simple. Clearly there are occasions when our actions contradict our thoughts and feelings, such as when we have perfectly confident beliefs and fail, or significant anxiety and perform successfully. Such instances illustrate what we might call a “2-dimensional” quality of experience; it is the content of experience and the context of experience that determine the influence exerted. Suffice it to say acceptance-based methods are designed to address the difference between experiences that are difficult to control, such as thoughts and feelings, and things that are easier to control: the actions we take in relation to our thoughts and feelings. They do this by taking a focus on creating changes in context and ultimately in behavior. Acceptance includes especially a focus on allowing or opening up to feelings rather than struggling with them or retreating from them. Here, the capacity for openness is a contextual process.

Acceptance methods are not used in isolation. They are usually used in combination with other traditional behavior change strategies, with methods to facilitate values clarification, committed action, and other methods from ACT. Notions of acceptance have even been incorporated into many behavioral and cognitive therapies before, including dialectical behavior therapy [13] and mindfulness-based treatment [14,15], and so this process is not the exclusive domain of ACT. In implementing acceptance-based methods, patients are taught skills, such as to (a) notice feelings specifically in detail, (b) notice that thoughts about pain are products of thinking and not the same as direct experience, (c) notice urges to struggle with thoughts and feelings, (d) to practice refraining from struggling and adopt an observing, allowing, and “making room”–type posture, and (e) take action in line with their goals [4,5].

The wider processes around acceptance in combination are referred to as psychological flexibility [16]. Psychological flexibility relates to one’s ability to directly contact the present moment; to be aware of the thoughts, feelings and potentially unwanted internal experiences it brings; and to follow through with a behavior change or persist with a chosen behavior in the direction of chosen values. Psychological flexibility is the model for psychological health from an ACT perspective [17].

Psychological Flexibility and the 6 Core ACT Processes

Acceptance

Acceptance involves the patients’ willingness to have pain while remaining able to actively choose to continue participating in their life as they want it to be. ACT encour-ages patients to act in ways that are consistent with direct experiences rather than what the mind interprets these events to mean.

Cognitive Defusion

Cognitive defusion is the process of modifying one’s reaction to thoughts by constructing contexts where the influences of these thoughts on behavior are lessened [18]. Unlike traditional cognitive behavior approaches, in ACT it is not the content and actual validity of these thoughts that is challenged but the functions, or influences, of thoughts [19].

Present Moment Awareness

Contact with the present moment reflects the process wherein the person is aware of the situation in “the now” as opposed to focusing on events that happened in the past or might happen in the future [18]. To be “present” requires the individual to flexibly focus attention on experiences as they are happening in the environment, in real time, and to be fully open to what is taking place [20]. It is important the individual is able to notice when he or she is not acting in relation to the present moment and has the ability to shift attention to the present if this shift benefits them.

Self as Context

The sense of self-as-context or self-as-observer is considered the ability to adopt a perspective or point of view that is separate from and not defined by thoughts and feelings or even the physical body. This contrasts a sense of self as made up of personality characteristics, self-evaluations, or a narrative about who we are [5,16]. In ACT, perspective taking can be trained to help people connect with the experience of a distinction between self and psychological experiences. From this, one can choose to follow one’s inner verbal constructions of what defines us, our “stories” of who we are, in certain situations when it works to do so, and not in situations where it leads to unhealthy responses and behavioral restriction.

Values

Values are defined as guiding principles in one’s life. Values are often contrasted with goals, where the difference is that goals can be achieved while values are part of an ongoing process of action and cannot be completed once and for all. In a sense, goals represent set plans of action to be achieved while values are general life directions. If life is like a journey, then goals would be the chosen destination and values would simply be represented by a general direction of travel. Values are helpful when patients struggle with unwanted internal experiences like pain, as they not only serve as a guide for the client to persist in behavior change but also function as a motivating element. Values clarification exercise in therapy encourages the patient to define their values in specific domains of “career, family, intimate relationships, friendships, health, education and spirituality” [4,21] regardless of the primary problem. Personally chosen and clarified values can function as guides when people have difficulty initiating and maintaining behavior change in the presence of unwanted internal experiences.

Committed Action

Committed action is an ongoing process of redirecting behavior in order to create patterns of flexible and effective action in line with a defined value [22]. Patients are encouraged to follow through with their chosen actions that are in line with their values, and to persist or alter their course flexibly. Without the capacity for committed action, behavior change is less likely to persist and integrate into patterns of behavior more generally.

Case Study

Initial Presentation and History

Ms X, a 45-year-old woman, presents with the chief complaint of low back pain, which she has experienced for 3 years. She works part-time due to her pain problem. When she is not at work, she busies herself with seeking both conventional and alternative treatments for her pain condition. In the past, during periods where she experienced pain relief, she attempted to engage in her hobby of photography. However, this often led to a pain flare the next day and required 2 to 3 days of medical leave with increased medication from her PCP before she is able to return to work. As a result, Ms X chose to give up her hobby and focus on treating her pain instead. Ms X in in a constant struggle with her pain condition and believes that she can only return to photography, and live a more normal life, after her pain is cured.

• What are considerations for applying ACT in this scenario?

From an ACT conceptualization this case shows patterns of avoidance that are apparently not helping the person to reach her goals but are causing her distress and restrictions in functioning. An ACT therapist would approach this scenario by first reflecting how normal it is to struggle with pain and stop activities when in pain. From there they might (a) identify what the patient wants from treatment, (b) look at what has been done so far to attain this, (c) examine how well those things have been working, (d) consider the costs of the approach being taken, and (e) if the approach is not working and the cost is high, see if the patient is willing to stop this approach [23].

Therapist’s Initial Approach

Therapist: By what you have told me, your pain has become a big problem for you and it has been going on a long time—3 years. I can see some of the impacts it has had in your life, such as on your work, your photography, and time spent seeking treatment.

Ms X: Yes, it seems like pain has taken over …

Therapist: Exactly, it seems that is a good way to say it. So, understanding that pain has taken over, can I ask you another question?

Ms X: If your question will help me get over this problem, of course.

Therapist: Ok. What is it you want from coming here to participate in this treatment?

Ms X: Well, I want to get rid of this pain, obviously. It’s ruining my life.

Therapist: Ah, that makes sense. You want to eliminate your pain because it has, as you say, ruined your life, and then I guess your life will be better again.

Ms X: Correct.

Therapist: So, can I check in with the things you have been doing so far to reach this goal to eliminate pain?

 Ms X: You name it, I’ve tried it: acupuncture, medication, herbs, rest, exercise, magnets, yoga, and more.

 Therapist: Ok, you have tried many treatments focused on trying to get rid of the pain. I think that’s a very natural thing to do. In your experience have these methods been successful?

 Ms X: Well, some of them seem to work at the time but it all becomes very confusing, because here I am looking for another treatment. It can feel good to get away from the pain for a little while, but soon I will experience a pain flare bringing me back to square one.

 Therapist: I see what you are saying. Let me ask my earlier question in a different way. What would your life look like, and what would you be doing, if your pain were not the problem it is today?

 Ms X: I would be taking pictures again, be more consistent at work, and spend less time seeking treatments.

Therapist: So, is it your experience that the methods you have been using have helped you to live life this way?

Ms X: … I never thought about it that way ...

• What exercises or techniques are used in ACT?

In practice, ACT is somewhat unique in that it often relies on the use of metaphors and experiential exercises in treatment delivery. Metaphors and stories are used in treatment and communicated in terms that fit with the experience and background of the person seeking treatment. Although therapists can select from among many widely used and often appropriate metaphors and stories, an experienced therapist is likely to create patient specific metaphors “live,” within the context of a particular session. This is consistent with the philosophical underpinning of ACT in its aims for individual tailoring of methods. Unlike other current psychotherapeutic approaches that place a higher value on sticking to a specified protocol, the theory and philosophy behind ACT allow for flexibility and are open to creativity, individual style, and situational sensitivity of the therapist. This is expected to allow the patient to also adopt a similar sensitivity to changing environmental contingencies [19]. In ACT, the techniques typically do not follow a cookbook style of treatment delivery.

Case Continued

Therapist: What if trying to control your thoughts and feelings were not the answer?

Ms X: I have no idea what you mean.

Therapist: Well, you certainly have focused a lot of your effort on trying not to have the thoughts and feelings that seem to block you.

Ms X: What else is there to do, really?

Therapist: If you are willing to experiment with something, try this. Don’t think of a pineapple. (pause for 30 to 60 seconds). Ok, what happens.

Ms X: It didn’t work—I kept thinking about a pineapple.

Therapist: Weird, huh? Notice what is happening here. I wonder if some of your struggles with your experiences are just like this. It’s like by trying to get rid of something, there it is! I wonder if there were another way to do this, do you think you might be willing to test it out?

Ms X: Yes, I can try.

Further ACT Methods

ACT includes numerous experience-based methods and also direct rehearsal of targeted skills. In the previous scen-ario, the therapist might then proceed to instruction and practice of one or another type of acceptance-based skill, something like an “exposure” session or a mindfulness type of exercise that includes having the participant sit with the experience without doing anything else but observe it. The other type of method used includes metaphors that reveal how circumstances and behavior often work in life [4,16].

An Acceptance-Based Metaphor

Therapist: Imagine that you are new to the neighborhood and you invited all your neighbors over to a housewarming party. Everyone in the neighborhood is invited. On that day, the party’s going great, and here comes Joe, who smells and looks like he has not bathed in days. You are embarrassed by the way he looks and smells and try to close the door on him. However, he shows you a flyer that you put up stating that everyone in the neighborhood is invited. So you let him in and quickly shove him to the kitchen so that he will not embarrass you and disrupt your party. However, to stop him from leaving the kitchen, you end up having to stand guard at the doorway. Meanwhile the party is going on and your guests are enjoying themselves, but do you notice what else is happening here?

Ms X: I’ve stopped myself from enjoying my party in order to keep Joe away.

Therapist: What if your pain was like Joe?

Ms X: Huh? … Ah, I think I see what you are saying…

Therapist: It’s like if you allow Joe to simply be another guest, you can do whatever you like at your party. On the other hand, if you say “no” to Joe you also say “no” to the party.

Ms X: Are you saying that it is for me to choose?

• What is the role of therapist in modeling behavior change in ACT?

An important distinction can be made between talking about behavior change and doing behavior change. Within the psychological flexibility model the emphasis is placed on the latter. Here, especially through the use of experiential exercises, clients are put into contact with the experiences that have coordinated unhealthy behavior patterns in the past so that more effective behavior patterns can be acquired. Treatment delivery is guided by the underlying behavioral philosophy and theory. Patients learn to reduce the dominant influence of the literal meaning of language as the only tool for behavior change. Direct experience is moved to the front of awareness and literal meaning, mental and verbal analysis, and so forth, are moved to the back [20]. In treatment, the therapist models for the patient the behavior change processes that are being targeted and also may use examples from his or her life as well as that of the patient’s to develop psychological flexibility [22]. An example might include a therapist’s response to a person who shows an experience of emotional distress and struggling to manage this distress. Here the therapist, in line with ACT, instead of acting in some way to attempt to lessen the distress, would consciously show openness to the experiences and to their own reactions to helplessness around these experiences.

The therapist might say:

 “I would feel tired and probably in pain too if I did what you just did. Could we do a little closed-eyes exercise? Shall we put the distressing thought you are having on the table, and focus on it, and we can “observe” what your mind does, and what happens in your body and your emotions when that thought shows up? Are you willing?”

 “I’m feeling confused about this issue myself - how about both of us sitting quietly for a moment or two and observe what our minds do in response to this, just slowing things down, and watching?”

 “I feel anxious when I believe that my thoughts about pain are true - like I have to do something to make it go away but I don’t know how. What shows up for you when you believe such thoughts about pain?”

• How and when should ACT be used?

Based on current evidence how and when ACT ought to be used, as opposed to other treatment options, will be largely up to the individual professional and their level of competence. ACT is a form of CBT and many of the same guides pertain. In line with the pragmatic approach of ACT, an approach that makes ACT broadly applicable, there is no one particular manualised or scripted treatment protocol that must be adhered to in treatment for one specific condition or another. As mentioned earlier, the ACT approach does not usually follow a cookbook style of delivery, nor is it rigidly guided by strict protocols. There are protocols shared by researchers to support further development but there is no process by which these are deemed “official” or “recognized” or approved by anyone in particular.

A wide range of metaphors and exercises based on a set of behavioral principles that target a particular function has been proposed in ACT and this is part of its uniqueness as a therapeutic model.

Those developing ACT also have not required a standardised certification process to delivering ACT. Instead, they have chosen to create an open community of contributing researchers and clinicians who are “members” by virtue of their commitment to the same approach to clinical development and the same clinical model. Practicing ACT requires that the clinician is aware of their own competencies and delivers treatment accordingly.

• How effective is ACT?

Numerous studies have supported a general role of psychological flexibility in improving the well-being and physical functioning of patients with chronic pain, including patients in specialty care [24,28] and primary care [26]. Many studies support the particular role of acceptance of pain in adjustment to chronic pain [27–30]. Pain acceptance is a better predictor of outcomes than pain severity itself [31,32].

There are now several relatively large-scale studies conducted in actual clinical practice settings that demonstrate the effectiveness of ACT for chronic pain [25,27,33,34]. A more recent study, also conducted in an actual clinical practice setting, provided support for the specific treatment processes proposed within this approach [35]. This study showed that changes in traditionally conceived methods of pain management were unrelated to treatment improvements of pain intensity, physical disability, anxiety and depression for those who participated in treatment, while changes in psychological flexibility were consistently and significantly related to these improvements, with the exception of the results for depression.

Randomised Controlled Trials (RCTs)

To date, there are a total of 7 RCTs related to ACT and chronic pain [36–42], each providing supportive evidence. For example, in one of the early studies, Dahl and colleagues [36] showed that in comparison to treatment as usual, a group of workers who were at risk of long-term absenteeism from work due to pain or stress had a significant reduction in sick leave and healthcare usage after attending four hours of ACT sessions.

Wicksell and colleagues [37,38] conducted 2 separate RCTs with participants who suffered whiplash-associated disorder (WAD) and fibromyalgia, respectively. Post-treatment results of both RCTs showed an improvement in physical functioning, depression and psychological flexibility in the treatment group with gains maintained at follow-up. In addition, participants in the treatment group with WAD showed an improvement in life satisfaction and fear of movement while those in the treatment group with fibromyalgia showed significant improvements in fibromyalgia impact, self-efficacy and anxiety. There was however no change in pain intensity in those who received the ACT-based treatments.

An ACT-based treatment including a self-help manual showed a significant increase in acceptance, satisfaction in life with a higher level of function and decreased pain intensity compared with a wait-list condition and with applied relaxation (AR) [40]. In comparison to the AR condition, participants in the ACT condition also reported a significantly higher level of engagement in meaningful activities and a willingness to experience pain. Follow-up data support the maintenance of these improvements at first follow-up but differences were not significant at the second follow-up. Both depression and anxiety scores improved in both treatment groups.

Wetherell and colleagues [39] compared the effectiveness of ACT and traditional CBT and found that they both produced positive results. Results from the study also showed higher satisfaction in participants who attended ACT treatment than those that attended CBT treatment, suggesting that ACT “is an effective and acceptable” intervention for patients with chronic pain. Overall acceptance of pain was shown to differentiate patients who could function well with chronic pain from those that continued to suffer with it after treatment.

More recently the first internet-based RCT for ACT with chronic pain was conducted [41]. The authors found a reduction in measures of pain-related distress, depressive symptoms, and anxiety, with these gains maintained at 6 months follow-up in the ACT treatment group compared with controls. The most recent RCT was a pilot trial of a group-based treatment of people with chronic pain recruited from general practices in the UK [42]. Participants were randomised to either an ACT-based treatment or treatment as usual. Participants in the ACT-based group underwent 4 sessions each lasting 4 hours with the first 3 sessions completed in 1 week and the last session completed a week later. At 3 months follow-up, participants in the ACT group had lower disability, depression, and higher pain acceptance.

In general, results from the ACT-based RCTs on chronic pain support the efficacy of the treatment and reflect a high degree of versatility, based on the wide variety of modes of delivery tested. However, RCTs for chronic pain are still relatively few with some studies limited to small sample sizes, thus making it difficult to reach definitive conclusions on the general efficacy of ACT in chronic pain treatment. What the studies do seem to show is that ACT is a good alternative treatment option to more traditionally conceived current CBT-based treatments for chronic pain. Larger sample sizes and higher quality studies are needed to strengthen and establish the effectiveness of ACT and to understand the potential impact of wider implementation in clinical practice.

Meta-Analyses

A total of 4 meta-analyses [43–46] have been conducted on acceptance- or ACT-based treatment studies. Although the earlier meta-analyses [43,44] did not separately report the effectiveness of ACT for chronic pain, they reported a moderate effect size for ACT in general, with no evidence that ACT is more effective than established treatments.

Ruiz [46] conducted a review focusing on outcome or mediation/moderation type studies that compared ACT and CBT treatments. His review was not specific to chronic pain, although one study [39] involving a sample of chronic pain patients was included. Moderate effect sizes were found that favored ACT, with ACT showing a greater impact on change processes (g = 0.38) compared to no impact found in CBT (g = 0.05).

Essentially, only one meta-analysis [45] specifically reviewed the efficacy in chronic pain studies. Pain inten-sity and depression were selected as primary outcome measures, with anxiety, physical well-being, and quality of life selected as secondary outcomes. Out of 22 studies that were included in the review, only 2 studies [36,37] were ACT-based RCTs, with the rest of the studies mindfulness-based interventions. The overall effect size of 0.37 was found for pain and 0.32 for depression. In general, results showed significant effect sizes for both primary and secondary outcome measures in favor of the “acceptance-based treatments.” The authors concluded that at present, mindfulness-based stress reduction programs and ACT-based programs may not be superior to CBT but could be good alternatives for people with chronic pain.

The appropriateness of using pain intensity as a primary outcome measure for ACT-based studies is questionable [45]. The focus of ACT is to increase function rather than to reduce pain symptoms; hence possibly including interference of pain in daily life might be a more appropriate outcome measure.

Other Studies

A particularly important question to answer about ACT concerns its cost-effectivness, and we still know relatively little about this. We do know that when people participate in ACT-based treatments they are able to reduce medication use and health care visits and return to work after extended periods away from work [27,28]. It remains to conduct full health economic analyses of this type of approach for chronic pain.

ACT is known to produce significant benefits widely, in other applications apart from chronic pain, such as in workplace stress [47], psychosis [48], obsessive-compulsive disorder [49], and depression [50], among other mental health conditions [51].

• What are implications for policy makers?

Results from studies of ACT in chronic pain and in other areas are disseminating rapidly. This dissemination is aided in part by a professional organization devoted to ACT and psychological flexibility (Association for Contextual Behavioral Science; www.contextualscience.org), which has a new journal, the Journal of Contextual Behavioral Science, started in 2012.

With the development of ACT a focus on implementation, training, and treatment integrity began early. There was an implementation study of ACT was published by Strosahl and colleagues in 1998. Their study showed that training clinicians in ACT produced better outcomes and better treatment completion rates in an outpatient setting in comparison to clinicians not receiving this training.

Processes of training have also appeared during relatively early phases of research into ACT. Lappalainen and colleagues [52] compared the impact of treatment provided by trainee therapists trained in both a traditional CBT model and ACT. Here each trainee therapist treated one patient with traditional CBT and one with ACT. Although the therapists reported higher confidence in delivering traditional CBT, patients treated within an ACT model showed better symptoms improvement. Also, improved acceptance during treatment significantly predicted improvements across both groups of patients. Essentially, therapists with only a limited amount of training in both models demonstrated better clinical results with ACT.

A group-based ACT intervention has also been shown to be effective in reducing stress and improving the professional performance of clinical psychology trainees [53]. Here the trainees found the intervention personally and professionally useful and a majority showed a significant increase in psychological flexibility. This supports the applicability of ACT not only as a model to guide therapy but also as a model to guide training and professional performance [54]. Other results in a pain management setting show that transitioning to ACT as a treatment model can have similar benefits and may increase job satisfaction and staff well-
being [55].

• What are criticisms of ACT?

Many strong supporters of cognitive therapy and more traditional versions of CBT in the field claim that ACT is not new nor better than other current versions of CBT [56]. The proponents of ACT openly acknowledge that many methods used within ACT are adopted or modified from other established therapies [4]. Criticisms are not specific to the application of ACT with chronic pain but are based on others’ perceptions of ACT as a treatment approach and treatment techniques used in ACT in general.

Ost [43] criticised ACT and the third-wave therapies on 2 main grounds. First, he concluded that ACT and the rest of the third-wave therapies were not meeting the criteria of empirically supported treatments. He further concluded that there is no strong evidence to show that ACT is more effective than cognitive therapy. The methods of the Ost review have been challenged [57], yet to a certain degree the points raised are correct. Most of the limitations noted reflect a difference in the maturity of the evidence base for ACT versus traditional CBT-based approaches. Indeed, in comparison to CBT, which is the most empirically established form of psychotherapy and an active area of research for more than 40 years, ACT can be considered to be in its infancy stage of empirically supported treatments, where treatment evidence and availability of high-quality RCTs in general are few at present. Specific research on ACT for chronic pain though supportive is still preliminary to a certain degree. Even so, ACT for pain is regarded as an empirically supported treatment by the body within the American Psychological Association authorized to make this determination [58].

Conclusion

ACT is essentially a form of CBT, considered broadly. ACT brings with it a different philosophy and approach to science compared with some other forms of CBT—this can lead to some distinctive strategies and methods in treatment for chronic pain. Like traditionally designed CBT, however, ACT similarly aims for behavior change as the end point.

ACT is grounded in specific philosophical assumptions and includes the model of psychological flexibility at its core. Preliminary findings in broad clinical and nonclinical populations support the efficacy, effectiveness, and processes in the psychological flexibility model as mediators of change, in ACT [46,59]. Research has shown that most of the 6 ACT processes, all of those so far investigated, correlate with improved daily functioning and emotional well-being in patients with chronic pain. The evidence base for ACT is still developing. Larger trials, more carefully designed trials, and a continued focus on processes of change will be needed to strengthen this base.

Corresponding author: Su-Yin Yang, Health Psychology Section, Psychology Department, Institute of Psychiatry, King’s College London, 5th Fl, Bermondsey Wing, Guy’s Campus, London SE1 9RT, su-yin.yang@kcl.ac.uk.

Financial disclosures: None.

Author contributions: conception and design, SY, LMM; analysis and interpretation of data, SY; drafting of article, SY, LMM; critical revision of the article, LMM; administrative or technical support, LMM; collection and assembly of data, SY.

From the Kaiser Permanente Center for Health Research Southeast, Atlanta, GA (Dr. Lewis) and the Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Gudzune).

Abstract

• Objective: To review challenges to obesity counseling in the primary care setting and suggest potential solutions.
• Methods: Review of the literature.
• Results: There are many challenges to obesity counseling in the primary care setting, including lack of primary care provider (PCP) training, provider weight bias, lack of reimbursement, lack of time during outpatient encounters, and limited ability to refer patients to structured weight loss support programs. However, there are potential solutions to overcome these challenges. By seeking continuing medical education on weight management and communication skills, PCPs can address any training gaps and establish rapport with patients when delivering obesity counseling. Recent policy changes including Medicare coverage of obesity counseling visits may reduce PCPs' concern about lack of reimbursement and time, and the rise of new models of care delivery and reimbursement, such as patient-centered medical homes or accountable care organizations, may facilitate referrals to ancillary providers like registered dietitians or multi-component weight loss programs.
• Conclusion: Although providers face several challenges in delivering effective obesity counseling, PCPs may overcome these obstacles by pursuing continuing medical education in this area and taking advantage of new health care benefits coverage and care delivery models.

Over one-third of U.S. adults are now obese [1] and the prevalence of obesity is rising globally (2). In 2003 and 2012, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation that health care providers screen all patients for obesity and offer intensive, multicomponent behavioral interventions to obese patients [3,4]. Screening for obesity typically involves assessment and classification of a patient’s body mass index (BMI). In the primary care setting, weight management may include a range of therapeutic options such as intensive behavioral counseling, prescription anti-obesity medications, and referral to bariatric surgery. Behavioral interventions typically include activities such as goal setting, diet and exercise change, and self-monitoring. A recent systematic review showed that primary care–based behavioral interventions could result in modest weight losses of 3 kg over a 12-month period, and prevent the development of diabetes and hypertension in at-risk patients [5].

PCP Concern: “I never learned about weight management during my training”

One of the most common barriers to providing the recommended counseling reported by health care providers is inadequate training in nutrition, exercise, and weight loss counseling [10–12]. Many providers have knowledge deficiencies in basic weight management [13,14]. In addition, few PCPs who have received obesity-related training rate that training as good quality during medical school (23%) and residency (35%) [15].

Pursuing Additional Training in Weight Management

Providers could address their lack of training in weight management by participating in an obesity curriculum. When surveyed, PCPs have identified that additional training in nutrition counseling (93%) and exercise counseling (92%) would help them improve the care for obese patients, and many (60%) reported receiving good continuing medical education (CME) on this topic [15]. Much research in this area has examined the impact of such training on residents’ provision of obesity counseling. Residents who completed training improved the quality of obesity care that they provided [16], and those who learned appropriate obesity screening and counseling practices were more likely to report discussing lifestyle changes with their patients [17]. The vast majority of surveyed PCPs (86%) also felt that motivational interviewing [15], a technique that can effectively promote weight loss, would help them improve obesity care [18,19]. Patients demonstrated greater confidence in their ability to change their diet when their PCP used motivational interviewing–consistent techniques during counseling [20]; however, few PCPs utilize motivational interviewing techniques [20,21]. Offering CME opportunities for practicing PCPs to obtain skills in nutrition, exercise, and motivational interviewing would likely improve the quality of obesity care and weight loss counseling that are being delivered. PCPs could also consider attending an in-depth weight management and obesity 

Applying a Universal Behavior Change Approach to Obesity and Other Behaviors

Another option may be encouraging PCPs to use a universal approach to behavioral counseling across multiple domains [22]. Using a single technique may lend familiarity and efficiency to the health care providers’ counseling [23]. The 5A’s—Assess, Advise, Agree, Assist, Arrange—has been proposed as a possible “universal” strategy that has demonstrated efficacy in both smoking cessation [24] and weight loss [25,26]. Using the 5A’s has been associated with increased motivation to lose weight [25] and increased weight loss [26]. Many physicians are familiar with the 5A’s; however, few physicians use the complete technique. PCPs have been found to most frequently “assess” and “advise” when using the 5A’s technique for weight loss counseling [26,27], although assisting and arranging are the components that have been associated with dietary change and weight loss [26]. PCPs could incorporate these A’s into their counseling routine by ensuring that they “assist” the patient by establishing appropriate lifestyle changes (eg, calorie tracking to achieve a 500 to 1000 calorie reduction per day) or referring to a weight loss program, and “arrange” for follow-up by scheduling an appointment in a few weeks to discuss the patient’s progress [23]. While the 5A’s can effectively promote weight loss, many PCPs would likely require training or retraining in this method to ensure its proper use. For PCPs interested in integrating the 5A’s into their weight management practice, we refer them to the algorithm described by Serdula and colleagues [23].

Cultural Influences on Weight Management

A final weight management training consideration relates to cultural awareness for patients who are from different racial or ethnic backgrounds than the PCP. In the United States, racial and ethnic minority groups are disproportionately burdened by obesity. Nearly 60% of non-Hispanic black women and 41% of Hispanic women are obese, compared with 33% of non-Hispanic whites [28]. Despite this fact, obese non-Hispanic black and Hispanic patients are more likely than white patients to perceive themselves as “slightly overweight” and to rate their health as good to excellent despite their obesity [29,30]. As a result, they may be less likely to seek out weight loss strategies on their own or ask for weight control advice from their providers [31]. Additionally, racial and ethnic disparities in access to healthy foods [32,33], safe areas for engaging in physical activity [34], and lack of social support for healthy behaviors may make it much more difficult for some minority patients to act on their PCP's advice.

Because of different cultures, social influences, and norms, what an individual patient perceives as obese or unhealthy may differ dramatically from what his or her physician views as obese or unhealthy [35–38]. Therefore, it is important that PCPs have a discussion with their patients about their subjective weight and health perceptions before beginning any prescriptive weight management strategies or discussions of “normal BMI” [39,40]. If an obese patient views herself as being at a normal weight for her culture, she is unlikely to respond well to being told by her doctor that she needs to lose 40 pounds to get to a healthy weight. Recent research suggests that alternative goals, such as encouraging weight maintenance for non-Hispanic black women, may be a successful alternative to the traditional pathway of encouraging weight loss [41].

In addition to understanding cultural context during weight status discussions, it is also important to give behavior change advice that is sensitive to the culture, race, and ethnicity of the patient. Dietary recommendations should take into account the patient’s culture. For example, Lindbergh et al have noted that cooking in traditional Hispanic culture does not rely as much on measurements as does cooking for non-Hispanic whites [42]. Therefore, measurement-based dietary advice (the cornerstone of portion control) may be a more problematic concept for these patients to incorporate into their home cooking styles [42]. Physical activity recommendations should also be given in context of cultural acceptability. A recent study by Hall and others concluded that some African-American women may be reluctant to follow exercise advice for fear that sweating will ruin their hairstyles [43]. Although providers need not be experts on the cultural norms of all of their patients, they should be open to discussing them, and to asking about the patient’s goals, ideal body type, comfort with physical activity, diet advice and other issues that will make individualized counseling much more effective.

PCP Concern: “Weight gain reflects the patient’s lack of will power and laziness”

Bias towards obese patients has been documented among health care providers [44,45]. Studies have shown that some providers have less respect for obese patients [46], perceive obese patients as nonadherent to medications [47], and associate obesity with “laziness,” “stupidity,” and “worthlessness” [48]. Furthermore, obese patients identify physicians as a primary source of stigma [49] and many report stigmatizing experiences during interactions with the healthcare system [44,45]. In one study, a considerable proportion of obese patients reported ever experiencing stigma from a doctor (69%) or a nurse (46%) [49]. As a result of these negative experiences, obese patients have reported avoiding or delaying medical services such as gynecological cancer screening [50]. A recent study by Gudzune et al found that obese patients had significantly greater odds of “doctor shopping,” where individuals saw 5 or more primary care providers in a 2-year period [51]. This doctor shopping behavior may also be motivated by dissatisfaction with care, as focus groups of obese women have reported doctor shopping until they find a health care provider who is comfortable, experienced, and skilled in treating obese patients [50].

Assessing Implicit and Explicit Weight Bias

In addition to explicit negative attitudes, health care providers may also hold implicit biases towards obese patients [52]. A recent study found that over half of medical students held an implicit anti-fat bias [53]. These implicit attitudes may manifest more subtly during patient encounters. PCPs engage in less emotional rapport building during visits with overweight and obese patients as compared to normal weight patients [54], which include behaviors such as expressing empathy, concern, reassurance, and partnership. The lack of rapport building could negatively influence the patient-provider relationship and decrease the effectiveness of weight loss counseling. PCPs may need to consider undergoing self-assessment to determine whether or not they hold negative implicit and/or explicit attitudes towards obese patients. PCPs can complete the Weight Implicit Association Test (IAT) for free online at https://implicit.harvard.edu/implicit/demo/. To determine whether they hold negative explicit attitudes, PCPs can download and complete assessments offered by the Yale Rudd Center for Food Policy and Obesity (www.yaleruddcenter.org/resources/bias_toolkit/index.html).

Pursuing Additional Training in Communication Skills

If weight bias is indeed present, PCPs may benefit from additional training in communication skills as well as specific guidance on how to discuss weight loss with overweight and obese patients. For example, an observational study found that patients lost more weight when they had weight loss counseling visits with physicians who used motivational interviewing strategies [20,21]. Additional PCP training in this area would benefit the patient-provider relationship, as research has shown that such patient-centered communication strategies lead to greater patient satisfaction [55,56], improvement in some clinical outcomes [57,58], and less physician burnout [59]. In fact, some medical schools address student weight bias during their obesity curricula [60]. Building communication skills helps improve PCPs’ capacity to show concern and empathy for patients’ struggles, avoid judgment and criticism, and give emotional support and encouragement, which may all improve PCPs’ ability to execute more sensitive weight loss discussions. For providers who are more interested in CME opportunities, the American Academy on Communication in Healthcare offers an online interactive learning program in this area called “Doc Com” (http://doccom.aachonline.org/dnn/Home.aspx).

PCP Concern: “I may not get reimbursed for weight management services”

Traditional metrics for how doctors are reimbursed and how the quality of their care is measured have not promoted weight loss counseling by PCPs. Prior to 2012, physicians could not bill Medicare for obesity-specific counseling visits [61]. Given that many private insurers follow the lead of the Centers for Medicare and Medicaid Services (CMS) for patterns of reimbursement, this issue has been pervasive in U.S. medical practice for a number of years, with considerable variability between plans on which obesity-related services are covered [62]. A recent study of U.S. health plans indicated that most would reject a claim for an office visit where obesity was the only coded diagnosis [62]. Additionally, the quality improvement movement has only recently begun to focus on issues of obesity. In 2009, the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) added 2 new measures pertaining to the documentation of a patient’s BMI status. Prior to this time, even the simple act of acknowledging obesity was routinely underperformed and quite variable across health plans in the United States [63].

Obesity Screening and Counseling Benefits Coverage

In 2012, CMS made a major coverage change decision when they agreed to reimburse providers for delivering intensive behavioral interventions for obesity [61]. Namely, CMS will now cover a 6-month series of visits for Medicare patients (weekly for month 1, every other week for months 2–6), followed by monthly visits for an additional 6 months in patients who have been able to lose 3 kg. For PCPs and other providers who have long hoped for more opportunity to discuss nutrition, weight, and physical activity with their Medicare patients, these policy changes are exciting. Hopefully, this move by CMS will stimulate similar changes in the private insurance market.

Greater reimbursement of obesity-related care is also more likely given the overall trend of the U.S. health care system—with the focus shifting away from traditional fee-for-service models that have de-emphasized preventive care and counseling and toward a model that rewards well care [64]. Large employer groups, who represent an important voice in any discussion of health insurance and reimbursement, are also increasingly interested in the use of wellness programs and weight loss to decrease their own health care costs. This trend could further stimulate insurers to cover programs that allow providers to engage in weight counseling as a way of attracting or retaining large employer groups as customers [62].

Obesity Screening and Counseling Quality Metrics

A parallel movement in the quality of care realm would serve to bolster any forthcoming changes in reimbursement. For example, an expansion of the HEDIS “wellness and health promotion” measures, or going beyond “BMI assessment” to include a brief assessment of key dietary factors or physical activity level as a routine quality measure, would go a long way toward emphasizing to payers and providers the need for more routine obesity counseling. Professional provider organizations have been increasingly engaged in this area as well. The recent recognition by the American Medical Association of obesity as a disease may also influence organizations such as the NCQA and payers who may be considering how to encourage providers to better address this important issue.

PCP Concern: “I don’t have time to discuss weight loss during outpatient visits”

The average continuity visit for an adult patient in the United States is about 20 minutes in duration, with a mean of 6 to 7 clinical items to be addressed during that time-period [65]. This leaves little time for providers to perform the necessary history and physical portions of the visit, educate patients on various topics, and write out prescriptions or referrals. Not surprisingly, such extreme time pressure leads many PCPs to feel overwhelmed and burned out [66], and the idea of adding another “to-do” to office visits may be resisted. For obese patients, many of whom are likely to have multiple chronic conditions, PCPs are faced with the task of both discussing active issues such as hypertension, diabetes, and sleep apnea, and also potentially discussing the patient’s weight status in a very brief amount of time. Under such time pressures, PCPs often adopt a “putting out fires” mentality and therefore tackle what they see as the most pressing issues—eg, deal with out of control blood pressure by adding a new medication, or lowering hemoglobin A1c by upping the insulin dose, rather than dealing with the 20-lb weight gain that might be leading to the high pressures and hyperglycemia.

Compounding this problem is the fact that well-delivered preventive health advice can be time-consuming, and with so many topics to choose from, it may be difficult for providers to know which issues make the most sense to prioritize [67]. A recent study estimated that PCPs routinely under-counsel patients about nutrition (an advice topic that earns a “B” rating from the USPSTF), while they over-counsel them on exercise and PSA testing (topics that earn an “I” rating from the USPSTF) [68]. Topics of discussion and the time spent on them may reflect patient priorities or PCP comfort with various issues, but it is clear that some improvements could be made to better utilize available time with patients.

In the face of time and resource pressures, many PCPs may not be ideally suited to deliver the kind of intensive behavioral weight loss interventions that are supported by the best scientific evidence [69]. In fact, there is little evidence to support even brief weight counseling sessions by PCPs [70]. However, for busy providers, there are several brief and potentially impactful tasks that could enable them to better support their obese patients.

Brief Counseling Interventions in the Primary Care Setting

First, primary care providers should routinely measure and discuss their patients BMIs as they would any other vital sign. In addition, other brief measures such as “Exercise as a Vital Sign” [71] can be incorporated into the visit, so that behaviors linked to weight can inform the strategy adopted and monitored over time. After a brief discussion is initiated, a referral can be placed for patients who wish to pursue more intense therapy for weight loss—this may be to behavioral health, nutrition, bariatric surgery or a comprehensive weight management clinic. Practices can support their providers by streamlining this referral process and educating providers and patients on available resources. PCPs also may be able to engage their patients in self-monitoring (eg, calorie tracking, exercise tracking, self weighing) so that most of the work and learning takes place outside of the primary care office. For example, PCPs can promote the use of a food diary, a practice that has been shown to improve weight loss success [72]. Review of the diary could take place at a separate visit with the PCP or in follow-up with a weight loss specialist or dietitian.

A major strength of the primary care setting is its longitudinal nature. Even if available time at individual visits is short, advice and support can be given repeatedly over a longer period of time than may often be achieved with a specialist consultant. For patients who are in the maintenance phase of weight loss, having long-term frequent contacts with a provider has been shown to prevent weight regain [73]. The use of group visits and physician extenders (RNs, NPs, PAs) for delivering obesity-related behavioral advice might offer another way to relieve some of the time pressures faced by PCPs in the one-on-one chronic disease management visit [69,74].

PCP Concern: “I don’t know where to refer patients for weight management”

Surveys of obese patients and their doctors indicate that PCPs may not often enough refer patients to structured weight loss programs or registered dietitians [75,76]. Furthermore, PCPs are often isolated from other providers who might be important in a team-based model of obesity care, such as pharmacists, registered dietitians, endocrinologists, and bariatric surgeons. The implementation of the Affordable Care Act, including payment reform and the rise of accountable care organizations, should begin changing the relative isolation of the PCP. If more practices attempt to conform to medical home models, the interconnectedness of PCPs to other health care team members may increase, thus facilitating a more team-based approach to obesity care and easier referrals to specialized team members [77].

Weight Management Resources

Aside from some academic centers and large private health care institutions, many primary care practices lack access to structured obesity care clinics that can help manage the challenges of guiding patients through their weight loss options. For providers who practice in areas that do not afford them easy access to obesity care clinics, it is worth seeking out available resources in the nonmedical community that might provide a structured support system for patients. One low-cost community-based program, Take Off Pounds Sensibly (TOPS; www.tops.org), can achieve and sustain a 6% weight loss for active members [78]. Groups such as Overeaters Anonymous are found in most U.S. cities, and have helpful websites including podcasts that patients can access even in the absence of a local branch (www.oa.org). Organizations like the YMCA, which have good penetration into most areas of the country, offer affordable access to physical activity and health programs including coaching that can promote all around healthier living and improved dietary habits (www.ymca.net). A final consideration could be referral to a commercial weight loss program. A 2005 review of the major U.S. commercial weight loss programs concluded that there was suboptimal evidence for or against these programs’ efficacy [79]. A recent randomized controlled trial showed that patients referred by their PCP to a commercial weight loss program (Weight Watchers) lost significantly more weight (2.3 kg) at 12 months as compared to patients who only received weight loss advice from their PCP [80]. However, it is important to keep in mind that not all commercial programs are the same and some programs can be ineffective or even dangerous for some patients. The PCP may need to take an active role monitoring their patient’s health and safety when using these programs.

A Strategy to Incorporate Weight Management into Current Practice

Summary

Given the obesity epidemic, PCPs will need to begin addressing weight loss as a part of their normal practice; however, providers face several challenges in implementing weight management services. Many PCPs report receiving inadequate training in weight management during their training; however, many CME opportunities exist for providers to reduce their knowledge and skills deficit. Depending upon the prevalence of obesity in their practice and interest in offering weight management services, PCPs may need to consider more intensive weight management training or even pursue certification as an obesity medicine provider through the American Board of Obesity Medicine. For providers with a more general interest in obesity counseling, applying a consistent counseling approach like the 5A’s to several behaviors (eg, obesity, smoking cessation) may facilitate such counseling as a regular part of the outpatient encounter. PCPs should also be aware of different cultural considerations with respect to obesity including different body image perceptions and cooking styles. Obesity bias is pervasive in our society; therefore, PCPs may similarly hold negative explicit or implicit attitudes towards these patients. Providers can engage in online self-assessment about their explicit and implicit biases in order to understand whether they hold any negative attitudes towards obese patients. Additional training in communication skills and empathy may improve these patient-provider relationships and translate into more effective behavioral counseling. PCPs may be concerned about a lack of reimbursement for weight management services or a lack of time to perform counseling during outpatient encounters. With the new obesity counseling benefits coverage by CMS, PCPs should be reimbursed for obesity counseling services and provide additional time through dedicated weight management visits for Medicare patients. The new primary care practice models including the patient-centered medical home may facilitate PCP referrals to other weight management providers such as registered dieticians and health coaches, which could offset the PCP’s time pressures. Finally, PCPs can consider referrals to community resources, such as programs like Overeaters Anonymous, TOPS or the YMCA, to help provide patients group support for behavior change. In summary, PCPs may need to consider additional training to be prepared to deliver high quality obesity care in collaboration with other local partners and weight management specialists.

Corresponding author: Kimberly A. Gudzune, MD, MPH, 2024 E. Monument St, Room 2-611, Baltimore, MD 21287, gudzune@jhu.edu.

Funding/support: Dr. Gudzune received support through a career development award from the National Heart, Lung, and Blood Institute (K23HL116601).

Financial disclosures: None

From the Kaiser Permanente Center for Health Research Southeast, Atlanta, GA (Dr. Lewis) and the Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Gudzune).

Abstract

• Objective: To review challenges to obesity counseling in the primary care setting and suggest potential solutions.
• Methods: Review of the literature.
• Results: There are many challenges to obesity counseling in the primary care setting, including lack of primary care provider (PCP) training, provider weight bias, lack of reimbursement, lack of time during outpatient encounters, and limited ability to refer patients to structured weight loss support programs. However, there are potential solutions to overcome these challenges. By seeking continuing medical education on weight management and communication skills, PCPs can address any training gaps and establish rapport with patients when delivering obesity counseling. Recent policy changes including Medicare coverage of obesity counseling visits may reduce PCPs' concern about lack of reimbursement and time, and the rise of new models of care delivery and reimbursement, such as patient-centered medical homes or accountable care organizations, may facilitate referrals to ancillary providers like registered dietitians or multi-component weight loss programs.
• Conclusion: Although providers face several challenges in delivering effective obesity counseling, PCPs may overcome these obstacles by pursuing continuing medical education in this area and taking advantage of new health care benefits coverage and care delivery models.

Over one-third of U.S. adults are now obese [1] and the prevalence of obesity is rising globally (2). In 2003 and 2012, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation that health care providers screen all patients for obesity and offer intensive, multicomponent behavioral interventions to obese patients [3,4]. Screening for obesity typically involves assessment and classification of a patient’s body mass index (BMI). In the primary care setting, weight management may include a range of therapeutic options such as intensive behavioral counseling, prescription anti-obesity medications, and referral to bariatric surgery. Behavioral interventions typically include activities such as goal setting, diet and exercise change, and self-monitoring. A recent systematic review showed that primary care–based behavioral interventions could result in modest weight losses of 3 kg over a 12-month period, and prevent the development of diabetes and hypertension in at-risk patients [5].

PCP Concern: “I never learned about weight management during my training”

One of the most common barriers to providing the recommended counseling reported by health care providers is inadequate training in nutrition, exercise, and weight loss counseling [10–12]. Many providers have knowledge deficiencies in basic weight management [13,14]. In addition, few PCPs who have received obesity-related training rate that training as good quality during medical school (23%) and residency (35%) [15].

Pursuing Additional Training in Weight Management

Providers could address their lack of training in weight management by participating in an obesity curriculum. When surveyed, PCPs have identified that additional training in nutrition counseling (93%) and exercise counseling (92%) would help them improve the care for obese patients, and many (60%) reported receiving good continuing medical education (CME) on this topic [15]. Much research in this area has examined the impact of such training on residents’ provision of obesity counseling. Residents who completed training improved the quality of obesity care that they provided [16], and those who learned appropriate obesity screening and counseling practices were more likely to report discussing lifestyle changes with their patients [17]. The vast majority of surveyed PCPs (86%) also felt that motivational interviewing [15], a technique that can effectively promote weight loss, would help them improve obesity care [18,19]. Patients demonstrated greater confidence in their ability to change their diet when their PCP used motivational interviewing–consistent techniques during counseling [20]; however, few PCPs utilize motivational interviewing techniques [20,21]. Offering CME opportunities for practicing PCPs to obtain skills in nutrition, exercise, and motivational interviewing would likely improve the quality of obesity care and weight loss counseling that are being delivered. PCPs could also consider attending an in-depth weight management and obesity 

Applying a Universal Behavior Change Approach to Obesity and Other Behaviors

Another option may be encouraging PCPs to use a universal approach to behavioral counseling across multiple domains [22]. Using a single technique may lend familiarity and efficiency to the health care providers’ counseling [23]. The 5A’s—Assess, Advise, Agree, Assist, Arrange—has been proposed as a possible “universal” strategy that has demonstrated efficacy in both smoking cessation [24] and weight loss [25,26]. Using the 5A’s has been associated with increased motivation to lose weight [25] and increased weight loss [26]. Many physicians are familiar with the 5A’s; however, few physicians use the complete technique. PCPs have been found to most frequently “assess” and “advise” when using the 5A’s technique for weight loss counseling [26,27], although assisting and arranging are the components that have been associated with dietary change and weight loss [26]. PCPs could incorporate these A’s into their counseling routine by ensuring that they “assist” the patient by establishing appropriate lifestyle changes (eg, calorie tracking to achieve a 500 to 1000 calorie reduction per day) or referring to a weight loss program, and “arrange” for follow-up by scheduling an appointment in a few weeks to discuss the patient’s progress [23]. While the 5A’s can effectively promote weight loss, many PCPs would likely require training or retraining in this method to ensure its proper use. For PCPs interested in integrating the 5A’s into their weight management practice, we refer them to the algorithm described by Serdula and colleagues [23].

Cultural Influences on Weight Management

A final weight management training consideration relates to cultural awareness for patients who are from different racial or ethnic backgrounds than the PCP. In the United States, racial and ethnic minority groups are disproportionately burdened by obesity. Nearly 60% of non-Hispanic black women and 41% of Hispanic women are obese, compared with 33% of non-Hispanic whites [28]. Despite this fact, obese non-Hispanic black and Hispanic patients are more likely than white patients to perceive themselves as “slightly overweight” and to rate their health as good to excellent despite their obesity [29,30]. As a result, they may be less likely to seek out weight loss strategies on their own or ask for weight control advice from their providers [31]. Additionally, racial and ethnic disparities in access to healthy foods [32,33], safe areas for engaging in physical activity [34], and lack of social support for healthy behaviors may make it much more difficult for some minority patients to act on their PCP's advice.

Because of different cultures, social influences, and norms, what an individual patient perceives as obese or unhealthy may differ dramatically from what his or her physician views as obese or unhealthy [35–38]. Therefore, it is important that PCPs have a discussion with their patients about their subjective weight and health perceptions before beginning any prescriptive weight management strategies or discussions of “normal BMI” [39,40]. If an obese patient views herself as being at a normal weight for her culture, she is unlikely to respond well to being told by her doctor that she needs to lose 40 pounds to get to a healthy weight. Recent research suggests that alternative goals, such as encouraging weight maintenance for non-Hispanic black women, may be a successful alternative to the traditional pathway of encouraging weight loss [41].

In addition to understanding cultural context during weight status discussions, it is also important to give behavior change advice that is sensitive to the culture, race, and ethnicity of the patient. Dietary recommendations should take into account the patient’s culture. For example, Lindbergh et al have noted that cooking in traditional Hispanic culture does not rely as much on measurements as does cooking for non-Hispanic whites [42]. Therefore, measurement-based dietary advice (the cornerstone of portion control) may be a more problematic concept for these patients to incorporate into their home cooking styles [42]. Physical activity recommendations should also be given in context of cultural acceptability. A recent study by Hall and others concluded that some African-American women may be reluctant to follow exercise advice for fear that sweating will ruin their hairstyles [43]. Although providers need not be experts on the cultural norms of all of their patients, they should be open to discussing them, and to asking about the patient’s goals, ideal body type, comfort with physical activity, diet advice and other issues that will make individualized counseling much more effective.

PCP Concern: “Weight gain reflects the patient’s lack of will power and laziness”

Bias towards obese patients has been documented among health care providers [44,45]. Studies have shown that some providers have less respect for obese patients [46], perceive obese patients as nonadherent to medications [47], and associate obesity with “laziness,” “stupidity,” and “worthlessness” [48]. Furthermore, obese patients identify physicians as a primary source of stigma [49] and many report stigmatizing experiences during interactions with the healthcare system [44,45]. In one study, a considerable proportion of obese patients reported ever experiencing stigma from a doctor (69%) or a nurse (46%) [49]. As a result of these negative experiences, obese patients have reported avoiding or delaying medical services such as gynecological cancer screening [50]. A recent study by Gudzune et al found that obese patients had significantly greater odds of “doctor shopping,” where individuals saw 5 or more primary care providers in a 2-year period [51]. This doctor shopping behavior may also be motivated by dissatisfaction with care, as focus groups of obese women have reported doctor shopping until they find a health care provider who is comfortable, experienced, and skilled in treating obese patients [50].

Assessing Implicit and Explicit Weight Bias

In addition to explicit negative attitudes, health care providers may also hold implicit biases towards obese patients [52]. A recent study found that over half of medical students held an implicit anti-fat bias [53]. These implicit attitudes may manifest more subtly during patient encounters. PCPs engage in less emotional rapport building during visits with overweight and obese patients as compared to normal weight patients [54], which include behaviors such as expressing empathy, concern, reassurance, and partnership. The lack of rapport building could negatively influence the patient-provider relationship and decrease the effectiveness of weight loss counseling. PCPs may need to consider undergoing self-assessment to determine whether or not they hold negative implicit and/or explicit attitudes towards obese patients. PCPs can complete the Weight Implicit Association Test (IAT) for free online at https://implicit.harvard.edu/implicit/demo/. To determine whether they hold negative explicit attitudes, PCPs can download and complete assessments offered by the Yale Rudd Center for Food Policy and Obesity (www.yaleruddcenter.org/resources/bias_toolkit/index.html).

Pursuing Additional Training in Communication Skills

If weight bias is indeed present, PCPs may benefit from additional training in communication skills as well as specific guidance on how to discuss weight loss with overweight and obese patients. For example, an observational study found that patients lost more weight when they had weight loss counseling visits with physicians who used motivational interviewing strategies [20,21]. Additional PCP training in this area would benefit the patient-provider relationship, as research has shown that such patient-centered communication strategies lead to greater patient satisfaction [55,56], improvement in some clinical outcomes [57,58], and less physician burnout [59]. In fact, some medical schools address student weight bias during their obesity curricula [60]. Building communication skills helps improve PCPs’ capacity to show concern and empathy for patients’ struggles, avoid judgment and criticism, and give emotional support and encouragement, which may all improve PCPs’ ability to execute more sensitive weight loss discussions. For providers who are more interested in CME opportunities, the American Academy on Communication in Healthcare offers an online interactive learning program in this area called “Doc Com” (http://doccom.aachonline.org/dnn/Home.aspx).

PCP Concern: “I may not get reimbursed for weight management services”

Traditional metrics for how doctors are reimbursed and how the quality of their care is measured have not promoted weight loss counseling by PCPs. Prior to 2012, physicians could not bill Medicare for obesity-specific counseling visits [61]. Given that many private insurers follow the lead of the Centers for Medicare and Medicaid Services (CMS) for patterns of reimbursement, this issue has been pervasive in U.S. medical practice for a number of years, with considerable variability between plans on which obesity-related services are covered [62]. A recent study of U.S. health plans indicated that most would reject a claim for an office visit where obesity was the only coded diagnosis [62]. Additionally, the quality improvement movement has only recently begun to focus on issues of obesity. In 2009, the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) added 2 new measures pertaining to the documentation of a patient’s BMI status. Prior to this time, even the simple act of acknowledging obesity was routinely underperformed and quite variable across health plans in the United States [63].

Obesity Screening and Counseling Benefits Coverage

In 2012, CMS made a major coverage change decision when they agreed to reimburse providers for delivering intensive behavioral interventions for obesity [61]. Namely, CMS will now cover a 6-month series of visits for Medicare patients (weekly for month 1, every other week for months 2–6), followed by monthly visits for an additional 6 months in patients who have been able to lose 3 kg. For PCPs and other providers who have long hoped for more opportunity to discuss nutrition, weight, and physical activity with their Medicare patients, these policy changes are exciting. Hopefully, this move by CMS will stimulate similar changes in the private insurance market.

Greater reimbursement of obesity-related care is also more likely given the overall trend of the U.S. health care system—with the focus shifting away from traditional fee-for-service models that have de-emphasized preventive care and counseling and toward a model that rewards well care [64]. Large employer groups, who represent an important voice in any discussion of health insurance and reimbursement, are also increasingly interested in the use of wellness programs and weight loss to decrease their own health care costs. This trend could further stimulate insurers to cover programs that allow providers to engage in weight counseling as a way of attracting or retaining large employer groups as customers [62].

Obesity Screening and Counseling Quality Metrics

A parallel movement in the quality of care realm would serve to bolster any forthcoming changes in reimbursement. For example, an expansion of the HEDIS “wellness and health promotion” measures, or going beyond “BMI assessment” to include a brief assessment of key dietary factors or physical activity level as a routine quality measure, would go a long way toward emphasizing to payers and providers the need for more routine obesity counseling. Professional provider organizations have been increasingly engaged in this area as well. The recent recognition by the American Medical Association of obesity as a disease may also influence organizations such as the NCQA and payers who may be considering how to encourage providers to better address this important issue.

PCP Concern: “I don’t have time to discuss weight loss during outpatient visits”

The average continuity visit for an adult patient in the United States is about 20 minutes in duration, with a mean of 6 to 7 clinical items to be addressed during that time-period [65]. This leaves little time for providers to perform the necessary history and physical portions of the visit, educate patients on various topics, and write out prescriptions or referrals. Not surprisingly, such extreme time pressure leads many PCPs to feel overwhelmed and burned out [66], and the idea of adding another “to-do” to office visits may be resisted. For obese patients, many of whom are likely to have multiple chronic conditions, PCPs are faced with the task of both discussing active issues such as hypertension, diabetes, and sleep apnea, and also potentially discussing the patient’s weight status in a very brief amount of time. Under such time pressures, PCPs often adopt a “putting out fires” mentality and therefore tackle what they see as the most pressing issues—eg, deal with out of control blood pressure by adding a new medication, or lowering hemoglobin A1c by upping the insulin dose, rather than dealing with the 20-lb weight gain that might be leading to the high pressures and hyperglycemia.

Compounding this problem is the fact that well-delivered preventive health advice can be time-consuming, and with so many topics to choose from, it may be difficult for providers to know which issues make the most sense to prioritize [67]. A recent study estimated that PCPs routinely under-counsel patients about nutrition (an advice topic that earns a “B” rating from the USPSTF), while they over-counsel them on exercise and PSA testing (topics that earn an “I” rating from the USPSTF) [68]. Topics of discussion and the time spent on them may reflect patient priorities or PCP comfort with various issues, but it is clear that some improvements could be made to better utilize available time with patients.

In the face of time and resource pressures, many PCPs may not be ideally suited to deliver the kind of intensive behavioral weight loss interventions that are supported by the best scientific evidence [69]. In fact, there is little evidence to support even brief weight counseling sessions by PCPs [70]. However, for busy providers, there are several brief and potentially impactful tasks that could enable them to better support their obese patients.

Brief Counseling Interventions in the Primary Care Setting

First, primary care providers should routinely measure and discuss their patients BMIs as they would any other vital sign. In addition, other brief measures such as “Exercise as a Vital Sign” [71] can be incorporated into the visit, so that behaviors linked to weight can inform the strategy adopted and monitored over time. After a brief discussion is initiated, a referral can be placed for patients who wish to pursue more intense therapy for weight loss—this may be to behavioral health, nutrition, bariatric surgery or a comprehensive weight management clinic. Practices can support their providers by streamlining this referral process and educating providers and patients on available resources. PCPs also may be able to engage their patients in self-monitoring (eg, calorie tracking, exercise tracking, self weighing) so that most of the work and learning takes place outside of the primary care office. For example, PCPs can promote the use of a food diary, a practice that has been shown to improve weight loss success [72]. Review of the diary could take place at a separate visit with the PCP or in follow-up with a weight loss specialist or dietitian.

A major strength of the primary care setting is its longitudinal nature. Even if available time at individual visits is short, advice and support can be given repeatedly over a longer period of time than may often be achieved with a specialist consultant. For patients who are in the maintenance phase of weight loss, having long-term frequent contacts with a provider has been shown to prevent weight regain [73]. The use of group visits and physician extenders (RNs, NPs, PAs) for delivering obesity-related behavioral advice might offer another way to relieve some of the time pressures faced by PCPs in the one-on-one chronic disease management visit [69,74].

PCP Concern: “I don’t know where to refer patients for weight management”

Surveys of obese patients and their doctors indicate that PCPs may not often enough refer patients to structured weight loss programs or registered dietitians [75,76]. Furthermore, PCPs are often isolated from other providers who might be important in a team-based model of obesity care, such as pharmacists, registered dietitians, endocrinologists, and bariatric surgeons. The implementation of the Affordable Care Act, including payment reform and the rise of accountable care organizations, should begin changing the relative isolation of the PCP. If more practices attempt to conform to medical home models, the interconnectedness of PCPs to other health care team members may increase, thus facilitating a more team-based approach to obesity care and easier referrals to specialized team members [77].

Weight Management Resources

Aside from some academic centers and large private health care institutions, many primary care practices lack access to structured obesity care clinics that can help manage the challenges of guiding patients through their weight loss options. For providers who practice in areas that do not afford them easy access to obesity care clinics, it is worth seeking out available resources in the nonmedical community that might provide a structured support system for patients. One low-cost community-based program, Take Off Pounds Sensibly (TOPS; www.tops.org), can achieve and sustain a 6% weight loss for active members [78]. Groups such as Overeaters Anonymous are found in most U.S. cities, and have helpful websites including podcasts that patients can access even in the absence of a local branch (www.oa.org). Organizations like the YMCA, which have good penetration into most areas of the country, offer affordable access to physical activity and health programs including coaching that can promote all around healthier living and improved dietary habits (www.ymca.net). A final consideration could be referral to a commercial weight loss program. A 2005 review of the major U.S. commercial weight loss programs concluded that there was suboptimal evidence for or against these programs’ efficacy [79]. A recent randomized controlled trial showed that patients referred by their PCP to a commercial weight loss program (Weight Watchers) lost significantly more weight (2.3 kg) at 12 months as compared to patients who only received weight loss advice from their PCP [80]. However, it is important to keep in mind that not all commercial programs are the same and some programs can be ineffective or even dangerous for some patients. The PCP may need to take an active role monitoring their patient’s health and safety when using these programs.

A Strategy to Incorporate Weight Management into Current Practice

Summary

Given the obesity epidemic, PCPs will need to begin addressing weight loss as a part of their normal practice; however, providers face several challenges in implementing weight management services. Many PCPs report receiving inadequate training in weight management during their training; however, many CME opportunities exist for providers to reduce their knowledge and skills deficit. Depending upon the prevalence of obesity in their practice and interest in offering weight management services, PCPs may need to consider more intensive weight management training or even pursue certification as an obesity medicine provider through the American Board of Obesity Medicine. For providers with a more general interest in obesity counseling, applying a consistent counseling approach like the 5A’s to several behaviors (eg, obesity, smoking cessation) may facilitate such counseling as a regular part of the outpatient encounter. PCPs should also be aware of different cultural considerations with respect to obesity including different body image perceptions and cooking styles. Obesity bias is pervasive in our society; therefore, PCPs may similarly hold negative explicit or implicit attitudes towards these patients. Providers can engage in online self-assessment about their explicit and implicit biases in order to understand whether they hold any negative attitudes towards obese patients. Additional training in communication skills and empathy may improve these patient-provider relationships and translate into more effective behavioral counseling. PCPs may be concerned about a lack of reimbursement for weight management services or a lack of time to perform counseling during outpatient encounters. With the new obesity counseling benefits coverage by CMS, PCPs should be reimbursed for obesity counseling services and provide additional time through dedicated weight management visits for Medicare patients. The new primary care practice models including the patient-centered medical home may facilitate PCP referrals to other weight management providers such as registered dieticians and health coaches, which could offset the PCP’s time pressures. Finally, PCPs can consider referrals to community resources, such as programs like Overeaters Anonymous, TOPS or the YMCA, to help provide patients group support for behavior change. In summary, PCPs may need to consider additional training to be prepared to deliver high quality obesity care in collaboration with other local partners and weight management specialists.

Corresponding author: Kimberly A. Gudzune, MD, MPH, 2024 E. Monument St, Room 2-611, Baltimore, MD 21287, gudzune@jhu.edu.

Funding/support: Dr. Gudzune received support through a career development award from the National Heart, Lung, and Blood Institute (K23HL116601).

Financial disclosures: None

From the Kaiser Permanente Center for Health Research Southeast, Atlanta, GA (Dr. Lewis) and the Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Gudzune).

Abstract

• Objective: To review challenges to obesity counseling in the primary care setting and suggest potential solutions.
• Methods: Review of the literature.
• Results: There are many challenges to obesity counseling in the primary care setting, including lack of primary care provider (PCP) training, provider weight bias, lack of reimbursement, lack of time during outpatient encounters, and limited ability to refer patients to structured weight loss support programs. However, there are potential solutions to overcome these challenges. By seeking continuing medical education on weight management and communication skills, PCPs can address any training gaps and establish rapport with patients when delivering obesity counseling. Recent policy changes including Medicare coverage of obesity counseling visits may reduce PCPs' concern about lack of reimbursement and time, and the rise of new models of care delivery and reimbursement, such as patient-centered medical homes or accountable care organizations, may facilitate referrals to ancillary providers like registered dietitians or multi-component weight loss programs.
• Conclusion: Although providers face several challenges in delivering effective obesity counseling, PCPs may overcome these obstacles by pursuing continuing medical education in this area and taking advantage of new health care benefits coverage and care delivery models.

Over one-third of U.S. adults are now obese [1] and the prevalence of obesity is rising globally (2). In 2003 and 2012, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation that health care providers screen all patients for obesity and offer intensive, multicomponent behavioral interventions to obese patients [3,4]. Screening for obesity typically involves assessment and classification of a patient’s body mass index (BMI). In the primary care setting, weight management may include a range of therapeutic options such as intensive behavioral counseling, prescription anti-obesity medications, and referral to bariatric surgery. Behavioral interventions typically include activities such as goal setting, diet and exercise change, and self-monitoring. A recent systematic review showed that primary care–based behavioral interventions could result in modest weight losses of 3 kg over a 12-month period, and prevent the development of diabetes and hypertension in at-risk patients [5].

PCP Concern: “I never learned about weight management during my training”

One of the most common barriers to providing the recommended counseling reported by health care providers is inadequate training in nutrition, exercise, and weight loss counseling [10–12]. Many providers have knowledge deficiencies in basic weight management [13,14]. In addition, few PCPs who have received obesity-related training rate that training as good quality during medical school (23%) and residency (35%) [15].

Pursuing Additional Training in Weight Management

Providers could address their lack of training in weight management by participating in an obesity curriculum. When surveyed, PCPs have identified that additional training in nutrition counseling (93%) and exercise counseling (92%) would help them improve the care for obese patients, and many (60%) reported receiving good continuing medical education (CME) on this topic [15]. Much research in this area has examined the impact of such training on residents’ provision of obesity counseling. Residents who completed training improved the quality of obesity care that they provided [16], and those who learned appropriate obesity screening and counseling practices were more likely to report discussing lifestyle changes with their patients [17]. The vast majority of surveyed PCPs (86%) also felt that motivational interviewing [15], a technique that can effectively promote weight loss, would help them improve obesity care [18,19]. Patients demonstrated greater confidence in their ability to change their diet when their PCP used motivational interviewing–consistent techniques during counseling [20]; however, few PCPs utilize motivational interviewing techniques [20,21]. Offering CME opportunities for practicing PCPs to obtain skills in nutrition, exercise, and motivational interviewing would likely improve the quality of obesity care and weight loss counseling that are being delivered. PCPs could also consider attending an in-depth weight management and obesity 

Applying a Universal Behavior Change Approach to Obesity and Other Behaviors

Another option may be encouraging PCPs to use a universal approach to behavioral counseling across multiple domains [22]. Using a single technique may lend familiarity and efficiency to the health care providers’ counseling [23]. The 5A’s—Assess, Advise, Agree, Assist, Arrange—has been proposed as a possible “universal” strategy that has demonstrated efficacy in both smoking cessation [24] and weight loss [25,26]. Using the 5A’s has been associated with increased motivation to lose weight [25] and increased weight loss [26]. Many physicians are familiar with the 5A’s; however, few physicians use the complete technique. PCPs have been found to most frequently “assess” and “advise” when using the 5A’s technique for weight loss counseling [26,27], although assisting and arranging are the components that have been associated with dietary change and weight loss [26]. PCPs could incorporate these A’s into their counseling routine by ensuring that they “assist” the patient by establishing appropriate lifestyle changes (eg, calorie tracking to achieve a 500 to 1000 calorie reduction per day) or referring to a weight loss program, and “arrange” for follow-up by scheduling an appointment in a few weeks to discuss the patient’s progress [23]. While the 5A’s can effectively promote weight loss, many PCPs would likely require training or retraining in this method to ensure its proper use. For PCPs interested in integrating the 5A’s into their weight management practice, we refer them to the algorithm described by Serdula and colleagues [23].

Cultural Influences on Weight Management

A final weight management training consideration relates to cultural awareness for patients who are from different racial or ethnic backgrounds than the PCP. In the United States, racial and ethnic minority groups are disproportionately burdened by obesity. Nearly 60% of non-Hispanic black women and 41% of Hispanic women are obese, compared with 33% of non-Hispanic whites [28]. Despite this fact, obese non-Hispanic black and Hispanic patients are more likely than white patients to perceive themselves as “slightly overweight” and to rate their health as good to excellent despite their obesity [29,30]. As a result, they may be less likely to seek out weight loss strategies on their own or ask for weight control advice from their providers [31]. Additionally, racial and ethnic disparities in access to healthy foods [32,33], safe areas for engaging in physical activity [34], and lack of social support for healthy behaviors may make it much more difficult for some minority patients to act on their PCP's advice.

Because of different cultures, social influences, and norms, what an individual patient perceives as obese or unhealthy may differ dramatically from what his or her physician views as obese or unhealthy [35–38]. Therefore, it is important that PCPs have a discussion with their patients about their subjective weight and health perceptions before beginning any prescriptive weight management strategies or discussions of “normal BMI” [39,40]. If an obese patient views herself as being at a normal weight for her culture, she is unlikely to respond well to being told by her doctor that she needs to lose 40 pounds to get to a healthy weight. Recent research suggests that alternative goals, such as encouraging weight maintenance for non-Hispanic black women, may be a successful alternative to the traditional pathway of encouraging weight loss [41].

In addition to understanding cultural context during weight status discussions, it is also important to give behavior change advice that is sensitive to the culture, race, and ethnicity of the patient. Dietary recommendations should take into account the patient’s culture. For example, Lindbergh et al have noted that cooking in traditional Hispanic culture does not rely as much on measurements as does cooking for non-Hispanic whites [42]. Therefore, measurement-based dietary advice (the cornerstone of portion control) may be a more problematic concept for these patients to incorporate into their home cooking styles [42]. Physical activity recommendations should also be given in context of cultural acceptability. A recent study by Hall and others concluded that some African-American women may be reluctant to follow exercise advice for fear that sweating will ruin their hairstyles [43]. Although providers need not be experts on the cultural norms of all of their patients, they should be open to discussing them, and to asking about the patient’s goals, ideal body type, comfort with physical activity, diet advice and other issues that will make individualized counseling much more effective.

PCP Concern: “Weight gain reflects the patient’s lack of will power and laziness”

Bias towards obese patients has been documented among health care providers [44,45]. Studies have shown that some providers have less respect for obese patients [46], perceive obese patients as nonadherent to medications [47], and associate obesity with “laziness,” “stupidity,” and “worthlessness” [48]. Furthermore, obese patients identify physicians as a primary source of stigma [49] and many report stigmatizing experiences during interactions with the healthcare system [44,45]. In one study, a considerable proportion of obese patients reported ever experiencing stigma from a doctor (69%) or a nurse (46%) [49]. As a result of these negative experiences, obese patients have reported avoiding or delaying medical services such as gynecological cancer screening [50]. A recent study by Gudzune et al found that obese patients had significantly greater odds of “doctor shopping,” where individuals saw 5 or more primary care providers in a 2-year period [51]. This doctor shopping behavior may also be motivated by dissatisfaction with care, as focus groups of obese women have reported doctor shopping until they find a health care provider who is comfortable, experienced, and skilled in treating obese patients [50].

Assessing Implicit and Explicit Weight Bias

In addition to explicit negative attitudes, health care providers may also hold implicit biases towards obese patients [52]. A recent study found that over half of medical students held an implicit anti-fat bias [53]. These implicit attitudes may manifest more subtly during patient encounters. PCPs engage in less emotional rapport building during visits with overweight and obese patients as compared to normal weight patients [54], which include behaviors such as expressing empathy, concern, reassurance, and partnership. The lack of rapport building could negatively influence the patient-provider relationship and decrease the effectiveness of weight loss counseling. PCPs may need to consider undergoing self-assessment to determine whether or not they hold negative implicit and/or explicit attitudes towards obese patients. PCPs can complete the Weight Implicit Association Test (IAT) for free online at https://implicit.harvard.edu/implicit/demo/. To determine whether they hold negative explicit attitudes, PCPs can download and complete assessments offered by the Yale Rudd Center for Food Policy and Obesity (www.yaleruddcenter.org/resources/bias_toolkit/index.html).

Pursuing Additional Training in Communication Skills

If weight bias is indeed present, PCPs may benefit from additional training in communication skills as well as specific guidance on how to discuss weight loss with overweight and obese patients. For example, an observational study found that patients lost more weight when they had weight loss counseling visits with physicians who used motivational interviewing strategies [20,21]. Additional PCP training in this area would benefit the patient-provider relationship, as research has shown that such patient-centered communication strategies lead to greater patient satisfaction [55,56], improvement in some clinical outcomes [57,58], and less physician burnout [59]. In fact, some medical schools address student weight bias during their obesity curricula [60]. Building communication skills helps improve PCPs’ capacity to show concern and empathy for patients’ struggles, avoid judgment and criticism, and give emotional support and encouragement, which may all improve PCPs’ ability to execute more sensitive weight loss discussions. For providers who are more interested in CME opportunities, the American Academy on Communication in Healthcare offers an online interactive learning program in this area called “Doc Com” (http://doccom.aachonline.org/dnn/Home.aspx).

PCP Concern: “I may not get reimbursed for weight management services”

Traditional metrics for how doctors are reimbursed and how the quality of their care is measured have not promoted weight loss counseling by PCPs. Prior to 2012, physicians could not bill Medicare for obesity-specific counseling visits [61]. Given that many private insurers follow the lead of the Centers for Medicare and Medicaid Services (CMS) for patterns of reimbursement, this issue has been pervasive in U.S. medical practice for a number of years, with considerable variability between plans on which obesity-related services are covered [62]. A recent study of U.S. health plans indicated that most would reject a claim for an office visit where obesity was the only coded diagnosis [62]. Additionally, the quality improvement movement has only recently begun to focus on issues of obesity. In 2009, the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) added 2 new measures pertaining to the documentation of a patient’s BMI status. Prior to this time, even the simple act of acknowledging obesity was routinely underperformed and quite variable across health plans in the United States [63].

Obesity Screening and Counseling Benefits Coverage

In 2012, CMS made a major coverage change decision when they agreed to reimburse providers for delivering intensive behavioral interventions for obesity [61]. Namely, CMS will now cover a 6-month series of visits for Medicare patients (weekly for month 1, every other week for months 2–6), followed by monthly visits for an additional 6 months in patients who have been able to lose 3 kg. For PCPs and other providers who have long hoped for more opportunity to discuss nutrition, weight, and physical activity with their Medicare patients, these policy changes are exciting. Hopefully, this move by CMS will stimulate similar changes in the private insurance market.

Greater reimbursement of obesity-related care is also more likely given the overall trend of the U.S. health care system—with the focus shifting away from traditional fee-for-service models that have de-emphasized preventive care and counseling and toward a model that rewards well care [64]. Large employer groups, who represent an important voice in any discussion of health insurance and reimbursement, are also increasingly interested in the use of wellness programs and weight loss to decrease their own health care costs. This trend could further stimulate insurers to cover programs that allow providers to engage in weight counseling as a way of attracting or retaining large employer groups as customers [62].

Obesity Screening and Counseling Quality Metrics

A parallel movement in the quality of care realm would serve to bolster any forthcoming changes in reimbursement. For example, an expansion of the HEDIS “wellness and health promotion” measures, or going beyond “BMI assessment” to include a brief assessment of key dietary factors or physical activity level as a routine quality measure, would go a long way toward emphasizing to payers and providers the need for more routine obesity counseling. Professional provider organizations have been increasingly engaged in this area as well. The recent recognition by the American Medical Association of obesity as a disease may also influence organizations such as the NCQA and payers who may be considering how to encourage providers to better address this important issue.

PCP Concern: “I don’t have time to discuss weight loss during outpatient visits”

The average continuity visit for an adult patient in the United States is about 20 minutes in duration, with a mean of 6 to 7 clinical items to be addressed during that time-period [65]. This leaves little time for providers to perform the necessary history and physical portions of the visit, educate patients on various topics, and write out prescriptions or referrals. Not surprisingly, such extreme time pressure leads many PCPs to feel overwhelmed and burned out [66], and the idea of adding another “to-do” to office visits may be resisted. For obese patients, many of whom are likely to have multiple chronic conditions, PCPs are faced with the task of both discussing active issues such as hypertension, diabetes, and sleep apnea, and also potentially discussing the patient’s weight status in a very brief amount of time. Under such time pressures, PCPs often adopt a “putting out fires” mentality and therefore tackle what they see as the most pressing issues—eg, deal with out of control blood pressure by adding a new medication, or lowering hemoglobin A1c by upping the insulin dose, rather than dealing with the 20-lb weight gain that might be leading to the high pressures and hyperglycemia.

Compounding this problem is the fact that well-delivered preventive health advice can be time-consuming, and with so many topics to choose from, it may be difficult for providers to know which issues make the most sense to prioritize [67]. A recent study estimated that PCPs routinely under-counsel patients about nutrition (an advice topic that earns a “B” rating from the USPSTF), while they over-counsel them on exercise and PSA testing (topics that earn an “I” rating from the USPSTF) [68]. Topics of discussion and the time spent on them may reflect patient priorities or PCP comfort with various issues, but it is clear that some improvements could be made to better utilize available time with patients.

In the face of time and resource pressures, many PCPs may not be ideally suited to deliver the kind of intensive behavioral weight loss interventions that are supported by the best scientific evidence [69]. In fact, there is little evidence to support even brief weight counseling sessions by PCPs [70]. However, for busy providers, there are several brief and potentially impactful tasks that could enable them to better support their obese patients.

Brief Counseling Interventions in the Primary Care Setting

First, primary care providers should routinely measure and discuss their patients BMIs as they would any other vital sign. In addition, other brief measures such as “Exercise as a Vital Sign” [71] can be incorporated into the visit, so that behaviors linked to weight can inform the strategy adopted and monitored over time. After a brief discussion is initiated, a referral can be placed for patients who wish to pursue more intense therapy for weight loss—this may be to behavioral health, nutrition, bariatric surgery or a comprehensive weight management clinic. Practices can support their providers by streamlining this referral process and educating providers and patients on available resources. PCPs also may be able to engage their patients in self-monitoring (eg, calorie tracking, exercise tracking, self weighing) so that most of the work and learning takes place outside of the primary care office. For example, PCPs can promote the use of a food diary, a practice that has been shown to improve weight loss success [72]. Review of the diary could take place at a separate visit with the PCP or in follow-up with a weight loss specialist or dietitian.

A major strength of the primary care setting is its longitudinal nature. Even if available time at individual visits is short, advice and support can be given repeatedly over a longer period of time than may often be achieved with a specialist consultant. For patients who are in the maintenance phase of weight loss, having long-term frequent contacts with a provider has been shown to prevent weight regain [73]. The use of group visits and physician extenders (RNs, NPs, PAs) for delivering obesity-related behavioral advice might offer another way to relieve some of the time pressures faced by PCPs in the one-on-one chronic disease management visit [69,74].

PCP Concern: “I don’t know where to refer patients for weight management”

Surveys of obese patients and their doctors indicate that PCPs may not often enough refer patients to structured weight loss programs or registered dietitians [75,76]. Furthermore, PCPs are often isolated from other providers who might be important in a team-based model of obesity care, such as pharmacists, registered dietitians, endocrinologists, and bariatric surgeons. The implementation of the Affordable Care Act, including payment reform and the rise of accountable care organizations, should begin changing the relative isolation of the PCP. If more practices attempt to conform to medical home models, the interconnectedness of PCPs to other health care team members may increase, thus facilitating a more team-based approach to obesity care and easier referrals to specialized team members [77].

Weight Management Resources

Aside from some academic centers and large private health care institutions, many primary care practices lack access to structured obesity care clinics that can help manage the challenges of guiding patients through their weight loss options. For providers who practice in areas that do not afford them easy access to obesity care clinics, it is worth seeking out available resources in the nonmedical community that might provide a structured support system for patients. One low-cost community-based program, Take Off Pounds Sensibly (TOPS; www.tops.org), can achieve and sustain a 6% weight loss for active members [78]. Groups such as Overeaters Anonymous are found in most U.S. cities, and have helpful websites including podcasts that patients can access even in the absence of a local branch (www.oa.org). Organizations like the YMCA, which have good penetration into most areas of the country, offer affordable access to physical activity and health programs including coaching that can promote all around healthier living and improved dietary habits (www.ymca.net). A final consideration could be referral to a commercial weight loss program. A 2005 review of the major U.S. commercial weight loss programs concluded that there was suboptimal evidence for or against these programs’ efficacy [79]. A recent randomized controlled trial showed that patients referred by their PCP to a commercial weight loss program (Weight Watchers) lost significantly more weight (2.3 kg) at 12 months as compared to patients who only received weight loss advice from their PCP [80]. However, it is important to keep in mind that not all commercial programs are the same and some programs can be ineffective or even dangerous for some patients. The PCP may need to take an active role monitoring their patient’s health and safety when using these programs.

A Strategy to Incorporate Weight Management into Current Practice

Summary

Given the obesity epidemic, PCPs will need to begin addressing weight loss as a part of their normal practice; however, providers face several challenges in implementing weight management services. Many PCPs report receiving inadequate training in weight management during their training; however, many CME opportunities exist for providers to reduce their knowledge and skills deficit. Depending upon the prevalence of obesity in their practice and interest in offering weight management services, PCPs may need to consider more intensive weight management training or even pursue certification as an obesity medicine provider through the American Board of Obesity Medicine. For providers with a more general interest in obesity counseling, applying a consistent counseling approach like the 5A’s to several behaviors (eg, obesity, smoking cessation) may facilitate such counseling as a regular part of the outpatient encounter. PCPs should also be aware of different cultural considerations with respect to obesity including different body image perceptions and cooking styles. Obesity bias is pervasive in our society; therefore, PCPs may similarly hold negative explicit or implicit attitudes towards these patients. Providers can engage in online self-assessment about their explicit and implicit biases in order to understand whether they hold any negative attitudes towards obese patients. Additional training in communication skills and empathy may improve these patient-provider relationships and translate into more effective behavioral counseling. PCPs may be concerned about a lack of reimbursement for weight management services or a lack of time to perform counseling during outpatient encounters. With the new obesity counseling benefits coverage by CMS, PCPs should be reimbursed for obesity counseling services and provide additional time through dedicated weight management visits for Medicare patients. The new primary care practice models including the patient-centered medical home may facilitate PCP referrals to other weight management providers such as registered dieticians and health coaches, which could offset the PCP’s time pressures. Finally, PCPs can consider referrals to community resources, such as programs like Overeaters Anonymous, TOPS or the YMCA, to help provide patients group support for behavior change. In summary, PCPs may need to consider additional training to be prepared to deliver high quality obesity care in collaboration with other local partners and weight management specialists.

Corresponding author: Kimberly A. Gudzune, MD, MPH, 2024 E. Monument St, Room 2-611, Baltimore, MD 21287, gudzune@jhu.edu.

Funding/support: Dr. Gudzune received support through a career development award from the National Heart, Lung, and Blood Institute (K23HL116601).

Financial disclosures: None

A mouse fetus purportedly

generated from STAP cells

Credit: Haruko Obokata

The Japanese research institute RIKEN has released early results of its investigation into allegations of misconduct leveled against the creators of STAP cells (stimulus-triggered acquisition of pluripotency cells).

RIKEN has confirmed 2 cases of “inappropriate data handling” but said the circumstances did not constitute misconduct.

The investigation is ongoing, with 4 issues—including charges of plagiarism and doctored figures—still to be resolved.

Research prompts questions, criticism

The investigation began shortly after a group of RIKEN scientists and colleagues from a few other institutions announced their creation of STAP cells.

The researchers said they could induce pluripotency in somatic cells by introducing the cells to a low-pH environment, and they reported this discovery in an article and a letter to Nature.

Not long after the papers were published, members of the scientific community began questioning the validity of the research, citing issues with images, possible plagiarism, and an inability to replicate the experiments described.

In light of these issues, one of the study authors recently called for the research to be retracted.

Teruhiko Wakayama, PhD, formerly of RIKEN but now a professor at the University of Yamanashi, said there are “too many uncertainties” surrounding the research at this point. After a retraction, the researchers could collect new data and images to ensure their accuracy and resubmit the research for publication.

On the other hand, fellow study author Charles Vacanti, MD, of Brigham and Women’s Hospital in Boston, has said a retraction is unnecessary.

“I firmly believe that the questions and concerns raised about our STAP cell paper published in Nature do not affect our findings or conclusions,” Dr Vacanti said.

Investigation launched

In response to the questions and allegations, RIKEN formed a committee to investigate the possibility of misconduct.

The investigation is focusing on 4 of the researchers involved: Haruko Obokata, PhD; Yoshiki Sasai, MD, PhD; Hitoshi Niwa, MD, PhD; and Dr Wakayama.

The committee is also looking into 6 issues with the research, 2 of which have been resolved.

Resolved issues

(1) Critics have questioned the “unnatural appearance of colored cell parts shown by arrows in d2 and d3 images of Figure 1f” in the article.

RIKEN concluded that the process of preparing these images did not constitute fabrication within the context of research misconduct.

(2) Questions have been raised about a “strong resemblance between the rightmost panel in Figure 1b and the lower panel in Figure 2g, both showing a fluorescence image of mice placenta” in the letter.

There is no reference to the figures in the figure legends or the main body of text, and RIKEN does define this sort of discrepancy as fabrication. However, the researchers claimed they had intended to delete one of the figures prior to publication but forgot, and there is no evidence to contradict that explanation. So RIKEN concluded that no malice was intended, and this should not be considered misconduct.

Issues under investigation

(1) In Figure 1i of the article, lane 3 appears to have been inserted.

(2) A part of the article’s “Methods” section on karyotyping analysis appears to have been copied from another paper.

(3) Some of the description of karyotyping in the “Methods” section of the article is different from the procedure the researchers followed.

(4) In the article, the image of differentiated cells for Figures 2d and 2e and the image of chimera mouse immunostaining data are incorrect, and investigation revealed that these images closely resemble images Dr Obokata used in her doctoral dissertation.

Next steps

RIKEN said it will continue with the investigation and issue a full report upon its completion. The institute also aims to determine whether the STAP cell experiments can be reproduced.

“The reproducibility and credibility of the STAP phenomenon must be rigorously validated, not only by RIKEN scientists, but also by others,” said RIKEN President Ryoji Noyori, PhD.

“I have instructed our people to cooperate fully with researchers at outside institutions in their efforts to replicate the STAP cell results.”

Dr Noyori added that RIKEN is prepared to withdraw the Nature papers and take “strict disciplinary action” against the researchers involved if the investigation reveals deliberate misconduct.

A mouse fetus purportedly

generated from STAP cells

Credit: Haruko Obokata

The Japanese research institute RIKEN has released early results of its investigation into allegations of misconduct leveled against the creators of STAP cells (stimulus-triggered acquisition of pluripotency cells).

RIKEN has confirmed 2 cases of “inappropriate data handling” but said the circumstances did not constitute misconduct.

The investigation is ongoing, with 4 issues—including charges of plagiarism and doctored figures—still to be resolved.

Research prompts questions, criticism

The investigation began shortly after a group of RIKEN scientists and colleagues from a few other institutions announced their creation of STAP cells.

The researchers said they could induce pluripotency in somatic cells by introducing the cells to a low-pH environment, and they reported this discovery in an article and a letter to Nature.

Not long after the papers were published, members of the scientific community began questioning the validity of the research, citing issues with images, possible plagiarism, and an inability to replicate the experiments described.

In light of these issues, one of the study authors recently called for the research to be retracted.

Teruhiko Wakayama, PhD, formerly of RIKEN but now a professor at the University of Yamanashi, said there are “too many uncertainties” surrounding the research at this point. After a retraction, the researchers could collect new data and images to ensure their accuracy and resubmit the research for publication.

On the other hand, fellow study author Charles Vacanti, MD, of Brigham and Women’s Hospital in Boston, has said a retraction is unnecessary.

“I firmly believe that the questions and concerns raised about our STAP cell paper published in Nature do not affect our findings or conclusions,” Dr Vacanti said.

Investigation launched

In response to the questions and allegations, RIKEN formed a committee to investigate the possibility of misconduct.

The investigation is focusing on 4 of the researchers involved: Haruko Obokata, PhD; Yoshiki Sasai, MD, PhD; Hitoshi Niwa, MD, PhD; and Dr Wakayama.

The committee is also looking into 6 issues with the research, 2 of which have been resolved.

Resolved issues

(1) Critics have questioned the “unnatural appearance of colored cell parts shown by arrows in d2 and d3 images of Figure 1f” in the article.

RIKEN concluded that the process of preparing these images did not constitute fabrication within the context of research misconduct.

(2) Questions have been raised about a “strong resemblance between the rightmost panel in Figure 1b and the lower panel in Figure 2g, both showing a fluorescence image of mice placenta” in the letter.

There is no reference to the figures in the figure legends or the main body of text, and RIKEN does define this sort of discrepancy as fabrication. However, the researchers claimed they had intended to delete one of the figures prior to publication but forgot, and there is no evidence to contradict that explanation. So RIKEN concluded that no malice was intended, and this should not be considered misconduct.

Issues under investigation

(1) In Figure 1i of the article, lane 3 appears to have been inserted.

(2) A part of the article’s “Methods” section on karyotyping analysis appears to have been copied from another paper.

(3) Some of the description of karyotyping in the “Methods” section of the article is different from the procedure the researchers followed.

(4) In the article, the image of differentiated cells for Figures 2d and 2e and the image of chimera mouse immunostaining data are incorrect, and investigation revealed that these images closely resemble images Dr Obokata used in her doctoral dissertation.

Next steps

RIKEN said it will continue with the investigation and issue a full report upon its completion. The institute also aims to determine whether the STAP cell experiments can be reproduced.

“The reproducibility and credibility of the STAP phenomenon must be rigorously validated, not only by RIKEN scientists, but also by others,” said RIKEN President Ryoji Noyori, PhD.

“I have instructed our people to cooperate fully with researchers at outside institutions in their efforts to replicate the STAP cell results.”

Dr Noyori added that RIKEN is prepared to withdraw the Nature papers and take “strict disciplinary action” against the researchers involved if the investigation reveals deliberate misconduct.

A mouse fetus purportedly

generated from STAP cells

Credit: Haruko Obokata

The Japanese research institute RIKEN has released early results of its investigation into allegations of misconduct leveled against the creators of STAP cells (stimulus-triggered acquisition of pluripotency cells).

RIKEN has confirmed 2 cases of “inappropriate data handling” but said the circumstances did not constitute misconduct.

The investigation is ongoing, with 4 issues—including charges of plagiarism and doctored figures—still to be resolved.

Research prompts questions, criticism

The investigation began shortly after a group of RIKEN scientists and colleagues from a few other institutions announced their creation of STAP cells.

The researchers said they could induce pluripotency in somatic cells by introducing the cells to a low-pH environment, and they reported this discovery in an article and a letter to Nature.

Not long after the papers were published, members of the scientific community began questioning the validity of the research, citing issues with images, possible plagiarism, and an inability to replicate the experiments described.

In light of these issues, one of the study authors recently called for the research to be retracted.

Teruhiko Wakayama, PhD, formerly of RIKEN but now a professor at the University of Yamanashi, said there are “too many uncertainties” surrounding the research at this point. After a retraction, the researchers could collect new data and images to ensure their accuracy and resubmit the research for publication.

On the other hand, fellow study author Charles Vacanti, MD, of Brigham and Women’s Hospital in Boston, has said a retraction is unnecessary.

“I firmly believe that the questions and concerns raised about our STAP cell paper published in Nature do not affect our findings or conclusions,” Dr Vacanti said.

Investigation launched

In response to the questions and allegations, RIKEN formed a committee to investigate the possibility of misconduct.

The investigation is focusing on 4 of the researchers involved: Haruko Obokata, PhD; Yoshiki Sasai, MD, PhD; Hitoshi Niwa, MD, PhD; and Dr Wakayama.

The committee is also looking into 6 issues with the research, 2 of which have been resolved.

Resolved issues

(1) Critics have questioned the “unnatural appearance of colored cell parts shown by arrows in d2 and d3 images of Figure 1f” in the article.

RIKEN concluded that the process of preparing these images did not constitute fabrication within the context of research misconduct.

(2) Questions have been raised about a “strong resemblance between the rightmost panel in Figure 1b and the lower panel in Figure 2g, both showing a fluorescence image of mice placenta” in the letter.

There is no reference to the figures in the figure legends or the main body of text, and RIKEN does define this sort of discrepancy as fabrication. However, the researchers claimed they had intended to delete one of the figures prior to publication but forgot, and there is no evidence to contradict that explanation. So RIKEN concluded that no malice was intended, and this should not be considered misconduct.

Issues under investigation

(1) In Figure 1i of the article, lane 3 appears to have been inserted.

(2) A part of the article’s “Methods” section on karyotyping analysis appears to have been copied from another paper.

(3) Some of the description of karyotyping in the “Methods” section of the article is different from the procedure the researchers followed.

(4) In the article, the image of differentiated cells for Figures 2d and 2e and the image of chimera mouse immunostaining data are incorrect, and investigation revealed that these images closely resemble images Dr Obokata used in her doctoral dissertation.

Next steps

RIKEN said it will continue with the investigation and issue a full report upon its completion. The institute also aims to determine whether the STAP cell experiments can be reproduced.

“The reproducibility and credibility of the STAP phenomenon must be rigorously validated, not only by RIKEN scientists, but also by others,” said RIKEN President Ryoji Noyori, PhD.

“I have instructed our people to cooperate fully with researchers at outside institutions in their efforts to replicate the STAP cell results.”

Dr Noyori added that RIKEN is prepared to withdraw the Nature papers and take “strict disciplinary action” against the researchers involved if the investigation reveals deliberate misconduct.

CHAMPIONSGATE, FLA. – "Aging doesn’t happen overnight," according to Dr. Wendy Roberts, medical director of Desert Dermatology in Rancho Mirage, Calif.

In a video interview at the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Roberts explained the concept of "generational dermatology" and how dermatologists are uniquely qualified to educate patients about taking a long-term, preventative approach to skin care.

hsplete@frontlinemedcom.com

CHAMPIONSGATE, FLA. – "Aging doesn’t happen overnight," according to Dr. Wendy Roberts, medical director of Desert Dermatology in Rancho Mirage, Calif.

In a video interview at the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Roberts explained the concept of "generational dermatology" and how dermatologists are uniquely qualified to educate patients about taking a long-term, preventative approach to skin care.

hsplete@frontlinemedcom.com

CHAMPIONSGATE, FLA. – "Aging doesn’t happen overnight," according to Dr. Wendy Roberts, medical director of Desert Dermatology in Rancho Mirage, Calif.

In a video interview at the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Roberts explained the concept of "generational dermatology" and how dermatologists are uniquely qualified to educate patients about taking a long-term, preventative approach to skin care.

hsplete@frontlinemedcom.com

CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.

hsplete@frontlinemedcom.com

CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.

hsplete@frontlinemedcom.com

CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.

hsplete@frontlinemedcom.com

Chronic myeloid leukemia cells

Credit: UC San Diego

Preclinical research in chronic myeloid leukemia (CML) has pointed to a relationship between cell adherence and treatment resistance.

Investigators found that a population of plastic-adherent K562 cells with increased expression of BCR-ABL exhibited greater resistance to the tyrosine kinase inhibitor imatinib than nonadherent K562 cells.

“Previous studies have linked high levels of the BCR-ABL mutation with drug resistance,” said Richard Byers, PhD, of The University of Manchester in the UK.

“We wanted to see how expression of BCR-ABL differed across groups of CML cells and, in particular, whether there were differences between adherent and nonadherent populations.”

Dr Byers and his colleagues described this investigation in Experimental Hematology.

The researchers evaluated the heterogeneity of BCR-ABL expression at DNA, messenger RNA, and protein levels, using the CML-derived K562 cell line.

They grew cells in suspension and found that some cells adhered to the plastic dish. The investigators then separated the plastic-adherent and nonadherent cell populations and studied them as single cells and in bulk.

The first discovery was that adherent and nonadherent cells had similar BCR-ABL fusion gene copy numbers.

In bulk-cell analysis, the mean relative normalized ratio for genomic ABL DNA copy number was 47.73 for adherent cells and 53.40 for nonadherent cells (P=0.11). In single-cell analysis, the mean copy numbers were 13.83 and 14.22, respectively (P=0.63).

On the other hand, there was a significant difference in BCR-ABL messenger RNA expression between adherent and nonadherent cells.

In bulk cells, the level of BCR-ABL messenger RNA transcripts was 11-fold higher in adherent cells than in nondherent cells (P=0.022). And single-cell analysis revealed the mean BCR-ABL copy number was 53.11 for adherent cells and 14.06 for nonadherent cells (P=0.0013).

Adherent cells also exhibited significantly upregulated phosphorylation of BCR protein compared to nonadherent cells.

Flow cytometry showed that a mean of 61.9% of adherent cells were positive for phosphor-BCR, compared to 14.5% of nonadherent cells (P=0.0074). And single-cell analysis revealed a mean signal number per cell of 8.23 among adherent cells and 3.02 among nonadherent cells (P<0.0001).

In addition, whole-genome microRNA profiling showed that adherent and nonadherent cell populations expressed significantly different microRNA species.

Finally, the researchers found that treatment with imatinib reduced cell viability more rapidly in nonadherent cells than in adherent cells (P<0.005). The adherent cells showed a decrease in cell viability at 24 hours, compared to 4 hours for nonadherent cells.

The investigators said this research suggests that CML patients may have a similar adherent cell population that mediates resistance to imatinib. And the study highlights the importance of single-cell analysis.

“The small number of cells that show high levels of BCR-ABL may not be detectable through bulk analysis of large samples,” Dr Byers said. “It looks like it is important to look at protein levels in single cells.”

“In future, it may be possible to measure BCR-ABL levels in individual cells in the clinic. This will help us identify the resistant, high-BCR-ABL cells and better understand how patients develop resistance to imatinib treatment, with the aim of combating this resistance to make response more durable and the treatment more effective.”

Chronic myeloid leukemia cells

Credit: UC San Diego

Preclinical research in chronic myeloid leukemia (CML) has pointed to a relationship between cell adherence and treatment resistance.

Investigators found that a population of plastic-adherent K562 cells with increased expression of BCR-ABL exhibited greater resistance to the tyrosine kinase inhibitor imatinib than nonadherent K562 cells.

“Previous studies have linked high levels of the BCR-ABL mutation with drug resistance,” said Richard Byers, PhD, of The University of Manchester in the UK.

“We wanted to see how expression of BCR-ABL differed across groups of CML cells and, in particular, whether there were differences between adherent and nonadherent populations.”

Dr Byers and his colleagues described this investigation in Experimental Hematology.

The researchers evaluated the heterogeneity of BCR-ABL expression at DNA, messenger RNA, and protein levels, using the CML-derived K562 cell line.

They grew cells in suspension and found that some cells adhered to the plastic dish. The investigators then separated the plastic-adherent and nonadherent cell populations and studied them as single cells and in bulk.

The first discovery was that adherent and nonadherent cells had similar BCR-ABL fusion gene copy numbers.

In bulk-cell analysis, the mean relative normalized ratio for genomic ABL DNA copy number was 47.73 for adherent cells and 53.40 for nonadherent cells (P=0.11). In single-cell analysis, the mean copy numbers were 13.83 and 14.22, respectively (P=0.63).

On the other hand, there was a significant difference in BCR-ABL messenger RNA expression between adherent and nonadherent cells.

In bulk cells, the level of BCR-ABL messenger RNA transcripts was 11-fold higher in adherent cells than in nondherent cells (P=0.022). And single-cell analysis revealed the mean BCR-ABL copy number was 53.11 for adherent cells and 14.06 for nonadherent cells (P=0.0013).

Adherent cells also exhibited significantly upregulated phosphorylation of BCR protein compared to nonadherent cells.

Flow cytometry showed that a mean of 61.9% of adherent cells were positive for phosphor-BCR, compared to 14.5% of nonadherent cells (P=0.0074). And single-cell analysis revealed a mean signal number per cell of 8.23 among adherent cells and 3.02 among nonadherent cells (P<0.0001).

In addition, whole-genome microRNA profiling showed that adherent and nonadherent cell populations expressed significantly different microRNA species.

Finally, the researchers found that treatment with imatinib reduced cell viability more rapidly in nonadherent cells than in adherent cells (P<0.005). The adherent cells showed a decrease in cell viability at 24 hours, compared to 4 hours for nonadherent cells.

The investigators said this research suggests that CML patients may have a similar adherent cell population that mediates resistance to imatinib. And the study highlights the importance of single-cell analysis.

“The small number of cells that show high levels of BCR-ABL may not be detectable through bulk analysis of large samples,” Dr Byers said. “It looks like it is important to look at protein levels in single cells.”

“In future, it may be possible to measure BCR-ABL levels in individual cells in the clinic. This will help us identify the resistant, high-BCR-ABL cells and better understand how patients develop resistance to imatinib treatment, with the aim of combating this resistance to make response more durable and the treatment more effective.”

Chronic myeloid leukemia cells

Credit: UC San Diego

Preclinical research in chronic myeloid leukemia (CML) has pointed to a relationship between cell adherence and treatment resistance.

Investigators found that a population of plastic-adherent K562 cells with increased expression of BCR-ABL exhibited greater resistance to the tyrosine kinase inhibitor imatinib than nonadherent K562 cells.

“Previous studies have linked high levels of the BCR-ABL mutation with drug resistance,” said Richard Byers, PhD, of The University of Manchester in the UK.

“We wanted to see how expression of BCR-ABL differed across groups of CML cells and, in particular, whether there were differences between adherent and nonadherent populations.”

Dr Byers and his colleagues described this investigation in Experimental Hematology.

The researchers evaluated the heterogeneity of BCR-ABL expression at DNA, messenger RNA, and protein levels, using the CML-derived K562 cell line.

They grew cells in suspension and found that some cells adhered to the plastic dish. The investigators then separated the plastic-adherent and nonadherent cell populations and studied them as single cells and in bulk.

The first discovery was that adherent and nonadherent cells had similar BCR-ABL fusion gene copy numbers.

In bulk-cell analysis, the mean relative normalized ratio for genomic ABL DNA copy number was 47.73 for adherent cells and 53.40 for nonadherent cells (P=0.11). In single-cell analysis, the mean copy numbers were 13.83 and 14.22, respectively (P=0.63).

On the other hand, there was a significant difference in BCR-ABL messenger RNA expression between adherent and nonadherent cells.

In bulk cells, the level of BCR-ABL messenger RNA transcripts was 11-fold higher in adherent cells than in nondherent cells (P=0.022). And single-cell analysis revealed the mean BCR-ABL copy number was 53.11 for adherent cells and 14.06 for nonadherent cells (P=0.0013).

Adherent cells also exhibited significantly upregulated phosphorylation of BCR protein compared to nonadherent cells.

Flow cytometry showed that a mean of 61.9% of adherent cells were positive for phosphor-BCR, compared to 14.5% of nonadherent cells (P=0.0074). And single-cell analysis revealed a mean signal number per cell of 8.23 among adherent cells and 3.02 among nonadherent cells (P<0.0001).

In addition, whole-genome microRNA profiling showed that adherent and nonadherent cell populations expressed significantly different microRNA species.

Finally, the researchers found that treatment with imatinib reduced cell viability more rapidly in nonadherent cells than in adherent cells (P<0.005). The adherent cells showed a decrease in cell viability at 24 hours, compared to 4 hours for nonadherent cells.

The investigators said this research suggests that CML patients may have a similar adherent cell population that mediates resistance to imatinib. And the study highlights the importance of single-cell analysis.

“The small number of cells that show high levels of BCR-ABL may not be detectable through bulk analysis of large samples,” Dr Byers said. “It looks like it is important to look at protein levels in single cells.”

“In future, it may be possible to measure BCR-ABL levels in individual cells in the clinic. This will help us identify the resistant, high-BCR-ABL cells and better understand how patients develop resistance to imatinib treatment, with the aim of combating this resistance to make response more durable and the treatment more effective.”

Bone marrow harvest

Credit: Chad McNeeley

Researchers have found evidence suggesting that perivascular mesenchymal stromal cells (MSCs) are a reservoir of human cytomegalovirus (HCMV).

This opens up the possibility of therapeutically targeting these cells, which surround blood vessels in the organs and can be found in the bone marrow.

If effective, such a treatment method could prove life-saving for individuals who experience HCMV reactivation, such as transplant recipients and patients receiving chemotherapy.

“There are antiviral medications designed to prevent HCMV from re-activating, but HCMV infection remains one of the major complications after both organ and bone marrow transplants,” said study author Graca Almeida-Porada, MD, PhD, of Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

“The question scientists have been asking for years is, ‘Where does the virus hide when it is latent?’ Maybe if we knew, we could target it.”

Previous research showed that hematopoietic stem cells can harbor HCMV. Dr Almeida-Porada and her colleagues hypothesized that other cell populations may also harbor the virus, and they suspected that perivascular MSCs were a likely culprit.

The team’s suspicions were confirmed when testing revealed that perivascular MSCs are susceptible to HCMV infection and that the virus can grow within these cells.

The researchers also compared the susceptibility of perivascular MSCs from the liver, brain, lung, and bone marrow. And they found the highest rate of HCMV infection in cells from the lung.

“This may explain why pneumonia is the primary manifestation of the HCMV infection in bone marrow transplant recipients,” Dr Almeida-Porada said.

To expand upon these findings, she and her colleagues analyzed bone marrow samples from 19 healthy individuals who had tested positive for HCMV. Quantitative PCR revealed HCMV DNA in perivascular MSCs from 7 of the subjects.

This suggests bone marrow-derived perivascular MSCs may be a natural HCMV reservoir, according to the researchers.

“We have found another source of cells that can harbor HCMV virus,” Dr Almeida-Porada concluded. “Knowing the identity of the cells opens the possibility of targeting treatments to stop its re-activation.”

Dr Almeida-Porada and her colleagues recounted their discoveries in the American Journal of Transplantation.

Bone marrow harvest

Credit: Chad McNeeley

Researchers have found evidence suggesting that perivascular mesenchymal stromal cells (MSCs) are a reservoir of human cytomegalovirus (HCMV).

This opens up the possibility of therapeutically targeting these cells, which surround blood vessels in the organs and can be found in the bone marrow.

If effective, such a treatment method could prove life-saving for individuals who experience HCMV reactivation, such as transplant recipients and patients receiving chemotherapy.

“There are antiviral medications designed to prevent HCMV from re-activating, but HCMV infection remains one of the major complications after both organ and bone marrow transplants,” said study author Graca Almeida-Porada, MD, PhD, of Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

“The question scientists have been asking for years is, ‘Where does the virus hide when it is latent?’ Maybe if we knew, we could target it.”

Previous research showed that hematopoietic stem cells can harbor HCMV. Dr Almeida-Porada and her colleagues hypothesized that other cell populations may also harbor the virus, and they suspected that perivascular MSCs were a likely culprit.

The team’s suspicions were confirmed when testing revealed that perivascular MSCs are susceptible to HCMV infection and that the virus can grow within these cells.

The researchers also compared the susceptibility of perivascular MSCs from the liver, brain, lung, and bone marrow. And they found the highest rate of HCMV infection in cells from the lung.

“This may explain why pneumonia is the primary manifestation of the HCMV infection in bone marrow transplant recipients,” Dr Almeida-Porada said.

To expand upon these findings, she and her colleagues analyzed bone marrow samples from 19 healthy individuals who had tested positive for HCMV. Quantitative PCR revealed HCMV DNA in perivascular MSCs from 7 of the subjects.

This suggests bone marrow-derived perivascular MSCs may be a natural HCMV reservoir, according to the researchers.

“We have found another source of cells that can harbor HCMV virus,” Dr Almeida-Porada concluded. “Knowing the identity of the cells opens the possibility of targeting treatments to stop its re-activation.”

Dr Almeida-Porada and her colleagues recounted their discoveries in the American Journal of Transplantation.

Bone marrow harvest

Credit: Chad McNeeley

Researchers have found evidence suggesting that perivascular mesenchymal stromal cells (MSCs) are a reservoir of human cytomegalovirus (HCMV).

This opens up the possibility of therapeutically targeting these cells, which surround blood vessels in the organs and can be found in the bone marrow.

If effective, such a treatment method could prove life-saving for individuals who experience HCMV reactivation, such as transplant recipients and patients receiving chemotherapy.

“There are antiviral medications designed to prevent HCMV from re-activating, but HCMV infection remains one of the major complications after both organ and bone marrow transplants,” said study author Graca Almeida-Porada, MD, PhD, of Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

“The question scientists have been asking for years is, ‘Where does the virus hide when it is latent?’ Maybe if we knew, we could target it.”

Previous research showed that hematopoietic stem cells can harbor HCMV. Dr Almeida-Porada and her colleagues hypothesized that other cell populations may also harbor the virus, and they suspected that perivascular MSCs were a likely culprit.

The team’s suspicions were confirmed when testing revealed that perivascular MSCs are susceptible to HCMV infection and that the virus can grow within these cells.

The researchers also compared the susceptibility of perivascular MSCs from the liver, brain, lung, and bone marrow. And they found the highest rate of HCMV infection in cells from the lung.

“This may explain why pneumonia is the primary manifestation of the HCMV infection in bone marrow transplant recipients,” Dr Almeida-Porada said.

To expand upon these findings, she and her colleagues analyzed bone marrow samples from 19 healthy individuals who had tested positive for HCMV. Quantitative PCR revealed HCMV DNA in perivascular MSCs from 7 of the subjects.

This suggests bone marrow-derived perivascular MSCs may be a natural HCMV reservoir, according to the researchers.

“We have found another source of cells that can harbor HCMV virus,” Dr Almeida-Porada concluded. “Knowing the identity of the cells opens the possibility of targeting treatments to stop its re-activation.”

Dr Almeida-Porada and her colleagues recounted their discoveries in the American Journal of Transplantation.

GRAPEVINE, TEXAS—An analysis of more than 8000 patients provides insights regarding HLA disparity that may help optimize outcomes in individuals undergoing unrelated-donor hematopoietic stem cell transplant.

The study showed that a single allele- or antigen-level HLA mismatch (7/8) increased the risk for acute and chronic graft-vs-host disease (GVHD) and worsened survival rates.

However, there were no locus-specific effects on survival, and there was no impact of allele- vs antigen-level mismatch on survival.

In addition, patients with an 8/8 matched graft had an increased risk of acute GVHD if they had a DQB1 mismatch or a DPB1 mismatch. DPB1 mismatch also decreased the risk of relapse, and nonpermissive DPB1 mismatch was associated with worse survival.

“Thus, we believe that consideration of DPB1 in donor selection may permit skewing toward donors with permissive DPB1 mismatch and may improve outcomes,” said study investigator Joseph Pidala, MD, of the H. Lee Moffitt Cancer Center in Tampa, Florida.

He presented these findings at the 2014 BMT Tandem Meetings as abstract 5, which was designated one of the meeting’s “Best Abstracts.”

Patient characteristics

Dr Pidala and his colleagues evaluated data from 8003 adult and pediatric patients who had undergone their first myeloablative, unrelated transplant between 1999 and 2011. The patients had been diagnosed with acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, or myelodysplastic syndrome.

Patients and their donors had high-resolution typing for HLA-A, -B, -C, -DRB1, -DQB1, and -DPB1. Most cases were 8/8 matched (n=5449), followed by 7/8 (n=2071) and 6/8 (n=483).

“Those with a greater extent of HLA mismatch were younger, less likely to be Caucasian, they differed according to disease indication for transplant, and had a greater proportion of advanced disease stage,” Dr Pidala noted.

“Additionally, those with a greater extent of HLA mismatch were more likely to receive bone marrow grafts in comparison to peripheral blood, total body irradiation, and also to receive in vivo T-cell depletion.”

Furthermore, there was a declining proportion of 6/8 match over time. It decreased from 49% (1999-2002) to 37% (2003-2006) to 14% (2007-2011).

Effects of HLA mismatch

In all analyses, the researchers considered findings significant if the P value was less than 0.01.

Compared to an 8/8 matched graft, receiving a 7/8 graft was significantly associated with an increase in acute grade 2-4, acute grade 3-4, and chronic GVHD; higher transplant-related mortality (TRM); lower disease-free survival (DFS) among patients with early stage or intermediate (but not advanced) disease; and lower overall survival (OS) regardless of disease stage.

Receiving a 6/8 graft was significantly associated with an increase in acute grade 2-4 and 3-4 GVHD, increased TRM, decreased DFS (early stage or intermediate disease), and decreased OS (early stage or intermediate disease).

“In no cases did we find [that mismatch had] an impact on the incidence of primary disease relapse,” Dr Pidala said. “Comparing 7/8 to 6/8 cases, we found that those with 7/8 had improved transplant-related mortality and disease-free and overall survival [only] in the context of early stage disease.”

The team also confirmed these findings in an analysis of 5846 unique cases. In this cohort, 2528 patients were 8/8 matched, 882 were 7/8, and 157 were 6/8.

Locus-specific effects

Mismatch at HLA-A (n=743) was significantly associated with an increase in acute grade 2-4/3-4 and chronic GVHD, increased TRM, decreased DFS, and decreased OS.

Mismatch at HLA-B (n=345) was significantly associated with an increase in grade 2-4/3-4 acute GHVD, chronic GVHD, and TRM. And mismatch at HLA-C (n=766) was significantly associated with an increase in acute grade 3-4 GVHD and TRM and a decrease in DFS and OS.

There were no significant differences in the case of DRB1 mismatch. However, Dr Pidala noted that this group had the smallest number of patients, at 217.

“I’d also like to point out that in direct, pair-wise comparisons across the mismatched loci, we did not observe any significant differences in overall survival,” Dr Pidala said. “Similarly, we found no impact of allele- vs antigen-level mismatch on overall survival.”

DP and DQ mismatch

Among 8/8 matched cases, DPB1 mismatch led to a significantly increased risk for acute grade 2-4 and 3-4 GHVD, as well as a significant reduction in the risk of relapse. This was the case whether patients had a single- or double-allele mismatch.

The addition of DQB1 mismatch significantly increased the risk of grade 2-4 acute GVHD among 8/8 matched cases only if it was a single-antigen mismatch.

Neither DPB1 nor DQB1 mismatch had a significant effect on OS, DFS, or TRM in 8/8 matched cases. And neither DPB1 nor DQB1 mismatch had a significant effect on outcomes of patients who received 7/8 matched grafts.

Among 8/8 matched cases, those with permissive DPB1 mismatch had a significantly lower risk of acute grade 2-4 and 3-4 GVHD and a significantly higher risk of relapse than patients with nonpermissive DPB1 mismatch. Patients with nonpermissive mismatch also had significantly higher TRM and significantly lower DFS and OS.

However, there were no significant differences between permissive and nonpermissive mismatches for patients with 7/8 matched grafts.

Treatment implications

Based on these results and those of previous studies, Dr Pidala said we can conclude that 8/8 matched grafts confer better survival than mismatched grafts. And a permissive DPB1 mismatch can further improve survival in 8/8 cases.

Among patients receiving a 7/8 matched graft, it is preferable to identify those with HLA-C 03:03/03:04 mismatches, as these patients appear to have mortality rates comparable to 8/8 matched cases.

Among 7/8 matched cases, we should avoid nonpermissive DPB1 mismatch, having 3 or more low-expression loci mismatches (DP, DQ, DRB3/4/5), and nonpermissive allele combinations and amino acid substitutions.

GRAPEVINE, TEXAS—An analysis of more than 8000 patients provides insights regarding HLA disparity that may help optimize outcomes in individuals undergoing unrelated-donor hematopoietic stem cell transplant.

The study showed that a single allele- or antigen-level HLA mismatch (7/8) increased the risk for acute and chronic graft-vs-host disease (GVHD) and worsened survival rates.

However, there were no locus-specific effects on survival, and there was no impact of allele- vs antigen-level mismatch on survival.

In addition, patients with an 8/8 matched graft had an increased risk of acute GVHD if they had a DQB1 mismatch or a DPB1 mismatch. DPB1 mismatch also decreased the risk of relapse, and nonpermissive DPB1 mismatch was associated with worse survival.

“Thus, we believe that consideration of DPB1 in donor selection may permit skewing toward donors with permissive DPB1 mismatch and may improve outcomes,” said study investigator Joseph Pidala, MD, of the H. Lee Moffitt Cancer Center in Tampa, Florida.

He presented these findings at the 2014 BMT Tandem Meetings as abstract 5, which was designated one of the meeting’s “Best Abstracts.”

Patient characteristics

Dr Pidala and his colleagues evaluated data from 8003 adult and pediatric patients who had undergone their first myeloablative, unrelated transplant between 1999 and 2011. The patients had been diagnosed with acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, or myelodysplastic syndrome.

Patients and their donors had high-resolution typing for HLA-A, -B, -C, -DRB1, -DQB1, and -DPB1. Most cases were 8/8 matched (n=5449), followed by 7/8 (n=2071) and 6/8 (n=483).

“Those with a greater extent of HLA mismatch were younger, less likely to be Caucasian, they differed according to disease indication for transplant, and had a greater proportion of advanced disease stage,” Dr Pidala noted.

“Additionally, those with a greater extent of HLA mismatch were more likely to receive bone marrow grafts in comparison to peripheral blood, total body irradiation, and also to receive in vivo T-cell depletion.”

Furthermore, there was a declining proportion of 6/8 match over time. It decreased from 49% (1999-2002) to 37% (2003-2006) to 14% (2007-2011).

Effects of HLA mismatch

In all analyses, the researchers considered findings significant if the P value was less than 0.01.

Compared to an 8/8 matched graft, receiving a 7/8 graft was significantly associated with an increase in acute grade 2-4, acute grade 3-4, and chronic GVHD; higher transplant-related mortality (TRM); lower disease-free survival (DFS) among patients with early stage or intermediate (but not advanced) disease; and lower overall survival (OS) regardless of disease stage.

Receiving a 6/8 graft was significantly associated with an increase in acute grade 2-4 and 3-4 GVHD, increased TRM, decreased DFS (early stage or intermediate disease), and decreased OS (early stage or intermediate disease).

“In no cases did we find [that mismatch had] an impact on the incidence of primary disease relapse,” Dr Pidala said. “Comparing 7/8 to 6/8 cases, we found that those with 7/8 had improved transplant-related mortality and disease-free and overall survival [only] in the context of early stage disease.”

The team also confirmed these findings in an analysis of 5846 unique cases. In this cohort, 2528 patients were 8/8 matched, 882 were 7/8, and 157 were 6/8.

Locus-specific effects

Mismatch at HLA-A (n=743) was significantly associated with an increase in acute grade 2-4/3-4 and chronic GVHD, increased TRM, decreased DFS, and decreased OS.

Mismatch at HLA-B (n=345) was significantly associated with an increase in grade 2-4/3-4 acute GHVD, chronic GVHD, and TRM. And mismatch at HLA-C (n=766) was significantly associated with an increase in acute grade 3-4 GVHD and TRM and a decrease in DFS and OS.

There were no significant differences in the case of DRB1 mismatch. However, Dr Pidala noted that this group had the smallest number of patients, at 217.

“I’d also like to point out that in direct, pair-wise comparisons across the mismatched loci, we did not observe any significant differences in overall survival,” Dr Pidala said. “Similarly, we found no impact of allele- vs antigen-level mismatch on overall survival.”

DP and DQ mismatch

Among 8/8 matched cases, DPB1 mismatch led to a significantly increased risk for acute grade 2-4 and 3-4 GHVD, as well as a significant reduction in the risk of relapse. This was the case whether patients had a single- or double-allele mismatch.

The addition of DQB1 mismatch significantly increased the risk of grade 2-4 acute GVHD among 8/8 matched cases only if it was a single-antigen mismatch.

Neither DPB1 nor DQB1 mismatch had a significant effect on OS, DFS, or TRM in 8/8 matched cases. And neither DPB1 nor DQB1 mismatch had a significant effect on outcomes of patients who received 7/8 matched grafts.

Among 8/8 matched cases, those with permissive DPB1 mismatch had a significantly lower risk of acute grade 2-4 and 3-4 GVHD and a significantly higher risk of relapse than patients with nonpermissive DPB1 mismatch. Patients with nonpermissive mismatch also had significantly higher TRM and significantly lower DFS and OS.

However, there were no significant differences between permissive and nonpermissive mismatches for patients with 7/8 matched grafts.

Treatment implications

Based on these results and those of previous studies, Dr Pidala said we can conclude that 8/8 matched grafts confer better survival than mismatched grafts. And a permissive DPB1 mismatch can further improve survival in 8/8 cases.

Among patients receiving a 7/8 matched graft, it is preferable to identify those with HLA-C 03:03/03:04 mismatches, as these patients appear to have mortality rates comparable to 8/8 matched cases.

Among 7/8 matched cases, we should avoid nonpermissive DPB1 mismatch, having 3 or more low-expression loci mismatches (DP, DQ, DRB3/4/5), and nonpermissive allele combinations and amino acid substitutions.

GRAPEVINE, TEXAS—An analysis of more than 8000 patients provides insights regarding HLA disparity that may help optimize outcomes in individuals undergoing unrelated-donor hematopoietic stem cell transplant.

The study showed that a single allele- or antigen-level HLA mismatch (7/8) increased the risk for acute and chronic graft-vs-host disease (GVHD) and worsened survival rates.

However, there were no locus-specific effects on survival, and there was no impact of allele- vs antigen-level mismatch on survival.

In addition, patients with an 8/8 matched graft had an increased risk of acute GVHD if they had a DQB1 mismatch or a DPB1 mismatch. DPB1 mismatch also decreased the risk of relapse, and nonpermissive DPB1 mismatch was associated with worse survival.

“Thus, we believe that consideration of DPB1 in donor selection may permit skewing toward donors with permissive DPB1 mismatch and may improve outcomes,” said study investigator Joseph Pidala, MD, of the H. Lee Moffitt Cancer Center in Tampa, Florida.

He presented these findings at the 2014 BMT Tandem Meetings as abstract 5, which was designated one of the meeting’s “Best Abstracts.”

Patient characteristics

Dr Pidala and his colleagues evaluated data from 8003 adult and pediatric patients who had undergone their first myeloablative, unrelated transplant between 1999 and 2011. The patients had been diagnosed with acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, or myelodysplastic syndrome.

Patients and their donors had high-resolution typing for HLA-A, -B, -C, -DRB1, -DQB1, and -DPB1. Most cases were 8/8 matched (n=5449), followed by 7/8 (n=2071) and 6/8 (n=483).

“Those with a greater extent of HLA mismatch were younger, less likely to be Caucasian, they differed according to disease indication for transplant, and had a greater proportion of advanced disease stage,” Dr Pidala noted.

“Additionally, those with a greater extent of HLA mismatch were more likely to receive bone marrow grafts in comparison to peripheral blood, total body irradiation, and also to receive in vivo T-cell depletion.”

Furthermore, there was a declining proportion of 6/8 match over time. It decreased from 49% (1999-2002) to 37% (2003-2006) to 14% (2007-2011).

Effects of HLA mismatch

In all analyses, the researchers considered findings significant if the P value was less than 0.01.

Compared to an 8/8 matched graft, receiving a 7/8 graft was significantly associated with an increase in acute grade 2-4, acute grade 3-4, and chronic GVHD; higher transplant-related mortality (TRM); lower disease-free survival (DFS) among patients with early stage or intermediate (but not advanced) disease; and lower overall survival (OS) regardless of disease stage.

Receiving a 6/8 graft was significantly associated with an increase in acute grade 2-4 and 3-4 GVHD, increased TRM, decreased DFS (early stage or intermediate disease), and decreased OS (early stage or intermediate disease).

“In no cases did we find [that mismatch had] an impact on the incidence of primary disease relapse,” Dr Pidala said. “Comparing 7/8 to 6/8 cases, we found that those with 7/8 had improved transplant-related mortality and disease-free and overall survival [only] in the context of early stage disease.”

The team also confirmed these findings in an analysis of 5846 unique cases. In this cohort, 2528 patients were 8/8 matched, 882 were 7/8, and 157 were 6/8.

Locus-specific effects

Mismatch at HLA-A (n=743) was significantly associated with an increase in acute grade 2-4/3-4 and chronic GVHD, increased TRM, decreased DFS, and decreased OS.

Mismatch at HLA-B (n=345) was significantly associated with an increase in grade 2-4/3-4 acute GHVD, chronic GVHD, and TRM. And mismatch at HLA-C (n=766) was significantly associated with an increase in acute grade 3-4 GVHD and TRM and a decrease in DFS and OS.

There were no significant differences in the case of DRB1 mismatch. However, Dr Pidala noted that this group had the smallest number of patients, at 217.

“I’d also like to point out that in direct, pair-wise comparisons across the mismatched loci, we did not observe any significant differences in overall survival,” Dr Pidala said. “Similarly, we found no impact of allele- vs antigen-level mismatch on overall survival.”

DP and DQ mismatch

Among 8/8 matched cases, DPB1 mismatch led to a significantly increased risk for acute grade 2-4 and 3-4 GHVD, as well as a significant reduction in the risk of relapse. This was the case whether patients had a single- or double-allele mismatch.

The addition of DQB1 mismatch significantly increased the risk of grade 2-4 acute GVHD among 8/8 matched cases only if it was a single-antigen mismatch.

Neither DPB1 nor DQB1 mismatch had a significant effect on OS, DFS, or TRM in 8/8 matched cases. And neither DPB1 nor DQB1 mismatch had a significant effect on outcomes of patients who received 7/8 matched grafts.

Among 8/8 matched cases, those with permissive DPB1 mismatch had a significantly lower risk of acute grade 2-4 and 3-4 GVHD and a significantly higher risk of relapse than patients with nonpermissive DPB1 mismatch. Patients with nonpermissive mismatch also had significantly higher TRM and significantly lower DFS and OS.

However, there were no significant differences between permissive and nonpermissive mismatches for patients with 7/8 matched grafts.

Treatment implications

Based on these results and those of previous studies, Dr Pidala said we can conclude that 8/8 matched grafts confer better survival than mismatched grafts. And a permissive DPB1 mismatch can further improve survival in 8/8 cases.

Among patients receiving a 7/8 matched graft, it is preferable to identify those with HLA-C 03:03/03:04 mismatches, as these patients appear to have mortality rates comparable to 8/8 matched cases.

Among 7/8 matched cases, we should avoid nonpermissive DPB1 mismatch, having 3 or more low-expression loci mismatches (DP, DQ, DRB3/4/5), and nonpermissive allele combinations and amino acid substitutions.

Lab mouse

Scientists have created a mouse that expresses a fluorescing biosensor in every cell of its body, allowing diseased cells and drugs to be tracked and evaluated in real time.

The biosensor is a single-molecule probe called Raichu-Rac, which was invented in 2002.

Although Raichu-Rac has been used by many research groups since then, this is the first time researchers have successfully modified a mouse to express the molecule throughout the body without affecting cell function.

The team described this work in Cell Reports.

Raichu-Rac mimics the action of the protein Rac, which drives cell movement and oscillates between active and inactive states. When Rac is active, Raichu-Rac picks up chemical cues and glows blue. When Rac is inactive, the molecule glows yellow.

Researchers found they could use imaging techniques to follow Rac activation in any organ at any time. They could watch moment-by-moment oscillation of Rac activity at the front or back of cells as they moved in the body. And they used the technology to monitor Rac activity in response to treatment.

“It allows us to watch and map, in real time, parts of a cell or organ where Rac is active and driving invasion,” said study author Paul Timpson, PhD, of the Garvan Institute of Medical Research in Darlinghurst, New South Wales, Australia.

“In cancers, a lot of blue indicates an aggressive tumor that is in the process of spreading. You can literally watch parts of a tumor turn from blue to yellow as a drug hits its target. This can be an hour or more after the drug is administered, and the effect can wane quickly or slowly. Drug companies need to know these details—specifically, how much, how often, and how long to administer drugs.”

The researchers said the mouse can be used to study any cancer type by crossing it with other models, limiting expression of Raichu-Rac to specific cell or tissue types. And the mouse can be adapted to study other diseases by expressing Raichu-Rac in different disease models.

“The great thing about this mouse is its flexibility and potential for looking at a broad range of diseases and molecular targets,” Dr Timpson said.

The mouse was created by Heidi Welch, PhD, of the Babraham Institute in Cambridge, UK, although she said she cannot take all the credit.

“The credit must go to Professor Miki Matsuda, the genius who invented [Raichu-Rac] in the first place 12 years ago,” Dr Welch said. “He made his discovery freely available to the scientific community and has been very open about his findings since.”

“Miki Matsuda was super helpful in suggesting the expression levels we should be looking for and in recommending the exact biosensor we should use, out of many he developed.”

Lab mouse

Scientists have created a mouse that expresses a fluorescing biosensor in every cell of its body, allowing diseased cells and drugs to be tracked and evaluated in real time.

The biosensor is a single-molecule probe called Raichu-Rac, which was invented in 2002.

Although Raichu-Rac has been used by many research groups since then, this is the first time researchers have successfully modified a mouse to express the molecule throughout the body without affecting cell function.

The team described this work in Cell Reports.

Raichu-Rac mimics the action of the protein Rac, which drives cell movement and oscillates between active and inactive states. When Rac is active, Raichu-Rac picks up chemical cues and glows blue. When Rac is inactive, the molecule glows yellow.

Researchers found they could use imaging techniques to follow Rac activation in any organ at any time. They could watch moment-by-moment oscillation of Rac activity at the front or back of cells as they moved in the body. And they used the technology to monitor Rac activity in response to treatment.

“It allows us to watch and map, in real time, parts of a cell or organ where Rac is active and driving invasion,” said study author Paul Timpson, PhD, of the Garvan Institute of Medical Research in Darlinghurst, New South Wales, Australia.

“In cancers, a lot of blue indicates an aggressive tumor that is in the process of spreading. You can literally watch parts of a tumor turn from blue to yellow as a drug hits its target. This can be an hour or more after the drug is administered, and the effect can wane quickly or slowly. Drug companies need to know these details—specifically, how much, how often, and how long to administer drugs.”

The researchers said the mouse can be used to study any cancer type by crossing it with other models, limiting expression of Raichu-Rac to specific cell or tissue types. And the mouse can be adapted to study other diseases by expressing Raichu-Rac in different disease models.

“The great thing about this mouse is its flexibility and potential for looking at a broad range of diseases and molecular targets,” Dr Timpson said.

The mouse was created by Heidi Welch, PhD, of the Babraham Institute in Cambridge, UK, although she said she cannot take all the credit.

“The credit must go to Professor Miki Matsuda, the genius who invented [Raichu-Rac] in the first place 12 years ago,” Dr Welch said. “He made his discovery freely available to the scientific community and has been very open about his findings since.”

“Miki Matsuda was super helpful in suggesting the expression levels we should be looking for and in recommending the exact biosensor we should use, out of many he developed.”

Lab mouse

Scientists have created a mouse that expresses a fluorescing biosensor in every cell of its body, allowing diseased cells and drugs to be tracked and evaluated in real time.

The biosensor is a single-molecule probe called Raichu-Rac, which was invented in 2002.

Although Raichu-Rac has been used by many research groups since then, this is the first time researchers have successfully modified a mouse to express the molecule throughout the body without affecting cell function.

The team described this work in Cell Reports.

Raichu-Rac mimics the action of the protein Rac, which drives cell movement and oscillates between active and inactive states. When Rac is active, Raichu-Rac picks up chemical cues and glows blue. When Rac is inactive, the molecule glows yellow.

Researchers found they could use imaging techniques to follow Rac activation in any organ at any time. They could watch moment-by-moment oscillation of Rac activity at the front or back of cells as they moved in the body. And they used the technology to monitor Rac activity in response to treatment.

“It allows us to watch and map, in real time, parts of a cell or organ where Rac is active and driving invasion,” said study author Paul Timpson, PhD, of the Garvan Institute of Medical Research in Darlinghurst, New South Wales, Australia.

“In cancers, a lot of blue indicates an aggressive tumor that is in the process of spreading. You can literally watch parts of a tumor turn from blue to yellow as a drug hits its target. This can be an hour or more after the drug is administered, and the effect can wane quickly or slowly. Drug companies need to know these details—specifically, how much, how often, and how long to administer drugs.”

The researchers said the mouse can be used to study any cancer type by crossing it with other models, limiting expression of Raichu-Rac to specific cell or tissue types. And the mouse can be adapted to study other diseases by expressing Raichu-Rac in different disease models.

“The great thing about this mouse is its flexibility and potential for looking at a broad range of diseases and molecular targets,” Dr Timpson said.

The mouse was created by Heidi Welch, PhD, of the Babraham Institute in Cambridge, UK, although she said she cannot take all the credit.

“The credit must go to Professor Miki Matsuda, the genius who invented [Raichu-Rac] in the first place 12 years ago,” Dr Welch said. “He made his discovery freely available to the scientific community and has been very open about his findings since.”

“Miki Matsuda was super helpful in suggesting the expression levels we should be looking for and in recommending the exact biosensor we should use, out of many he developed.”

The 2014 Residents’ Symposium at the STS 50th Annual Meeting in Orlando was heavily attended and greatly appreciated by current thoracic surgical trainees.

This outstanding forum boasted several experienced and informative speakers, with the overall goals of helping residents to find the right job and transition to practice.

Moderated by Dr. Sidhu Gangadharan, Dr. Sandra Starnes, and Dr. Ara A. Vaporciyan, this session addressed several key foci, specifically aiming to help residents plan a successful job search, negotiate important elements of a contract, plan for ways to bring new technologies into a practice, recognize the legal issues of billing and coding, and identify the important aspects of early career development. This phenomenal collection of talks featured a number of key speakers, who provided tips and recommendations received with great interest by the resident participants.

The symposium was kicked off by Dr. Danny Chu of the University of Pittsburgh Medical Center, who spoke on how to find a job position. He shared his personal experiences and gave attendees an overview of the actual job-search process. He provided several tips for finding the best job. He stated that since, "good positions are almost never advertised until they are filled, it helps to have a big network." He explained that, "in such a small community, there are literally 3 degrees of separation, and everyone knows everyone. In addition to being a good surgeon, being a nice and affable person will get you a good position." His top tips for finding a job are to "Work hard, be nice, and be social." Dr. Chu concluded his presentation by explaining that there’s no magic formula for finding a job, but that it’s very much like dating. He warns that money is not everything, details are all negotiable, and one should be cautious in trusting others. In the end, he believes that "nice guys will win," and tells the group despite much anxiety, it will work out in the end.

This was followed by a talk from Dr. Christine Lau of the University of Virginia, Charlottesville, on interviewing and self-marketing. Dr. Lau provided her insights on how to best represent yourself in the interview process, with a number of great points about putting your best foot forward. She emphasized the importance of being prepared, and she strongly advised that, prior to going on an interview, you do your homework. "Know what the position entails," explained Dr. Lau, "and have a well-thought-out plan regarding what you uniquely bring to it."

She advised speaking to a number of people in advance in order to elucidate the specific needs of the group. And, while Dr. Lau encourages you to have a clear explanation as to how you might meet the expectations of the job, she offered a reminder of the importance of being honest. "Yes, you want to explain how you fit into the spot; however, if it’s not a good fit, don’t try to be something that you’re not. You won’t be happy in the long run, and neither will they." Dr. Lau also offered some advice regarding the concept of specialization.

"Everybody wants to have a niche. But you don’t need to force yourself to differentiate early on." She continued, "If your interests and skills are broad at this point, that’s not a bad thing. You can always morph later."

Dr. Faiz Bhora of Columbia University, N.Y., wrapped up the first session with a discussion of contract negotiations – helping attendees prioritize what’s worth fighting for, how to fight for it, and how to avoid going so far as to negotiate oneself out of a job.

After the opportunity to partake in both small and large group sessions and a short break, the symposium resumed, with the second half focusing on the transition from trainee to attending surgeon.

Dr. Edward Chen of Emory University in Atlanta provided suggestions for adding new technologies to one’s practice and the effective team interactions required to do so. He listed several key strategies that he feels are critical to a successful transition. Communication, communication, and communication were at the top of his list. He advised that it’s a two-way street and that ample meetings may be necessary regarding one’s needs and expectations. He warned not to make any assumptions and to be flexible about adapting to the system that is in place. He also stressed the importance of a willingness to educate the staff about specific technology – in the ICU, in the OR, and on the ward. Dr. Chen also spoke about professional behavior and team building once one is out in the real world.

His advice to trainees entering practice entails the following three recommendations: "1) Make patient care your absolute top priority. 2) Treat everyone around you with utmost respect and dignity. Care about and find value in all team members, even those who are not the strongest members. Always have your team member’s back and never openly criticize anyone. And 3) embrace your new institution and new team members." These suggestions are useful for trainees entering their first job; however, they are also incredibly practical advice for anybody working on a medical team, regardless of the environment or their role on the team.

Dr. Francis C. Nichols, from the Mayo Clinic, in Rochester, Minn., gave a great update on the new ICD-10, explaining key differences between previous coding systems and the new one.

He provided attendees with a helpful understanding of the importance of appropriate coding and billing strategies, and offered tips for accurately optimizing one’s ability to bill for provided services.

Finally, this wonderful series of brief lectures was finished off with a top-notch presentation from Dr. Elizabeth A. David of the University of California, Davis, who spoke about the various means of developing your career in the early years. She provided insight and details about developing reasonable, achievable 5- and 10-year plans; finding mentors (both within and outside of one’s institution); and how not to fail as a junior attending. The most important thing that you should do as a junior attending, according to Dr. David, is to make sure that your patients do well. She recommends, "Check everything, be vigilant, make sure your outcomes are yours, and be available to your patients and your referring physicians."

When asked what she wishes she’d known before venturing into practice, Dr. David states, "I wish I had known how hard I was going to work as a junior faculty member. People had told me that the first year would be a hard year, but it never really sunk in until I was experiencing it." She continues, "my first year was definitely a challenging year, but like all things you work hard for – it was very rewarding!"

Likewise, the symposium was incredibly rewarding. States Dr. Michelle Ellis, a finishing fellow at the University of Michigan, Ann Arbor, "I enjoyed the symposium very much. It was timely and relevant. I would definitely recommend it to other residents and fellows. I especially liked the break-out sessions which allowed for detailed discussion."

Dr. Antonoff is a second-year, thoracic-track trainee at Washington University in St Louis.

The 2014 Residents’ Symposium at the STS 50th Annual Meeting in Orlando was heavily attended and greatly appreciated by current thoracic surgical trainees.

This outstanding forum boasted several experienced and informative speakers, with the overall goals of helping residents to find the right job and transition to practice.

Moderated by Dr. Sidhu Gangadharan, Dr. Sandra Starnes, and Dr. Ara A. Vaporciyan, this session addressed several key foci, specifically aiming to help residents plan a successful job search, negotiate important elements of a contract, plan for ways to bring new technologies into a practice, recognize the legal issues of billing and coding, and identify the important aspects of early career development. This phenomenal collection of talks featured a number of key speakers, who provided tips and recommendations received with great interest by the resident participants.

The symposium was kicked off by Dr. Danny Chu of the University of Pittsburgh Medical Center, who spoke on how to find a job position. He shared his personal experiences and gave attendees an overview of the actual job-search process. He provided several tips for finding the best job. He stated that since, "good positions are almost never advertised until they are filled, it helps to have a big network." He explained that, "in such a small community, there are literally 3 degrees of separation, and everyone knows everyone. In addition to being a good surgeon, being a nice and affable person will get you a good position." His top tips for finding a job are to "Work hard, be nice, and be social." Dr. Chu concluded his presentation by explaining that there’s no magic formula for finding a job, but that it’s very much like dating. He warns that money is not everything, details are all negotiable, and one should be cautious in trusting others. In the end, he believes that "nice guys will win," and tells the group despite much anxiety, it will work out in the end.

This was followed by a talk from Dr. Christine Lau of the University of Virginia, Charlottesville, on interviewing and self-marketing. Dr. Lau provided her insights on how to best represent yourself in the interview process, with a number of great points about putting your best foot forward. She emphasized the importance of being prepared, and she strongly advised that, prior to going on an interview, you do your homework. "Know what the position entails," explained Dr. Lau, "and have a well-thought-out plan regarding what you uniquely bring to it."

She advised speaking to a number of people in advance in order to elucidate the specific needs of the group. And, while Dr. Lau encourages you to have a clear explanation as to how you might meet the expectations of the job, she offered a reminder of the importance of being honest. "Yes, you want to explain how you fit into the spot; however, if it’s not a good fit, don’t try to be something that you’re not. You won’t be happy in the long run, and neither will they." Dr. Lau also offered some advice regarding the concept of specialization.

"Everybody wants to have a niche. But you don’t need to force yourself to differentiate early on." She continued, "If your interests and skills are broad at this point, that’s not a bad thing. You can always morph later."

Dr. Faiz Bhora of Columbia University, N.Y., wrapped up the first session with a discussion of contract negotiations – helping attendees prioritize what’s worth fighting for, how to fight for it, and how to avoid going so far as to negotiate oneself out of a job.

After the opportunity to partake in both small and large group sessions and a short break, the symposium resumed, with the second half focusing on the transition from trainee to attending surgeon.

Dr. Edward Chen of Emory University in Atlanta provided suggestions for adding new technologies to one’s practice and the effective team interactions required to do so. He listed several key strategies that he feels are critical to a successful transition. Communication, communication, and communication were at the top of his list. He advised that it’s a two-way street and that ample meetings may be necessary regarding one’s needs and expectations. He warned not to make any assumptions and to be flexible about adapting to the system that is in place. He also stressed the importance of a willingness to educate the staff about specific technology – in the ICU, in the OR, and on the ward. Dr. Chen also spoke about professional behavior and team building once one is out in the real world.

His advice to trainees entering practice entails the following three recommendations: "1) Make patient care your absolute top priority. 2) Treat everyone around you with utmost respect and dignity. Care about and find value in all team members, even those who are not the strongest members. Always have your team member’s back and never openly criticize anyone. And 3) embrace your new institution and new team members." These suggestions are useful for trainees entering their first job; however, they are also incredibly practical advice for anybody working on a medical team, regardless of the environment or their role on the team.

Dr. Francis C. Nichols, from the Mayo Clinic, in Rochester, Minn., gave a great update on the new ICD-10, explaining key differences between previous coding systems and the new one.

He provided attendees with a helpful understanding of the importance of appropriate coding and billing strategies, and offered tips for accurately optimizing one’s ability to bill for provided services.

Finally, this wonderful series of brief lectures was finished off with a top-notch presentation from Dr. Elizabeth A. David of the University of California, Davis, who spoke about the various means of developing your career in the early years. She provided insight and details about developing reasonable, achievable 5- and 10-year plans; finding mentors (both within and outside of one’s institution); and how not to fail as a junior attending. The most important thing that you should do as a junior attending, according to Dr. David, is to make sure that your patients do well. She recommends, "Check everything, be vigilant, make sure your outcomes are yours, and be available to your patients and your referring physicians."

When asked what she wishes she’d known before venturing into practice, Dr. David states, "I wish I had known how hard I was going to work as a junior faculty member. People had told me that the first year would be a hard year, but it never really sunk in until I was experiencing it." She continues, "my first year was definitely a challenging year, but like all things you work hard for – it was very rewarding!"

Likewise, the symposium was incredibly rewarding. States Dr. Michelle Ellis, a finishing fellow at the University of Michigan, Ann Arbor, "I enjoyed the symposium very much. It was timely and relevant. I would definitely recommend it to other residents and fellows. I especially liked the break-out sessions which allowed for detailed discussion."

Dr. Antonoff is a second-year, thoracic-track trainee at Washington University in St Louis.

The 2014 Residents’ Symposium at the STS 50th Annual Meeting in Orlando was heavily attended and greatly appreciated by current thoracic surgical trainees.

This outstanding forum boasted several experienced and informative speakers, with the overall goals of helping residents to find the right job and transition to practice.

Moderated by Dr. Sidhu Gangadharan, Dr. Sandra Starnes, and Dr. Ara A. Vaporciyan, this session addressed several key foci, specifically aiming to help residents plan a successful job search, negotiate important elements of a contract, plan for ways to bring new technologies into a practice, recognize the legal issues of billing and coding, and identify the important aspects of early career development. This phenomenal collection of talks featured a number of key speakers, who provided tips and recommendations received with great interest by the resident participants.

The symposium was kicked off by Dr. Danny Chu of the University of Pittsburgh Medical Center, who spoke on how to find a job position. He shared his personal experiences and gave attendees an overview of the actual job-search process. He provided several tips for finding the best job. He stated that since, "good positions are almost never advertised until they are filled, it helps to have a big network." He explained that, "in such a small community, there are literally 3 degrees of separation, and everyone knows everyone. In addition to being a good surgeon, being a nice and affable person will get you a good position." His top tips for finding a job are to "Work hard, be nice, and be social." Dr. Chu concluded his presentation by explaining that there’s no magic formula for finding a job, but that it’s very much like dating. He warns that money is not everything, details are all negotiable, and one should be cautious in trusting others. In the end, he believes that "nice guys will win," and tells the group despite much anxiety, it will work out in the end.

This was followed by a talk from Dr. Christine Lau of the University of Virginia, Charlottesville, on interviewing and self-marketing. Dr. Lau provided her insights on how to best represent yourself in the interview process, with a number of great points about putting your best foot forward. She emphasized the importance of being prepared, and she strongly advised that, prior to going on an interview, you do your homework. "Know what the position entails," explained Dr. Lau, "and have a well-thought-out plan regarding what you uniquely bring to it."

She advised speaking to a number of people in advance in order to elucidate the specific needs of the group. And, while Dr. Lau encourages you to have a clear explanation as to how you might meet the expectations of the job, she offered a reminder of the importance of being honest. "Yes, you want to explain how you fit into the spot; however, if it’s not a good fit, don’t try to be something that you’re not. You won’t be happy in the long run, and neither will they." Dr. Lau also offered some advice regarding the concept of specialization.

"Everybody wants to have a niche. But you don’t need to force yourself to differentiate early on." She continued, "If your interests and skills are broad at this point, that’s not a bad thing. You can always morph later."

Dr. Faiz Bhora of Columbia University, N.Y., wrapped up the first session with a discussion of contract negotiations – helping attendees prioritize what’s worth fighting for, how to fight for it, and how to avoid going so far as to negotiate oneself out of a job.

After the opportunity to partake in both small and large group sessions and a short break, the symposium resumed, with the second half focusing on the transition from trainee to attending surgeon.

Dr. Edward Chen of Emory University in Atlanta provided suggestions for adding new technologies to one’s practice and the effective team interactions required to do so. He listed several key strategies that he feels are critical to a successful transition. Communication, communication, and communication were at the top of his list. He advised that it’s a two-way street and that ample meetings may be necessary regarding one’s needs and expectations. He warned not to make any assumptions and to be flexible about adapting to the system that is in place. He also stressed the importance of a willingness to educate the staff about specific technology – in the ICU, in the OR, and on the ward. Dr. Chen also spoke about professional behavior and team building once one is out in the real world.

His advice to trainees entering practice entails the following three recommendations: "1) Make patient care your absolute top priority. 2) Treat everyone around you with utmost respect and dignity. Care about and find value in all team members, even those who are not the strongest members. Always have your team member’s back and never openly criticize anyone. And 3) embrace your new institution and new team members." These suggestions are useful for trainees entering their first job; however, they are also incredibly practical advice for anybody working on a medical team, regardless of the environment or their role on the team.

Dr. Francis C. Nichols, from the Mayo Clinic, in Rochester, Minn., gave a great update on the new ICD-10, explaining key differences between previous coding systems and the new one.

He provided attendees with a helpful understanding of the importance of appropriate coding and billing strategies, and offered tips for accurately optimizing one’s ability to bill for provided services.

Finally, this wonderful series of brief lectures was finished off with a top-notch presentation from Dr. Elizabeth A. David of the University of California, Davis, who spoke about the various means of developing your career in the early years. She provided insight and details about developing reasonable, achievable 5- and 10-year plans; finding mentors (both within and outside of one’s institution); and how not to fail as a junior attending. The most important thing that you should do as a junior attending, according to Dr. David, is to make sure that your patients do well. She recommends, "Check everything, be vigilant, make sure your outcomes are yours, and be available to your patients and your referring physicians."

When asked what she wishes she’d known before venturing into practice, Dr. David states, "I wish I had known how hard I was going to work as a junior faculty member. People had told me that the first year would be a hard year, but it never really sunk in until I was experiencing it." She continues, "my first year was definitely a challenging year, but like all things you work hard for – it was very rewarding!"

Likewise, the symposium was incredibly rewarding. States Dr. Michelle Ellis, a finishing fellow at the University of Michigan, Ann Arbor, "I enjoyed the symposium very much. It was timely and relevant. I would definitely recommend it to other residents and fellows. I especially liked the break-out sessions which allowed for detailed discussion."

Dr. Antonoff is a second-year, thoracic-track trainee at Washington University in St Louis.