PHYSICIAN - EDUCATOR
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Pearls from a Clinician-Researcher (TPJ, June 2021)
Tribute in Menopause by Wulf Utian, MD and Isacc Schiff, MD (NAMS)
Tribute in JBMR By Robert Marcus MD, Steve Cummings MD, Joan Lo MD, Harry Genant MD
Adjunct Investigator, Division of Research, Kaiser Permanente Northern California 2003-2020
Clinical Professor (Emeritus) of Medicine & Radiology, UCSF 1986-2020 Senior Investigator, Division of Research, Kaiser Permanent Northern California 1990-2003 Metabolic Endocrinologist & Internist, Kaiser Permanente San Francisco Medical Center, 1970-2003 Chair of the Chiefs of Endocrinology, Kaiser Permanente Northern California, 1980-2003 Chief of Endocrinology, Kaiser Permanente San Francisco Medical Center, 1974-2003 Medical Liaison to Regional Laboratory, Kaiser Permanente Northern California, 1985-2003 Chief, Bone Densitometry Services, Kaiser Permanente Northern California, 1990-2003 Assistant & Associate Clinical Professor of Medicine, Univ. of California San Francisco, 1974-1986 Chair, Patient Services Committee, Kaiser Permanente Northern California, 1973-1976 |
A graduate of Columbia College (A.B. Liberal Arts: cum laude) and Harvard Medical School (M.D. cum laude), Bruce Ettinger completed his Internal Medicine residency at the II & IV (Harvard) Medical Service, Boston City Hospital. Following a fellowship in Endocrinology at the UCSF Metabolic Research Unit, Dr. Ettinger joined The Permanente Medical Group (TPMG) in 1970 as a Senior Physician in Endocrinology and Medicine at Kaiser Permanente San Francisco Medical Center. Throughout this tenure, he served in multiple leadership positions: Chair of Patient Rights Committee, TPMG 1970s; Regional Chair of Chiefs of Endocrinology, TPMG 1980-2003; Medical Liaison for the Regional Laboratory Services, KPNC 1985-2003; and Regional Chief of Densitometry Services, KPNC 1992-2003. As founding Chair of Endocrinology for KPNC and to many “The Father of TPMG Endocrinology”, he mentored countless TPMG residents, physicians, and researchers during his nearly 50-year career. His expertise in providing clear explanations that reassured patients navigating an uncertain medical diagnosis was remarkable. He is especially remembered for his curiosity, clinical insights, kindness, collegiality, and generosity of time.
As a Senior Investigator at the KPNC Division of Research 1990-2003, Dr. Ettinger spearheaded highly impactful research in women’s health related to menopause, osteoporosis, and fractures. His primary areas of research focused on kidney stones, osteoporosis epidemiology, fracture risk prediction, menopause management, and prevention and treatment of osteoporotic fractures. In addition to “stones and bones,” he was most proud of his women’s health research portfolio, which focused on efficacy and safety studies. Collaborating with scientists both nationally and internationally, he designed, planned, and executed both epidemiologic studies and clinical trials to identify acceptable, effective treatments for women’s menopause management and osteoporosis prevention. In 1996-1997, Dr. Ettinger served as President of the North American Menopause Society (NAMS). In addition to several awards from NAMS for his work advancing postmenopausal health, the journal Menopause selected three of Dr. Ettinger’s papers [1996 (1,2), 1997 (3,4), 2012 (5,6)] for its 25th Anniversary Commemorative Issue highlighting the most impactful paper from each of its 25 years of publication.(7)
As a metabolic endocrinologist at TPMG, Dr. Ettinger’s early work focused on kidney stones (nephrolithiasis) (9,10,11). He was the first to identify triamterene renal calculi in treated patients (12) and conducted the first epidemiologic study of triamterene nephrolithiasis in the U.S.(13) Over 20 years working with the Kaiser Permanente population, Dr. Ettinger built upon these early investigations to advance the field of kidney stones and their prevention (14, 15, 16, 17, 18).
As bone densitometry became the clinical standard for osteoporosis screening, Dr. Ettinger implemented a large KPNC BMD surveillance program for older women. He set up 15 bone densitometry imaging centers across Northern California; he provided leadership for the program and performed ongoing quality monitoring.
A clinician's researcher motivated by the mission to improve the health of Kaiser members, Dr. Ettinger’s research advanced the quality of care and choices available to menopausal women. In his curiosity-driven pursuit to identify the lowest dose needed to treat, Dr. Ettinger led several randomized clinical trials that demonstrated lower than standard dosages of estrogen could adequately maintain bone density after menopause.(22,27) Designing research from his clinical practice, Dr. Ettinger initiated several studies to examine how to improve menopause management; these studies evaluated the gynecologic consequences of cyclic estrogen and progestin (28,29) and unopposed estrogen therapy,(30) the risk of breast cancer with long-term estrogen use,(3,4) and the challenges relating to estrogen discontinuation.(31,32) After he and other clinicians began to encounter patients who reported that their “TCM prescribed dong quai for menopause,” he designed studies to determine whether the Chinese herb “dong quai” had estrogenic properties(33) and to assess diagnostic consistency among Traditional Chinese Medicine (TCM) practitioners.(34)
Remembered for his reassuring presence and expertise at communicating complex issues to patients, Dr. Ettinger was passionate about helping women and their clinicians understand osteoporotic fracture risk. (38) He designed, tested, and refined a web-based Fracture Risk Calculator (FRC) tool that communicates fracture risk in an accessible manner for patients.(39,40) Dr. Ettinger led several studies to validate the FORE FRC tool and the U.S. FRAX® tool. Early studies focused on validating the FORE FRC(41) and examining the performance of FRAX® in women(42) with Kaiser Permanente’s population data. In collaboration with the Osteoporotic Fractures in Men study (MrOS), Dr. Ettinger also validated the FORE FRC in men(43) and assessed the performance of FRAX® in this population.(44)
Bruce loved teaching and learning with his patients, trainees, and colleagues, especially his TPMG 'family' - with whom he worked for 50 years!
As a Senior Investigator at the KPNC Division of Research 1990-2003, Dr. Ettinger spearheaded highly impactful research in women’s health related to menopause, osteoporosis, and fractures. His primary areas of research focused on kidney stones, osteoporosis epidemiology, fracture risk prediction, menopause management, and prevention and treatment of osteoporotic fractures. In addition to “stones and bones,” he was most proud of his women’s health research portfolio, which focused on efficacy and safety studies. Collaborating with scientists both nationally and internationally, he designed, planned, and executed both epidemiologic studies and clinical trials to identify acceptable, effective treatments for women’s menopause management and osteoporosis prevention. In 1996-1997, Dr. Ettinger served as President of the North American Menopause Society (NAMS). In addition to several awards from NAMS for his work advancing postmenopausal health, the journal Menopause selected three of Dr. Ettinger’s papers [1996 (1,2), 1997 (3,4), 2012 (5,6)] for its 25th Anniversary Commemorative Issue highlighting the most impactful paper from each of its 25 years of publication.(7)
As a metabolic endocrinologist at TPMG, Dr. Ettinger’s early work focused on kidney stones (nephrolithiasis) (9,10,11). He was the first to identify triamterene renal calculi in treated patients (12) and conducted the first epidemiologic study of triamterene nephrolithiasis in the U.S.(13) Over 20 years working with the Kaiser Permanente population, Dr. Ettinger built upon these early investigations to advance the field of kidney stones and their prevention (14, 15, 16, 17, 18).
As bone densitometry became the clinical standard for osteoporosis screening, Dr. Ettinger implemented a large KPNC BMD surveillance program for older women. He set up 15 bone densitometry imaging centers across Northern California; he provided leadership for the program and performed ongoing quality monitoring.
A clinician's researcher motivated by the mission to improve the health of Kaiser members, Dr. Ettinger’s research advanced the quality of care and choices available to menopausal women. In his curiosity-driven pursuit to identify the lowest dose needed to treat, Dr. Ettinger led several randomized clinical trials that demonstrated lower than standard dosages of estrogen could adequately maintain bone density after menopause.(22,27) Designing research from his clinical practice, Dr. Ettinger initiated several studies to examine how to improve menopause management; these studies evaluated the gynecologic consequences of cyclic estrogen and progestin (28,29) and unopposed estrogen therapy,(30) the risk of breast cancer with long-term estrogen use,(3,4) and the challenges relating to estrogen discontinuation.(31,32) After he and other clinicians began to encounter patients who reported that their “TCM prescribed dong quai for menopause,” he designed studies to determine whether the Chinese herb “dong quai” had estrogenic properties(33) and to assess diagnostic consistency among Traditional Chinese Medicine (TCM) practitioners.(34)
Remembered for his reassuring presence and expertise at communicating complex issues to patients, Dr. Ettinger was passionate about helping women and their clinicians understand osteoporotic fracture risk. (38) He designed, tested, and refined a web-based Fracture Risk Calculator (FRC) tool that communicates fracture risk in an accessible manner for patients.(39,40) Dr. Ettinger led several studies to validate the FORE FRC tool and the U.S. FRAX® tool. Early studies focused on validating the FORE FRC(41) and examining the performance of FRAX® in women(42) with Kaiser Permanente’s population data. In collaboration with the Osteoporotic Fractures in Men study (MrOS), Dr. Ettinger also validated the FORE FRC in men(43) and assessed the performance of FRAX® in this population.(44)
Bruce loved teaching and learning with his patients, trainees, and colleagues, especially his TPMG 'family' - with whom he worked for 50 years!
REFERENCES
1. Ettinger B, Li DK, Klein R. Continuation of postmenopausal hormone replacement therapy: comparison of cyclic versus continuous combined schedules. Menopause. 2018;25(11):1187-1190.
2. Ettinger B, Li DK, Klein R. Continuation of postmenopausal hormone replacement therapy: Comparison of cyclic versus continuous combined schedules. Menopause. 1996;3(4):185-189.
3. Ettinger B, Quesenberry C, Schroeder DA, Friedman G. Long-term postmenopausal estrogen therapy may be associated with increased risk of breast cancer: A cohort study. Menopause. 2018;25(11):1191-1194.
4. Ettinger B, Quesenberry C, Schroeder DA, Friedman G. Long-term postmenopausal estrogen therapy may be associated with increased risk of breast cancer: A cohort study. Menopause. 1997;4(3):125-129.
5. Ettinger B, Wang SM, Leslie RS, Patel BV, Boulware MJ, Mann ME, McBride M. Evolution of postmenopausal hormone therapy between 2002 and 2009. Menopause. 2012;19(6):610-615.
6. Ettinger B, Wang SM, Leslie RS, Patel BV, Boulware MJ, Mann ME, McBride M. Evolution of postmenopausal hormone therapy between 2002 and 2009. Menopause. 2018;25(11):1306-1312.
7. Menopause 25th Anniversary Commemorative Issue. Menopause. 2018;25(11):1171.
9. Ettinger B, Kolb FO. Chlordiazepoxide and cystinuric calculus. JAMA. 1970;212(4):627.
10. Ettinger B, Kolb FO. Factors involved in crystal formation in cystinuria. In vivo and in vitro crystallization dynamics and a simple, quantitative colorimetic assay for cystine. J Urol. 1971;106(1):106-110.
11. Ettinger B, Kolb FO. Inorganic phosphate treatment of nephrolithiasis. Am J Med. 1973;55(1):32-37.
12. Ettinger B, Weil E, Mandel NS, Darling S. Triamterene-induced nephrolithiasis. Ann Intern Med. 1979;91(5):745-746.
13. Ettinger B, Oldroyd NO, Sorgel F. Triamterene nephrolithiasis. JAMA. 1980;244(21):2443-2445.
14. Ettinger B. Recurrent nephrolithiasis: natural history and effect of phosphate therapy. A double-blind controlled study. Am J Med. 1976;61(2):200-206.
15. Ettinger B. Recurrence of nephrolithiasis. A six-year prospective study. Am J Med. 1979;67(2):245-248.
16. Ettinger B, Tang A, Citron JT, Livermore B, Williams T. Randomized trial of allopurinol in the prevention of calcium oxalate calculi. N Engl J Med. 1986;315(22):1386-1389.
17. Ettinger B, Citron JT, Livermore B, Dolman LI. Chlorthalidone reduces calcium oxalate calculous recurrence but magnesium hydroxide does not. J Urol. 1988;139(4):679-684.
18. Ettinger B, Pak CY, Citron JT, Thomas C, Adams-Huet B, Vangessel A. Potassium-magnesium citrate is an effective prophylaxis against recurrent calcium oxalate nephrolithiasis. J Urol. 1997;158(6):2069-2073.22. Ettinger B, Genant HK, Cann CE. Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium. Ann Intern Med. 1987;106(1):40-45.
22. Ettinger B, Genant HK, Cann CE. Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium. Ann Intern Med. 1987;106(1):40-45.
27. Ettinger B, Ensrud KE, Wallace R, Johnson KC, Cummings SR, Yankov V, Vittinghoff E, Grady D. Effects of ultralow-dose transdermal estradiol on bone mineral density: a randomized clinical trial. Obstet Gynecol. 2004;104(3):443-451.
28. Ettinger B, Selby JV, Citron JT, Ettinger VM, Zhang D. Gynecologic complications of cyclic estrogen progestin therapy. Maturitas. 1993;17(3):197-204.
29. Ettinger B, Selby J, Citron JT, Vangessel A, Ettinger VM, Hendrickson MR. Cyclic hormone replacement therapy using quarterly progestin. Obstet Gynecol. 1994;83(5 Pt 1):693-700.
30. Ettinger B, Golditch IM, Friedman G. Gynecologic consequences of long-term, unopposed estrogen replacement therapy. Maturitas. 1988;10(4):271-282.
31. Ettinger B, Grady D, Tosteson AN, Pressman A, Macer JL. Effect of the Women's Health Initiative on women's decisions to discontinue postmenopausal hormone therapy. Obstet Gynecol. 2003;102(6):1225-1232.
32. Grady D, Ettinger B, Tosteson AN, Pressman A, Macer JL. Predictors of difficulty when discontinuing postmenopausal hormone therapy. Obstet Gynecol. 2003;102(6):1233-1239.
33. Hirata JD, Swiersz LM, Zell B, Small R, Ettinger B. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril. 1997;68(6):981-986.
34. Zell B, Hirata J, Marcus A, Ettinger B, Pressman A, Ettinger KM. Diagnosis of symptomatic postmenopausal women by traditional Chinese medicine practitioners. Menopause. 2000;7(2):129-134.Ettinger B, Hillier TA, Pressman A, Che M, Hanley DA. Simple computer model for calculating and reporting 5-year osteoporotic fracture risk in postmenopausal women. J Womens Health (Larchmt). 2005;14(2):159-171.
39. FORE 10-Year Fracture Risk Calcuator for Health Care Professionals. http://riskcalculator.fore.org/. Accessed July 18, 2010.
40. Ettinger B. A personal perspective on fracture risk assessment tools. Menopause. 2008;15(5):1023-1026.
41. Lo JC, Pressman AR, Chandra M, Ettinger B. Fracture risk tool validation in an integrated healthcare delivery system. Am J Manag Care. 2011;17(3):188-194.
42. Pressman AR, Lo JC, Chandra M, Ettinger B. Methods for assessing fracture risk prediction models: experience with FRAX in a large integrated health care delivery system. J Clin Densitom. 2011;14(4):407-415.
43. Ettinger B, Liu H, Blackwell T, Hoffman AR, Ensrud KE, Orwoll ES. Validation of FRC, a fracture risk assessment tool, in a cohort of older men: the Osteoporotic Fractures in Men (MrOS) Study. J Clin Densitom. 2012;15(3):334-342.
44. Ettinger B, Ensrud KE, Blackwell T, Curtis JR, Lapidus JA, Orwoll ES, Osteoporotic Fracture in Men Study Research G. Performance of FRAX in a cohort of community-dwelling, ambulatory older men: the Osteoporotic Fractures in Men (MrOS) study. Osteoporos Int. 2013;24(4):1185-1193.
1. Ettinger B, Li DK, Klein R. Continuation of postmenopausal hormone replacement therapy: comparison of cyclic versus continuous combined schedules. Menopause. 2018;25(11):1187-1190.
2. Ettinger B, Li DK, Klein R. Continuation of postmenopausal hormone replacement therapy: Comparison of cyclic versus continuous combined schedules. Menopause. 1996;3(4):185-189.
3. Ettinger B, Quesenberry C, Schroeder DA, Friedman G. Long-term postmenopausal estrogen therapy may be associated with increased risk of breast cancer: A cohort study. Menopause. 2018;25(11):1191-1194.
4. Ettinger B, Quesenberry C, Schroeder DA, Friedman G. Long-term postmenopausal estrogen therapy may be associated with increased risk of breast cancer: A cohort study. Menopause. 1997;4(3):125-129.
5. Ettinger B, Wang SM, Leslie RS, Patel BV, Boulware MJ, Mann ME, McBride M. Evolution of postmenopausal hormone therapy between 2002 and 2009. Menopause. 2012;19(6):610-615.
6. Ettinger B, Wang SM, Leslie RS, Patel BV, Boulware MJ, Mann ME, McBride M. Evolution of postmenopausal hormone therapy between 2002 and 2009. Menopause. 2018;25(11):1306-1312.
7. Menopause 25th Anniversary Commemorative Issue. Menopause. 2018;25(11):1171.
9. Ettinger B, Kolb FO. Chlordiazepoxide and cystinuric calculus. JAMA. 1970;212(4):627.
10. Ettinger B, Kolb FO. Factors involved in crystal formation in cystinuria. In vivo and in vitro crystallization dynamics and a simple, quantitative colorimetic assay for cystine. J Urol. 1971;106(1):106-110.
11. Ettinger B, Kolb FO. Inorganic phosphate treatment of nephrolithiasis. Am J Med. 1973;55(1):32-37.
12. Ettinger B, Weil E, Mandel NS, Darling S. Triamterene-induced nephrolithiasis. Ann Intern Med. 1979;91(5):745-746.
13. Ettinger B, Oldroyd NO, Sorgel F. Triamterene nephrolithiasis. JAMA. 1980;244(21):2443-2445.
14. Ettinger B. Recurrent nephrolithiasis: natural history and effect of phosphate therapy. A double-blind controlled study. Am J Med. 1976;61(2):200-206.
15. Ettinger B. Recurrence of nephrolithiasis. A six-year prospective study. Am J Med. 1979;67(2):245-248.
16. Ettinger B, Tang A, Citron JT, Livermore B, Williams T. Randomized trial of allopurinol in the prevention of calcium oxalate calculi. N Engl J Med. 1986;315(22):1386-1389.
17. Ettinger B, Citron JT, Livermore B, Dolman LI. Chlorthalidone reduces calcium oxalate calculous recurrence but magnesium hydroxide does not. J Urol. 1988;139(4):679-684.
18. Ettinger B, Pak CY, Citron JT, Thomas C, Adams-Huet B, Vangessel A. Potassium-magnesium citrate is an effective prophylaxis against recurrent calcium oxalate nephrolithiasis. J Urol. 1997;158(6):2069-2073.22. Ettinger B, Genant HK, Cann CE. Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium. Ann Intern Med. 1987;106(1):40-45.
22. Ettinger B, Genant HK, Cann CE. Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium. Ann Intern Med. 1987;106(1):40-45.
27. Ettinger B, Ensrud KE, Wallace R, Johnson KC, Cummings SR, Yankov V, Vittinghoff E, Grady D. Effects of ultralow-dose transdermal estradiol on bone mineral density: a randomized clinical trial. Obstet Gynecol. 2004;104(3):443-451.
28. Ettinger B, Selby JV, Citron JT, Ettinger VM, Zhang D. Gynecologic complications of cyclic estrogen progestin therapy. Maturitas. 1993;17(3):197-204.
29. Ettinger B, Selby J, Citron JT, Vangessel A, Ettinger VM, Hendrickson MR. Cyclic hormone replacement therapy using quarterly progestin. Obstet Gynecol. 1994;83(5 Pt 1):693-700.
30. Ettinger B, Golditch IM, Friedman G. Gynecologic consequences of long-term, unopposed estrogen replacement therapy. Maturitas. 1988;10(4):271-282.
31. Ettinger B, Grady D, Tosteson AN, Pressman A, Macer JL. Effect of the Women's Health Initiative on women's decisions to discontinue postmenopausal hormone therapy. Obstet Gynecol. 2003;102(6):1225-1232.
32. Grady D, Ettinger B, Tosteson AN, Pressman A, Macer JL. Predictors of difficulty when discontinuing postmenopausal hormone therapy. Obstet Gynecol. 2003;102(6):1233-1239.
33. Hirata JD, Swiersz LM, Zell B, Small R, Ettinger B. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril. 1997;68(6):981-986.
34. Zell B, Hirata J, Marcus A, Ettinger B, Pressman A, Ettinger KM. Diagnosis of symptomatic postmenopausal women by traditional Chinese medicine practitioners. Menopause. 2000;7(2):129-134.Ettinger B, Hillier TA, Pressman A, Che M, Hanley DA. Simple computer model for calculating and reporting 5-year osteoporotic fracture risk in postmenopausal women. J Womens Health (Larchmt). 2005;14(2):159-171.
39. FORE 10-Year Fracture Risk Calcuator for Health Care Professionals. http://riskcalculator.fore.org/. Accessed July 18, 2010.
40. Ettinger B. A personal perspective on fracture risk assessment tools. Menopause. 2008;15(5):1023-1026.
41. Lo JC, Pressman AR, Chandra M, Ettinger B. Fracture risk tool validation in an integrated healthcare delivery system. Am J Manag Care. 2011;17(3):188-194.
42. Pressman AR, Lo JC, Chandra M, Ettinger B. Methods for assessing fracture risk prediction models: experience with FRAX in a large integrated health care delivery system. J Clin Densitom. 2011;14(4):407-415.
43. Ettinger B, Liu H, Blackwell T, Hoffman AR, Ensrud KE, Orwoll ES. Validation of FRC, a fracture risk assessment tool, in a cohort of older men: the Osteoporotic Fractures in Men (MrOS) Study. J Clin Densitom. 2012;15(3):334-342.
44. Ettinger B, Ensrud KE, Blackwell T, Curtis JR, Lapidus JA, Orwoll ES, Osteoporotic Fracture in Men Study Research G. Performance of FRAX in a cohort of community-dwelling, ambulatory older men: the Osteoporotic Fractures in Men (MrOS) study. Osteoporos Int. 2013;24(4):1185-1193.