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Drive, chip, and putt your way to osteoarthritis relief
Taking a swing against arthritis
Osteoarthritis is a tough disease to manage. Exercise helps ease the stiffness and pain of the joints, but at the same time, the disease makes it difficult to do that beneficial exercise. Even a relatively simple activity like jogging can hurt more than it helps. If only there were a low-impact exercise that was incredibly popular among the generally older population who are likely to have arthritis.
We love a good golf study here at LOTME, and a group of Australian and U.K. researchers have provided. Osteoarthritis affects 2 million people in the land down under, making it the most common source of disability there. In that population, only 64% reported their physical health to be good, very good, or excellent. Among the 459 golfers with OA that the study authors surveyed, however, the percentage reporting good health rose to more than 90%.
A similar story emerged when they looked at mental health. Nearly a quarter of nongolfers with OA reported high or very high levels of psychological distress, compared with just 8% of golfers. This pattern of improved physical and mental health remained when the researchers looked at the general, non-OA population.
This isn’t the first time golf’s been connected with improved health, and previous studies have shown golf to reduce the risks of cardiovascular disease, diabetes, and obesity, among other things. Just walking one 18-hole round significantly exceeds the CDC’s recommended 150 minutes of physical activity per week. Go out multiple times a week – leaving the cart and beer at home, American golfers – and you’ll be fit for a lifetime.
The golfers on our staff, however, are still waiting for those mental health benefits to kick in. Because when we’re adding up our scorecard after that string of four double bogeys to end the round, we’re most definitely thinking: “Yes, this sport is reducing my psychological distress. I am having fun right now.”
Battle of the sexes’ intestines
There are, we’re sure you’ve noticed, some differences between males and females. Females, for one thing, have longer small intestines than males. Everybody knows that, right? You didn’t know? Really? … Really?
Well, then, we’re guessing you haven’t read “Hidden diversity: Comparative functional morphology of humans and other species” by Erin A. McKenney, PhD, of North Carolina State University, Raleigh, and associates, which just appeared in PeerJ. We couldn’t put it down, even in the shower – a real page-turner/scroller. (It’s a great way to clean a phone, for those who also like to scroll, text, or talk on the toilet.)
The researchers got out their rulers, calipers, and string and took many measurements of the digestive systems of 45 human cadavers (21 female and 24 male), which were compared with data from 10 rats, 10 pigs, and 10 bullfrogs, which had been collected (the measurements, not the animals) by undergraduate students enrolled in a comparative anatomy laboratory course at the university.
There was little intestinal-length variation among the four-legged subjects, but when it comes to humans, females have “consistently and significantly longer small intestines than males,” the investigators noted.
The women’s small intestines, almost 14 feet long on average, were about a foot longer than the men’s, which suggests that women are better able to extract nutrients from food and “supports the canalization hypothesis, which posits that women are better able to survive during periods of stress,” coauthor Amanda Hale said in a written statement from the school. The way to a man’s heart may be through his stomach, but the way to a woman’s heart is through her duodenum, it seems.
Fascinating stuff, to be sure, but the thing that really caught our eye in the PeerJ article was the authors’ suggestion “that organs behave independently of one another, both within and across species.” Organs behaving independently? A somewhat ominous concept, no doubt, but it does explain a lot of the sounds we hear coming from our guts, which can get pretty frightening, especially on chili night.
Dog walking is dangerous business
Yes, you did read that right. A lot of strange things can send you to the emergency department. Go ahead and add dog walking onto that list.
Investigators from Johns Hopkins University estimate that over 422,000 adults presented to U.S. emergency departments with leash-dependent dog walking-related injuries between 2001 and 2020.
With almost 53% of U.S. households owning at least one dog in 2021-2022 in the wake of the COVID pet boom, this kind of occurrence is becoming more common than you think. The annual number of dog-walking injuries more than quadrupled from 7,300 to 32,000 over the course of the study, and the researchers link that spike to the promotion of dog walking for fitness, along with the boost of ownership itself.
The most common injuries listed in the National Electronic Injury Surveillance System database were finger fracture, traumatic brain injury, and shoulder sprain or strain. These mostly involved falls from being pulled, tripped, or tangled up in the leash while walking. For those aged 65 years and older, traumatic brain injury and hip fracture were the most common.
Women were 50% more likely to sustain a fracture than were men, and dog owners aged 65 and older were three times as likely to fall, twice as likely to get a fracture, and 60% more likely to have brain injury than were younger people. Now, that’s not to say younger people don’t also get hurt. After all, dogs aren’t ageists. The researchers have that data but it’s coming out later.
Meanwhile, the pitfalls involved with just trying to get our daily steps in while letting Muffin do her business have us on the lookout for random squirrels.
Taking a swing against arthritis
Osteoarthritis is a tough disease to manage. Exercise helps ease the stiffness and pain of the joints, but at the same time, the disease makes it difficult to do that beneficial exercise. Even a relatively simple activity like jogging can hurt more than it helps. If only there were a low-impact exercise that was incredibly popular among the generally older population who are likely to have arthritis.
We love a good golf study here at LOTME, and a group of Australian and U.K. researchers have provided. Osteoarthritis affects 2 million people in the land down under, making it the most common source of disability there. In that population, only 64% reported their physical health to be good, very good, or excellent. Among the 459 golfers with OA that the study authors surveyed, however, the percentage reporting good health rose to more than 90%.
A similar story emerged when they looked at mental health. Nearly a quarter of nongolfers with OA reported high or very high levels of psychological distress, compared with just 8% of golfers. This pattern of improved physical and mental health remained when the researchers looked at the general, non-OA population.
This isn’t the first time golf’s been connected with improved health, and previous studies have shown golf to reduce the risks of cardiovascular disease, diabetes, and obesity, among other things. Just walking one 18-hole round significantly exceeds the CDC’s recommended 150 minutes of physical activity per week. Go out multiple times a week – leaving the cart and beer at home, American golfers – and you’ll be fit for a lifetime.
The golfers on our staff, however, are still waiting for those mental health benefits to kick in. Because when we’re adding up our scorecard after that string of four double bogeys to end the round, we’re most definitely thinking: “Yes, this sport is reducing my psychological distress. I am having fun right now.”
Battle of the sexes’ intestines
There are, we’re sure you’ve noticed, some differences between males and females. Females, for one thing, have longer small intestines than males. Everybody knows that, right? You didn’t know? Really? … Really?
Well, then, we’re guessing you haven’t read “Hidden diversity: Comparative functional morphology of humans and other species” by Erin A. McKenney, PhD, of North Carolina State University, Raleigh, and associates, which just appeared in PeerJ. We couldn’t put it down, even in the shower – a real page-turner/scroller. (It’s a great way to clean a phone, for those who also like to scroll, text, or talk on the toilet.)
The researchers got out their rulers, calipers, and string and took many measurements of the digestive systems of 45 human cadavers (21 female and 24 male), which were compared with data from 10 rats, 10 pigs, and 10 bullfrogs, which had been collected (the measurements, not the animals) by undergraduate students enrolled in a comparative anatomy laboratory course at the university.
There was little intestinal-length variation among the four-legged subjects, but when it comes to humans, females have “consistently and significantly longer small intestines than males,” the investigators noted.
The women’s small intestines, almost 14 feet long on average, were about a foot longer than the men’s, which suggests that women are better able to extract nutrients from food and “supports the canalization hypothesis, which posits that women are better able to survive during periods of stress,” coauthor Amanda Hale said in a written statement from the school. The way to a man’s heart may be through his stomach, but the way to a woman’s heart is through her duodenum, it seems.
Fascinating stuff, to be sure, but the thing that really caught our eye in the PeerJ article was the authors’ suggestion “that organs behave independently of one another, both within and across species.” Organs behaving independently? A somewhat ominous concept, no doubt, but it does explain a lot of the sounds we hear coming from our guts, which can get pretty frightening, especially on chili night.
Dog walking is dangerous business
Yes, you did read that right. A lot of strange things can send you to the emergency department. Go ahead and add dog walking onto that list.
Investigators from Johns Hopkins University estimate that over 422,000 adults presented to U.S. emergency departments with leash-dependent dog walking-related injuries between 2001 and 2020.
With almost 53% of U.S. households owning at least one dog in 2021-2022 in the wake of the COVID pet boom, this kind of occurrence is becoming more common than you think. The annual number of dog-walking injuries more than quadrupled from 7,300 to 32,000 over the course of the study, and the researchers link that spike to the promotion of dog walking for fitness, along with the boost of ownership itself.
The most common injuries listed in the National Electronic Injury Surveillance System database were finger fracture, traumatic brain injury, and shoulder sprain or strain. These mostly involved falls from being pulled, tripped, or tangled up in the leash while walking. For those aged 65 years and older, traumatic brain injury and hip fracture were the most common.
Women were 50% more likely to sustain a fracture than were men, and dog owners aged 65 and older were three times as likely to fall, twice as likely to get a fracture, and 60% more likely to have brain injury than were younger people. Now, that’s not to say younger people don’t also get hurt. After all, dogs aren’t ageists. The researchers have that data but it’s coming out later.
Meanwhile, the pitfalls involved with just trying to get our daily steps in while letting Muffin do her business have us on the lookout for random squirrels.
Taking a swing against arthritis
Osteoarthritis is a tough disease to manage. Exercise helps ease the stiffness and pain of the joints, but at the same time, the disease makes it difficult to do that beneficial exercise. Even a relatively simple activity like jogging can hurt more than it helps. If only there were a low-impact exercise that was incredibly popular among the generally older population who are likely to have arthritis.
We love a good golf study here at LOTME, and a group of Australian and U.K. researchers have provided. Osteoarthritis affects 2 million people in the land down under, making it the most common source of disability there. In that population, only 64% reported their physical health to be good, very good, or excellent. Among the 459 golfers with OA that the study authors surveyed, however, the percentage reporting good health rose to more than 90%.
A similar story emerged when they looked at mental health. Nearly a quarter of nongolfers with OA reported high or very high levels of psychological distress, compared with just 8% of golfers. This pattern of improved physical and mental health remained when the researchers looked at the general, non-OA population.
This isn’t the first time golf’s been connected with improved health, and previous studies have shown golf to reduce the risks of cardiovascular disease, diabetes, and obesity, among other things. Just walking one 18-hole round significantly exceeds the CDC’s recommended 150 minutes of physical activity per week. Go out multiple times a week – leaving the cart and beer at home, American golfers – and you’ll be fit for a lifetime.
The golfers on our staff, however, are still waiting for those mental health benefits to kick in. Because when we’re adding up our scorecard after that string of four double bogeys to end the round, we’re most definitely thinking: “Yes, this sport is reducing my psychological distress. I am having fun right now.”
Battle of the sexes’ intestines
There are, we’re sure you’ve noticed, some differences between males and females. Females, for one thing, have longer small intestines than males. Everybody knows that, right? You didn’t know? Really? … Really?
Well, then, we’re guessing you haven’t read “Hidden diversity: Comparative functional morphology of humans and other species” by Erin A. McKenney, PhD, of North Carolina State University, Raleigh, and associates, which just appeared in PeerJ. We couldn’t put it down, even in the shower – a real page-turner/scroller. (It’s a great way to clean a phone, for those who also like to scroll, text, or talk on the toilet.)
The researchers got out their rulers, calipers, and string and took many measurements of the digestive systems of 45 human cadavers (21 female and 24 male), which were compared with data from 10 rats, 10 pigs, and 10 bullfrogs, which had been collected (the measurements, not the animals) by undergraduate students enrolled in a comparative anatomy laboratory course at the university.
There was little intestinal-length variation among the four-legged subjects, but when it comes to humans, females have “consistently and significantly longer small intestines than males,” the investigators noted.
The women’s small intestines, almost 14 feet long on average, were about a foot longer than the men’s, which suggests that women are better able to extract nutrients from food and “supports the canalization hypothesis, which posits that women are better able to survive during periods of stress,” coauthor Amanda Hale said in a written statement from the school. The way to a man’s heart may be through his stomach, but the way to a woman’s heart is through her duodenum, it seems.
Fascinating stuff, to be sure, but the thing that really caught our eye in the PeerJ article was the authors’ suggestion “that organs behave independently of one another, both within and across species.” Organs behaving independently? A somewhat ominous concept, no doubt, but it does explain a lot of the sounds we hear coming from our guts, which can get pretty frightening, especially on chili night.
Dog walking is dangerous business
Yes, you did read that right. A lot of strange things can send you to the emergency department. Go ahead and add dog walking onto that list.
Investigators from Johns Hopkins University estimate that over 422,000 adults presented to U.S. emergency departments with leash-dependent dog walking-related injuries between 2001 and 2020.
With almost 53% of U.S. households owning at least one dog in 2021-2022 in the wake of the COVID pet boom, this kind of occurrence is becoming more common than you think. The annual number of dog-walking injuries more than quadrupled from 7,300 to 32,000 over the course of the study, and the researchers link that spike to the promotion of dog walking for fitness, along with the boost of ownership itself.
The most common injuries listed in the National Electronic Injury Surveillance System database were finger fracture, traumatic brain injury, and shoulder sprain or strain. These mostly involved falls from being pulled, tripped, or tangled up in the leash while walking. For those aged 65 years and older, traumatic brain injury and hip fracture were the most common.
Women were 50% more likely to sustain a fracture than were men, and dog owners aged 65 and older were three times as likely to fall, twice as likely to get a fracture, and 60% more likely to have brain injury than were younger people. Now, that’s not to say younger people don’t also get hurt. After all, dogs aren’t ageists. The researchers have that data but it’s coming out later.
Meanwhile, the pitfalls involved with just trying to get our daily steps in while letting Muffin do her business have us on the lookout for random squirrels.
Motixafortide may improve MM outcomes
Motixafortide, a novel cyclic-peptide CXCR4 inhibitor with extended in vivo activity , appears to increase the number of stem cells that can be harvested from transplant candidates, thereby increasing the likelihood of successful transplant, the authors reported.
An application for a new drug approval is currently under review by the Food and Drug Administration.
In the prospective, international, phase 3 GENESIS clinical trial , motixafortide plus granulocyte colony-stimulating factor (G-CSF) – the standard therapy for mobilizing stem cells – significantly increased the number stem cells harvested, when compared with standard therapy plus placebo. After one collection procedure, the combination approach allowed for harvesting of an optimal number of cells in 88% versus 9% of patients who received G-CSF plus placebo. After two collections, optimal collection occurred in 92% versus 26% of patients in the groups, respectively, first author Zachary D. Crees, MD, and colleagues found.
Motixafortide plus G-CSF was also associated with a tenfold increase in the number of primitive stem cells that could be collected. These stem cells are particularly effective for reconstituting red blood cells, white blood cells, and platelets, which all are important for patients’ recovery, they noted.
Stem cells mobilized by motixafortide were also associated with increased expression of genes and genetic pathways involved in self-renewal and regeneration, which are also of benefit for increasing the effectiveness of stem cell transplantation.
The findings were published in Nature Medicine.
“Stem cell transplantation is central to the treatment of multiple myeloma, but some patients don’t see as much benefit because standard therapies can’t harvest enough stem cells for the transplant to be effective, senior author John F. DiPersio, MD, PhD, stated in a news release . “This study suggests motixafortide works extremely well in combination with [G-CSF] in mobilizing stem cells in patients with multiple myeloma.
“The study also found that the combination worked rapidly and was generally well tolerated by patients,” added Dr. DiPersio, the Virginia E. & Sam J. Goldman Professor of Medicine at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University.
Dr. DiPersio is the lead author of another study investigating therapies beyond stem cell transplants. He and his colleagues recently reported the first comprehensive genomic and protein-based analysis of bone marrow samples from patients with multiple myeloma in an effort to identify targets for immunotherapies.
That study, published online in Cancer Research, identified 53 genes that could be targets, including 38 that are responsible for creating abnormal proteins on the surface of multiple myeloma cells; 11 of the 38 had not been previously identified as potential targets.
Dr. DiPersio and Dr. Crees, an assistant professor of medicine and the assistant clinical director of the Washington University Center for Gene and Cellular Immunotherapy, are also evaluating motixafortide’s potential for mobilizing stem cells to support “the genetic correction of the inherited disease sickle cell anemia.”
“This work is of particular importance because patients with sickle cell disease can’t be treated with G-CSF … due to dangerous side effects,” the news release stated. “The hope is that development of a novel, effective, and well-tolerated stem cell mobilizing regimen for a viral-based gene therapy approach using CRISPR-based gene editing will lead to improved outcomes for patients with sickle cell disease.”
The study published in Nature Medicine was supported by the National Institutes of Health and BioLineRx, which makes motixafortide. The study published in Cancer Research was supported by the Paula C. And Rodger O. Riney Blood Cancer Research Fund and the National Cancer Institute.
Dr. Crees reported research funding from BioLineRx. Dr. DiPersio reported relationships with Magenta Therapeutics, WUGEN, Incyte, RiverVest Venture Partners, Cellworks Group, Amphivena Therapeutics, NeoImmune Tech, Macrogenics, and BioLineRx.
Correction, 4/26/23: The headline on an earlier version of this article mischaracterized the study findings.
Motixafortide, a novel cyclic-peptide CXCR4 inhibitor with extended in vivo activity , appears to increase the number of stem cells that can be harvested from transplant candidates, thereby increasing the likelihood of successful transplant, the authors reported.
An application for a new drug approval is currently under review by the Food and Drug Administration.
In the prospective, international, phase 3 GENESIS clinical trial , motixafortide plus granulocyte colony-stimulating factor (G-CSF) – the standard therapy for mobilizing stem cells – significantly increased the number stem cells harvested, when compared with standard therapy plus placebo. After one collection procedure, the combination approach allowed for harvesting of an optimal number of cells in 88% versus 9% of patients who received G-CSF plus placebo. After two collections, optimal collection occurred in 92% versus 26% of patients in the groups, respectively, first author Zachary D. Crees, MD, and colleagues found.
Motixafortide plus G-CSF was also associated with a tenfold increase in the number of primitive stem cells that could be collected. These stem cells are particularly effective for reconstituting red blood cells, white blood cells, and platelets, which all are important for patients’ recovery, they noted.
Stem cells mobilized by motixafortide were also associated with increased expression of genes and genetic pathways involved in self-renewal and regeneration, which are also of benefit for increasing the effectiveness of stem cell transplantation.
The findings were published in Nature Medicine.
“Stem cell transplantation is central to the treatment of multiple myeloma, but some patients don’t see as much benefit because standard therapies can’t harvest enough stem cells for the transplant to be effective, senior author John F. DiPersio, MD, PhD, stated in a news release . “This study suggests motixafortide works extremely well in combination with [G-CSF] in mobilizing stem cells in patients with multiple myeloma.
“The study also found that the combination worked rapidly and was generally well tolerated by patients,” added Dr. DiPersio, the Virginia E. & Sam J. Goldman Professor of Medicine at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University.
Dr. DiPersio is the lead author of another study investigating therapies beyond stem cell transplants. He and his colleagues recently reported the first comprehensive genomic and protein-based analysis of bone marrow samples from patients with multiple myeloma in an effort to identify targets for immunotherapies.
That study, published online in Cancer Research, identified 53 genes that could be targets, including 38 that are responsible for creating abnormal proteins on the surface of multiple myeloma cells; 11 of the 38 had not been previously identified as potential targets.
Dr. DiPersio and Dr. Crees, an assistant professor of medicine and the assistant clinical director of the Washington University Center for Gene and Cellular Immunotherapy, are also evaluating motixafortide’s potential for mobilizing stem cells to support “the genetic correction of the inherited disease sickle cell anemia.”
“This work is of particular importance because patients with sickle cell disease can’t be treated with G-CSF … due to dangerous side effects,” the news release stated. “The hope is that development of a novel, effective, and well-tolerated stem cell mobilizing regimen for a viral-based gene therapy approach using CRISPR-based gene editing will lead to improved outcomes for patients with sickle cell disease.”
The study published in Nature Medicine was supported by the National Institutes of Health and BioLineRx, which makes motixafortide. The study published in Cancer Research was supported by the Paula C. And Rodger O. Riney Blood Cancer Research Fund and the National Cancer Institute.
Dr. Crees reported research funding from BioLineRx. Dr. DiPersio reported relationships with Magenta Therapeutics, WUGEN, Incyte, RiverVest Venture Partners, Cellworks Group, Amphivena Therapeutics, NeoImmune Tech, Macrogenics, and BioLineRx.
Correction, 4/26/23: The headline on an earlier version of this article mischaracterized the study findings.
Motixafortide, a novel cyclic-peptide CXCR4 inhibitor with extended in vivo activity , appears to increase the number of stem cells that can be harvested from transplant candidates, thereby increasing the likelihood of successful transplant, the authors reported.
An application for a new drug approval is currently under review by the Food and Drug Administration.
In the prospective, international, phase 3 GENESIS clinical trial , motixafortide plus granulocyte colony-stimulating factor (G-CSF) – the standard therapy for mobilizing stem cells – significantly increased the number stem cells harvested, when compared with standard therapy plus placebo. After one collection procedure, the combination approach allowed for harvesting of an optimal number of cells in 88% versus 9% of patients who received G-CSF plus placebo. After two collections, optimal collection occurred in 92% versus 26% of patients in the groups, respectively, first author Zachary D. Crees, MD, and colleagues found.
Motixafortide plus G-CSF was also associated with a tenfold increase in the number of primitive stem cells that could be collected. These stem cells are particularly effective for reconstituting red blood cells, white blood cells, and platelets, which all are important for patients’ recovery, they noted.
Stem cells mobilized by motixafortide were also associated with increased expression of genes and genetic pathways involved in self-renewal and regeneration, which are also of benefit for increasing the effectiveness of stem cell transplantation.
The findings were published in Nature Medicine.
“Stem cell transplantation is central to the treatment of multiple myeloma, but some patients don’t see as much benefit because standard therapies can’t harvest enough stem cells for the transplant to be effective, senior author John F. DiPersio, MD, PhD, stated in a news release . “This study suggests motixafortide works extremely well in combination with [G-CSF] in mobilizing stem cells in patients with multiple myeloma.
“The study also found that the combination worked rapidly and was generally well tolerated by patients,” added Dr. DiPersio, the Virginia E. & Sam J. Goldman Professor of Medicine at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University.
Dr. DiPersio is the lead author of another study investigating therapies beyond stem cell transplants. He and his colleagues recently reported the first comprehensive genomic and protein-based analysis of bone marrow samples from patients with multiple myeloma in an effort to identify targets for immunotherapies.
That study, published online in Cancer Research, identified 53 genes that could be targets, including 38 that are responsible for creating abnormal proteins on the surface of multiple myeloma cells; 11 of the 38 had not been previously identified as potential targets.
Dr. DiPersio and Dr. Crees, an assistant professor of medicine and the assistant clinical director of the Washington University Center for Gene and Cellular Immunotherapy, are also evaluating motixafortide’s potential for mobilizing stem cells to support “the genetic correction of the inherited disease sickle cell anemia.”
“This work is of particular importance because patients with sickle cell disease can’t be treated with G-CSF … due to dangerous side effects,” the news release stated. “The hope is that development of a novel, effective, and well-tolerated stem cell mobilizing regimen for a viral-based gene therapy approach using CRISPR-based gene editing will lead to improved outcomes for patients with sickle cell disease.”
The study published in Nature Medicine was supported by the National Institutes of Health and BioLineRx, which makes motixafortide. The study published in Cancer Research was supported by the Paula C. And Rodger O. Riney Blood Cancer Research Fund and the National Cancer Institute.
Dr. Crees reported research funding from BioLineRx. Dr. DiPersio reported relationships with Magenta Therapeutics, WUGEN, Incyte, RiverVest Venture Partners, Cellworks Group, Amphivena Therapeutics, NeoImmune Tech, Macrogenics, and BioLineRx.
Correction, 4/26/23: The headline on an earlier version of this article mischaracterized the study findings.
FROM NATURE MEDICINE
Frontline CLL treatment: Avoiding adverse events
NEW YORK – The Food and Drug Administration’s 2016 approval of the Bruton’s tyrosine kinase inhibitor ibrutinib (IB) as a frontline therapy for chronic lymphocytic leukemia (CLL) dramatically improved overall survival rates for patients with this condition. Follow-up data from 8 years after the RESONATE-2 trial indicated that patients with CLL (65 years or older) who remain on IB therapy can expect to live as long as someone in the general population.
Physicians now face two challenges in frontline CLL treatment: finding safe and effective drugs with fewer side effects, allowing patients to maintain therapy; and offering young or genomically high-risk patients treatments that reduce the risk of relapse.
said John N. Allan, associate professor at Weill Cornell Medicine, New York, in his presentation on frontline CLL treatments at the Great Debates and Updates Hematologic Malignancies Conference. “This is true even of older patients or those with comorbidities because this class of drug allows us to keep patients on treatment with excellent long-term outcomes.”
Results from the Alpine trial (NCT03734016), which included patients with and without high genomic risk, confirmed the superiority of the second generation Bruton’s tyrosine kinase inhibitor zanubrutinib (ZB) versus ibrutinib in terms of overall response rate 86.2% versus 75.5%, progression free survival 2-years after treatment 79.5% versus 67.3%, and adverse events (AEs) leading to discontinuation 15.4% versus 22.2% respectively.
The SEQUOIA trial (NCT03336333) demonstrated the effectiveness of ZB versus bendamustine + rituximab combination (BR) therapy in treatment-naive CLL / small lymphocytic leukemia patients with normal and high genomic risk. Overall 24-month progression free survival (PFS) was 85% in the ZB cohort vs. 69% in the BR cohort. This trend held true among high-risk subgroups like patients with an unmutated IgVH gene or 11q22.3 gene deletion.
Therapies known as “doublets” and “triplets” (which include a Bruton’s tyrosine kinase inhibitor in addition to other drugs) are not FDA approved for frontline CLL treatment. Yet studies suggest that young patients who are better able to tolerate AEs or high-risk patients with a greater risk of relapse (even on monotherapy maintenance), may derive benefits from multidrug frontline treatment.
“With doublets and triplets, doctors add treatment intensity up front so that patients can have a fixed duration of therapy versus continuous indefinite therapy,” said Vu Nguyen MD, a hematologist at Oakland (Calif.) Medical Center. “This is encouraging because if you can have a fixed duration of treatment, patients can come off treatment agents and hopefully have a prolonged remission and normal lifespan without chronic therapy and side effects.”
The CAPTIVATE study confirmed this approach with 3 cycles of IB followed by 12 cycles of IB + venetoclax leading to a 24-month PFS rate of 94% in patients with high risk or relapse. “Furthermore, 95% of study participants patients less than 70 years old completed 12 months of combination treatment without major problems,” said Dr. Allan. He concluded his remarks by noting that “we need longer term data on the use of combination therapy for frontline CLL treatment to confirm if and when it should be used.”
Dr. Allan disclosed relationships with Adaptive Biotechnologies, ADC Therapeutics, AstraZeneca, BeiGene, Epizyme, Genentech, Janssen, Lilly, Pharmacyclics, and TG Therapeutics. Dr. Nguyen reported no disclosures.
NEW YORK – The Food and Drug Administration’s 2016 approval of the Bruton’s tyrosine kinase inhibitor ibrutinib (IB) as a frontline therapy for chronic lymphocytic leukemia (CLL) dramatically improved overall survival rates for patients with this condition. Follow-up data from 8 years after the RESONATE-2 trial indicated that patients with CLL (65 years or older) who remain on IB therapy can expect to live as long as someone in the general population.
Physicians now face two challenges in frontline CLL treatment: finding safe and effective drugs with fewer side effects, allowing patients to maintain therapy; and offering young or genomically high-risk patients treatments that reduce the risk of relapse.
said John N. Allan, associate professor at Weill Cornell Medicine, New York, in his presentation on frontline CLL treatments at the Great Debates and Updates Hematologic Malignancies Conference. “This is true even of older patients or those with comorbidities because this class of drug allows us to keep patients on treatment with excellent long-term outcomes.”
Results from the Alpine trial (NCT03734016), which included patients with and without high genomic risk, confirmed the superiority of the second generation Bruton’s tyrosine kinase inhibitor zanubrutinib (ZB) versus ibrutinib in terms of overall response rate 86.2% versus 75.5%, progression free survival 2-years after treatment 79.5% versus 67.3%, and adverse events (AEs) leading to discontinuation 15.4% versus 22.2% respectively.
The SEQUOIA trial (NCT03336333) demonstrated the effectiveness of ZB versus bendamustine + rituximab combination (BR) therapy in treatment-naive CLL / small lymphocytic leukemia patients with normal and high genomic risk. Overall 24-month progression free survival (PFS) was 85% in the ZB cohort vs. 69% in the BR cohort. This trend held true among high-risk subgroups like patients with an unmutated IgVH gene or 11q22.3 gene deletion.
Therapies known as “doublets” and “triplets” (which include a Bruton’s tyrosine kinase inhibitor in addition to other drugs) are not FDA approved for frontline CLL treatment. Yet studies suggest that young patients who are better able to tolerate AEs or high-risk patients with a greater risk of relapse (even on monotherapy maintenance), may derive benefits from multidrug frontline treatment.
“With doublets and triplets, doctors add treatment intensity up front so that patients can have a fixed duration of therapy versus continuous indefinite therapy,” said Vu Nguyen MD, a hematologist at Oakland (Calif.) Medical Center. “This is encouraging because if you can have a fixed duration of treatment, patients can come off treatment agents and hopefully have a prolonged remission and normal lifespan without chronic therapy and side effects.”
The CAPTIVATE study confirmed this approach with 3 cycles of IB followed by 12 cycles of IB + venetoclax leading to a 24-month PFS rate of 94% in patients with high risk or relapse. “Furthermore, 95% of study participants patients less than 70 years old completed 12 months of combination treatment without major problems,” said Dr. Allan. He concluded his remarks by noting that “we need longer term data on the use of combination therapy for frontline CLL treatment to confirm if and when it should be used.”
Dr. Allan disclosed relationships with Adaptive Biotechnologies, ADC Therapeutics, AstraZeneca, BeiGene, Epizyme, Genentech, Janssen, Lilly, Pharmacyclics, and TG Therapeutics. Dr. Nguyen reported no disclosures.
NEW YORK – The Food and Drug Administration’s 2016 approval of the Bruton’s tyrosine kinase inhibitor ibrutinib (IB) as a frontline therapy for chronic lymphocytic leukemia (CLL) dramatically improved overall survival rates for patients with this condition. Follow-up data from 8 years after the RESONATE-2 trial indicated that patients with CLL (65 years or older) who remain on IB therapy can expect to live as long as someone in the general population.
Physicians now face two challenges in frontline CLL treatment: finding safe and effective drugs with fewer side effects, allowing patients to maintain therapy; and offering young or genomically high-risk patients treatments that reduce the risk of relapse.
said John N. Allan, associate professor at Weill Cornell Medicine, New York, in his presentation on frontline CLL treatments at the Great Debates and Updates Hematologic Malignancies Conference. “This is true even of older patients or those with comorbidities because this class of drug allows us to keep patients on treatment with excellent long-term outcomes.”
Results from the Alpine trial (NCT03734016), which included patients with and without high genomic risk, confirmed the superiority of the second generation Bruton’s tyrosine kinase inhibitor zanubrutinib (ZB) versus ibrutinib in terms of overall response rate 86.2% versus 75.5%, progression free survival 2-years after treatment 79.5% versus 67.3%, and adverse events (AEs) leading to discontinuation 15.4% versus 22.2% respectively.
The SEQUOIA trial (NCT03336333) demonstrated the effectiveness of ZB versus bendamustine + rituximab combination (BR) therapy in treatment-naive CLL / small lymphocytic leukemia patients with normal and high genomic risk. Overall 24-month progression free survival (PFS) was 85% in the ZB cohort vs. 69% in the BR cohort. This trend held true among high-risk subgroups like patients with an unmutated IgVH gene or 11q22.3 gene deletion.
Therapies known as “doublets” and “triplets” (which include a Bruton’s tyrosine kinase inhibitor in addition to other drugs) are not FDA approved for frontline CLL treatment. Yet studies suggest that young patients who are better able to tolerate AEs or high-risk patients with a greater risk of relapse (even on monotherapy maintenance), may derive benefits from multidrug frontline treatment.
“With doublets and triplets, doctors add treatment intensity up front so that patients can have a fixed duration of therapy versus continuous indefinite therapy,” said Vu Nguyen MD, a hematologist at Oakland (Calif.) Medical Center. “This is encouraging because if you can have a fixed duration of treatment, patients can come off treatment agents and hopefully have a prolonged remission and normal lifespan without chronic therapy and side effects.”
The CAPTIVATE study confirmed this approach with 3 cycles of IB followed by 12 cycles of IB + venetoclax leading to a 24-month PFS rate of 94% in patients with high risk or relapse. “Furthermore, 95% of study participants patients less than 70 years old completed 12 months of combination treatment without major problems,” said Dr. Allan. He concluded his remarks by noting that “we need longer term data on the use of combination therapy for frontline CLL treatment to confirm if and when it should be used.”
Dr. Allan disclosed relationships with Adaptive Biotechnologies, ADC Therapeutics, AstraZeneca, BeiGene, Epizyme, Genentech, Janssen, Lilly, Pharmacyclics, and TG Therapeutics. Dr. Nguyen reported no disclosures.
AT 2023 GREAT DEBATES AND UPDATES HEMATOLOGIC MALIGNANCIES CONFERENCE
Five chronic mistakes that can sabotage your medical practice
A physician who in the past has led medical groups as both chief medical officer and president, Gerda Maissel, MD, president of My MD Advisor, a private patient advocacy group, has seen the good, bad, and ugly of practice administration. There’s a spectrum of infractions: Anything from doctors making inappropriate jokes with staff or patients, to failing to establish key relationships with other critical entities, says Dr. Maissel.
“Being a good physician who provides value is important in building a practice,” explained Dr. Maissel. “But it is not the be-all and end-all.”
While the number of physician-owned practices is declining, just under 50% are still in private practice, according to the American Medical Association’s 2020 survey. There’s also a continuing trend toward larger practices. Whatever the size, the physicians are responsible for strategy, marketing, building the practice, and maintaining profitability.
Catherine Lightfoot, CPA, CHBC, president of the National Society of Certified Healthcare Business Consultants (NSCHBC), has her finger on the pulse of what’s right and what’s wrong when it comes to running a medical practice. Although she says there are no hard and fast rules on how to run a thriving medical group, there are common mistakes that physicians often don’t recognize.
Here are the five key mistakes that commonly crop up, and the experts’ thoughts on how to prevent or fix them.
1. Failing to engage in outreach activities and community efforts to build your practice.
Yes, physicians earn good reputations through dedicated work, and that often precedes them when it comes to building a practice. But assuming that hanging a shingle backed by strong credentials is all it takes for success is akin to building a website and assuming people will find it organically. Maybe there was a time, in a small community, where this was good enough. But no longer.
It’s important to plan to get your practice and your name known to potential patients. “Most physicians think that means advertising, but that’s not the complete case,” Dr. Maissel said.
Much of the equation involves ensuring availability. This means setting office hours that work for your target audience of patients, and then ensuring you stick to those hours. This extends beyond scheduling your current patients and into referral patients, too. And it’s particularly true while in the building phase of a new practice.
“If one of your colleagues calls with a referral patient, and they consider the matter urgent, you need to heed that,” explained Dr. Maissel. “So have a breadth of availability for these referral cases.” Through word of mouth, you’ll get a good reputation for patient care and availability, and that will go a long way toward helping to grow your practice.
Establishing a culture that doesn’t involve canceling and rescheduling patients is part of the scheduling equation, too. “I’ve seen the full gamut of cancellation policies, ranging from a month’s notice on changes to 3 months’ notice,” said Dr. Maissel. “It all gets at the same issue, which is failing to set up a culture where doctors don’t change their schedules and leave patients hanging.”
In the end, wonky scheduling, cancellations, and a lack of respect for the urgency of referrals can cost a practice. Forge a reputation in reliability and word will get around, in all the right ways.
2. Not having enough oversight of your outsourced billing service
Billing is one of the biggest pieces of running a successful and profitable practice, yet too many practices ignore it once they’ve handed it off to a billing company. That can cost you in more ways than one, said Ms. Lightfoot. “Billing changes all the time, and if you’re not monitoring your billing partner, you don’t know what you’re getting,” she said.
Ms. Lightfoot said that a decade ago, billing was much more straightforward – essentially, you did the work and received payment. Today’s complex insurance, Medicare, and Medicaid environment have changed the landscape. “Now you have to fight for every dollar you’re billing,” said Ms. Lightfoot. “Rates get cut all the time, you might miss out on a claim, and the rules are constantly changing.”
The solution for many practices is to outsource billing, which Ms. Lightfoot supports. “They specialize in this, and that’s a great start,” she said. “But it’s not as simple as handing it off and forgetting it.”
Instead, ensure your internal staff is up to date on all things coding and billing so that they can catch what your outsourced billing partner doesn’t. Your internal staff should be prepared to carry out coding, check coding, and stay on top of the billing company if they aren’t processing claims quickly enough. For instance: If there’s a denial, how many times will the billing company go after that money?
Other questions to ask when entering a billing relationship: What does the billing company expect from your practice? Do they communicate what needs to be worked on or fixed? Are they providing you with monthly reports? “You want to make sure you’re getting those reports every month and reading them over carefully,” said Ms. Lightfoot.
This means that if you have a large practice, you should have a point person within your billing department to handle the relationship with your billing partner. If it’s a smaller practice, the task will likely fall to the office manager. The ‘who’ isn’t important, but having someone on the case is.
Another important aspect of this billing relationship is understanding what you’re receiving for your payment. “Sometimes going with the cheapest offer amounts to a billing partner who isn’t working on those claims and denials as much as they should,” said Ms. Lightfoot. “I’ve seen fees anywhere from 4% to 9%, and the lower end can mean you’ll need to chase down every penny.”
3. Neglecting to forge the right relationships in the community.
Another common mistake physicians make is failing to develop the professional relationships that will help you thrive. Successful practices need to establish relationships with the right people and organizations. While the occasional afternoon of golf used to serve this purpose, today outreach must go beyond that, said Dr. Maissel. “You need to create relationships with hospitals and hospital-based practices because you may have value to them,” she said. “You should also get into some sort of relationship with your local ACO (Accountable Care Organization) or PHO (Physician Hospital Organization). Identify the leaders there and let them know you exist.”
Establishing these relationships goes beyond that first step of introducing yourself, or you risk losing their benefits. You must also nurture and “fertilize” these relationships in an ongoing fashion. “For years, as the head of employee practice, I had a competitor who would go out of his way to invite me to lunch regularly,” said Dr. Maissel. “When there were opportunities for his group, I would connect him. I wouldn’t have done that had he not worked on our relationship over time.”
The adage of “it’s not what you know but who you know” holds up here. If you don’t do the reach out to the right people and organizations in your community, you will have a harder time succeeding as a practice.
4. Hiring the wrong person/a family member for the job.
When starting a new practice, or if you’re running a small practice, it can be tempting to look for affordable or reliable staffing from among family members or friends. That’s fine if your family member or friend is also qualified for the job. If they aren’t, however, you might be setting up for failure.
“When you hire someone without the right qualifications, you need to be willing to train them for the job,” said Ms. Lightfoot. “Doctors don’t have that kind of time.”
Too often, Ms. Lightfoot said, a doctor will have a position like officer manager open and fill it with an in-law, whether he or she is experienced or not. “Now you have someone in the role who is unqualified, and the rest of the office can’t speak up about that because it’s a relative to the lead physician,” she said. “That doesn’t create a good environment for anyone.”
Also, a setup for failure is hiring someone who might be qualified, but not possessing the right personality for the role. A front desk position, for instance, should be held by someone who’s a bit upbeat and able to multitask. “You can’t put a shy, quiet person in that job,” said Ms. Lightfoot. “So, if you see a person with 10 years’ experience in a medical practice, but they’re reserved, what will happen? You must think about this when hiring.”
One PA recalled a small family practice in which the lead physician’s wife was the office manager. To save money, the wife removed lights from the staff restroom and staff lunchroom and declined staff requests for earned vacation. The staff felt unable to speak up, and they – and all new office staff members – ultimately left the practice.
5. Overlooking the importance of acting like a professional and respecting your staff.
This one might seem obvious, but many physicians get a bit too comfortable in the office environment, said Dr. Maissel. This can encompass a whole host of bad behaviors, from making inappropriate jokes to staff and patients, to trash-talking colleagues. None of this behavior is acceptable and can set you up for things to go wrong, especially when good labor is hard to come by. “Your staff is made up of people for whom 50 cents an hour is meaningful,” she said. “If they don’t have a warm, supportive office, they will look elsewhere.”
This is especially true of younger people now entering the workforce – they are less tolerant than generations past of egregious behavior. Try to establish a professional, yet nurturing environment for your staff. “Inquire about things that matter to them,” said Dr. Maissel. “Small talk can go a long way. See them as human beings, not cogs in the wheel.”
Inappropriate and uncaring behaviors will give physician leaders a reputation, one that sticks. “The medical community is pretty connected, and if you behave inappropriately enough times, it will circle back to you,” said Dr. Maissel.
Launching, and sustaining, a successful medical practice is never a given, but mistakes are. With the right approach, however, you can avoid these common – and impactful – errors and set your practice up for success.
A version of this article first appeared on Medscape.com.
A physician who in the past has led medical groups as both chief medical officer and president, Gerda Maissel, MD, president of My MD Advisor, a private patient advocacy group, has seen the good, bad, and ugly of practice administration. There’s a spectrum of infractions: Anything from doctors making inappropriate jokes with staff or patients, to failing to establish key relationships with other critical entities, says Dr. Maissel.
“Being a good physician who provides value is important in building a practice,” explained Dr. Maissel. “But it is not the be-all and end-all.”
While the number of physician-owned practices is declining, just under 50% are still in private practice, according to the American Medical Association’s 2020 survey. There’s also a continuing trend toward larger practices. Whatever the size, the physicians are responsible for strategy, marketing, building the practice, and maintaining profitability.
Catherine Lightfoot, CPA, CHBC, president of the National Society of Certified Healthcare Business Consultants (NSCHBC), has her finger on the pulse of what’s right and what’s wrong when it comes to running a medical practice. Although she says there are no hard and fast rules on how to run a thriving medical group, there are common mistakes that physicians often don’t recognize.
Here are the five key mistakes that commonly crop up, and the experts’ thoughts on how to prevent or fix them.
1. Failing to engage in outreach activities and community efforts to build your practice.
Yes, physicians earn good reputations through dedicated work, and that often precedes them when it comes to building a practice. But assuming that hanging a shingle backed by strong credentials is all it takes for success is akin to building a website and assuming people will find it organically. Maybe there was a time, in a small community, where this was good enough. But no longer.
It’s important to plan to get your practice and your name known to potential patients. “Most physicians think that means advertising, but that’s not the complete case,” Dr. Maissel said.
Much of the equation involves ensuring availability. This means setting office hours that work for your target audience of patients, and then ensuring you stick to those hours. This extends beyond scheduling your current patients and into referral patients, too. And it’s particularly true while in the building phase of a new practice.
“If one of your colleagues calls with a referral patient, and they consider the matter urgent, you need to heed that,” explained Dr. Maissel. “So have a breadth of availability for these referral cases.” Through word of mouth, you’ll get a good reputation for patient care and availability, and that will go a long way toward helping to grow your practice.
Establishing a culture that doesn’t involve canceling and rescheduling patients is part of the scheduling equation, too. “I’ve seen the full gamut of cancellation policies, ranging from a month’s notice on changes to 3 months’ notice,” said Dr. Maissel. “It all gets at the same issue, which is failing to set up a culture where doctors don’t change their schedules and leave patients hanging.”
In the end, wonky scheduling, cancellations, and a lack of respect for the urgency of referrals can cost a practice. Forge a reputation in reliability and word will get around, in all the right ways.
2. Not having enough oversight of your outsourced billing service
Billing is one of the biggest pieces of running a successful and profitable practice, yet too many practices ignore it once they’ve handed it off to a billing company. That can cost you in more ways than one, said Ms. Lightfoot. “Billing changes all the time, and if you’re not monitoring your billing partner, you don’t know what you’re getting,” she said.
Ms. Lightfoot said that a decade ago, billing was much more straightforward – essentially, you did the work and received payment. Today’s complex insurance, Medicare, and Medicaid environment have changed the landscape. “Now you have to fight for every dollar you’re billing,” said Ms. Lightfoot. “Rates get cut all the time, you might miss out on a claim, and the rules are constantly changing.”
The solution for many practices is to outsource billing, which Ms. Lightfoot supports. “They specialize in this, and that’s a great start,” she said. “But it’s not as simple as handing it off and forgetting it.”
Instead, ensure your internal staff is up to date on all things coding and billing so that they can catch what your outsourced billing partner doesn’t. Your internal staff should be prepared to carry out coding, check coding, and stay on top of the billing company if they aren’t processing claims quickly enough. For instance: If there’s a denial, how many times will the billing company go after that money?
Other questions to ask when entering a billing relationship: What does the billing company expect from your practice? Do they communicate what needs to be worked on or fixed? Are they providing you with monthly reports? “You want to make sure you’re getting those reports every month and reading them over carefully,” said Ms. Lightfoot.
This means that if you have a large practice, you should have a point person within your billing department to handle the relationship with your billing partner. If it’s a smaller practice, the task will likely fall to the office manager. The ‘who’ isn’t important, but having someone on the case is.
Another important aspect of this billing relationship is understanding what you’re receiving for your payment. “Sometimes going with the cheapest offer amounts to a billing partner who isn’t working on those claims and denials as much as they should,” said Ms. Lightfoot. “I’ve seen fees anywhere from 4% to 9%, and the lower end can mean you’ll need to chase down every penny.”
3. Neglecting to forge the right relationships in the community.
Another common mistake physicians make is failing to develop the professional relationships that will help you thrive. Successful practices need to establish relationships with the right people and organizations. While the occasional afternoon of golf used to serve this purpose, today outreach must go beyond that, said Dr. Maissel. “You need to create relationships with hospitals and hospital-based practices because you may have value to them,” she said. “You should also get into some sort of relationship with your local ACO (Accountable Care Organization) or PHO (Physician Hospital Organization). Identify the leaders there and let them know you exist.”
Establishing these relationships goes beyond that first step of introducing yourself, or you risk losing their benefits. You must also nurture and “fertilize” these relationships in an ongoing fashion. “For years, as the head of employee practice, I had a competitor who would go out of his way to invite me to lunch regularly,” said Dr. Maissel. “When there were opportunities for his group, I would connect him. I wouldn’t have done that had he not worked on our relationship over time.”
The adage of “it’s not what you know but who you know” holds up here. If you don’t do the reach out to the right people and organizations in your community, you will have a harder time succeeding as a practice.
4. Hiring the wrong person/a family member for the job.
When starting a new practice, or if you’re running a small practice, it can be tempting to look for affordable or reliable staffing from among family members or friends. That’s fine if your family member or friend is also qualified for the job. If they aren’t, however, you might be setting up for failure.
“When you hire someone without the right qualifications, you need to be willing to train them for the job,” said Ms. Lightfoot. “Doctors don’t have that kind of time.”
Too often, Ms. Lightfoot said, a doctor will have a position like officer manager open and fill it with an in-law, whether he or she is experienced or not. “Now you have someone in the role who is unqualified, and the rest of the office can’t speak up about that because it’s a relative to the lead physician,” she said. “That doesn’t create a good environment for anyone.”
Also, a setup for failure is hiring someone who might be qualified, but not possessing the right personality for the role. A front desk position, for instance, should be held by someone who’s a bit upbeat and able to multitask. “You can’t put a shy, quiet person in that job,” said Ms. Lightfoot. “So, if you see a person with 10 years’ experience in a medical practice, but they’re reserved, what will happen? You must think about this when hiring.”
One PA recalled a small family practice in which the lead physician’s wife was the office manager. To save money, the wife removed lights from the staff restroom and staff lunchroom and declined staff requests for earned vacation. The staff felt unable to speak up, and they – and all new office staff members – ultimately left the practice.
5. Overlooking the importance of acting like a professional and respecting your staff.
This one might seem obvious, but many physicians get a bit too comfortable in the office environment, said Dr. Maissel. This can encompass a whole host of bad behaviors, from making inappropriate jokes to staff and patients, to trash-talking colleagues. None of this behavior is acceptable and can set you up for things to go wrong, especially when good labor is hard to come by. “Your staff is made up of people for whom 50 cents an hour is meaningful,” she said. “If they don’t have a warm, supportive office, they will look elsewhere.”
This is especially true of younger people now entering the workforce – they are less tolerant than generations past of egregious behavior. Try to establish a professional, yet nurturing environment for your staff. “Inquire about things that matter to them,” said Dr. Maissel. “Small talk can go a long way. See them as human beings, not cogs in the wheel.”
Inappropriate and uncaring behaviors will give physician leaders a reputation, one that sticks. “The medical community is pretty connected, and if you behave inappropriately enough times, it will circle back to you,” said Dr. Maissel.
Launching, and sustaining, a successful medical practice is never a given, but mistakes are. With the right approach, however, you can avoid these common – and impactful – errors and set your practice up for success.
A version of this article first appeared on Medscape.com.
A physician who in the past has led medical groups as both chief medical officer and president, Gerda Maissel, MD, president of My MD Advisor, a private patient advocacy group, has seen the good, bad, and ugly of practice administration. There’s a spectrum of infractions: Anything from doctors making inappropriate jokes with staff or patients, to failing to establish key relationships with other critical entities, says Dr. Maissel.
“Being a good physician who provides value is important in building a practice,” explained Dr. Maissel. “But it is not the be-all and end-all.”
While the number of physician-owned practices is declining, just under 50% are still in private practice, according to the American Medical Association’s 2020 survey. There’s also a continuing trend toward larger practices. Whatever the size, the physicians are responsible for strategy, marketing, building the practice, and maintaining profitability.
Catherine Lightfoot, CPA, CHBC, president of the National Society of Certified Healthcare Business Consultants (NSCHBC), has her finger on the pulse of what’s right and what’s wrong when it comes to running a medical practice. Although she says there are no hard and fast rules on how to run a thriving medical group, there are common mistakes that physicians often don’t recognize.
Here are the five key mistakes that commonly crop up, and the experts’ thoughts on how to prevent or fix them.
1. Failing to engage in outreach activities and community efforts to build your practice.
Yes, physicians earn good reputations through dedicated work, and that often precedes them when it comes to building a practice. But assuming that hanging a shingle backed by strong credentials is all it takes for success is akin to building a website and assuming people will find it organically. Maybe there was a time, in a small community, where this was good enough. But no longer.
It’s important to plan to get your practice and your name known to potential patients. “Most physicians think that means advertising, but that’s not the complete case,” Dr. Maissel said.
Much of the equation involves ensuring availability. This means setting office hours that work for your target audience of patients, and then ensuring you stick to those hours. This extends beyond scheduling your current patients and into referral patients, too. And it’s particularly true while in the building phase of a new practice.
“If one of your colleagues calls with a referral patient, and they consider the matter urgent, you need to heed that,” explained Dr. Maissel. “So have a breadth of availability for these referral cases.” Through word of mouth, you’ll get a good reputation for patient care and availability, and that will go a long way toward helping to grow your practice.
Establishing a culture that doesn’t involve canceling and rescheduling patients is part of the scheduling equation, too. “I’ve seen the full gamut of cancellation policies, ranging from a month’s notice on changes to 3 months’ notice,” said Dr. Maissel. “It all gets at the same issue, which is failing to set up a culture where doctors don’t change their schedules and leave patients hanging.”
In the end, wonky scheduling, cancellations, and a lack of respect for the urgency of referrals can cost a practice. Forge a reputation in reliability and word will get around, in all the right ways.
2. Not having enough oversight of your outsourced billing service
Billing is one of the biggest pieces of running a successful and profitable practice, yet too many practices ignore it once they’ve handed it off to a billing company. That can cost you in more ways than one, said Ms. Lightfoot. “Billing changes all the time, and if you’re not monitoring your billing partner, you don’t know what you’re getting,” she said.
Ms. Lightfoot said that a decade ago, billing was much more straightforward – essentially, you did the work and received payment. Today’s complex insurance, Medicare, and Medicaid environment have changed the landscape. “Now you have to fight for every dollar you’re billing,” said Ms. Lightfoot. “Rates get cut all the time, you might miss out on a claim, and the rules are constantly changing.”
The solution for many practices is to outsource billing, which Ms. Lightfoot supports. “They specialize in this, and that’s a great start,” she said. “But it’s not as simple as handing it off and forgetting it.”
Instead, ensure your internal staff is up to date on all things coding and billing so that they can catch what your outsourced billing partner doesn’t. Your internal staff should be prepared to carry out coding, check coding, and stay on top of the billing company if they aren’t processing claims quickly enough. For instance: If there’s a denial, how many times will the billing company go after that money?
Other questions to ask when entering a billing relationship: What does the billing company expect from your practice? Do they communicate what needs to be worked on or fixed? Are they providing you with monthly reports? “You want to make sure you’re getting those reports every month and reading them over carefully,” said Ms. Lightfoot.
This means that if you have a large practice, you should have a point person within your billing department to handle the relationship with your billing partner. If it’s a smaller practice, the task will likely fall to the office manager. The ‘who’ isn’t important, but having someone on the case is.
Another important aspect of this billing relationship is understanding what you’re receiving for your payment. “Sometimes going with the cheapest offer amounts to a billing partner who isn’t working on those claims and denials as much as they should,” said Ms. Lightfoot. “I’ve seen fees anywhere from 4% to 9%, and the lower end can mean you’ll need to chase down every penny.”
3. Neglecting to forge the right relationships in the community.
Another common mistake physicians make is failing to develop the professional relationships that will help you thrive. Successful practices need to establish relationships with the right people and organizations. While the occasional afternoon of golf used to serve this purpose, today outreach must go beyond that, said Dr. Maissel. “You need to create relationships with hospitals and hospital-based practices because you may have value to them,” she said. “You should also get into some sort of relationship with your local ACO (Accountable Care Organization) or PHO (Physician Hospital Organization). Identify the leaders there and let them know you exist.”
Establishing these relationships goes beyond that first step of introducing yourself, or you risk losing their benefits. You must also nurture and “fertilize” these relationships in an ongoing fashion. “For years, as the head of employee practice, I had a competitor who would go out of his way to invite me to lunch regularly,” said Dr. Maissel. “When there were opportunities for his group, I would connect him. I wouldn’t have done that had he not worked on our relationship over time.”
The adage of “it’s not what you know but who you know” holds up here. If you don’t do the reach out to the right people and organizations in your community, you will have a harder time succeeding as a practice.
4. Hiring the wrong person/a family member for the job.
When starting a new practice, or if you’re running a small practice, it can be tempting to look for affordable or reliable staffing from among family members or friends. That’s fine if your family member or friend is also qualified for the job. If they aren’t, however, you might be setting up for failure.
“When you hire someone without the right qualifications, you need to be willing to train them for the job,” said Ms. Lightfoot. “Doctors don’t have that kind of time.”
Too often, Ms. Lightfoot said, a doctor will have a position like officer manager open and fill it with an in-law, whether he or she is experienced or not. “Now you have someone in the role who is unqualified, and the rest of the office can’t speak up about that because it’s a relative to the lead physician,” she said. “That doesn’t create a good environment for anyone.”
Also, a setup for failure is hiring someone who might be qualified, but not possessing the right personality for the role. A front desk position, for instance, should be held by someone who’s a bit upbeat and able to multitask. “You can’t put a shy, quiet person in that job,” said Ms. Lightfoot. “So, if you see a person with 10 years’ experience in a medical practice, but they’re reserved, what will happen? You must think about this when hiring.”
One PA recalled a small family practice in which the lead physician’s wife was the office manager. To save money, the wife removed lights from the staff restroom and staff lunchroom and declined staff requests for earned vacation. The staff felt unable to speak up, and they – and all new office staff members – ultimately left the practice.
5. Overlooking the importance of acting like a professional and respecting your staff.
This one might seem obvious, but many physicians get a bit too comfortable in the office environment, said Dr. Maissel. This can encompass a whole host of bad behaviors, from making inappropriate jokes to staff and patients, to trash-talking colleagues. None of this behavior is acceptable and can set you up for things to go wrong, especially when good labor is hard to come by. “Your staff is made up of people for whom 50 cents an hour is meaningful,” she said. “If they don’t have a warm, supportive office, they will look elsewhere.”
This is especially true of younger people now entering the workforce – they are less tolerant than generations past of egregious behavior. Try to establish a professional, yet nurturing environment for your staff. “Inquire about things that matter to them,” said Dr. Maissel. “Small talk can go a long way. See them as human beings, not cogs in the wheel.”
Inappropriate and uncaring behaviors will give physician leaders a reputation, one that sticks. “The medical community is pretty connected, and if you behave inappropriately enough times, it will circle back to you,” said Dr. Maissel.
Launching, and sustaining, a successful medical practice is never a given, but mistakes are. With the right approach, however, you can avoid these common – and impactful – errors and set your practice up for success.
A version of this article first appeared on Medscape.com.
From Beirut to frontline hematology research
“If we start treatment earlier, in the smoldering phase, maybe there is a chance of actually curing the disease and completely getting rid of it,” said Dr. Mouhieddine, 31, a research fellow at the Icahn School of Medicine at Mount Sinai, in New York. “We haven’t proven that yet, and it’s going to take years before we’re able to prove it. I’m hoping to be one of those spearheading the initiative.”
As he develops clinical trials, the young physician scientist has another focus: A deeply personal connection to the very disease he’s trying to cure. Last year Dr. Mouhieddine diagnosed his aunt back in Lebanon with multiple myeloma. “I have always been close to her, and I’m like her son,” he said, and her situation is especially scary because she lives in a country where treatment options are limited.
Dr. Mouhieddine was born and raised in Beirut, the son of a sports journalist father and a mother who worked in a bank. Lebanon’s civil war ended in 1990, shortly before his birth, but political instability returned when he was a child.
“Everything was a disaster,” he recalled. “There was a period of time when there were bombs throughout the city because certain politicians were being targeted. I remember when groups of people would have gunfights in the street.”
Dr. Mouhieddine attended the American University of Beirut, then after college and medical school there, he headed to the United States.
“I wanted to make a difference in medicine. And I knew that if I stayed back home, I wouldn’t be able to,” he said. Fortunately, “everybody has made me feel that I really belong here, and I’ve never felt like I’m an outsider.”
Early on, as he went through fellowships and residency, he developed an interest in multiple myeloma.
Ajai Chari, MD, a colleague of Dr. Mouhieddine’s at Icahn School of Medicine, said in an interview, “I remember meeting him at a conference before he had even started an internal medicine residency, let alone a hematology oncology fellowship. He was already certain he wanted to work in multiple myeloma, due to his work at Dana-Farber Cancer Institute.”
Myeloma was especially intriguing to Dr. Mouhieddine because of the rapid rate of progress in treating the disease. “Over the past 10 years, the myeloma field has advanced at such an extremely fast pace, more than any other cancer,” he said. “Maybe 15 years ago, you would tell someone with newly diagnosed myeloma that they had a chance for an average of another 2 years. Now, we tell patients they have 10 years to live on average, which means you could live 15 or 20 years. That alone was astounding to me and piqued my interest in myeloma.”
At the same time, smoldering myeloma – which can be discovered during routine blood work – remains little understood. As the National Cancer Institute explains, “smoldering myeloma is a precancerous condition that alters certain proteins in blood and/or increases plasma cells in bone marrow, but it does not cause symptoms of disease. About half of those diagnosed with the condition, however, will develop multiple myeloma within 5 years.”
“If we understand what drives smoldering myeloma, we may be able to prevent it from progressing to its active form,” said hematologist oncologist Samir Parekh, MD, who works with Dr. Mouhieddine at Icahn School of Medicine. “Or at the minimum, we could better predict who will progress so we can tailor therapy for high-risk patients and minimize toxicity by not overtreating patients who may not need therapy.”
Dr. Mouhieddine’s current work is focusing on developing clinical trials to test whether immunotherapy can snuff out myeloma when it’s at the smoldering stage, “before anything bad happens.
“If a myeloma patient comes in with renal failure, and we treat the myeloma at that stage, it doesn’t mean that the patient’s kidneys are gonna go back to normal. A lot of the damage can be permanent,” he said. “Even when you treat multiple myeloma, and it goes into remission, it ends up coming back. And you just have to go from one therapy to the other.”
In contrast, a successful treatment for smoldering myeloma would prevent progression to the full disease. In other words, it would be a cure – which is now elusive.
Specifically, Dr. Mouhieddine hopes to test whether bispecific antibodies, a type of immunotherapy that enlists the body’s T cells to kill myeloma cells, will be effective in the smoldering phase. Bispecific antibodies are now being explored as treatments for full multiple myeloma when the immune system is weaker, he said, and they may be even more effective earlier, when the body is better equipped to fight off the disease.
Dr. Mouhieddine hopes better treatments for multiple myeloma itself will help save his 64-year-old aunt Hassana, back in Beirut. He diagnosed her in 2022 after she told him that she felt tired all the time and underwent various tests. The woman he calls his “second mom” is doing well, despite struggles to buy medication due to the lack of access to bank funds in Lebanon.
“I’m always going to be afraid that the disease is going to progress or come back at some point,” he said. “Lebanon doesn’t have as many options as people in the U.S. do. Once you exhaust your first option, and maybe your second option, then you don’t have any other options. Here, we have outpatients who exhaust option number 15 and go to option number 16. That’s definitely not the case over there.”
For now, Dr. Mouhieddine is treating patients and working to launch clinical trials into smoldering myeloma. “His work ethic is incredible,” said his colleague, Dr. Chari. “He has seen multiple projects to publication, and he develops deep connections with his patients and follows up on their care whether or not he is in clinic on a particular day.”
Dr. Parekh, another colleague, said Dr. Mouhieddine can even be a role model. “Other trainees may benefit from thinking about their career early on and exploring both lab and clinical research projects, so that they can develop the necessary experience to be competitive in academia later on.”
His workload can a burden for Dr. Mouhieddine, who is Muslim. He expressed regret that his busy schedule does not always permit him to fast during Ramadan. On a nonmedical front, his recent efforts have paid off. In March 2023 Dr. Mouhieddine became a U.S. citizen.
“It’s surreal,” he said, “but also a dream come true. I feel very grateful, like it’s like an appreciation of who I am, what I’ve done, and what I can do for this country.”
“If we start treatment earlier, in the smoldering phase, maybe there is a chance of actually curing the disease and completely getting rid of it,” said Dr. Mouhieddine, 31, a research fellow at the Icahn School of Medicine at Mount Sinai, in New York. “We haven’t proven that yet, and it’s going to take years before we’re able to prove it. I’m hoping to be one of those spearheading the initiative.”
As he develops clinical trials, the young physician scientist has another focus: A deeply personal connection to the very disease he’s trying to cure. Last year Dr. Mouhieddine diagnosed his aunt back in Lebanon with multiple myeloma. “I have always been close to her, and I’m like her son,” he said, and her situation is especially scary because she lives in a country where treatment options are limited.
Dr. Mouhieddine was born and raised in Beirut, the son of a sports journalist father and a mother who worked in a bank. Lebanon’s civil war ended in 1990, shortly before his birth, but political instability returned when he was a child.
“Everything was a disaster,” he recalled. “There was a period of time when there were bombs throughout the city because certain politicians were being targeted. I remember when groups of people would have gunfights in the street.”
Dr. Mouhieddine attended the American University of Beirut, then after college and medical school there, he headed to the United States.
“I wanted to make a difference in medicine. And I knew that if I stayed back home, I wouldn’t be able to,” he said. Fortunately, “everybody has made me feel that I really belong here, and I’ve never felt like I’m an outsider.”
Early on, as he went through fellowships and residency, he developed an interest in multiple myeloma.
Ajai Chari, MD, a colleague of Dr. Mouhieddine’s at Icahn School of Medicine, said in an interview, “I remember meeting him at a conference before he had even started an internal medicine residency, let alone a hematology oncology fellowship. He was already certain he wanted to work in multiple myeloma, due to his work at Dana-Farber Cancer Institute.”
Myeloma was especially intriguing to Dr. Mouhieddine because of the rapid rate of progress in treating the disease. “Over the past 10 years, the myeloma field has advanced at such an extremely fast pace, more than any other cancer,” he said. “Maybe 15 years ago, you would tell someone with newly diagnosed myeloma that they had a chance for an average of another 2 years. Now, we tell patients they have 10 years to live on average, which means you could live 15 or 20 years. That alone was astounding to me and piqued my interest in myeloma.”
At the same time, smoldering myeloma – which can be discovered during routine blood work – remains little understood. As the National Cancer Institute explains, “smoldering myeloma is a precancerous condition that alters certain proteins in blood and/or increases plasma cells in bone marrow, but it does not cause symptoms of disease. About half of those diagnosed with the condition, however, will develop multiple myeloma within 5 years.”
“If we understand what drives smoldering myeloma, we may be able to prevent it from progressing to its active form,” said hematologist oncologist Samir Parekh, MD, who works with Dr. Mouhieddine at Icahn School of Medicine. “Or at the minimum, we could better predict who will progress so we can tailor therapy for high-risk patients and minimize toxicity by not overtreating patients who may not need therapy.”
Dr. Mouhieddine’s current work is focusing on developing clinical trials to test whether immunotherapy can snuff out myeloma when it’s at the smoldering stage, “before anything bad happens.
“If a myeloma patient comes in with renal failure, and we treat the myeloma at that stage, it doesn’t mean that the patient’s kidneys are gonna go back to normal. A lot of the damage can be permanent,” he said. “Even when you treat multiple myeloma, and it goes into remission, it ends up coming back. And you just have to go from one therapy to the other.”
In contrast, a successful treatment for smoldering myeloma would prevent progression to the full disease. In other words, it would be a cure – which is now elusive.
Specifically, Dr. Mouhieddine hopes to test whether bispecific antibodies, a type of immunotherapy that enlists the body’s T cells to kill myeloma cells, will be effective in the smoldering phase. Bispecific antibodies are now being explored as treatments for full multiple myeloma when the immune system is weaker, he said, and they may be even more effective earlier, when the body is better equipped to fight off the disease.
Dr. Mouhieddine hopes better treatments for multiple myeloma itself will help save his 64-year-old aunt Hassana, back in Beirut. He diagnosed her in 2022 after she told him that she felt tired all the time and underwent various tests. The woman he calls his “second mom” is doing well, despite struggles to buy medication due to the lack of access to bank funds in Lebanon.
“I’m always going to be afraid that the disease is going to progress or come back at some point,” he said. “Lebanon doesn’t have as many options as people in the U.S. do. Once you exhaust your first option, and maybe your second option, then you don’t have any other options. Here, we have outpatients who exhaust option number 15 and go to option number 16. That’s definitely not the case over there.”
For now, Dr. Mouhieddine is treating patients and working to launch clinical trials into smoldering myeloma. “His work ethic is incredible,” said his colleague, Dr. Chari. “He has seen multiple projects to publication, and he develops deep connections with his patients and follows up on their care whether or not he is in clinic on a particular day.”
Dr. Parekh, another colleague, said Dr. Mouhieddine can even be a role model. “Other trainees may benefit from thinking about their career early on and exploring both lab and clinical research projects, so that they can develop the necessary experience to be competitive in academia later on.”
His workload can a burden for Dr. Mouhieddine, who is Muslim. He expressed regret that his busy schedule does not always permit him to fast during Ramadan. On a nonmedical front, his recent efforts have paid off. In March 2023 Dr. Mouhieddine became a U.S. citizen.
“It’s surreal,” he said, “but also a dream come true. I feel very grateful, like it’s like an appreciation of who I am, what I’ve done, and what I can do for this country.”
“If we start treatment earlier, in the smoldering phase, maybe there is a chance of actually curing the disease and completely getting rid of it,” said Dr. Mouhieddine, 31, a research fellow at the Icahn School of Medicine at Mount Sinai, in New York. “We haven’t proven that yet, and it’s going to take years before we’re able to prove it. I’m hoping to be one of those spearheading the initiative.”
As he develops clinical trials, the young physician scientist has another focus: A deeply personal connection to the very disease he’s trying to cure. Last year Dr. Mouhieddine diagnosed his aunt back in Lebanon with multiple myeloma. “I have always been close to her, and I’m like her son,” he said, and her situation is especially scary because she lives in a country where treatment options are limited.
Dr. Mouhieddine was born and raised in Beirut, the son of a sports journalist father and a mother who worked in a bank. Lebanon’s civil war ended in 1990, shortly before his birth, but political instability returned when he was a child.
“Everything was a disaster,” he recalled. “There was a period of time when there were bombs throughout the city because certain politicians were being targeted. I remember when groups of people would have gunfights in the street.”
Dr. Mouhieddine attended the American University of Beirut, then after college and medical school there, he headed to the United States.
“I wanted to make a difference in medicine. And I knew that if I stayed back home, I wouldn’t be able to,” he said. Fortunately, “everybody has made me feel that I really belong here, and I’ve never felt like I’m an outsider.”
Early on, as he went through fellowships and residency, he developed an interest in multiple myeloma.
Ajai Chari, MD, a colleague of Dr. Mouhieddine’s at Icahn School of Medicine, said in an interview, “I remember meeting him at a conference before he had even started an internal medicine residency, let alone a hematology oncology fellowship. He was already certain he wanted to work in multiple myeloma, due to his work at Dana-Farber Cancer Institute.”
Myeloma was especially intriguing to Dr. Mouhieddine because of the rapid rate of progress in treating the disease. “Over the past 10 years, the myeloma field has advanced at such an extremely fast pace, more than any other cancer,” he said. “Maybe 15 years ago, you would tell someone with newly diagnosed myeloma that they had a chance for an average of another 2 years. Now, we tell patients they have 10 years to live on average, which means you could live 15 or 20 years. That alone was astounding to me and piqued my interest in myeloma.”
At the same time, smoldering myeloma – which can be discovered during routine blood work – remains little understood. As the National Cancer Institute explains, “smoldering myeloma is a precancerous condition that alters certain proteins in blood and/or increases plasma cells in bone marrow, but it does not cause symptoms of disease. About half of those diagnosed with the condition, however, will develop multiple myeloma within 5 years.”
“If we understand what drives smoldering myeloma, we may be able to prevent it from progressing to its active form,” said hematologist oncologist Samir Parekh, MD, who works with Dr. Mouhieddine at Icahn School of Medicine. “Or at the minimum, we could better predict who will progress so we can tailor therapy for high-risk patients and minimize toxicity by not overtreating patients who may not need therapy.”
Dr. Mouhieddine’s current work is focusing on developing clinical trials to test whether immunotherapy can snuff out myeloma when it’s at the smoldering stage, “before anything bad happens.
“If a myeloma patient comes in with renal failure, and we treat the myeloma at that stage, it doesn’t mean that the patient’s kidneys are gonna go back to normal. A lot of the damage can be permanent,” he said. “Even when you treat multiple myeloma, and it goes into remission, it ends up coming back. And you just have to go from one therapy to the other.”
In contrast, a successful treatment for smoldering myeloma would prevent progression to the full disease. In other words, it would be a cure – which is now elusive.
Specifically, Dr. Mouhieddine hopes to test whether bispecific antibodies, a type of immunotherapy that enlists the body’s T cells to kill myeloma cells, will be effective in the smoldering phase. Bispecific antibodies are now being explored as treatments for full multiple myeloma when the immune system is weaker, he said, and they may be even more effective earlier, when the body is better equipped to fight off the disease.
Dr. Mouhieddine hopes better treatments for multiple myeloma itself will help save his 64-year-old aunt Hassana, back in Beirut. He diagnosed her in 2022 after she told him that she felt tired all the time and underwent various tests. The woman he calls his “second mom” is doing well, despite struggles to buy medication due to the lack of access to bank funds in Lebanon.
“I’m always going to be afraid that the disease is going to progress or come back at some point,” he said. “Lebanon doesn’t have as many options as people in the U.S. do. Once you exhaust your first option, and maybe your second option, then you don’t have any other options. Here, we have outpatients who exhaust option number 15 and go to option number 16. That’s definitely not the case over there.”
For now, Dr. Mouhieddine is treating patients and working to launch clinical trials into smoldering myeloma. “His work ethic is incredible,” said his colleague, Dr. Chari. “He has seen multiple projects to publication, and he develops deep connections with his patients and follows up on their care whether or not he is in clinic on a particular day.”
Dr. Parekh, another colleague, said Dr. Mouhieddine can even be a role model. “Other trainees may benefit from thinking about their career early on and exploring both lab and clinical research projects, so that they can develop the necessary experience to be competitive in academia later on.”
His workload can a burden for Dr. Mouhieddine, who is Muslim. He expressed regret that his busy schedule does not always permit him to fast during Ramadan. On a nonmedical front, his recent efforts have paid off. In March 2023 Dr. Mouhieddine became a U.S. citizen.
“It’s surreal,” he said, “but also a dream come true. I feel very grateful, like it’s like an appreciation of who I am, what I’ve done, and what I can do for this country.”
Living the introvert’s dream: Alone for 500 days, but never lonely
Beating the allegory of the cave
When Beatriz Flamini spoke with reporters on April 14, she knew nothing of the previous 18 months. The Russian invasion of Ukraine? Nope. The death of Queen Elizabeth? Also no. But before you make fun of her, she has an excuse. She’s been living under a rock.
As part of an experiment to test how social isolation and disorientation affect a person’s mind, sense of time, and sleeping patterns, Ms. Flamini lived in a 70-meter-deep cave in southern Spain for 500 days, starting in November 2021. Alone. No outside communication with the outside world in any way, though she was constantly monitored by a team of researchers. She also had multiple cameras filming her for an upcoming documentary.
This is a massive step up from the previous record for time spent underground for science: A team of 15 spent 50 days underground in 2021 to similar study of isolation and how it affected circadian rhythms. It’s also almost certainly a world record for time spent underground.
All that time alone certainly sounds like some sort of medieval torture, but Ms. Flamini had access to food, water, and a library of books. Which she made liberal use of, reading at least 60 books during her stay. She also had a panic button in case the isolation became too much or an emergency developed, but she never considered using it.
She lost track of time after 2 months, flies invaded the cave on occasion, and maintaining coherence was occasionally a struggle, but she kept things together very well. In fact, she didn’t even want to leave when her team came for her. She wasn’t even finished with her 61st book.
When she spoke with gathered reporters after the ordeal, words were obviously difficult to come by for her, having not spoken in nearly 18 months, but her mind was clearly still sharp and she had a very important question for everyone gathered around her.
Who’s buying the beer?
We approve of this request.
Staphylococcus and the speed of evolution
Bacteria, we know, are tough little buggers that are hard to see and even harder to get rid of. So hard, actually, that human bodies eventually gave up on the task and decided to just incorporate them into our organ systems. But why are bacteria so hard to eliminate?
Two words: rapid evolution. How rapid? For the first time, scientists have directly observed adaptive evolution by Staphylococcus aureus in a single person’s skin microbiome. That’s how rapid.
For their study, the researchers collected samples from the nostrils, backs of knees, insides of elbows, and forearms of 23 children with eczema. They eventually cultured almost 1,500 unique colonies of S. aureus cells from those samples and sequenced the cells’ genomes.
All that sampling and culturing and sequencing showed that it was rare for a new S. aureus strain to come in and replace the existing strain. “Despite the stability at the lineage level, we see a lot of dynamics at the whole genome level, where new mutations are constantly arising in these bacteria and then spreading throughout the entire body,” Tami D. Lieberman, PhD, of the Massachusetts Institute of Technology, Cambridge, said in a written statement from MIT.
One frequent mutation involved a gene called capD, which encodes an enzyme necessary for synthesizing the capsular polysaccharide – a coating that protects S. aureus from recognition by immune cells. In one patient, four different mutations of capD arose independently in different samples before one variant became dominant and spread over the entire microbiome, MIT reported.
The mutation, which actually results in the loss of the polysaccharide capsule, may allow cells to grow faster than those without the mutation because they have more fuel to power their own growth, the researchers suggested. It’s also possible that loss of the capsule allows S. aureus cells to stick to the skin better because proteins that allow them to adhere to the skin are more exposed.
Dr. Lieberman and her associates hope that these variant-containing cells could be a new target for eczema treatments, but we’re never optimistic when it comes to bacteria. That’s because some of us are old enough to remember evolutionary biologist Stephen Jay Gould, who wrote in his book “Full House”: “Our planet has always been in the ‘Age of Bacteria,’ ever since the first fossils – bacteria, of course – were entombed in rocks more than 3 billion years ago. On any possible, reasonable or fair criterion, bacteria are – and always have been – the dominant forms of life on Earth.”
In the distant future, long after humans have left the scene, the bacteria will be laughing at the last rats and cockroaches scurrying across the landscape. Wanna bet?
The height of genetic prediction
Genetics are practically a DNA Scrabble bag. Traits like eye color and hair texture are chosen in the same fashion, based on what gets pulled from our own genetic bag of letters, but what about height? Researchers may now have a way to predict adult height and make it more than just an educated guess.
How? By looking at the genes in our growth plates. The cartilage on the ends of our bones hardens as we age, eventually deciding an individual’s stature. In a recently published study, a research team looked at 600 million cartilage cells linked to maturation and cell growth in mice. Because everything starts with rodents.
After that search identified 145 genes linked to growth plate maturation and formation of the bones, they compared the mouse genes with data from genome-wide association studies (GWAS) of human height to look for hotspots where the height genes exist in human DNA.
The results showed which genes play a role in deciding height, and the GWAS data also suggested that genetic changes affecting cartilage cell maturation may strongly influence adult height, said the investigators, who hope that earlier interventions can improve outcomes in patients with conditions such as skeletal dysplasia.
So, yeah, you may want to be a little taller or shorter, but the outcome of that particular Scrabble game was determined when your parents, you know, dropped the letters in the bag.
Beating the allegory of the cave
When Beatriz Flamini spoke with reporters on April 14, she knew nothing of the previous 18 months. The Russian invasion of Ukraine? Nope. The death of Queen Elizabeth? Also no. But before you make fun of her, she has an excuse. She’s been living under a rock.
As part of an experiment to test how social isolation and disorientation affect a person’s mind, sense of time, and sleeping patterns, Ms. Flamini lived in a 70-meter-deep cave in southern Spain for 500 days, starting in November 2021. Alone. No outside communication with the outside world in any way, though she was constantly monitored by a team of researchers. She also had multiple cameras filming her for an upcoming documentary.
This is a massive step up from the previous record for time spent underground for science: A team of 15 spent 50 days underground in 2021 to similar study of isolation and how it affected circadian rhythms. It’s also almost certainly a world record for time spent underground.
All that time alone certainly sounds like some sort of medieval torture, but Ms. Flamini had access to food, water, and a library of books. Which she made liberal use of, reading at least 60 books during her stay. She also had a panic button in case the isolation became too much or an emergency developed, but she never considered using it.
She lost track of time after 2 months, flies invaded the cave on occasion, and maintaining coherence was occasionally a struggle, but she kept things together very well. In fact, she didn’t even want to leave when her team came for her. She wasn’t even finished with her 61st book.
When she spoke with gathered reporters after the ordeal, words were obviously difficult to come by for her, having not spoken in nearly 18 months, but her mind was clearly still sharp and she had a very important question for everyone gathered around her.
Who’s buying the beer?
We approve of this request.
Staphylococcus and the speed of evolution
Bacteria, we know, are tough little buggers that are hard to see and even harder to get rid of. So hard, actually, that human bodies eventually gave up on the task and decided to just incorporate them into our organ systems. But why are bacteria so hard to eliminate?
Two words: rapid evolution. How rapid? For the first time, scientists have directly observed adaptive evolution by Staphylococcus aureus in a single person’s skin microbiome. That’s how rapid.
For their study, the researchers collected samples from the nostrils, backs of knees, insides of elbows, and forearms of 23 children with eczema. They eventually cultured almost 1,500 unique colonies of S. aureus cells from those samples and sequenced the cells’ genomes.
All that sampling and culturing and sequencing showed that it was rare for a new S. aureus strain to come in and replace the existing strain. “Despite the stability at the lineage level, we see a lot of dynamics at the whole genome level, where new mutations are constantly arising in these bacteria and then spreading throughout the entire body,” Tami D. Lieberman, PhD, of the Massachusetts Institute of Technology, Cambridge, said in a written statement from MIT.
One frequent mutation involved a gene called capD, which encodes an enzyme necessary for synthesizing the capsular polysaccharide – a coating that protects S. aureus from recognition by immune cells. In one patient, four different mutations of capD arose independently in different samples before one variant became dominant and spread over the entire microbiome, MIT reported.
The mutation, which actually results in the loss of the polysaccharide capsule, may allow cells to grow faster than those without the mutation because they have more fuel to power their own growth, the researchers suggested. It’s also possible that loss of the capsule allows S. aureus cells to stick to the skin better because proteins that allow them to adhere to the skin are more exposed.
Dr. Lieberman and her associates hope that these variant-containing cells could be a new target for eczema treatments, but we’re never optimistic when it comes to bacteria. That’s because some of us are old enough to remember evolutionary biologist Stephen Jay Gould, who wrote in his book “Full House”: “Our planet has always been in the ‘Age of Bacteria,’ ever since the first fossils – bacteria, of course – were entombed in rocks more than 3 billion years ago. On any possible, reasonable or fair criterion, bacteria are – and always have been – the dominant forms of life on Earth.”
In the distant future, long after humans have left the scene, the bacteria will be laughing at the last rats and cockroaches scurrying across the landscape. Wanna bet?
The height of genetic prediction
Genetics are practically a DNA Scrabble bag. Traits like eye color and hair texture are chosen in the same fashion, based on what gets pulled from our own genetic bag of letters, but what about height? Researchers may now have a way to predict adult height and make it more than just an educated guess.
How? By looking at the genes in our growth plates. The cartilage on the ends of our bones hardens as we age, eventually deciding an individual’s stature. In a recently published study, a research team looked at 600 million cartilage cells linked to maturation and cell growth in mice. Because everything starts with rodents.
After that search identified 145 genes linked to growth plate maturation and formation of the bones, they compared the mouse genes with data from genome-wide association studies (GWAS) of human height to look for hotspots where the height genes exist in human DNA.
The results showed which genes play a role in deciding height, and the GWAS data also suggested that genetic changes affecting cartilage cell maturation may strongly influence adult height, said the investigators, who hope that earlier interventions can improve outcomes in patients with conditions such as skeletal dysplasia.
So, yeah, you may want to be a little taller or shorter, but the outcome of that particular Scrabble game was determined when your parents, you know, dropped the letters in the bag.
Beating the allegory of the cave
When Beatriz Flamini spoke with reporters on April 14, she knew nothing of the previous 18 months. The Russian invasion of Ukraine? Nope. The death of Queen Elizabeth? Also no. But before you make fun of her, she has an excuse. She’s been living under a rock.
As part of an experiment to test how social isolation and disorientation affect a person’s mind, sense of time, and sleeping patterns, Ms. Flamini lived in a 70-meter-deep cave in southern Spain for 500 days, starting in November 2021. Alone. No outside communication with the outside world in any way, though she was constantly monitored by a team of researchers. She also had multiple cameras filming her for an upcoming documentary.
This is a massive step up from the previous record for time spent underground for science: A team of 15 spent 50 days underground in 2021 to similar study of isolation and how it affected circadian rhythms. It’s also almost certainly a world record for time spent underground.
All that time alone certainly sounds like some sort of medieval torture, but Ms. Flamini had access to food, water, and a library of books. Which she made liberal use of, reading at least 60 books during her stay. She also had a panic button in case the isolation became too much or an emergency developed, but she never considered using it.
She lost track of time after 2 months, flies invaded the cave on occasion, and maintaining coherence was occasionally a struggle, but she kept things together very well. In fact, she didn’t even want to leave when her team came for her. She wasn’t even finished with her 61st book.
When she spoke with gathered reporters after the ordeal, words were obviously difficult to come by for her, having not spoken in nearly 18 months, but her mind was clearly still sharp and she had a very important question for everyone gathered around her.
Who’s buying the beer?
We approve of this request.
Staphylococcus and the speed of evolution
Bacteria, we know, are tough little buggers that are hard to see and even harder to get rid of. So hard, actually, that human bodies eventually gave up on the task and decided to just incorporate them into our organ systems. But why are bacteria so hard to eliminate?
Two words: rapid evolution. How rapid? For the first time, scientists have directly observed adaptive evolution by Staphylococcus aureus in a single person’s skin microbiome. That’s how rapid.
For their study, the researchers collected samples from the nostrils, backs of knees, insides of elbows, and forearms of 23 children with eczema. They eventually cultured almost 1,500 unique colonies of S. aureus cells from those samples and sequenced the cells’ genomes.
All that sampling and culturing and sequencing showed that it was rare for a new S. aureus strain to come in and replace the existing strain. “Despite the stability at the lineage level, we see a lot of dynamics at the whole genome level, where new mutations are constantly arising in these bacteria and then spreading throughout the entire body,” Tami D. Lieberman, PhD, of the Massachusetts Institute of Technology, Cambridge, said in a written statement from MIT.
One frequent mutation involved a gene called capD, which encodes an enzyme necessary for synthesizing the capsular polysaccharide – a coating that protects S. aureus from recognition by immune cells. In one patient, four different mutations of capD arose independently in different samples before one variant became dominant and spread over the entire microbiome, MIT reported.
The mutation, which actually results in the loss of the polysaccharide capsule, may allow cells to grow faster than those without the mutation because they have more fuel to power their own growth, the researchers suggested. It’s also possible that loss of the capsule allows S. aureus cells to stick to the skin better because proteins that allow them to adhere to the skin are more exposed.
Dr. Lieberman and her associates hope that these variant-containing cells could be a new target for eczema treatments, but we’re never optimistic when it comes to bacteria. That’s because some of us are old enough to remember evolutionary biologist Stephen Jay Gould, who wrote in his book “Full House”: “Our planet has always been in the ‘Age of Bacteria,’ ever since the first fossils – bacteria, of course – were entombed in rocks more than 3 billion years ago. On any possible, reasonable or fair criterion, bacteria are – and always have been – the dominant forms of life on Earth.”
In the distant future, long after humans have left the scene, the bacteria will be laughing at the last rats and cockroaches scurrying across the landscape. Wanna bet?
The height of genetic prediction
Genetics are practically a DNA Scrabble bag. Traits like eye color and hair texture are chosen in the same fashion, based on what gets pulled from our own genetic bag of letters, but what about height? Researchers may now have a way to predict adult height and make it more than just an educated guess.
How? By looking at the genes in our growth plates. The cartilage on the ends of our bones hardens as we age, eventually deciding an individual’s stature. In a recently published study, a research team looked at 600 million cartilage cells linked to maturation and cell growth in mice. Because everything starts with rodents.
After that search identified 145 genes linked to growth plate maturation and formation of the bones, they compared the mouse genes with data from genome-wide association studies (GWAS) of human height to look for hotspots where the height genes exist in human DNA.
The results showed which genes play a role in deciding height, and the GWAS data also suggested that genetic changes affecting cartilage cell maturation may strongly influence adult height, said the investigators, who hope that earlier interventions can improve outcomes in patients with conditions such as skeletal dysplasia.
So, yeah, you may want to be a little taller or shorter, but the outcome of that particular Scrabble game was determined when your parents, you know, dropped the letters in the bag.
Physicians may retire en masse soon. What does that mean for medicine?
The double whammy of pandemic burnout and the aging of baby boomer physicians has, indeed, the makings of some scary headlines. A recent survey by Elsevier Health predicts that up to 75% of health care workers will leave the profession by 2025. And a 2020 study conducted by the Association of American Medical Colleges (AAMC) projected a shortfall of up to 139,000 physicians by 2033.
“We’ve paid a lot of attention to physician retirement,” says Michael Dill, AAMC’s director of workforce studies. “It’s a significant concern in terms of whether we have an adequate supply of physicians in the U.S. to meet our nation’s medical care needs. Anyone who thinks otherwise is incorrect.”
To Mr. Dill,
“The physician workforce as a whole is aging,” he said. “Close to a quarter of the physicians in the U.S. are 65 and over. So, you don’t need any extraordinary events driving retirement in order for retirement to be a real phenomenon of which we should all be concerned.”
And, although Mr. Dill said there aren’t any data to suggest that doctors in rural or urban areas are retiring faster than in the suburbs, that doesn’t mean retirement will have the same impact depending on where patients live.
“If you live in a rural area with one small practice in town and that physician retires, there goes the entirety of the physician supply,” he said. “In a major metro area, that’s not as big a deal.”
Why younger doctors are fast-tracking retirement
Fernando Mendoza, MD, 54, a pediatric emergency department physician in Miami, worries that physicians are getting so bogged down by paperwork that this may lead to even more doctors, at younger ages, leaving the profession.
“I love taking care of kids, but there’s going to be a cost to doing your work when you’re spending as much time as we need to spend on charts, pharmacy requests, and making sure all of the Medicare and Medicaid compliance issues are worked out.”
These stressors may compel some younger doctors to consider carving out a second career or fast-track younger physicians toward retirement.
“A medical degree carries a lot of weight, which helps when pivoting,” said Dr. Mendoza, who launched Scrivas, a Miami-based medical scribe agency, to help reduce the paperwork workload for physicians. “It might be that a doctor wants to get involved in the acquisition of medical equipment, or maybe they can focus on their investments. Either way, by leaving medicine, they’re not dealing with the hassle and churn-and-burn of seeing patients.”
What this means for patients
The time is now to stem the upcoming tide of retirement, said Mr. Dill. But the challenges remain daunting. For starters, the country needs more physicians trained now – but it will take years to replace those baby boomer doctors ready to hang up their white coats.
The medical profession also needs to find ways to support physicians who spend their days juggling an endless array of responsibilities, he said.
The AAMC study found that patients already feel the physician shortfall. Their public opinion research in 2019 said 35% of patients had trouble finding a physician over the past 2 or 3 years, up 10 percentage points since they asked the question in 2015.
Moreover, according to the report, the over-65 population is expected to grow by 45.1%, leaving a specialty care gap because older people generally have more complicated health cases that require specialists. In addition, physician burnout may lead more physicians under 65 to retire much earlier than expected.
Changes in how medicine is practiced, telemedicine care, and medical education – such as disruption of classes or clinical rotations, regulatory changes, and a lack of interest in certain specialties – could also be affected by a mass physician retirement.
What can we do about mass retirement?
The AAMC reports in “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” that federally funded GME support is in the works to train 15,000 physicians per year, with 3,000 new residency slots added per year over 5 years. The proposed model will add 3,750 new physicians each year beginning in 2026.
Other efforts include increasing use of APRNs and PAs, whose population is estimated to more than double by 2034, improve population health through preventive care, increase equity in health outcomes, and improve access and affordable care.
Removing licensing barriers for immigrant doctors can also help alleviate the shortage.
“We need to find better ways to leverage the entirety of the health care team so that not as much falls on physicians,” Mr. Dill said. “It’s also imperative that we focus on ways to support physician wellness and allow physicians to remain active in the field, but at a reduced rate.”
That’s precisely what Marie Brown, MD, director of practice redesign at the American Medical Association, is seeing nationwide. Cutting back their hours is not only trending, but it’s also helping doctors cope with burnout.
“We’re seeing physicians take a 20% or more cut in salary in order to decrease their burden,” she said. “They’ll spend 4 days on clinical time with patients so that on that fifth ‘day off,’ they’re doing the paperwork and documentation they need to do so they don’t compromise care on the other 4 days of the week.”
And this may only be a Band-Aid solution, she fears.
“If a physician is spending 3 hours a day doing unnecessary work that could be done by another team member, that’s contributing to burnout,” Dr. Brown said. “It’s no surprise that they’ll want to escape and retire if they’re in a financial situation to do so.”
“I advocate negotiating within your organization so you’re doing more of what you like, such as mentoring or running a residency, and less of what you don’t, while cutting back from full-time to something less than full-time while maintaining benefits,” said Joel Greenwald, MD, a certified financial planner in Minneapolis, who specializes in helping physicians manage their financial affairs.
“Falling into the ‘like less’ bucket are usually things like working weekends and taking calls,” he said.
“This benefits everyone on a large scale because those doctors who find things they enjoy are generally working to a later age but working less hard,” he said. “Remaining comfortably and happily gainfully employed for a longer period, even if you’re not working full-time, has a very powerful effect on your financial planning, and you’ll avoid the risk of running out of money.”
A version of this article first appeared on Medscape.com.
The double whammy of pandemic burnout and the aging of baby boomer physicians has, indeed, the makings of some scary headlines. A recent survey by Elsevier Health predicts that up to 75% of health care workers will leave the profession by 2025. And a 2020 study conducted by the Association of American Medical Colleges (AAMC) projected a shortfall of up to 139,000 physicians by 2033.
“We’ve paid a lot of attention to physician retirement,” says Michael Dill, AAMC’s director of workforce studies. “It’s a significant concern in terms of whether we have an adequate supply of physicians in the U.S. to meet our nation’s medical care needs. Anyone who thinks otherwise is incorrect.”
To Mr. Dill,
“The physician workforce as a whole is aging,” he said. “Close to a quarter of the physicians in the U.S. are 65 and over. So, you don’t need any extraordinary events driving retirement in order for retirement to be a real phenomenon of which we should all be concerned.”
And, although Mr. Dill said there aren’t any data to suggest that doctors in rural or urban areas are retiring faster than in the suburbs, that doesn’t mean retirement will have the same impact depending on where patients live.
“If you live in a rural area with one small practice in town and that physician retires, there goes the entirety of the physician supply,” he said. “In a major metro area, that’s not as big a deal.”
Why younger doctors are fast-tracking retirement
Fernando Mendoza, MD, 54, a pediatric emergency department physician in Miami, worries that physicians are getting so bogged down by paperwork that this may lead to even more doctors, at younger ages, leaving the profession.
“I love taking care of kids, but there’s going to be a cost to doing your work when you’re spending as much time as we need to spend on charts, pharmacy requests, and making sure all of the Medicare and Medicaid compliance issues are worked out.”
These stressors may compel some younger doctors to consider carving out a second career or fast-track younger physicians toward retirement.
“A medical degree carries a lot of weight, which helps when pivoting,” said Dr. Mendoza, who launched Scrivas, a Miami-based medical scribe agency, to help reduce the paperwork workload for physicians. “It might be that a doctor wants to get involved in the acquisition of medical equipment, or maybe they can focus on their investments. Either way, by leaving medicine, they’re not dealing with the hassle and churn-and-burn of seeing patients.”
What this means for patients
The time is now to stem the upcoming tide of retirement, said Mr. Dill. But the challenges remain daunting. For starters, the country needs more physicians trained now – but it will take years to replace those baby boomer doctors ready to hang up their white coats.
The medical profession also needs to find ways to support physicians who spend their days juggling an endless array of responsibilities, he said.
The AAMC study found that patients already feel the physician shortfall. Their public opinion research in 2019 said 35% of patients had trouble finding a physician over the past 2 or 3 years, up 10 percentage points since they asked the question in 2015.
Moreover, according to the report, the over-65 population is expected to grow by 45.1%, leaving a specialty care gap because older people generally have more complicated health cases that require specialists. In addition, physician burnout may lead more physicians under 65 to retire much earlier than expected.
Changes in how medicine is practiced, telemedicine care, and medical education – such as disruption of classes or clinical rotations, regulatory changes, and a lack of interest in certain specialties – could also be affected by a mass physician retirement.
What can we do about mass retirement?
The AAMC reports in “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” that federally funded GME support is in the works to train 15,000 physicians per year, with 3,000 new residency slots added per year over 5 years. The proposed model will add 3,750 new physicians each year beginning in 2026.
Other efforts include increasing use of APRNs and PAs, whose population is estimated to more than double by 2034, improve population health through preventive care, increase equity in health outcomes, and improve access and affordable care.
Removing licensing barriers for immigrant doctors can also help alleviate the shortage.
“We need to find better ways to leverage the entirety of the health care team so that not as much falls on physicians,” Mr. Dill said. “It’s also imperative that we focus on ways to support physician wellness and allow physicians to remain active in the field, but at a reduced rate.”
That’s precisely what Marie Brown, MD, director of practice redesign at the American Medical Association, is seeing nationwide. Cutting back their hours is not only trending, but it’s also helping doctors cope with burnout.
“We’re seeing physicians take a 20% or more cut in salary in order to decrease their burden,” she said. “They’ll spend 4 days on clinical time with patients so that on that fifth ‘day off,’ they’re doing the paperwork and documentation they need to do so they don’t compromise care on the other 4 days of the week.”
And this may only be a Band-Aid solution, she fears.
“If a physician is spending 3 hours a day doing unnecessary work that could be done by another team member, that’s contributing to burnout,” Dr. Brown said. “It’s no surprise that they’ll want to escape and retire if they’re in a financial situation to do so.”
“I advocate negotiating within your organization so you’re doing more of what you like, such as mentoring or running a residency, and less of what you don’t, while cutting back from full-time to something less than full-time while maintaining benefits,” said Joel Greenwald, MD, a certified financial planner in Minneapolis, who specializes in helping physicians manage their financial affairs.
“Falling into the ‘like less’ bucket are usually things like working weekends and taking calls,” he said.
“This benefits everyone on a large scale because those doctors who find things they enjoy are generally working to a later age but working less hard,” he said. “Remaining comfortably and happily gainfully employed for a longer period, even if you’re not working full-time, has a very powerful effect on your financial planning, and you’ll avoid the risk of running out of money.”
A version of this article first appeared on Medscape.com.
The double whammy of pandemic burnout and the aging of baby boomer physicians has, indeed, the makings of some scary headlines. A recent survey by Elsevier Health predicts that up to 75% of health care workers will leave the profession by 2025. And a 2020 study conducted by the Association of American Medical Colleges (AAMC) projected a shortfall of up to 139,000 physicians by 2033.
“We’ve paid a lot of attention to physician retirement,” says Michael Dill, AAMC’s director of workforce studies. “It’s a significant concern in terms of whether we have an adequate supply of physicians in the U.S. to meet our nation’s medical care needs. Anyone who thinks otherwise is incorrect.”
To Mr. Dill,
“The physician workforce as a whole is aging,” he said. “Close to a quarter of the physicians in the U.S. are 65 and over. So, you don’t need any extraordinary events driving retirement in order for retirement to be a real phenomenon of which we should all be concerned.”
And, although Mr. Dill said there aren’t any data to suggest that doctors in rural or urban areas are retiring faster than in the suburbs, that doesn’t mean retirement will have the same impact depending on where patients live.
“If you live in a rural area with one small practice in town and that physician retires, there goes the entirety of the physician supply,” he said. “In a major metro area, that’s not as big a deal.”
Why younger doctors are fast-tracking retirement
Fernando Mendoza, MD, 54, a pediatric emergency department physician in Miami, worries that physicians are getting so bogged down by paperwork that this may lead to even more doctors, at younger ages, leaving the profession.
“I love taking care of kids, but there’s going to be a cost to doing your work when you’re spending as much time as we need to spend on charts, pharmacy requests, and making sure all of the Medicare and Medicaid compliance issues are worked out.”
These stressors may compel some younger doctors to consider carving out a second career or fast-track younger physicians toward retirement.
“A medical degree carries a lot of weight, which helps when pivoting,” said Dr. Mendoza, who launched Scrivas, a Miami-based medical scribe agency, to help reduce the paperwork workload for physicians. “It might be that a doctor wants to get involved in the acquisition of medical equipment, or maybe they can focus on their investments. Either way, by leaving medicine, they’re not dealing with the hassle and churn-and-burn of seeing patients.”
What this means for patients
The time is now to stem the upcoming tide of retirement, said Mr. Dill. But the challenges remain daunting. For starters, the country needs more physicians trained now – but it will take years to replace those baby boomer doctors ready to hang up their white coats.
The medical profession also needs to find ways to support physicians who spend their days juggling an endless array of responsibilities, he said.
The AAMC study found that patients already feel the physician shortfall. Their public opinion research in 2019 said 35% of patients had trouble finding a physician over the past 2 or 3 years, up 10 percentage points since they asked the question in 2015.
Moreover, according to the report, the over-65 population is expected to grow by 45.1%, leaving a specialty care gap because older people generally have more complicated health cases that require specialists. In addition, physician burnout may lead more physicians under 65 to retire much earlier than expected.
Changes in how medicine is practiced, telemedicine care, and medical education – such as disruption of classes or clinical rotations, regulatory changes, and a lack of interest in certain specialties – could also be affected by a mass physician retirement.
What can we do about mass retirement?
The AAMC reports in “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” that federally funded GME support is in the works to train 15,000 physicians per year, with 3,000 new residency slots added per year over 5 years. The proposed model will add 3,750 new physicians each year beginning in 2026.
Other efforts include increasing use of APRNs and PAs, whose population is estimated to more than double by 2034, improve population health through preventive care, increase equity in health outcomes, and improve access and affordable care.
Removing licensing barriers for immigrant doctors can also help alleviate the shortage.
“We need to find better ways to leverage the entirety of the health care team so that not as much falls on physicians,” Mr. Dill said. “It’s also imperative that we focus on ways to support physician wellness and allow physicians to remain active in the field, but at a reduced rate.”
That’s precisely what Marie Brown, MD, director of practice redesign at the American Medical Association, is seeing nationwide. Cutting back their hours is not only trending, but it’s also helping doctors cope with burnout.
“We’re seeing physicians take a 20% or more cut in salary in order to decrease their burden,” she said. “They’ll spend 4 days on clinical time with patients so that on that fifth ‘day off,’ they’re doing the paperwork and documentation they need to do so they don’t compromise care on the other 4 days of the week.”
And this may only be a Band-Aid solution, she fears.
“If a physician is spending 3 hours a day doing unnecessary work that could be done by another team member, that’s contributing to burnout,” Dr. Brown said. “It’s no surprise that they’ll want to escape and retire if they’re in a financial situation to do so.”
“I advocate negotiating within your organization so you’re doing more of what you like, such as mentoring or running a residency, and less of what you don’t, while cutting back from full-time to something less than full-time while maintaining benefits,” said Joel Greenwald, MD, a certified financial planner in Minneapolis, who specializes in helping physicians manage their financial affairs.
“Falling into the ‘like less’ bucket are usually things like working weekends and taking calls,” he said.
“This benefits everyone on a large scale because those doctors who find things they enjoy are generally working to a later age but working less hard,” he said. “Remaining comfortably and happily gainfully employed for a longer period, even if you’re not working full-time, has a very powerful effect on your financial planning, and you’ll avoid the risk of running out of money.”
A version of this article first appeared on Medscape.com.
FDA OKs stem cell therapy for blood cancer patients to reduce infection risks
Omidubicel is made from umbilical cord donor stem cells that are processed with nicotinamide, a form of vitamin B3, to enhance and expand the number of progenitor cells, the product’s maker, Jerusalem-based Gamida Cell, explained in a press announcement.
The FDA approval was based on phase 3 testing that pitted the use of omidubicel in 62 patients against standard unmanipulated cord blood transplants in 63 patients following myeloablative conditioning.
The median time to neutrophil recovery was 12 days in the omidubicel group, compared with 22 days with standard care. Overall, 87% of patients who received omidubicel achieved neutrophil recovery versus 83% of patients with standard transplants.
The incidence of grade 2/3 bacterial or grade 3 fungal infections 100 days following transplant was 39% with omidubicel versus 60% with standard transplants.
The FDA’s “approval is an important advance in cell therapy treatment in patients with blood cancers. Hastening the return of the body’s white blood cells can reduce the possibility of serious or overwhelming infection associated with stem cell transplantation,” Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research, said in an agency press release.
Abbey Jenkins, president and CEO of Gamida, called the approval “a major advancement in the treatment of patients with hematologic malignancies that we believe may increase access to stem cell transplant and help improve patient outcomes.”
The most common grade 3–5 adverse reactions in the approval study were pain (33%), mucosal inflammation (31%), hypertension (25%), and gastrointestinal toxicity (19%).
Adverse events are consistent with allogeneic hematopoietic stem cell transplantation. Among 117 patients who received omidubicel for any indication, infusion reactions occurred in 47% of patients, acute graft-versus-host disease occurred in 58%, chronic GVHD occurred in 35%, and graft failure occurred in 3%. Labeling includes a boxed warning of the possibilities. There is also a small risk of infections and malignancies from donor blood.
Omidubicel is manufactured in Gamida’s facility in Kiryat Gat, Israel. It is available for order now and is expected to be delivered to transplant centers within 30 days after the start of manufacturing, the company said.
A version of this article originally appeared on Medscape.com.
Omidubicel is made from umbilical cord donor stem cells that are processed with nicotinamide, a form of vitamin B3, to enhance and expand the number of progenitor cells, the product’s maker, Jerusalem-based Gamida Cell, explained in a press announcement.
The FDA approval was based on phase 3 testing that pitted the use of omidubicel in 62 patients against standard unmanipulated cord blood transplants in 63 patients following myeloablative conditioning.
The median time to neutrophil recovery was 12 days in the omidubicel group, compared with 22 days with standard care. Overall, 87% of patients who received omidubicel achieved neutrophil recovery versus 83% of patients with standard transplants.
The incidence of grade 2/3 bacterial or grade 3 fungal infections 100 days following transplant was 39% with omidubicel versus 60% with standard transplants.
The FDA’s “approval is an important advance in cell therapy treatment in patients with blood cancers. Hastening the return of the body’s white blood cells can reduce the possibility of serious or overwhelming infection associated with stem cell transplantation,” Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research, said in an agency press release.
Abbey Jenkins, president and CEO of Gamida, called the approval “a major advancement in the treatment of patients with hematologic malignancies that we believe may increase access to stem cell transplant and help improve patient outcomes.”
The most common grade 3–5 adverse reactions in the approval study were pain (33%), mucosal inflammation (31%), hypertension (25%), and gastrointestinal toxicity (19%).
Adverse events are consistent with allogeneic hematopoietic stem cell transplantation. Among 117 patients who received omidubicel for any indication, infusion reactions occurred in 47% of patients, acute graft-versus-host disease occurred in 58%, chronic GVHD occurred in 35%, and graft failure occurred in 3%. Labeling includes a boxed warning of the possibilities. There is also a small risk of infections and malignancies from donor blood.
Omidubicel is manufactured in Gamida’s facility in Kiryat Gat, Israel. It is available for order now and is expected to be delivered to transplant centers within 30 days after the start of manufacturing, the company said.
A version of this article originally appeared on Medscape.com.
Omidubicel is made from umbilical cord donor stem cells that are processed with nicotinamide, a form of vitamin B3, to enhance and expand the number of progenitor cells, the product’s maker, Jerusalem-based Gamida Cell, explained in a press announcement.
The FDA approval was based on phase 3 testing that pitted the use of omidubicel in 62 patients against standard unmanipulated cord blood transplants in 63 patients following myeloablative conditioning.
The median time to neutrophil recovery was 12 days in the omidubicel group, compared with 22 days with standard care. Overall, 87% of patients who received omidubicel achieved neutrophil recovery versus 83% of patients with standard transplants.
The incidence of grade 2/3 bacterial or grade 3 fungal infections 100 days following transplant was 39% with omidubicel versus 60% with standard transplants.
The FDA’s “approval is an important advance in cell therapy treatment in patients with blood cancers. Hastening the return of the body’s white blood cells can reduce the possibility of serious or overwhelming infection associated with stem cell transplantation,” Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research, said in an agency press release.
Abbey Jenkins, president and CEO of Gamida, called the approval “a major advancement in the treatment of patients with hematologic malignancies that we believe may increase access to stem cell transplant and help improve patient outcomes.”
The most common grade 3–5 adverse reactions in the approval study were pain (33%), mucosal inflammation (31%), hypertension (25%), and gastrointestinal toxicity (19%).
Adverse events are consistent with allogeneic hematopoietic stem cell transplantation. Among 117 patients who received omidubicel for any indication, infusion reactions occurred in 47% of patients, acute graft-versus-host disease occurred in 58%, chronic GVHD occurred in 35%, and graft failure occurred in 3%. Labeling includes a boxed warning of the possibilities. There is also a small risk of infections and malignancies from donor blood.
Omidubicel is manufactured in Gamida’s facility in Kiryat Gat, Israel. It is available for order now and is expected to be delivered to transplant centers within 30 days after the start of manufacturing, the company said.
A version of this article originally appeared on Medscape.com.
Red-cell donor’s sex does not affect transfusion survival
In a randomized clinical trial with almost 9,000 patients, the adjusted hazard ratio of death among recipients of female donors’ blood, compared with recipients of male donors’ blood, was 0.98. The data contradict the finding of previous observational studies that donor sex is associated with recipient outcomes.
“The key finding was that we actually had a null result,” study author Dean Fergusson, MD, PhD, senior scientist at the Ottawa Hospital Research Institute, said in an interview. “We went in thinking that male donor blood would confer a benefit over female donor blood, and we found that there’s absolutely no difference between the donor sexes on recipient outcomes – mortality and other major secondary outcomes,” Dr. Fergusson added.
The study was published in the New England Journal of Medicine.
Differences ‘don’t matter’
A 2015 article from the National Heart, Lung, and Blood Institute identified a potential effect of donor sex on transfusion recipient survival. Since then, several observational studies have suggested that donor sex may influence survival after transfusion. This research includes two large studies, one from Canada and one from the Netherlands, that reported a heightened risk of death among recipients of red-cell units from female donors or donors who had been pregnant. Other studies, however, yielded conflicting results.
“The rationale was that female blood, because of biochemical properties, different hormones, exposure to babies and other males, all led to a different product, if you will, and these subtle changes could affect the blood product in terms of shelf life and potency,” said Dr. Fergusson. “That itself would have downstream effects on the recipient.”
The current double-blind study included 8,719 patients who received transfusions from September 2018 to December 2020 at three academic medical centers in Canada. Of this group, 5,190 received male donor blood, and 3,529 received blood from female donors.
The researchers randomly assigned patients in a 60:40 ratio to male and female donor groups. Data collection and follow-up were performed by the Ottawa Hospital Data Warehouse, Canadian Blood Services, and ICES, an independent research institute. Patient characteristics were similar in both trial groups at baseline.
After an average follow-up of 11.2 months, with a maximum follow-up of 29 months, 1,141 patients in the female donor group and 1,712 in the male donor group died. The study found no statistically significant difference in overall survival between the two groups. The unadjusted HR for death, with the male group as the reference, was 0.97, and the adjusted HR was 0.98. The rates of overall survival were 58% and 56.1% in the female and male donor groups, respectively.
The study did not prove that differences in outcome based on donor sex do not exist, said Dr. Fergusson. “But those differences really don’t matter in the recipient.”
The design of the trial itself was unique, Dr. Fergusson said. After patients consented to participate and underwent randomization, the study used routinely collected data from the participating hospitals’ electronic medical records rather than collect data anew for each patient. “That had a profound effect on the efficiency of the trial. We did this trial for a cost of less than $300,000, and typically it would cost $9 million by using high-quality electronic health data.”
The study also evaluated several secondary outcomes. Recipients of female donor blood had twice the incidence of MRSA infection. In addition, an unadjusted subgroup analysis suggested a 10% lower risk of death among male patients assigned to the female donor group, compared with those assigned to the male donor group.
The risk of death was almost three times higher among patients in the female donor group who received units from donors aged 20-29.9 years (HR, 2.93). “The inconsistency of the point estimates across groups and the multiplicity of analyses increase the risk that those findings were due to chance,” according to the authors.
Big data
Commenting on the study, Jeannie Callum, MD, professor and director of transfusion medicine at Queen’s University, Kingston, Ont., said that the use of routinely collected data from the participating hospitals’ electronic medical records was “one of the really great things about this paper.”
This use of Big Data “allows you to do a trial like this with almost 9,000 patients without spending millions and millions of dollars to have people go through charts and record data,” she added.
Dr. Callum also pointed out some of the trial’s limitations. “One of the things that kind of detracts from the study in my mind is that they randomized everybody that was getting a transfusion, but outpatients getting a transfusion have a very low mortality rate. So, you have a group of patients that are never going to have that endpoint being included in the study, and that might’ve diluted the findings.”
About 11.4% of participants received blood from a donor group other than the one to which they had been assigned, and this factor may further dilute the findings, said Dr. Callum. “That’s a difficult thing to avoid.” She noted that a trial in which she is collaborating, called Sex Matters, may answer some of these questions about the use of female versus male donor blood.
The investigators also noted that the findings may not be generalizable to other countries. “Just because we didn’t find something in Canada with our blood production system doesn’t mean that the United States might not find it different, because how they manufacture their red blood cells for transfusion is different than how we do them in Canada,” said Dr. Callum.
Nonetheless, this study shows the potential of using Big Data in medicine. “This is the future of large randomized clinical trials to quickly answer questions,” said Dr. Callum. “In the United States, Canada, and other countries that have these large electronic medical records systems, this kind of trial would be able to be done in other centers.”
The study was funded by the Canadian Institutes of Health Research. Dr. Fergusson and Dr. Callum disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a randomized clinical trial with almost 9,000 patients, the adjusted hazard ratio of death among recipients of female donors’ blood, compared with recipients of male donors’ blood, was 0.98. The data contradict the finding of previous observational studies that donor sex is associated with recipient outcomes.
“The key finding was that we actually had a null result,” study author Dean Fergusson, MD, PhD, senior scientist at the Ottawa Hospital Research Institute, said in an interview. “We went in thinking that male donor blood would confer a benefit over female donor blood, and we found that there’s absolutely no difference between the donor sexes on recipient outcomes – mortality and other major secondary outcomes,” Dr. Fergusson added.
The study was published in the New England Journal of Medicine.
Differences ‘don’t matter’
A 2015 article from the National Heart, Lung, and Blood Institute identified a potential effect of donor sex on transfusion recipient survival. Since then, several observational studies have suggested that donor sex may influence survival after transfusion. This research includes two large studies, one from Canada and one from the Netherlands, that reported a heightened risk of death among recipients of red-cell units from female donors or donors who had been pregnant. Other studies, however, yielded conflicting results.
“The rationale was that female blood, because of biochemical properties, different hormones, exposure to babies and other males, all led to a different product, if you will, and these subtle changes could affect the blood product in terms of shelf life and potency,” said Dr. Fergusson. “That itself would have downstream effects on the recipient.”
The current double-blind study included 8,719 patients who received transfusions from September 2018 to December 2020 at three academic medical centers in Canada. Of this group, 5,190 received male donor blood, and 3,529 received blood from female donors.
The researchers randomly assigned patients in a 60:40 ratio to male and female donor groups. Data collection and follow-up were performed by the Ottawa Hospital Data Warehouse, Canadian Blood Services, and ICES, an independent research institute. Patient characteristics were similar in both trial groups at baseline.
After an average follow-up of 11.2 months, with a maximum follow-up of 29 months, 1,141 patients in the female donor group and 1,712 in the male donor group died. The study found no statistically significant difference in overall survival between the two groups. The unadjusted HR for death, with the male group as the reference, was 0.97, and the adjusted HR was 0.98. The rates of overall survival were 58% and 56.1% in the female and male donor groups, respectively.
The study did not prove that differences in outcome based on donor sex do not exist, said Dr. Fergusson. “But those differences really don’t matter in the recipient.”
The design of the trial itself was unique, Dr. Fergusson said. After patients consented to participate and underwent randomization, the study used routinely collected data from the participating hospitals’ electronic medical records rather than collect data anew for each patient. “That had a profound effect on the efficiency of the trial. We did this trial for a cost of less than $300,000, and typically it would cost $9 million by using high-quality electronic health data.”
The study also evaluated several secondary outcomes. Recipients of female donor blood had twice the incidence of MRSA infection. In addition, an unadjusted subgroup analysis suggested a 10% lower risk of death among male patients assigned to the female donor group, compared with those assigned to the male donor group.
The risk of death was almost three times higher among patients in the female donor group who received units from donors aged 20-29.9 years (HR, 2.93). “The inconsistency of the point estimates across groups and the multiplicity of analyses increase the risk that those findings were due to chance,” according to the authors.
Big data
Commenting on the study, Jeannie Callum, MD, professor and director of transfusion medicine at Queen’s University, Kingston, Ont., said that the use of routinely collected data from the participating hospitals’ electronic medical records was “one of the really great things about this paper.”
This use of Big Data “allows you to do a trial like this with almost 9,000 patients without spending millions and millions of dollars to have people go through charts and record data,” she added.
Dr. Callum also pointed out some of the trial’s limitations. “One of the things that kind of detracts from the study in my mind is that they randomized everybody that was getting a transfusion, but outpatients getting a transfusion have a very low mortality rate. So, you have a group of patients that are never going to have that endpoint being included in the study, and that might’ve diluted the findings.”
About 11.4% of participants received blood from a donor group other than the one to which they had been assigned, and this factor may further dilute the findings, said Dr. Callum. “That’s a difficult thing to avoid.” She noted that a trial in which she is collaborating, called Sex Matters, may answer some of these questions about the use of female versus male donor blood.
The investigators also noted that the findings may not be generalizable to other countries. “Just because we didn’t find something in Canada with our blood production system doesn’t mean that the United States might not find it different, because how they manufacture their red blood cells for transfusion is different than how we do them in Canada,” said Dr. Callum.
Nonetheless, this study shows the potential of using Big Data in medicine. “This is the future of large randomized clinical trials to quickly answer questions,” said Dr. Callum. “In the United States, Canada, and other countries that have these large electronic medical records systems, this kind of trial would be able to be done in other centers.”
The study was funded by the Canadian Institutes of Health Research. Dr. Fergusson and Dr. Callum disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a randomized clinical trial with almost 9,000 patients, the adjusted hazard ratio of death among recipients of female donors’ blood, compared with recipients of male donors’ blood, was 0.98. The data contradict the finding of previous observational studies that donor sex is associated with recipient outcomes.
“The key finding was that we actually had a null result,” study author Dean Fergusson, MD, PhD, senior scientist at the Ottawa Hospital Research Institute, said in an interview. “We went in thinking that male donor blood would confer a benefit over female donor blood, and we found that there’s absolutely no difference between the donor sexes on recipient outcomes – mortality and other major secondary outcomes,” Dr. Fergusson added.
The study was published in the New England Journal of Medicine.
Differences ‘don’t matter’
A 2015 article from the National Heart, Lung, and Blood Institute identified a potential effect of donor sex on transfusion recipient survival. Since then, several observational studies have suggested that donor sex may influence survival after transfusion. This research includes two large studies, one from Canada and one from the Netherlands, that reported a heightened risk of death among recipients of red-cell units from female donors or donors who had been pregnant. Other studies, however, yielded conflicting results.
“The rationale was that female blood, because of biochemical properties, different hormones, exposure to babies and other males, all led to a different product, if you will, and these subtle changes could affect the blood product in terms of shelf life and potency,” said Dr. Fergusson. “That itself would have downstream effects on the recipient.”
The current double-blind study included 8,719 patients who received transfusions from September 2018 to December 2020 at three academic medical centers in Canada. Of this group, 5,190 received male donor blood, and 3,529 received blood from female donors.
The researchers randomly assigned patients in a 60:40 ratio to male and female donor groups. Data collection and follow-up were performed by the Ottawa Hospital Data Warehouse, Canadian Blood Services, and ICES, an independent research institute. Patient characteristics were similar in both trial groups at baseline.
After an average follow-up of 11.2 months, with a maximum follow-up of 29 months, 1,141 patients in the female donor group and 1,712 in the male donor group died. The study found no statistically significant difference in overall survival between the two groups. The unadjusted HR for death, with the male group as the reference, was 0.97, and the adjusted HR was 0.98. The rates of overall survival were 58% and 56.1% in the female and male donor groups, respectively.
The study did not prove that differences in outcome based on donor sex do not exist, said Dr. Fergusson. “But those differences really don’t matter in the recipient.”
The design of the trial itself was unique, Dr. Fergusson said. After patients consented to participate and underwent randomization, the study used routinely collected data from the participating hospitals’ electronic medical records rather than collect data anew for each patient. “That had a profound effect on the efficiency of the trial. We did this trial for a cost of less than $300,000, and typically it would cost $9 million by using high-quality electronic health data.”
The study also evaluated several secondary outcomes. Recipients of female donor blood had twice the incidence of MRSA infection. In addition, an unadjusted subgroup analysis suggested a 10% lower risk of death among male patients assigned to the female donor group, compared with those assigned to the male donor group.
The risk of death was almost three times higher among patients in the female donor group who received units from donors aged 20-29.9 years (HR, 2.93). “The inconsistency of the point estimates across groups and the multiplicity of analyses increase the risk that those findings were due to chance,” according to the authors.
Big data
Commenting on the study, Jeannie Callum, MD, professor and director of transfusion medicine at Queen’s University, Kingston, Ont., said that the use of routinely collected data from the participating hospitals’ electronic medical records was “one of the really great things about this paper.”
This use of Big Data “allows you to do a trial like this with almost 9,000 patients without spending millions and millions of dollars to have people go through charts and record data,” she added.
Dr. Callum also pointed out some of the trial’s limitations. “One of the things that kind of detracts from the study in my mind is that they randomized everybody that was getting a transfusion, but outpatients getting a transfusion have a very low mortality rate. So, you have a group of patients that are never going to have that endpoint being included in the study, and that might’ve diluted the findings.”
About 11.4% of participants received blood from a donor group other than the one to which they had been assigned, and this factor may further dilute the findings, said Dr. Callum. “That’s a difficult thing to avoid.” She noted that a trial in which she is collaborating, called Sex Matters, may answer some of these questions about the use of female versus male donor blood.
The investigators also noted that the findings may not be generalizable to other countries. “Just because we didn’t find something in Canada with our blood production system doesn’t mean that the United States might not find it different, because how they manufacture their red blood cells for transfusion is different than how we do them in Canada,” said Dr. Callum.
Nonetheless, this study shows the potential of using Big Data in medicine. “This is the future of large randomized clinical trials to quickly answer questions,” said Dr. Callum. “In the United States, Canada, and other countries that have these large electronic medical records systems, this kind of trial would be able to be done in other centers.”
The study was funded by the Canadian Institutes of Health Research. Dr. Fergusson and Dr. Callum disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Relapsed CLL: New approaches prolong survival
NEW YORK –
“In people who are genomically unstable, almost half will have their CLL progress on single agent BTK inhibitor therapy. These patients, I’d like to treat with combination of a Bruton’s tyrosine kinase inhibitor plus venetoclax,” said Richard R. Furman, MD, Morton Coleman MD Distinguished Professor of medicine at Weill Cornell Medicine/New York Presbyterian Hospital. He presented on treating relapsed CLL at the Great Debates and Updates Hematologic Malignancies Conference in New York, April 13-15.
The efficacy of venetoclax (VX) in treating high risk CLL patients was demonstrated in the 2019 CLL14 trial (NCT02242942) in which the main entry criteria were being treatment-naive and being considered “unfit” for treatment, meaning that a patient’s Cumulative Illness Rating Scale score was >6, or they presented with decreased kidney function. Study participants were treated with six cycles of either venetoclax-obinutuzumab (VO) or chlorambucil-obinutuzumab (CO); the 4-year PFS was 74% vs. 35.4% (P < .0001) respectively. After 12 cycles of treatment, the 74% of patients in the VO group achieved undetectable minimal residual disease rate (MRD) vs. 32% in the CO group.
Achievement of MRD did predict for outcome, but Dr. Furman concluded that while MRD is a powerful prognostic tool, it is not clinically useful given the inability of its results to guide therapy. He went on to emphasize that “of those patients who achieved MRD levels of 10-4 after 12 cycles of venetoclax, 50% had worsening and 50% had improvement of the residual disease, suggesting that we do not know the optimal duration of venetoclax treatment, as half of the patients still continue to derive benefit.”
Dr. Furman noted that ibrutinib (IB) and the second-generation drugs zanubrutinib (ZB) and acalabrutinib (AL) are all effective, but that the second-generation Bruton’s tyrosine kinase inhibitors enable patients to derive the benefit of remaining on treatment longer, because the rate of concerning cardiac complications is lower than with IB.
The ALPINE trial (NCT03734016) confirmed ZB’s significantly improved overall response rate at 78.3% vs. IB’s 62.5%, as well as a lower rate of atrial fibrillation (2.5%) vs. IB (10.1%).
Noninferiority of AL vs. IB in high-risk relapsed CLL patients was demonstrated in the ELEVATE-RR trial (NCT02477696) with both drugs having a median PFS of 38.4 months. With a median follow up of 41 months, AL demonstrated less atrial fibrillation/atrial flutter, compared with IB (9.4% vs. 16.0%) with no difference in grade > 3 infections. Furthermore, AL’s half-life being shorter than that of IB means that side effects are shorter lived.
“That’s the advantage of the second generation of Bruton’s tyrosine kinase inhibitors,” said Stefan Glück, MD, PhD, a hematologic oncologist and independent consultant who was formerly affiliated with the Sylvester Comprehensive Cancer Center and taught at the Miller School of Medicine at the University of Miami.
Dr. Glück added that “acalabrutinib and zanubrutinib have demonstrated strong efficacy and safety. When patients no longer respond to these drugs, the addition of VX is crucial. It has a completely different mechanism of action and can reverse resistance to Bruton’s tyrosine kinase inhibitors, allowing them to start working again.”
Dr. Furman also discussed proteolysis-targeting chimeras (PROTACs), one area that he expects to make a significant impact as a future therapy for CLL and many other malignancies. Despite the fact these agents are in phase I studies, he commented that “they appear, thus far, to have tremendous potential.”
Dr. Furman disclosed relationships with Abbvie, Acerta/AstraZeneca, Beigene, Jansen, TG Therapeutics, Genentech-Roche, Incyte Corporation, Loxo Oncology, MEI Pharma, Morphosys, Pharmacyclics, Sanofi/Genzyme, and X4 Pharmaceuticals. Dr. Glück reported no conflicts of interest.
NEW YORK –
“In people who are genomically unstable, almost half will have their CLL progress on single agent BTK inhibitor therapy. These patients, I’d like to treat with combination of a Bruton’s tyrosine kinase inhibitor plus venetoclax,” said Richard R. Furman, MD, Morton Coleman MD Distinguished Professor of medicine at Weill Cornell Medicine/New York Presbyterian Hospital. He presented on treating relapsed CLL at the Great Debates and Updates Hematologic Malignancies Conference in New York, April 13-15.
The efficacy of venetoclax (VX) in treating high risk CLL patients was demonstrated in the 2019 CLL14 trial (NCT02242942) in which the main entry criteria were being treatment-naive and being considered “unfit” for treatment, meaning that a patient’s Cumulative Illness Rating Scale score was >6, or they presented with decreased kidney function. Study participants were treated with six cycles of either venetoclax-obinutuzumab (VO) or chlorambucil-obinutuzumab (CO); the 4-year PFS was 74% vs. 35.4% (P < .0001) respectively. After 12 cycles of treatment, the 74% of patients in the VO group achieved undetectable minimal residual disease rate (MRD) vs. 32% in the CO group.
Achievement of MRD did predict for outcome, but Dr. Furman concluded that while MRD is a powerful prognostic tool, it is not clinically useful given the inability of its results to guide therapy. He went on to emphasize that “of those patients who achieved MRD levels of 10-4 after 12 cycles of venetoclax, 50% had worsening and 50% had improvement of the residual disease, suggesting that we do not know the optimal duration of venetoclax treatment, as half of the patients still continue to derive benefit.”
Dr. Furman noted that ibrutinib (IB) and the second-generation drugs zanubrutinib (ZB) and acalabrutinib (AL) are all effective, but that the second-generation Bruton’s tyrosine kinase inhibitors enable patients to derive the benefit of remaining on treatment longer, because the rate of concerning cardiac complications is lower than with IB.
The ALPINE trial (NCT03734016) confirmed ZB’s significantly improved overall response rate at 78.3% vs. IB’s 62.5%, as well as a lower rate of atrial fibrillation (2.5%) vs. IB (10.1%).
Noninferiority of AL vs. IB in high-risk relapsed CLL patients was demonstrated in the ELEVATE-RR trial (NCT02477696) with both drugs having a median PFS of 38.4 months. With a median follow up of 41 months, AL demonstrated less atrial fibrillation/atrial flutter, compared with IB (9.4% vs. 16.0%) with no difference in grade > 3 infections. Furthermore, AL’s half-life being shorter than that of IB means that side effects are shorter lived.
“That’s the advantage of the second generation of Bruton’s tyrosine kinase inhibitors,” said Stefan Glück, MD, PhD, a hematologic oncologist and independent consultant who was formerly affiliated with the Sylvester Comprehensive Cancer Center and taught at the Miller School of Medicine at the University of Miami.
Dr. Glück added that “acalabrutinib and zanubrutinib have demonstrated strong efficacy and safety. When patients no longer respond to these drugs, the addition of VX is crucial. It has a completely different mechanism of action and can reverse resistance to Bruton’s tyrosine kinase inhibitors, allowing them to start working again.”
Dr. Furman also discussed proteolysis-targeting chimeras (PROTACs), one area that he expects to make a significant impact as a future therapy for CLL and many other malignancies. Despite the fact these agents are in phase I studies, he commented that “they appear, thus far, to have tremendous potential.”
Dr. Furman disclosed relationships with Abbvie, Acerta/AstraZeneca, Beigene, Jansen, TG Therapeutics, Genentech-Roche, Incyte Corporation, Loxo Oncology, MEI Pharma, Morphosys, Pharmacyclics, Sanofi/Genzyme, and X4 Pharmaceuticals. Dr. Glück reported no conflicts of interest.
NEW YORK –
“In people who are genomically unstable, almost half will have their CLL progress on single agent BTK inhibitor therapy. These patients, I’d like to treat with combination of a Bruton’s tyrosine kinase inhibitor plus venetoclax,” said Richard R. Furman, MD, Morton Coleman MD Distinguished Professor of medicine at Weill Cornell Medicine/New York Presbyterian Hospital. He presented on treating relapsed CLL at the Great Debates and Updates Hematologic Malignancies Conference in New York, April 13-15.
The efficacy of venetoclax (VX) in treating high risk CLL patients was demonstrated in the 2019 CLL14 trial (NCT02242942) in which the main entry criteria were being treatment-naive and being considered “unfit” for treatment, meaning that a patient’s Cumulative Illness Rating Scale score was >6, or they presented with decreased kidney function. Study participants were treated with six cycles of either venetoclax-obinutuzumab (VO) or chlorambucil-obinutuzumab (CO); the 4-year PFS was 74% vs. 35.4% (P < .0001) respectively. After 12 cycles of treatment, the 74% of patients in the VO group achieved undetectable minimal residual disease rate (MRD) vs. 32% in the CO group.
Achievement of MRD did predict for outcome, but Dr. Furman concluded that while MRD is a powerful prognostic tool, it is not clinically useful given the inability of its results to guide therapy. He went on to emphasize that “of those patients who achieved MRD levels of 10-4 after 12 cycles of venetoclax, 50% had worsening and 50% had improvement of the residual disease, suggesting that we do not know the optimal duration of venetoclax treatment, as half of the patients still continue to derive benefit.”
Dr. Furman noted that ibrutinib (IB) and the second-generation drugs zanubrutinib (ZB) and acalabrutinib (AL) are all effective, but that the second-generation Bruton’s tyrosine kinase inhibitors enable patients to derive the benefit of remaining on treatment longer, because the rate of concerning cardiac complications is lower than with IB.
The ALPINE trial (NCT03734016) confirmed ZB’s significantly improved overall response rate at 78.3% vs. IB’s 62.5%, as well as a lower rate of atrial fibrillation (2.5%) vs. IB (10.1%).
Noninferiority of AL vs. IB in high-risk relapsed CLL patients was demonstrated in the ELEVATE-RR trial (NCT02477696) with both drugs having a median PFS of 38.4 months. With a median follow up of 41 months, AL demonstrated less atrial fibrillation/atrial flutter, compared with IB (9.4% vs. 16.0%) with no difference in grade > 3 infections. Furthermore, AL’s half-life being shorter than that of IB means that side effects are shorter lived.
“That’s the advantage of the second generation of Bruton’s tyrosine kinase inhibitors,” said Stefan Glück, MD, PhD, a hematologic oncologist and independent consultant who was formerly affiliated with the Sylvester Comprehensive Cancer Center and taught at the Miller School of Medicine at the University of Miami.
Dr. Glück added that “acalabrutinib and zanubrutinib have demonstrated strong efficacy and safety. When patients no longer respond to these drugs, the addition of VX is crucial. It has a completely different mechanism of action and can reverse resistance to Bruton’s tyrosine kinase inhibitors, allowing them to start working again.”
Dr. Furman also discussed proteolysis-targeting chimeras (PROTACs), one area that he expects to make a significant impact as a future therapy for CLL and many other malignancies. Despite the fact these agents are in phase I studies, he commented that “they appear, thus far, to have tremendous potential.”
Dr. Furman disclosed relationships with Abbvie, Acerta/AstraZeneca, Beigene, Jansen, TG Therapeutics, Genentech-Roche, Incyte Corporation, Loxo Oncology, MEI Pharma, Morphosys, Pharmacyclics, Sanofi/Genzyme, and X4 Pharmaceuticals. Dr. Glück reported no conflicts of interest.
AT 2023 GREAT DEBATES AND UPDATES HEMATOLOGIC MALIGNANCIES CONFERENCE